Two-thirds of cancer centers remain noncompliant with price transparency standards, according to a recent JAMA study.
Two startups have teamed up to scale up access to price transparency information so patients understand the price of care.
Nearly two years after the Centers for Medicare & Medicaid Services (CMS) price transparency rules went into effect, fewer than one-third of National Cancer Institute cancer center designated hospitals met the required standards, according to the Pacific Coast Surgical Association study.
Ribbon Health, an API data platform, clears the smokescreen of the cost of treatment by collecting data on everything from quality of care to the price of chemotherapy. In June, Ribbon Health partnered with Turquoise Health to improve the accuracy of its information by integrating Turquoise Health's 1 billion records of pricing data from 4,500 hospitals.
“Our focus is to make sure that information on price transparency, wherever it's coming from, and cost effectiveness, which is kind of a cousin of price transparency, is accessible in a way that somebody can understand it without being a machine learning expert or a clinical filling expert, which is how a lot of this data is getting put out today,” said Nate Maslak, the CEO and co-founder of Ribbon Health. “Our focus as a company is to be able to power every care decision to be convenient, cost effective and high quality.”
CMS price transparency rules require that negotiated prices for 300 common services be listed in a consumer-friendly format, freely accessible without login, named appropriately, containing listed items and services offered and be uploaded in a machine-readable format. Along with the No Surprises Act, this price transparency legislation was created to help patients know the cost of a covered item or service before receiving care and to prevent predatory billing practices.
Only 20 of the 63 cancer centers surveyed in the August JAMA study were fully compliant, while 42 provided some information on negotiated charges and discounted cash prices.
Hospitals that were designated comprehensive cancer centers were more likely (74%) to be compliant than those with clinical cancer center designation (33%), the study found. Hospitals in the West were more likely (86%) to be compliant compared to hospitals in the South (57%).
"Improving population health, while delivering quality care at lower costs, is the holy grail of healthcare,” said Chris Severn, co-founder and CEO of Turquoise Health, in a press release. "Making previously secret prices accessible will have an outsized impact on intelligent care navigation. This new data will allow anyone to reliably find high-quality care with upfront prices instead of a leap of faith into the healthcare unknown. Together with Ribbon Health, we have the ability to elevate millions of patient journeys in one single solution."
Requiring machine-readable formats aids platforms like Ribbon Health in accessing the information patients most need. In their raw formats, hospital and payer machine-readable data are not easily understood or actionable given their complexity. The study found that most website files required advanced coding to open or comprehend with some files having tens of thousands of rows of information.
The August study joins a slew of others that have shared similar findings including PatientsRightsAdvocate.org’s Semi-Annual Hospital Price Transparency Report released Aug. 9, which found that only 16% of 2,000 hospitals are compliant with CMS' price transparency regulations. The report marks an increase from 14.6% compliance in February 2022 and 4.6% in July 2021.
“I understand why it's so hard for a hospital system to comply,” Maslak said. “These aren't technology organizations; these are care delivery organizations who are now being asked to share really complex contracting data in a machine-readable format in a way that makes sense for people. They've never really been asked to do that before. Some are better equipped than others to do it. As an industry, we have a long way to go to make sure that happens.”
With Turquoise Health, Ribbon sifts through mountains of data to provide the most up-to-date price of treatment. The data Ribbon collects is used to power its provider directory, referral management, care navigation and insurance enrollment. According to Maslak, something as simple as provider location is incorrect half the time. Similarly, without in-depth information on providers, 20 million clinically inappropriate referrals occur every year in the U.S., according to the Ribbon Health website.
The platform reveals the nuts and bolts of real-time out-of-pocket prices based on deductibles, contracted charges and insurance plans. Over half of Americans say they are "completely lost" when it comes to understanding their insurance plan, according to 2021 data from Bend Financial. Ribbon's insurance enrollment resource aids those lost to jargon by including cost comparison across insurance plans.
“The way the CMS regulation is really written and driven, it's not asking hospitals to make sense of this information for a patient,” Maslak said. “That's the role that Ribbon really plays here, is to make sure that we can not only access this data, but also make sense of it in a way that it really resonates with patients.”
By working with insurance companies, third-party administrators, referral manager software, electronic health record systems, hospital systems and digital health platforms, Ribbon accesses a wide array of information to determine the ever-nebulous “cost effectiveness of care” by comparing quality of care with transparent prices.
Quality is determined by data points like provider treatment area, patient satisfaction scores, health outcomes, complication rate and relative experience performing specific procedures. The information is then offered in an array of formats varying from an easy-to-read 10-point scale to itemized lists.
“But when we do our research on how people see that care, they're trying to get to that headline number,” Maslak said. "My personal view is that the human component here is, ‘Can I afford this?’ There's so much anxiety that we have a medical system of, ‘If I do this, I might go broke.’ Like we hear about these surprise medical bills and how damaging they are. And so, I think it's important that we can move away from that and build confidence that people can just go get the care they need to be better.”
Hospitals with less than 30 beds that do not comply with CMS standards will be fined $300 per days; those with more than 31 beds incur penalties of $10 per bed per day. The maximum daily fine is capped at $5,500. In June, two Georgia hospitals were fined $214,320 and $833,180, respectively, after not answering CMS warning notices.