Alec Stein wants to organize independent software developers to collect health insurance data to determine if companies are paying specific providers for specific services. Stein, a data bounty administrator at software company Dolthub, quickly ran into trouble.
On July 1, health insurers released public, machine-readable files that included the negotiated prices they paid to network providers and the allowable rates for out-of-network providers. These trillions of dollars require sophisticated software to parse, and insurers don’t use standard file formats, making it nearly impossible to compare their reimbursement rates. can be done. Furthermore, requiring insurers to update their data every month to keep them up-to-date has the side effect of making it difficult for data analysts to assess information across the industry.
“Nobody appreciates the scope of the data,” says Stein. He estimates that uncompressed data from the five largest health insurers reduces the amount of information stored by the US Library of Congress, English Wikipedia, and the entire Netflix catalog.
Other software developers have faced similar challenges working with this data, which health insurers recently disclosed as part of a broader federal effort to demonstrate white price. Regulators have asked for input on upcoming additional transparency requirements. But before officials begin issuing final guidance regarding enhanced interpretations of benefits and other transparency requirements, insurers, developers and researchers are asking China to Center for Medicare and Medicaid Services for clarification on current regulations.
The Insurance Transparency Rule, which emerged from the Affordable Care Act, is intended to shed light on how confidential the rates health insurers negotiate with individual providers, which can vary so many. Policymakers are open to providers, patients, researchers – and health insurers themselves – using this information for their own purposes. Hospitals and other healthcare providers can determine how they are paid relative to their peers, patients can maximize their coverage by shopping for services care at a lower cost and researchers can analyze high levels of healthcare spending.
But early difficulties in accessing and reviewing this data are hindering the potential for transparency to promote a more efficient health care system.
“There’s a lot of hope that this data will really shine in contract negotiations with pay providers,” said Sabrina Corlette, co-director of the Georgetown University Center for Health Insurance Reform. money, but we haven’t gotten there yet. “Just an incredible amount of disappointment. CMS really needs to rewrite the requirements here, otherwise it will never achieve the policy goals set forth by the administration.”
Big implications for big data
Request transparency on the price of supplemental health insurance for hospitals. But insurers are complying widely, in contrast to health systems, which have been slow to comply with the rule. According to Turquoise Health, a startup that aggregates data to sell to insurers, providers and researchers, within 100 days of the regulation going into effect, health insurers cover 90% of commercial contract holders have publicly announced their bargaining fees.
“We have actually seen the biggest carriers release important data. The implications of how much new price data are available are sizable,” said Turquoise Health CEO Chris Severn. However, insurers have provided so much information that it will take five years for it to be useful to patients, he said.
Too much of a good thing
Michael Chernew, a health economist at Harvard Medical School who also chairs the Medicare Payments Advisory Committee, said the file that health insurance companies have posted is so large that a typical personal computer cannot handle them. Chernew is leading a Harvard team that aims to use data to analyze price differences between insurers.
“We’re talking terabytes of data, not even gigabytes, we’re on a higher level than typical request databases, and they refresh the data monthly,” Chernew said. “Even if you think you’ve got a process to run through it, the way it’s posted can change.”
In particular, Humana’s pricing information has posed problems for developers, Stein said. The insurance company posted its information in a different file format than that required by the CMS. The company also doesn’t have enough server space to let developers download more than eight files at a time, he said.
“If you want someone to do the worst possible job of being technically compliant and containing all the information, Humana has done it,” says Stein. “Completely legal, but totally nasty.”
Matthew Robben, co-founder and chief technology officer at the startup, which helps small digital health companies negotiate with large insurers, said Serif Health had to lease multiple servers to provide services. all available insurance data.
Serif Health spent about two weeks of work downloading Humana’s complete data set, compared with several days it took to get comparable information from other insurers, Robben said. Humana is also the only provider that doesn’t include mandatory information about how rates for inpatient and outpatient services differ, he said.
Humana offers support through its website, where external developers can submit questions and get responses within days, a spokesperson wrote in an email. When Stein tried to use this function to email Humana’s developers, his request bounced.
Across the industry, developers are having a hard time working with insurance companies’ information.
CVS Health’s Aetna lists multiple rates, with significant differences, for identical services and websites, with no explanation as to why or when the different rates should apply, Robben said. “I’d like to see CMS provide clear instructions to payers for cases like this,” he said. “If there is some sort of tiered fee schedule in place, we can get a better idea of whether it’s credentials, location, or some other difference that’s driving the rate difference.” Is the price posted?”
Aetna files follow the format required by CMS and are not designed to serve as a membership cost estimator, a spokesperson wrote in an email.
Elevance Health, formerly Anthem, published several repetitive and redundant files that did not specify whether the networks listed were local area networks or represent national reciprocal agreements between insurance companies. Blue Cross and Blue Shield, Robben said. Elevance Health did not respond to requests for interviews.
The vast majority of insurance company filings that list out-of-network rates are empty, Robben said.
“We, as data consumers, had to do a lot more engineering and adaptation than we originally thought to work with it. Probably more than CMS hoped with this regulation,” Robben said. “But it’s also the reality of the intricacies of signing a contract.” The differences between insurers underscore the need for the CMS to host a single directory with rates listed in a standard format, he said.
That would be ideal, but unlikely, Corlette said. If the CMS remains with its current fragmentation approach, it should standardize the index that insurance companies use to explain where information is posted and how to search for specific services. Requiring insurers to adopt common file naming conventions, standardize codes involved in individual procedures, and organize different services into separate subdirectories, she said. useful to researchers. And forcing service providers to publish smaller files would expand public access to the data, she said.
Making these changes would not require new regulations because it could simply rewrite the specifications required by insurers, but the agency would benefit from the comments. public contributions, Corlette said.
Insurers have invested a lot of time and money to adhere to a policy of price transparency. Ceci Connolly, president and chief executive officer of Alliance of Community Health Plans, a trade group for nonprofit insurers, said CMS should make sure patients can use this information before taking supplements. add rules.
Next year, insurers will be required to disclose out-of-pocket costs for 500 covered services through online, self-service tools. Next year, insurers will need to include personalized information for all medical services. Finally, insurers may also need to disclose what they pay for prescription drugs, although the government has indefinitely delayed that requirement. Many provisions in the No Surprises and Insurance Transparency Act overlap, so CMS should work to refine them and focus on how they will benefit consumers, Connolly said.
“You’re piling up requests here, and it wasn’t clear to us that that would be very consumer-friendly,” Connolly said. “It can be very heavy, and it can overlap.”
