XPC explores the impact of price transparency regulations on primary care with Mark Slifer from Turquoise Health.

What are the important milestones in price transparency regulation?

When it comes to price transparency regulation, there are two main rules of importance. The first is the Hospital Price Transparency Rule. This rule went into effect on January 1st, 2021. It requires hospitals to annually publish a comprehensive list of charges for all services provided via a machine-readable file (MRF) and a consumer-friendly patient search tool on their website. As of July 1st, 2022, we have collected, parsed, enhanced, and aggregated 4,670 hospital files; about 2TB worth of rates data. There are 6,000+ hospitals in the US system, so still, some work to be done for hospitals to post. CMS has set fines for up to $2 million dollars per year per hospital for those out of compliance. In June, we saw the first hospital system get fined for noncompliance. You can keep track of the noncompliance fines CMS is issuing, here.

On July 1st, 2022, The Transparency in Coverage Final Rule went into effect. This rule requires payers to publish monthly MRFs for both in-network rates and out-of-network historical payments on their website. It also requires payers to create a patient estimator tool that will initially have 500 services. This must be available on January 1st, 2023. On January 1st, 2024, all services must be available within the tool. CMS has discussed fines of up to $100 per day per member covered for payers that are not in compliance with the rule but has not officially published any comments regarding fines.

💡 Check out Dr. Eric Bricker’s take on the Hospital Price Transparency Rule.

What are the implications for physicians and patients?

Because of the most recent rule, any provider or physician who does business with a payer will have their rates posted on their behalf. As of July 11th, we have picked up files for all the big five insurance payers: Blue Cross, United, Cigna, Aetna, and Humana. Humana posted 440,000 CSV files. Unfortunately, these files are non-compliant because they were not posted in the required JSON format. So far, we have collected, parsed, enhanced, and aggregated 500TB worth of rates data. As a reminder, the hospital data was 2TB worth of rates data. From a physician's perspective, this will highlight providers such as Direct Primary Care (DPC) practices, Ambulatory Surgery Centers (ASCs), imaging centers, and more. You may be wondering, how will it do that? So let’s break it down.

For example, as a DPC you have been transparent about your pricing from the get-go. The Transparency In Coverage Final Rule puts hospitals and other providers' prices into the public record like yours (already) are. You already know you provide a value proposition of better access, greater affordability, and more personalized care for your members. Preventive and routine care visits are often skipped by patients due to accessibility and affordability concerns. The ambiguity of "what will I pay" often plays a major factor in hesitancy to seek this basic and important care. As a result, poor health outcomes are far too common, and healthcare spending for individuals and employers has skyrocketed. With patients and employers now empowered by this newly available data, we're able to provide a clearer view of the true cost of care. Now, patients will have more power to understand the true cost of healthcare as this data comes out.

The same could be said for other providers such as surgery centers, imaging centers, behavioral health, physical therapy, etc. On average many of these providers offer much more affordable services (and often better outcomes) to patients for common procedures, but we have been conditioned as healthcare consumers to go where we are directed.

This could all shift quickly with this data coming out into the public eye.

One of the issues with hospital transparency was lack of compliance or finding loopholes by providing convoluted data. How does this legislation fix those issues to ensure proper compliance from insurance companies?

There was definitely some confusion around the Hospital Price Transparency Final Rule when it went into effect in 2021. Over time, CMS has worked to address the lack of guidance offered to hospitals. Having learned from the roll-out of the Hospital Price Transparency Final Rule, CMS bolstered the guidance offered to payers. CMS now provides a standardized schema for all payers to adopt and utilize in the crafting of their MRFs. We’re hoping that the increased guidance will result in a higher rate of payer compliance. We actually have a real time tracker of payers posting on our blog, which you can find here.

What is Turquoise Health and how does it relate to the new legislation?

Since its founding in 2020, Turquoise Health has aggregated billions of rate records to power a new price transparent marketplace for providers, payers, and patients. Turquoise Health recently announced a Series A funding of $20M led by Andreessen-Horowitz and is frequently featured in major media such as WSJ, NYT, and Axios. Across our suite of products, we guide providers and payers to simpler agreements, resulting in clearer prices. Through price transparency, service bundling, and simplified contract management, we rework the underlying infrastructure that blocks easy upfront pricing. We also reduce the need for complex billing and coding that causes pricing nightmares. The Turquoise vision is a not-so-distant future where prices have menu-like clarity at a fair market rate. Without price transparency regulations, Turquoise Health wouldn’t exist. As payers and providers are mandated to post their prices, we are directly enabled to collect, parse, enhance, and aggregate that data for consumer use.

Is there anyone else out there doing something similar?

As of now, we are unaware of any other company currently utilizing price transparency as we are. We anticipate more companies will begin to dive into the space, which we hope will bring more attention to price transparency.

How can primary care physicians work with or benefit from Turquoise Health?

There are various ways primary care physicians can benefit from working with Turquoise Health. The first is very simple: claiming your provider page at no cost. This marks your provider profile as “Claimed,” and gives you the opportunity to access our marketplace of payers, employers, brokers, coalitions who are leading patient volume to particular providers. Once you claim your page, you can then highlight your practice by adding in services (we have templates for DPCs) along with your cash pricing. With your profile complete, you can begin receiving messages within the platform from a payer or employer who may be interested in working with you. We have 30+ DPCs that have done this so far, and look to increase the amount within our marketplace over time. If you are a provider looking to contract, you can take advantage of our Clear Contracts platform, an end-to-end contracting platform with hospital and payer rates fully integrated into the experience.

We are dedicated to highlighting providers who are transparent about their pricing while providing excellent care. Claiming your profile page and joining the marketplace is the first step to join the movement.

Why should primary care physicians care about the new law and the work Turquoise Health is doing?

DPCs can definitely benefit from this new regulation. Payer rates data quite literally highlights your pricing and services with the value proposition you have of affordability and access. It will give employers and others who direct patient volume in healthcare the power to actually have market conditions in their negotiations, while helping guide where they decide to direct their patient volume.

How do you see this legislation changing the healthcare ecosystem in the next few years?

The price of every service, other than drugs, is now public. Take UHC for example, they have over 70 million lives covered. We now have every single price for every covered service for every in-network provider and care location. And that’s just for one payer! Put them all together, and we get an incredible map of healthcare prices across the US. Not only can we now conduct comparisons but we can map exactly who is in each payer’s network. Payers looking to break into a new market have the roster of other payers in that market and the exact rates those payers have negotiated. This is the first time payers and providers can have true market data when they are negotiating contracts or rates. With that knowledge, it takes little work to visualize how easy it would be to break into markets, disrupt existing ones, dig into how costs are being shared, or how profits are, and totally change the landscape of how business decisions in healthcare are made.

Are there any other important pieces of legislation or system wide changes coming down the pipeline?

For now, there are no new regulations coming down the pipeline, only the completion of regulations. Portions of the Transparency in Coverage Final Rule are not yet in effect but will be in January 2023 and 2024. Currently, all pharmaceutical transparency rules are on hold, potentially indefinitely.

As primary care physicians, it excites us to see Turquoise Health take on the important challenge of understanding prices in healthcare. Their recent partnership with Ribbon Health will add to the scale of this innovation. Empowering patients to become more informed in their care is an essential ingredient in driving a better primary care experience.

Price transparency in primary care