Insurer price transparency data vex developers

Alec Stein wanted to organize independent software developers to analyze health insurance data to determine what companies were paying specific providers for particular services. Stein, a data bounty administrator at software company Dolthub, soon ran into trouble.

On July 1, mutuals machine-readable published public files including the negotiated prices they pay to in-network providers and the permitted rates for out-of-network providers. These trillions of awards require sophisticated software to analyze, and insurers don’t use standardized file formats, making it nearly impossible to compare their reimbursement rates. Additionally, the requirement for insurance companies to update their data every month to keep it current has the side effect of making it difficult for data analysts to assess information across the industry.

“Nobody appreciates the scope of the data,” Stein said. Uncompressed data from the five largest health insurance companies dwarfs the amount of information held by the Library of Congress, English Wikipedia and the entire Netflix catalog combined, he estimated.

Other software developers have encountered similar challenges working with this data, which health insurance companies recently disclosed as part of a broader federal campaign for price transparency. Regulators have asked for comment on additional upcoming transparency requirements. But before authorities begin to issue final guidelines regarding the advanced explanations of benefits and other transparency requirements, insurers, developers and researchers are lobbying the Centers for Medicare and Medicaid Services for clarification on existing regulations.

The transparency in coverage rule, which emerged from the Affordable Care Act, aims to shed light on the long-secret rates that health insurance companies negotiate with individual providers, which can vary widely. Policymakers intended that providers, patients, researchers — and health insurers themselves — use this information for their own purposes. Hospitals and other healthcare providers could determine how they are paid relative to their peers, patients could maximize their insurance benefits by shopping for lower-cost care, and researchers could analyze healthcare spending at a high level.

But these early difficulties in accessing and reviewing this data hamper the potential for transparency to promote a more effective health system.

“There was a lot of hope that this data would really shine a light on these payor-provider contract negotiations, but we’re just not there yet,” said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at the Georgetown University. “There’s just an incredible amount of frustration. CMS really needs to rewrite the requirements here, otherwise it will never achieve the policy goals set by the administration.

Big Implications for Big Data

The requirement for transparency in health insurance prices complements the mandate of hospitals. But insurers largely comply, unlike health systems, which have lagged to follow the rule. Within 100 days of the regulations taking effect, health insurers covering 90% of commercial policyholders had made their negotiated rates public, according to Turquoise Health, a startup aggregating data for sell to insurers, service providers and researchers.

“We have really seen the biggest carriers release important data. The implications of the amount of new price data are quite significant,” said Turquoise Health CEO Chris Severn. However, insurers have produced so much information that it will take five years for it to be useful to patients, he said.

Too much of a good thing

The files that health insurance companies have released are so large that a typical personal computer can’t handle them, said Michael Chernew, a health economist at Harvard Medical School who also chairs the Medicare Payment Advisory Commission. Chernew leads a Harvard team that aims to use the data to analyze price variations between insurers.

“We’re talking about terabytes of data, not even gigabytes, we’re one level above normal claims databases, and they refresh the data every month,” Chernew said. “Even if you thought you had a process to go through it, the way it’s released may change.”

Humana’s pricing information, in particular, has caused problems for developers, Stein said. The insurer has published its information in a different file format than that required by CMS. The company also doesn’t have enough server capacity to allow developers to upload more than eight files at a time, he said.

“If you wanted someone to do the worst job possible that was technically compliant and contained all the information, Humana did it,” Stein said. “Absolutely legal, but completely boring.”

Serif Health had to lease multiple servers to house all of the insurance data available, said Matthew Robben, co-founder and chief technology officer of the startup, which helps small digital health companies negotiate with large insurers.

Serif Health spent about two weeks downloading the full dataset from Humana, compared to the few days it took to retrieve the equivalent information from other insurers, Robben said. Humana was also the only carrier that failed to include required information on the difference between inpatient and outpatient service rates, he said.

Humana offers support through its website, where outside developers can submit questions and receive answers within days, a spokesperson wrote in an email. When Stein tried to use this feature to email the Humana developers, his request bounced.

Across the industry, developers struggle to work with information from insurers.

CVS Health’s Aetna lists multiple prices, with significant scatter, for the exact same services and sites with no explanation why, or when, different prices should apply, Robben said. “I would like to see CMS offer some clarifying advice to payers for cases like this,” he said. “If there is some kind of tiered fee schedule, can we be more clear about whether it is a title, location, or some other distinction that drives the differences in the displayed rates?”

Aetna’s files follow the format required by CMS and were not designed to serve as an estimator of member costs, a spokesperson wrote in an email.

Elevance Health, formerly Anthem, posted several repetitive and redundant files without specifying whether the networks listed are local or represent the nationwide reciprocal agreement between insurers Blue Cross and Blue Shield, Robben said. Elevance Health did not respond to interview requests.

The majority of insurers’ records listing out-of-network rates are empty, Robben said.

“As consumers of data, we had to do a lot more engineering and adaptation than we originally thought to work with. Probably more than CMS was hoping for with the settlement,” Robben said. There’s also the reality of contract complexity.” The differences between insurers underscore the need for CMS to host a single directory with rates listed in a standard format, he said.

That would be ideal, but unlikely, Corlette said. If CMS maintains the current fragmented approach, it should standardize the index used by insurers to explain where information is published and how to search for specific services. Requiring insurers to adopt common file naming conventions, standardize codes associated with individual procedures and organize different services into separate subfolders would help researchers, she said. And requiring carriers to release smaller files would expand public access to data, she said.

Making these changes wouldn’t require new regulations because it might simply rewrite the technical specifications required of insurers, but the agency would benefit from public input, Corlette said.

Insurers have invested a lot of time and money to comply with the price transparency policy. CMS should make sure patients can use this information before adding more rules, said Ceci Connolly, president and CEO of the Alliance of Community Health Plans, a trade group for nonprofit insurers. .

Next year, insurers will be required to disclose disbursements for 500 common services covered through online self-service tools. Next year, insurance companies will have to include personalized information for all medical services. Eventually, insurers may also have to disclose what they pay for prescription drugs, although the government has postponed this requirement indefinitely. Many of them law without surprise and coverage transparency provisions overlap, so CMS should work to align them and focus on how they will benefit consumers, Connolly said.

“You’re sort of piling up the requirements here, and it’s not clear to us that it’s going to be very user-friendly,” Connolly said. “It could be very heavy and it could duplicate work.”

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