Texas Department of Insurance held a meeting to discuss health price transparency as it relates to legislation passed in the 80th Legislative Session.
Background:
SB 1731, enacted in the 80th Texas Legislature, provides consumers new rights to health care price transparency. TDI is working to accomplish this goal and connect consumers to meaningful information on health care prices and develop resources to help consumers make educated health care purchasing decisions.
Current Scope of Services:
- Intended to help both insured and uninsured consumers:
- Plan for health costs
- Benchmark for comparing price estimates
- Negotiate discounts or balance bills
- Choose between insurance plan designers (lower premiums vs. lower deductibles)
- Mainly driven by volume and cost; the previous approach didn’t necessarily target our ideal consumer—the commercially insured
- Focused on individual codes rather than treatment events
Revised Scope of Services:
- Looked at 8 states’ websites to determine what data is available in other states and identified important data points, then incorporated useful data points to help our consumers
- Review best practices, prioritize common services for the target population, and focus on procedures that allow for planning and choice
Proposed Scope of Services:
- Office Visits: check-ups, well-woman exams, physician care, and specialist consults for new and existing patients
- Imaging: MRIs and CT scans with and without contrast; digital and analog mammograms
- Facility Outpatient: vasectomy, hernia repair, knee and shoulder arthroscopy, endoscopy, tonsillectomy, spirometry
- Inpatient: bariatric surgery, stomach esophageal and duodenal procedure, cardiac, angioplasty, coronary bypass, c-section and vaginal delivery, hysterectomy, hip and knee replacements, back surgery
- Public Comment:
- An out-of-network Allowed Amount reflects variation in methodology
- If you’re averaging allowed amounts and charges that creates issues
- Pathology- with outpatient contracting issues some carriers have a national contract on outpatient pathology and that inhibits inpatient contracts
Data Issues:
- Averaging data produces only one data point per issuer
- Unable to report estimated range/amount of variability
- Unable to identify outliers—causes skewed data
- Inpatient and facility outpatient procedures don’t reflect full cost
- Facility outpatient CPTs don’t include full cost of care
- Inpatient DRGs are no used by all payers
- Six-month reporting period limits the number of data points
- Averaging at the regional level limits ability to reflect market-specific rates
- Public Comment:
- Would like to know if the DRG code-books are up to date
Data Recommendations:
- Collect data on median and quartiles to reflect variability and avoid influence of outliers
- Update data collection form to include units of service, place of service, and modifiers
- Group cost components into treatment events to give consumers a complete picture of the costs
- Develop more detailed instructions for reporting inpatient and outpatient procedure cost components
- Extend data reporting period to 12 months
- Collect data by 3-digit zip code, rather than 11 regions
Proposed Data Fields:
- Proposed data to collect for each code, in-network and out-of-network
- Number of unique claim IDs billed and allowed
- Number units of service billed and allowed
- Total amount billed and allowed
- Median amount billed and allowed
- Variation in billed and allowed (e.g. quartiles)
- TDI would calculate a weighted average
- Average billed and allowed
- Median billed and allowed
- Variation in billed and allowed
Consumer Display:
- Proposing to no longer show amount paid to provider
- Are in favor of Virginia Model’s Average table for Allowed Amounts for possible services associated with certain procedures, but dislike the bar graph
- The proposed display would implement a range with a median marker and compare Region data with Statewide data
Public Comment:
- Possibly include a link to Medicare data
Next Step:
- Assemble a technical working group for input and testing
- Draft amendments to reflect changes in data collection approach
- Solicit input on informal draft in the Spring of 2015
- Develop a rule proposal in the summer of 2015
Proposed Rule Changes:
- Considered changes to rule at 28 TAC Chapter 21, Subchapter KK
- Modify reporting period from 6 months to 1 year
- Collect data by 3-digit zip code, rather than 11 health care regions
- For applicable companies move cut-off from 10,000 lives (in HMO or PPO) to 20,000 lives (per NAIC Supplemental Health Care Exhibit)
- Consider excluding HMO claims
- Specify procedures on which data will be collected
- Specify data fields on which data will be collected
- Allow users to use a third party to process claims data in specified format
- TDI is attempting to assemble a technical group to assist with these changes by the end of November