Editorial: Follow through on promise of medical price clarity

By The Herald Editorial Board

The last few weeks have made clear — tragically so following the high-profile murder of an insurance executive and the misguided support expressed by many for the alleged assailant — that Americans remain frustrated with issues of access and expense regarding their health care.

Even as the number of uninsured Americans between the ages of birth to 64 years of age has reached new lows thanks to the Affordable Care Act — dropping from 46.5 million in 2010 to 25.3 million in 2022 — complaints persist regarding access to that care, even for those with coverage; the lack of timely availability of providers; delays and denials of payment for care and the costs of that care.

Efforts in recent years by Congress and presidential administrations have attempted to address lagging deficiencies, notably with agency rules and laws that are supposed to provide price transparency for hospital procedures and services, and end surprise medical billing, which relies on clear pricing.

But full compliance with those mandates, at least in terms of price transparency, remains a work in progress.

Patient Rights Advocate, a nonprofit, nonpartisan organization focused on price transparency, last month released its most recent report on hospitals’ compliance with providing clear explanations of prices for medical procedures and services. Of some 6,120 U.S. hospitals, PRA reviewed data and reports from about 2,000 hospitals and found that only 21 percent were in full compliance with the rule administered by the federal Centers for Medicare & Medicaid Services, actually declining from a compliance rate of 34 percent in February of this year.

“I think most disappointingly is that the hospitals now are obfuscating,” said Cynthia Fisher, founder and chairman of PRA, in an interview this week. “Clearly the compliance rate has declined in access to prices, and the completion of the prices and the naming of plans are now substantially deficient compared to where they were six months ago,” she said.

The advocacy group’s report also looked at hospitals in Washington state and found what was among the nation’s lowest compliance rates, with just two of 32 hospitals fully complying with the federal price transparency law, one in Olympia and another in Pullman.

As it had nationwide, compliance with the transparency law fell in Washington state, which was at 34 percent as recently as February, but had dropped to just 6 percent in the most recent report in November.

There is some disagreement regarding compliance rates. A federal report of transparency compliance by the inspector general for the U.S. Department of Health and Human Services looked at a smaller sample of 100 hospitals nationwide and found that 63 were in compliance, against 37 that were not.

Of hospitals in Snohomish County, Swedish Edmonds and both campuses of Providence Regional Medical Center Everett were not fully compliant, the PRA report found; all three satisfied requirements for all but one metric, providing accurate or complete information for what’s called “machine-readable files.”

Fisher explained that those files list prices for all procedures and services in a spreadsheet format that can be used by a developer to build a website or phone app that would list that information for patients to allow for easier comparison of prices offered by different providers.

“You could use Google, and ask ‘What’s the price of a colonoscopy with this plan,” and then compare it to other prices at X, Y and Z hospitals,” she said. The lack of complete or accurate machine-readable files was the most common failing for all hospitals in the state.

Providence, which operates 16 hospitals in the state reviewed by PRA, does offer a price estimate website for MyChart patients, including those at its Everett hospitals and at Swedish Edmonds.

CMS, which administers the transparency regulations, had required all U.S. hospitals to post machine-readable files by July 1, 2024, but until Jan. 1, 2025, the agency is allowing hospitals to post percentages and algorithms instead of dollars-and-cents figures.

But even when those algorithms were provided, Fisher said, the association’s technical staff had difficulty in many cases converting the data to a format that could be easily reviewed by patients.

The American Hospital Association, which represents hospitals and health care networks, says the hospitals it represents are working toward compliance but that the nature of hospital pricing and rate negotiations doesn’t easily translate as a fixed rate for many services and requires a significant investment in hospital staff time and resources.

Fisher faults the Biden administration, under pressure from the medical care industry, for relaxing standards and timelines for compliance with the transparency law. CMS, by law, has authority to issue fines of up to $2 million for noncompliance, she said; but as of April 2023, the agency had imposed civil fines against only 13 hospitals, three of which were fined more than $800,000.

Noting that the rule-making for the transparency law began during the end of the first Trump administration, which had started with more stringent requirements, Fisher is optimistic that the incoming administration — assuming that Dr. Mehmet Oz is confirmed as head of CMS —will refocus the effort.

“Oz has a great opportunity to affect real prices in health care by enforcing the law and by making it very clear that we all need financial certainty in dollars-and-cents prices,” she said.

There remains support in both chambers of Congress for the laws, though Fisher lamented the loss of Washington state Rep. Cathy McMorris Rodgers, the Republican who represented the state’s 5th district and was a leader for the transparency and surprise billing laws. McMorris Rodgers is leaving Congress at the end of this month.

But there’s also an opportunity for states to provide further enforcement.

Both Colorado and Ohio have passed laws that mirror the federal transparency rule; Washington state has the opportunity to do the same, she said.

Lawmakers and officials, at state and national levels, should be taking the temperature of the public now regarding these issues in particular for access and the costs of health care in general.

Correcting the lack of clarity on prices and the inability to make easy comparisons, Fisher said, was the intent of the laws. Efforts should now be made to follow through on those promise to patients to allow them to make decisions based on quality of care, location and price.

“Tell me, what market do you go to buy a car or anything, where you have to do complex math?” Fisher said.