Lancaster Physician Spring 2021 - 23

SPRING 2021

on Equal Opportunity and former health
policy advisor to Mitt Romney, Rick Perry,
and Marco Rubio.

will have the opportunity to become more
informed about what they may pay for
hospital items and services.

By 1973, Medicare beneficiaries exceeded
23 million, and Congress shifted medical
billing oversight to insurers through the
HMO Act. When the government was the
sole source of payment for billed medical
expenses, billing departments had to agree
to declared payment rates-much like you
still do with the Centers for Medicare and
Medicaid Services (CMS). For the broader
market, being governed by insurers, it
became more economical for providers to
merge and negotiate. Health systems became
a way for health providers to negotiate fair
and equitable compensation for work. Outsourcing credentialing, billing, and coding
services to the health system began the
process of desensitizing physicians from the
cost of care. Higher pay for health systems
led to higher health insurance premiums.
This domino effect finally led to discussing
the Affordable Care Act in 2008.

WHAT DOES HOSPITAL PRICE
TRANSPARENCY ENTAIL?
Under the Federal Register, CMS states
" This final rule establishes requirements
for hospitals operating in the United States
to establish, update, and make public a list
of their standard charges for the items and
services they provide. These actions are
necessary to promote price transparency
in health care and public access to hospital
standard charges.

ACA FRACTURES
Forty-three years after the introduction
of Medicare and Medicaid, old solutions
(subsidies) were proving to die hard. With
the introduction of premium tax credits,
Congress decided to throw more money at
the problem instead of looking at the root
issue. The solution was to have the Treasury,
the Department of Labor, and CMS agree
to a new way to handle health care. The
system would tether eligibility for tax credits
to consumers' income.
Fast forward, and we see for 2019 the
Kaiser Family Foundation estimated
$52,330,619,948 in premium1 tax subsidies were paid out to help consumers
curb premiums for health insurance. The
2019 CMS Report2 cites operating costs
for Medicare, Medicaid, and CHIP to be
another $1,087,271,000,000!
NOW
The Hospital price transparency rule is
intended to support a more patient-driven
health care system by making prices for
services provided by all U.S. hospitals more
transparent for patients. As a result, patients

" By disclosing hospital standard charges,
we believe the public (including patients,
employers, clinicians, and other third parties)
will have the information necessary to make
more informed decisions about their care.
We believe the impact of these final policies
will help to increase market competition,
and ultimately drive down the cost of health
care services, making them more affordable
for all patients. "
WHAT ARE THE REQUIREMENTS
FOR HOSPITALS?
On November 27th, 2019 the final rule
required as of January 1st, 2021, the following needed to be in place:
Hospitals needed to make a machine-readable file available publicly on their website
for anyone to download. This file must be
public, meaning no request for it is necessary,
and it's on the public domain. Additionally,
it can't be held behind a login, which would
impede access.
Hospitals must provide a dashboard to
price out up to 300 services for consumers
to hypothetically " shop " common procedures
by hospital.
The intended benefit to hospitals will be
improved initial data collection, lower bad
debt, lower cost to collect payments, and
improved patient satisfaction and retention.

WHAT CAN CONSUMERS EXPECT?
Our four local hospitals in alphabetical
order can be found online at the links below:
BIT.LY/PRICEHERSHEY
BIT.LY/PRICELGH
BIT.LY/PRICEUPMC
BIT.LY/PRICEWELLSPAN
IT'S IMPORTANT TO NOTE
SEVERAL THINGS:
1. The estimates do not take into consideration surgical complications or other
miscellaneous expenses. With that said, this
is a great start for anticipating costs.
2. If you have chest pain, that is not the
time to window shop.
3. Consider both cost and quality when
it comes to your health. Use the sites above
and also Medicare.gov's Hospital Compare system (medicare.gov/care-compare/
?providerType=Hospital&redirect=true) for
information. This system is a move in the
right direction for patient-driven health care.
OTHER RULINGS
CMS Rx Public Use Files - As of January
1st, 2021, CMS has made public files for
companies to access Medicare Rx costs by
drug, insurer, and pharmacy for real world
pricing. The hope is that the same will
happen for patients under 65.
CMS Interoperability and Patient Access
Ruling (March 9th, 2020) - This rule gives
consumers remote access to aggregate all their
health care data (health and claims history)
IF they want it regardless of insurance plan
or provider system.
Surprise Bill Act (December 27th, 2020)
For Consumers: Beginning January
1, 2022, it will be illegal for providers to
bill patients for more than the in-network
cost-sharing for (nearly all) scenarios in
which surprise bills arise. Ever go into the
hospital and find out a radiologist or anesthesiologist is actually billed separately or
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LANCASTER

23

PHYSICIAN


https://www.bit.ly/PriceHershey https://www.bit.ly/PriceLGH https://www.bit.ly/PriceUPMC https://www.bit.ly/PriceWellspan https://www.medicare.gov/care-compare/?providerType=Hospital&redirect=true https://www.medicare.gov/care-compare/?providerType=Hospital&redirect=true

Lancaster Physician Spring 2021

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