Policy & Regulation News

Providers Oppose ONC’s Healthcare Price Transparency Strategy

Major provider groups opposed ONC’s proposal to increase healthcare price transparency by including pricing information as part of new information blocking rules.

Healthcare price transparency and the Office of the National Coordinator for Health Information Technology (ONC)

Source: Getty Images

By Jacqueline LaPointe

- The devil is in the details according to major provider and payer groups commenting on strategies to promote healthcare price transparency in a proposed rule from the Office of the National Coordinator for Health Information Technology (ONC).

Proposed in February 2019, the rule titled “21st Century Cures Act: Interoperability, Information Blocking, and the ONC Health IT Certification Program” largely put forth rules governing interoperability and information blocking.

But within the 187-page proposed rule, ONC also included potential healthcare price transparency rules that would designate pricing information as electronic health information (EHI), meaning providers would face penalties for failing to share the information.

The agency explained that it has “a unique role in setting the stage for such future actions by establishing the framework to prevent the blocking of price information.”

However, major provider groups disagreed.

READ MORE: Going Above and Beyond the CMS Hospital Price Transparency Rule

In comments to the ONC, the American Hospital Association (AHA) applauded the push for healthcare price transparency, but argued that the ONC’s interpretation of what should be included in the definition of EHI goes beyond what Congress intended when creating information blocking rules in the 21st Century Cures Act.

“ONC lacks authority to include price information – a term it leaves undefined – in the definition of EHI for purposes of determining what constitutes information blocking,” wrote Thomas P. Nickels, AHA executive vice president.

The Healthcare Financial Management Association’s (HFMA) president and CEO Joseph J. Fifer, FHFMA, CPA also argued in a recent comment letter that the proposed rule’s definitional focus on the individual bars ONC from requiring the public disclosure of reimbursement rates negotiated by private payers and providers.

In the proposed rule, ONC asked stakeholders to comment on whether a provider’s negotiated rates for all plans and rates for the uninsured should be made available on public websites.

In addition to legal concerns, providers also raised concerns about the appropriateness of subjecting providers to information blocking penalties if they fail to share pricing information.

READ MORE: How Practices Can Benefit from Healthcare Price Transparency

Providers do not have robust enough pricing information to fully comply with proposed information blocking rules, AMGA explained.

“Providers are not the source of information regarding the individual benefit structure for patients and oftentimes do not know the financial responsibility of the patient until after the service has been provided. This information rests with payers,” wrote Jerry Penso, MD, MBA, AMGA president and CEO. “Payers should work to educate their members on the costs they may face when they receive a service. Because payers have all necessary financial data related to the patient, the focus should be placed on individual insurers to make pricing information available.”

Additionally, the proposed inclusion of pricing information in EHI unfairly holds providers accountable, the American Medical Association (AMA) stated.

“The AMA fully supports price transparency. However, we believe that defining EHI to include various types of price information and then holding physicians and other entities accountable under the information blocking provisions is inappropriate because this pricing information is generally held and controlled by health plans. These plans are not subject to the information blocking provisions and therefore do not have the same incentives to share information,” the association wrote.

The association also strongly opposed the proposal to use Medicare reimbursement rates as reference prices for patients.

READ MORE: Healthcare Price Transparency in NH Reduced Out-of-Pocket Costs

“Medicare payment rates do not reflect the costs of providing care, especially in the commercial market where the population varies greatly,” the association’s comments stated.

The AMA advised ONC to employ a non-profit entity, like FAIR Health, which already has information available to set reference prices at a level that reflects current market conditions and give consumers the ability to search for in- and out-of-network care. The entity should review reference prices annually and adjust prices based on changes in market conditions.

Provider groups were not the only stakeholders criticizing the fine print. The nation’s leading payer group, America’s Health Insurance Plans (AHIP), also opposed the ONC’s strategy for advancing healthcare price transparency.

“Shoehorning prospective price estimates in the definition of EHI in order to include it within information blocking is not substantiated by the underlying legal authority,” wrote Matthew Eyles, AHIP president and CEO. “HIPAA addresses availability of retrospectively provided service information to consumers and does not require prospective estimates be offered. The 21st Century Cures law provisions on interoperability focus on sharing information included in the clinical record. We do not believe ONC has the authority to mandate prospective pricing estimates as part of EHI.”

The payer group also urged ONC to consider the unintended consequences that publicizing negotiated rates would have on competition and existing private-sector efforts to provide consumers with price transparency.

ONC closed the proposed rule’s comment period on June 3 and is currently reviewing stakeholder feedback before finalizing the rule. The agency did not indicate when it expects to release a final rule.