Brian Klepper
Last week Anna Wilde Mathews at the Wall Street Journal published a nice piece that detailed the difficulties employers and consumers have getting meaningful health care data from health plans. As the article describes, that lock has been pried loose a little as a result of competition from health care data vendors like Castlight, Thomson Reuters and Healthcare Blue Book.
The health plans, particularly, are loathe to release any data that might reveal their pricing arrangements with providers, and they’ve used the protection of this proprietary information to justify continued data opacity, even though that information could be helpful to their employer clients and members as they try to cost-effectively negotiate the labyrinthine health care system.
We’re in a regulatory environment that has been neutralized, shaped largely by the organizations that would be regulated, and which, if it promotes transparency at all, does so grudgingly and with hurdles. Witness the open letter to Don Berwick, MD, CMS’ Administrator, by Bruce Boissonnault, the savvy, experienced CEO of the Niagara Quality Care Coalition in New York, decrying the tremendous barriers CMS has established that thwart organizations trying to access and analyze Medicare data.
Meanwhile, legacy health care organizations that work to maintain artificially high cost through protectionist maneuvers are really creating market vacuums that, in economically stressed times like the present, are highly susceptible to attack. We see this in the efforts of the health care data firms, and in my own onsite clinic/medical management sector, where we’re driving down cost significantly at the expense of the status quo. In the absence of public policy that is in the common interest, the market may not be as capable as we’d like, but it can sometimes be effective.
In other words, change is inevitable here, and soon.
Care And Cost 
Health systems that have created oligopolies in their market are also reticent to share pricing information for fear of being seen as completely uncompetitive in the marketplace. If pricing information were transparent is would foster competition and competition would lead to lower prices which health systems would abhor. Its one way that these large systems are able to attract and pay for the myriad of physician practices that they are buying left and right. As it stands now a large healthcare system can offer a physician a 25-30% raise in reimbursement almost overnight by simply billing under the system’s tax id versus the practice’s tax id while operational costs basically stay the same (or in some cases even decrease due to hospital subsidies). As it stands right now, the lack of pricing transparency creates a perverse system as large systems use opacity and their leverage in the market to keep prices high while small, independent practices get hammered on reimbursement by payers. Compare that to the rest of the world where large organizations have to use their economies of scale and scope to undercut the market on pricing in order to maintain or increase market share. Transparency isn’t the only answer to our healthcare woes but it is certainly one of the answers. Its time employers and patients demand it and payers begin stripping the language that prevents disclosure from their contracts.
Insurers and providers falsely advocate 1) disclosing provider data is somehow a HIPAA/privacy issue and 2) they “own” the data since their data formats are proprietary, therefore all data contained in their formats are their property. We may next hear insurers claim ownership of all symbols on keyboards since they use keyboards to input data.
Employers engage insurers to perform an administrative function; “work for hire” in legal terms. Insurers (ok let’s use the correct vernacular, third party administrators aka TPAs aka processing vendors) don’t “own” their customers’ data any more than banks “own” their customers’ money.
And yet CMS has done its best to prevent consumer access to the data needed by employers and employees to make informed decisions. Don’t believe it ? Visit http://www.npdb-hipdb.hrsa.gov/ the web site for the HHS/CMS sanctioned “National Practioner Health Integrity and Protection” organization aka The Data Bank. The first FAQ is:
Q: Is Data Bank information available to the public?
A: No. The Data Bank is prohibited by law from disclosing information on a specific practitioner, provider, or supplier to the general public. However, there is statistical data available to the public that does not identify individuals. See About Statistical Data for more information. You may also request information in a form that does not identify any particular health care organization or practitioner for research purposes.
So there you have it. HHS/CMS making health care transparency for consumers a crime. Our government needs to foster and empower transparency through private sector initiatives–not outlaw it.
Let the transparency companies unleash the power of market forces with full transparency through INDEPENDENT, OBJECTIVE organizations like Castlight and Monocle Health Data.
Darkness protects evil and HHS/CMS is now a co-conspirator in protecting poor performing providers at the expense–and health–of taxpaying consumers.
Michael Cadger, CEO
Monocle Health Data THE Healthcare Price & Quality Transparency Solution for Employers and Providers
mcadger@monoclehealth.com
404 630 8980