Data Transparency
This week I am talking to Morgane Mouslim, PhD (@MorganeMouslim) a Policy analyst at the Hilltop Institute at the University of Maryland Baltimore County and Morgan Henderson, PhD, (@morghend) a Data Scientist at the Hilltop Institute at the University of Maryland Baltimore County (@UMBC).
Together with Sarah Kliff (@sarahkliff) and Josh Katz (@jshkatz) from the NY Times (@NYTimes) they they carried out a seminal piece of data research using data published by hospitals required by the recent regulations requiring data transparency. The article (Hospitals and Insurers Didn’t Want You to See These Prices. Here’s Why) was published in The Upshot (@UpshotNYT) featuring the details that were surprising and revealing.
Unambiguously Non-Compliant
Their work started with the regulations that announced price transparency was here – something that might have passed unnoticed thanks to all the focus on COVID19 and Pandemic issues. Their early work focused on finding compliant organization and there were quickly able to determine those that were
“Unambiguously non-compliant”
This is code for organizations that had not published any pricing information. The regulations were fought hard by many interested parties using most of the tactics in the book to fight the release of information and continue to this day with many hospitals still claiming it is very difficult to comply. As noted by Micky Tripathi the push by the regulatory bodies is not for “Minimal Viable Compliance”
Ohhh. @mickytripathi1 talks about not falling into the trap of “minimal viable compliance” with respect to info blocking rules. He implores hospitals and medical groups to not aim for lowest possible information sharing. #HLTH2021 pic.twitter.com/gpxkitgdsm
— Craig Joseph, MD (@CraigJoseph) October 19, 2021
The early work focused on 60-70 hospitals to identify the variation in pricing for everything from basic test like a simple pregnancy test:
- for Blue Cross patients in Pennsylvania $18
- for Blue Cross HMO patients in New Jersey $58
- for Blue Cross PPO patients in New Jersey $93
- and for cash paying patients with no insurance $10
to procedures such as Colonoscopies
At the University of Mississippi Medical Center
- Cigna plan $1,463
- Aetna plan $2,144
- With No Insurance $782
We discuss the source data and the “Charge master” and how that relates to pricing and the importance of the data in the analysis that now includes cash based payments that to now have rarely if ever been contained in ay economists healthcare research data
As we discuss this is only the beginning as they work for a better future for everyone that decreases healthcare prices even in some of the currently less competitive marketplaces. As they reveal there remains some validation of this data and confirming that the prices paid, cash or insurance based are the actual prices being paid and importantly if these prices paid are changing over time, especially in response to the price transparency regulations.
There are some additional changes from CMS which now requires hospitals to publish on their website a consumer-friendly list of prices for 300 shoppable services – generally, non-emergency services that patients can choose – in addition to an overall list of prices for every item and service the hospital provides.
Morgane and Morgan continue their work in this area and their focus in the coming months include a desire to see:
- Full compliance by every hospital covered by these regulations
- Full compliance with Insurers to new regulation expected in mid 2022 that demands the same level of transparency from insurers pricing, and
- Importance of Data Standardization across these datasets
Listen in to hear what Morgane and Morgan have seen regarding price transparency changes following the publication of their data analysis and report with some institutions now pulling back and publishing less data
Listen live at 4:00 AM, 12:00 Noon or 8:00 PM ET, Monday through Friday for the next week at HealthcareNOW Radio. After that, you can listen on demand (See podcast information below.) Join the conversation on Twitter at #TheIncrementalist.
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Raw Transcript
Nick van Terheyden
Today I’m delighted to be joined by Dr. Henderson. He is a data scientist at the Hilltop Institute at the University of Maryland, Baltimore campus. And Dr. Muslim. She is also at the Hilltop Institute at the University of Maryland, Baltimore County, but a policy analyst. Both of them have the same first name Morgan, slightly different spelling. So, for the purposes of this episode, we’re going to reference you both by your title, Dr. Henderson. Dr. Muslim, thanks for joining me today.
Morgane Mouslim
Thanks for having us.
Mogan Henderson
Thanks, Dr. Nick, appreciate being here.
Nick van Terheyden
So if you would, you both have a interesting background, it would help if you could share a little bit of the highlights of how you arrived at this point in your career. Before we get into the topic at hand,
Morgane Mouslim
Dr. Henderson Do you want to go first?
Mogan Henderson
Sure, love to. So I graduated from the University of Michigan with my PhD in Economics go blue in 2017. And I worked on economic history and health economics while I was there. And within economic history, I worked on very data intensive projects involving historical records. And so this actually gave me a really good background in processing large, unwieldy files that aren’t in Nice, clean spreadsheet form. So I graduated in 2017. I worked for a year at Amazon out in Seattle as an economist. And then I moved to the Hilltop Institute, where I currently am and where I’ve been for about three and a half years. And I work on a variety of projects, price, transparency, and hospitals being one but predictive modeling, policy evaluation, kind of the big grab bag, which speaks to the versatility of the organization.
Morgane Mouslim
Yeah, then I can go next. So I have a bit of an unusual background for health wellness services researcher. My doctorate is actually in veterinary medicine. I got that at Michigan State University. But even back then I was interested in public health. So I did one year in Seattle, where I worked with the King County Department. And then I did my training and Epidemiology at Johns Hopkins where I was supported by a postdoctoral fellowship in pharmaco, epidemiology and where I did a lot of pharmaco economics. So looking at affordability issues surrounding drugs, especially high cost drugs. And once I was done with that, since I have a longtime interest in affordability and low income population, I joined the Hilltop Institute, which does amazing work with Maryland Medicaid and vulnerable populations. And this is where I joined up with Dr. Hundreds and, and started to look at more of the economics issues, including this hospital price transparency that we’re going to talk about today.
Nick van Terheyden
Fantastic. So for those of you listening, we’ll link to the article that appeared in the New York Times that featured all of the work that you did, you essentially did a deep dive into the data that has essentially become available since the government issued regulations and said that hospitals had to share their I’m going to say price. I don’t think it’s cost information. I think it’s price for the purposes of this conversation. And your piece, which if you haven’t read it, go read it now before you listen to the rest of it was just, I can only describe it as mind blowing. The differences that you found across the country for basic, common procedures was astounding. Tell us a little bit about the work, if you would, how you got there. What were the steps to arriving at this? And I’ve got to ask how difficult was the data analysis? Dr. H.
Mogan Henderson
FD, Nick. Well, thanks very much for the kind words about the article and we certainly want to credit Sarah cliff and Josh Katz, who wrote the piece, and Dr. Muslim and I provided the data analysis and kind of data support. It was a it was a long journey, I would have to say. It began in January 2021, where I had heard of the price transparency regulation and because this was actually supposed to start in 2019, but hospitals were given a one year delay. And then there was the lawsuit. So this was kind of a long time coming. And starting in January 2021, I just wanted to look at the data. You know, I’m a data person, I love data, this is what I do for fun. And so for fun, and it sounds weird to say the start is a fun project. But for fun, I wanted to just download some data from big hospitals and just look at what their prices were. And so this quickly became a separate piece that Dr. Muslim and I actually worked on together, which came out in the Health Affairs blog in March. And we just found that large hospitals weren’t posting their data. They were posting some, but it was clearly in the phrase we used was unambiguously non compliant, because you can’t really tell when our hospitals being perfectly compliant, but you can tell pretty well when it’s being non compliant. So so that was our first look was not, what is the prices and what’s the variation, but which hospitals are actually posting data. And so that led us to create a database of about 60-70 hospitals, within about the top 125 or so largest hospitals by bed count. And so we created this internal database, basically, downloading a bunch of huge spreadsheets. And we realized, hey, we have this really interesting tool here, where true, we can look at compliance. And we did, but we could also dive deeper, we could actually look into the data to see, hey, how much is this hospital charging for colonoscopy to Aetna, united, to Blue Cross Blue Shield, etc, etc. And so we got in touch with Upshot, and they got back in touch with us. And so we linked up with Sarah and Josh, at the New York Times, and, and just started working together to pull together some clean data on these the handful of procedures that that we wanted to collectively look at. And so the data analysis itself was honestly very straightforward. It was just counting stuff it that and that’s the kind of state of the world right now, where, before this regulation came out, the public didn’t know how much Aetna Student plan or whatever, Aetna charged a certain hospital for the or I’m sorry, how much they paid a certain hospital for a certain procedure. And now we know and so it was basically a summarizing process rather than a hardcore data analysis process.
Morgane Mouslim
Yeah, and, um, what’s interesting, and what I’d like to add is that hospital pricing is actually very complicated and very complex. And I’m sure a lot of people have heard of this. But if they haven’t, I’m going to briefly mention it. Hospitals have something that’s called a charge master, which is a list price. So it’s, it’s similar to when you’re buying a car, and it has, you know, this list price or this sticker price that you’re not necessarily going to pay, but that’s what is out there. And so in the hospital world, that’s the charge master, and that had been public for about a year in some states longer. And what this new regulation really changed is that we no longer just have this charge master price, which actually has the moderate amount of value. And we move towards getting these negotiated rates. So what a plan a specific insurer, and a specific plan is paying because just because you have been knighted, you don’t necessarily know what you’re paying, what kind of plan are you are you united PTO, or United EPO, and depending on that, you’ll get a different rate. And what we also got with this regulation is something called a discounted cash price. So if you are patient and you’re either uninsured or under insured, meaning maybe you’re out of network or you’re in a high deductible plan, you’re also typically not going to pay this charge master price you’re gonna pay a discounted price. And now these hospitals were required to post these. And to me, all of this was just incredibly interesting because this is the first time that nationally and not at a state level you were going to be able to delve deeper into what people in insurers were actually paying for health. Federal Services.
Nick van Terheyden
So, you know, great points there. I think in AI, I’ve got to say I’m surprised to hear you say it was easy, not least of all because there’s a degree of obfuscation and I love your sort of term of unambiguously non compliant. I’m definitely going to add that to my vocabulary. I think that makes entire sense. If you’re unambiguously non compliant, you should now be being fined I think, is the current circumstance. But making Tripathi talked about this recently, and he said, you know, please, institution stop being minimally viably compliant. And what he was referencing was the obfuscation of this data. And the fact that you said you could compare it, I imagine, and certainly some of the data that I’ve seen suggests that, you know, and let’s pick an example because you reference this in your data. And you know, the commentary, you talk about this cash price for people that are paying cash, actually lower than the price negotiated by a huge insurance company, let’s pick a colonoscopy from from the report, University of Mississippi Medical Center. 1463 was Cigna. 2144, at Aetna, and 782. With no insurance was a cash prize. So I’m paying less if I just say, No, I’m not using any of that we just completely blows my mind, I can’t even begin to understand a pricing model that works that way. And I know this is early data, but you’ve probably had the most experience with it. Tell us a little bit about how this unfolded and how you see all of that.
Morgane Mouslim
Dr. Muslim? Yeah, I think that. So yes, this was a huge, it’s still huge, because for the longest time, we didn’t know that these cash prices are these people that were paying cash were necessarily paying less than the people with insurance. And there were a couple reports, some in the Wall Street Journal, some in the LA Times, that said, Listen, I went to the hospital, I didn’t charge my insurance. And my bill is actually lower than I would have paid with my insurance. But up till now, this wasn’t known as a wide scale phenomenon. And then when we looked at the data, that’s when we started to see, wait a minute, these hospitals do give significant discounts to people who pay cash. And this seems to be pretty widespread. And then and Dr. Henderson is an economist, I’m sure will have much more to add to this. This is an interesting phenomenon where you’re seeing, okay, I’m a patient, I don’t have someone to negotiate with me. And yet, I’m getting a pretty steep discount off of the charge master price. And then there’s these big insurers that theoretically have a huge negotiating power. And yet, they’re not getting the same level of discount. And I’m actually going to turn it over to Dr. Henderson because I can see in his eye that he has so much to add.
Nick van Terheyden
So for those of you just joining, I’m Dr. Nick the incrementalist and today I’m talking to Dr. Henderson, and Dr. Muslim, they are both at the Hilltop Institute, we were just talking about the variation in pricing. And the fact that you discovered that this cash price was a lower value than that negotiated by the insurance. I have to believe that the insurance ago wait what? Dr. Henderson?
Mogan Henderson
Yeah. Thanks, Nick. That was definitely extremely interesting. As Dr. Muslim noted, there, I believe there could be anecdotal reporting about how you can get a lower cash price if you don’t pay through your insurance and instead pay cash and and I think there’s even some startup companies devoted to this concept. But But with this new data with this hospital standard charge data, we can actually see this systematically. And I want to say for the first time because and this is the thing that more Doctor most of them and I usually stress Pash pay patients do not show up in claims based datasets. This is what almost all hospital pricing research so far has used claims based data sets, usually within a large commercial data warehouse, like the health care cost Institute, which is which is great data. But these cash pay patients are effectively invisible. And so I didn’t I don’t know of any systematic research that that tries to look at this difference between cash pay price and negotiated rates. And you know, we’re just scratching the surface with this, I strongly believe that.
Nick van Terheyden
So I have to believe that this is going to drive down costs. Is that a reasonable assumption? Do you think that we’re going to see more affordable care? We haven’t seen much of it yet, I don’t think but it is still early days. But this seems like a seminal piece of data and the opportunity for research, Dr. Anderson,
Mogan Henderson
I really hope so. But I don’t think this is going to be the silver bullet to to the the rising hospital costs we have been seeing over the past 1015 years. In principle, it’s true. If a hospital is in a competitive market, and is competing against other hospitals, or patients, then certainly these hospitals should happen, it should now have more of an incentive to compete on price. In principle, I’m saying in principle. Now, this may not be true for hospitals that don’t have competitors in the market. It may not be true for hospitals that are competing on quality, or they’re kind of their own brand. And so I hope it’s going to lead to cost reductions. CMS certainly hopes it’s going to lead to cost reductions. But I think it’s too early to tell.
Nick van Terheyden
I mean, I’m thinking that this is going to be part of the opportunity for additional phone research here, where as we look to make healthcare more affordable, there is no one silver bullet. But now you’ve got this additional layer of data. Do you think that the value proposition that we’re now receiving as a result of this a has to be proven out? I mean, that I have to believe Dr. Muslim, that this is part of your future research is to say, Okay, we got this, do we see any change? And you gotta keep doing this? And you go, please tell me you’re expanding the database beyond 60?
Morgane Mouslim
Yes, so we are definitely, this is just the beginning, as Dr. Henderson said, so this is also just the beginning of the research. And, actually, so we did a big piece in the beginning about compliance. But we did not set out at first look at whether hospitals were compliant, we were hoping that they weren’t compliant. And we were hoping to jump straight into, okay, are these is this regulation, lowering health care costs. Which is why, though, I’m still optimistic, it is a little bit of a challenge. If hospitals do not comply with this regulation, it is going to be hard to systematically assess whether it’s working. And it’s also going to be hard for the regulation to do anything, you need data to get effects. So that’s going to be your guess, rate limiting step right here. Um, I also want to point out that it’s been a litigious process, I won’t go on too much about it. But this is something that is still quite controversial, um, between the hospitals and CMS, so that’s ongoing. As far as the research side of it, definitely interested to see where this is going to go, the challenge is going to be that this public data gets regularly updated by hospitals. But there’s, it’s hard to say when it’s updated, so you have to keep checking websites to see when this data becomes available. And so in research we like to do before and after, and it’s hard to sometimes determine the before and after when these things get continuously updated. Um, and so that’s on top of the compliance issue. But we are hoping to see some good results. Some states have put in price Transparency Regulations earlier than 2021. And are reporting some early positive results. So definitely stay tuned.
Nick van Terheyden
I think, you know, big citing because I’m with you without data, you can’t improve anything, we’ve got more data, that’s a good thing. You bring up an interesting point that I hadn’t even thought about until recently. So if they publish the data, how do we know that it’s accurate? I mean, did you have any assessment so you you look at that and say, This is what they say they’re charging. And you know, that’s important, because going forward that comparison of you know, do we see any changes? Couldn’t you just leave it and say, Well, this is it we published it? You know, that there’s tell us a little bit about why do you think this is going Dr. Muslim?
Morgane Mouslim
That has been actually our area of research current How do we validate this data? How exactly like you said, how do we know that these prices are actually correct. And we’ve been talking to other academics in this field actually about, for example, the cash price, which has gotten a lot of attention. And a lot of feedback that we’ve been getting is okay, how do you know that these patients that come to the hospital and say that they’re going to pay cash are actually getting the cash price? And, yes, till now, there’s not a very good way to validate it, which is something Dr. Henderson I are working on, is can we use other data such as IRS reporting or utilization data from hospitals to try and take that standard charge data that hospitals are posting and validate it? Is it correct? Is it what hospitals are actually charging patients and insurers?
Nick van Terheyden
So I think, extremely exciting times lots going on? Dr. Henderson, if you think about the future, if you had a wish, you know, what would you like? I’m not going to say institutions to do but you know, in terms of the data, what will be helpful in all this, because ultimately, that we’re all working together towards the same goal, which is, you know, affordable health care that is economically viable? What would really help you? And where do you see your research going?
Mogan Henderson
Gosh, that’s a good question. I would hope for three things, I would hope for full compliance among every hospital that is supposed to be complying with this regulation. So that’s one, I would hope for full compliance with the insurer price transparency regulation, which is a new regulation slated to begin mid 2022, where insurers are going to have to post public standard charge datasets, the equivalent datasets. And in an ideal world, there would be standardization and centralization of these disparate data sets, because, you know, like we mentioned earlier in the program, a large part of assembling this database was just collecting, pulling down, downloading, cleaning, synthesizing, assembling these essential spreadsheets from 6070 different hospitals, these were in different formats, the variables are called different things. And that was a very kind of mundane, but very real challenge to working with this data, you you, it doesn’t come with a nice data documentation codebook, like a lot of other datasets do. So it has been difficult to work with. And so if I had a if I had a wish, it would be for those three things. Now, I have to say, from what Dr. Muslim and I have observed, some hospitals that weren’t posting data, as of January 2021, are now posting more data it looks like, but we’ve also observed the reverse, where some hospitals that were posting big spreadsheets with names of Payers are now not posting them. Yeah, so that was very surprising when we learned that.
Nick van Terheyden
Wow. And in the remaining time, Dr. Muslim, what would your hopes for the future be?
Morgane Mouslim
I hope is really again, like Dr. Henderson said, compliance and ease of use right now, even with complying hospitals, this data is not easy to use for patients. So if I’m a patient who wants to price shop, it would be very difficult for me to do so. I’m hoping that this will change in the future, and this will effectively lower healthcare costs.
Nick van Terheyden
I concur. 100%. Unfortunately, as usual, we’ve run out of time, it just remains for me to thank you, I think on on a basic level for actually taking this task on achieving what you’ve managed to do, I think, you know, completely seminal piece of both data study and interpretation, and also the data processing to bring that so the normalization of that data, I can only imagine based on the limited data sets that I’ve seen, I think we all owe you a debt of gratitude. And I’m excited to watch and listen to this journey and hopefully, hear of you know, from you on an ongoing basis, there’s a part of me that wants to talk to you every year and hear your annual report. Maybe you don’t want to do that I can understand but I just have to say that this is extraordinarily valuable. really delighted and I’m I’m just so pleased that you are willing to come on the show and share some of the experiences. It’s been a true pleasure. Dr. Henderson, Dr. Muslim, thanks for joining me today.
Morgane Mouslim
Thank you so much for having us and talking to you.
Mogan Henderson
Thank you very much, Dr. Nick. The high end rising healthcare costs is I think a concern for all of us and I think it’s going to take all of us to find a solution to this
