| The Trump administration on Monday is finalizing a revamp of the rules that require health insurers publish the prices they negotiate with doctors and hospitals, officials at the Centers for Medicare and Medicaid Services tell me. The final rule comes from the CMS, in conjunction with agencies at the Labor Department and the Treasury Department, and updates the transparency in coverage, or TiC, requirements. The data dumps associated with the rules have been so sprawling and messy that even sophisticated researchers struggle to use them — something the update aims to fix. Under the current rules, insurers and most employer-sponsored health plans post monthly files listing in-network rates, out-of-network payments and drug prices. In practice, the files are packed with “ghost rates” — the term for prices for services a provider would (likely) never perform, such as a podiatrist delivering a baby. The rules move to quarterly reporting, while streamlining the files and making the data more standardized and usable. Why it matters: For the Trump administration, its work on price transparency is foundational to its health care agenda. The transparency rules, which originate from President Donald Trump’s first term, are intended to make the massive trove of data involving insurance rates more accessible, standardized, and useful for researchers and employers that purchase coverage for their workers. The administration says the rule changes will save plans about $174.5 million annually beginning in the second year of the rules, partially attributable to the quarterly (instead of monthly) reporting change. The idea behind the rule update is to give employers better data for coverage decisions, researchers a clearer view of health care markets and developers better data to build their price transparency platforms on, regulators say. “Greater transparency drives competition, reduces price disparities and helps lower healthcare costs,” CMS Administrator Mehmet Oz said in a statement. → However: the rule — which comes as Congress is also trying to codify bipartisan price-transparency requirements — could leave some of the key questions about the data unresolved. Let’s go through it. WHAT’S CHANGING Dollars and cents The rules finalize a requirement that in-network rates generally be reported in dollars, while allowing an exception for contracts that pay providers based on a percentage of their billed charges. This has been a priority for groups such as Consumers First, a coalition of patient, provider and employer groups led by Families USA. But the rule appears to not go as far as those groups may have hoped. For contracts based on a percentage of billed charges, Consumers First urged regulators to require insurers to also “post a historical average price in addition to the percentage.” CMS officials tell me that the dollars-and-cents requirement would apply to “the vast majority of items and services.” Accountability and attestation The rule adds a brand-new element that would put a person’s name behind the pricing data, which hadn’t been in the proposal but was supported by employer, health policy, and patient groups. Insurers and health plans will now have to certify that their published information is accurate and complete, in addition to identifying a CEO, president, or other senior executive responsible for making sure it is. Several comment letters said that this would discourage noncompliance and align it with the transparency rules for hospitals. Ghost rates Regulators and researchers have argued that the current files can be enormous because insurers often publish rates for provider-service combinations that aren’t realistically going to be used. The Trump administration is now allowing plans and insurers to exclude those unlikely provider-service combinations, which has been broadly supported as a way to reduce the amount of junk figures in the files. To decide what gets excluded, insurers can use the in-house methods they already use when processing claims. But insurers have to explain what data they’re deleting. → Checks and balances: Those explanations will be part of the new “taxonomy file” requirement in the final rule that maps out the internal criteria insurers used to make decisions about which provider-service combinations to leave out. Insurers will also have to post a utilization file showing which providers were paid for at least one covered service during the most recent year of claims data available — which CMS officials tell me will help users of the data cross-reference the in-network data files for accuracy. Out-of-network file changes The rule finalizes a proposal to lower the threshold for reporting an out-of-network allowed amount from 20 claims to 11 claims. It also expands the reporting window from 90 days to six months and requires insurers to aggregate the data by insurance market. Aggregating the out-of-network data by market — large group, small group, individual and self-insured — could make it easier to compare prices within similar coverage markets. Regulators say that the changes “will significantly increase the amount of out-of-network data disclosed to the public.” In a comment letter about the proposal, AHIP worried that lowering the claims threshold could pose a potential privacy risk. Meanwhile, PatientRightsAdvocate.org, an advocacy group pushing for tougher price-transparency rules, wanted regulators to go much further, and argued for a threshold of one claim to make more of the underlying price data public. Fewer files, less duplication Under the new rules, plans will report the negotiated rates by provider network rather than by individual plan or policy. Because multiple plans often use the same networks and rates, CMS says the change should reduce the number and size of the files insurers have to publish. Many commenters agreed, including Consumers First and the American Medical Association, which said in a comment letter that the change would also “better align with how hospital price transparency data is reported, which will facilitate easier comparisons between payer and hospital price files.” In a fact sheet about the rule, regulators say that alignment is what drove the decision, noting that harmonizing “payer and hospital data reporting” would, among other things, “improve consistency.” WHAT’S MISSING Change history dropped Regulators didn’t finalize the proposed change log that would show users what changed from one quarterly in-network rate file to the next — after insurers claimed that it would be too burdensome, while potentially not providing much value. Several groups, including Families USA, labor-management health fund 32BJ Health Fund and Arnold Ventures, supported the change log. Instead of downloading two enormous files and comparing them, a researcher could look at the change log and identify the rates that actually changed. Insurer group AHIP said in a comment that the log would “create a significant new operational burden” for health plans, pointing out that “without clear reporting guardrails, a renegotiated contract with a hospital system could result in thousands of entries in a change log for a relatively minor modification.” No volume or enrollment data The final rule also leaves out some of the context the administration had explored whether to add. Insurers won’t have to report how many claims a provider submitted, how often a particular service was used or how many people were covered by each plan. The proposed rule suggested including enrollment data in the in-network rate files that would have shown how many people were covered by each plan. This could have given researchers, employers and others a sense of how broadly a particular negotiated rate applied. This could allow users to understand which negotiated rates affect the most people and compare plans with similar coverage. Regulators decided that requiring disclosures of enrollment data went beyond the scope of the rulemaking, which is meant to focus on pricing, according to a CMS official. Separately, the administration asked in the proposed rule whether additional volume data would be useful. The idea was to show which providers handle the most services and how often their negotiated rates are actually used — giving users a better sense of which prices matter in the real world. But the administration also acknowledged that collecting the data could be difficult or burdensome for insurers to comply. WHAT’S NEXT Implementation Regulators have moved up the implementation timeline from the proposed 12 months: Changes to the data files already outlined in current rules kick in five months after publication, and the new files created by the update — including so-called taxonomy files — must be implemented by early next September. Upcoming drug transparency rules The final rule does not add new requirements for prescription drug price files, which would bolster existing transparency requirements. In the proposed rule, regulators noted that these would be handled separately. A CMS official tells me that the agency plans to begin developing the prescription drug reporting requirements in November, which will use the 2020 and 2026 TiC rules as a foundation. The data blueprint — known as a schema — is expected by next May, and enforcement is projected to begin in December. The delay is, in part, because these files are more complex, agency officials say. The White House is draining roughly $2 billion from a Medicare fund that lawmakers had expected to use to offset the cost of federal health programs, and redirecting the money to checks for more than 20 million older Americans. It’s an unexpected move that threatens to upend end-of-year congressional negotiations. Trump announced on Saturday that most Medicare Part B enrollees will receive a $90 payment this month — weeks before crucial midterm elections that could shift the balance of power in Congress. My WaPo colleague Dan Diamond has the details about the announcement, which he reports has caught congressional offices in both parties by surprise. → The money comes from the Medicare Improvement Fund, which was created in 2008 to improve Medicare’s hospital and medical insurance programs. Instead, Congress has repeatedly used the fund as part of broader budget deals. Why it matters: A GOP congressional aide told Dan that the move could complicate negotiations over health extenders — such as reupping federal funding for community health centers and several special diabetes programs — in any year-end legislative package. The maneuver could also potentially prompt lawmakers to delay some of Trump’s nominations, the staffer said. The White House said the payments represent Trump’s belief that the fund “should be used to directly help people on Medicare, not special interests.” Democrats, including Sen. Ron Wyden (Oregon), the top Democrat on the Senate Finance Committee, referred to Trump’s announcement as a political stunt. Read the full story: “Trump announces plan to send $90 payments to millions of seniors.” “FDA found cyclospora at Taylor Farms Mexico site and where lettuce was grown,” reports The Post’s Lena H. Sun. “Trump reveals Tom Cotton’s phone number in daylight saving time standoff,” The Post’s Dan Diamond reports. “White House monitors suspected plague outbreak in Russia,” Alex Isenstadt reports at Axios. “GE HealthCare to Buy Sofie for Nearly $1 Billion to Grow Medical-Imaging Business,” reports Peter Loftus at the Wall Street Journal.
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