Alec Stein wanted independent software developers to streamline health insurance data to determine what companies pay certain providers for certain services. Stein, data rewards officer at software company Dolthub, quickly ran into problems.

On July 1, health insurers published public, machine-readable files including the negotiated rates they pay to in-network providers and permitted rates to out-of-network providers. These trillions of rates require sophisticated software to analyze them and insurance companies don’t use standardized file formats, making comparisons of their reimbursement rates nearly impossible. Moreover, the requirement for insurance companies to update their data every month to keep it updated has the side effect of making it difficult for data analysts to assess information across the industry.

“Nobody appreciates the range of the data,” Stein said. He estimates that uncompressed data from the five largest health insurance companies dwarfs the amount of information held by the Library of Congress, English-language Wikipedia, and the entire Netflix catalog combined.

Other software developers have faced similar challenges dealing with this data, which health insurers recently revealed as part of a broader federal drive for price transparency. The organizers requested input on upcoming additional transparency requirements. But before officials begin issuing final guidance regarding advanced clarifications of benefits and other transparency requirements, insurers, developers and researchers are pressing the Centers for Medicare and Medicaid Services to clarify current regulations.

The Coverage Transparency Rule, which grew out of the Affordable Care Act, aims to highlight the long confidential rates that health insurers negotiate with individual providers, which can vary widely. Policymakers target providers, patients, and researchers — and the health insurance companies themselves — to use this information for their own purposes. Hospitals and other healthcare providers can determine how they are paid compared to their peers, patients can increase their insurance benefits by shopping for low-cost care, and researchers can analyze healthcare spending at a high level.

But these early difficulties in accessing and reviewing this data hinder the possibility of transparency to promote a more efficient healthcare system.

“There was a lot of hope that this data would really shed light on payer-provider contract negotiations, but we’re not there yet,” said Sabrina Corlett, associate director of the Center for Health Insurance Reforms at Georgetown University. “There is a tremendous amount of frustration. CMS really needs to rewrite the requirements here, or else it will not achieve the policy objectives set by management.”

Big data implications

The health insurance price transparency requirement complements the mandate of hospitals. But insurers are broadly complying, unlike health systems, which have been slow to stick to the rule. Within 100 days after the regulation went into effect, health insurers that cover 90% of commercial policyholders made their negotiated rates available to the public, according to Turquoise Health, a start-up that collects data to sell to insurers, providers and researchers.

“We’ve really seen the biggest carriers release important data. The implications for the amount of new pricing data are pretty significant,” said Chris Severn, CEO of Turquoise Health. However, insurers have produced a lot of information that will take five years to be useful to patients. , According to him.

a lot of good

The files released by health insurance companies are too large for a typical PC to handle, said Michael Chernow, a health economist at Harvard Medical School who also chairs the Medicare Payments Advisory Committee. Chernio leads a Harvard team that aims to use the data to analyze price changes between insurance companies.

“We are talking about terabytes of data, not even gigabytes, we are at a higher level than normal claims databases, and they update the data every month,” Chernio said. “Even if you think you have a process to run, the way it’s deployed can change.”

Stein said that Humana’s pricing information, in particular, has caused problems for developers. The insurance company posted its information in a different file format than the CMS requires. He said the company also does not have enough server capacity to allow developers to download more than eight files at once.

“If I wanted someone to do the worst job possible that was technically compliant and contained all the information, Humana did it,” Stein said. “Perfectly legal, but totally annoying.”

Matthew Rubin, co-founder and chief technology officer of the startup, which helps small digital health companies negotiate with large insurers, said Serif Health had to lease multiple servers to accommodate all of the insurance data available.

Robin said Serif Health spent about two weeks working to download Humana’s full data set, compared to the few days it took to retrieve equivalent information from other insurance companies. He said Humana was also the only carrier that did not include the requested information on how rates differ for inpatient versus outpatient services.

Humana offers support via its website, where outside developers can submit questions and receive responses within a few days, a Humana spokesperson wrote in an email. When Stein tried to use this functionality to email the Humana developers, his request bounced back.

Across the industry, developers are struggling to work with insurers’ information.

Robin said that CVS Health’s Aetna lists multiple rates, with a large spread, for the exact same services and locations without any explanation as to why, or when different rates should apply. “I’d like to see CMS provide guidance that clears case payers like this,” he said. “If there’s some sort of tiered fee schedule in place, can we get more clarity on whether credentials, location, or some other discrimination drives the differences in published rates?”

Aetna files follow the format required by the Content Management System (CMS) and are not designed to act as a member cost estimator, a spokesperson wrote in an email.

Rubin said Elibility Health, formerly known as Anthem, has posted multiple redundant files without specifying whether the listed networks are local or represent a national reciprocity agreement between insurers Blue Cross and Blue Shield. Health did not respond to interview requests.

Rubin said the majority of insurance company files that list off-network rates are blank.

“As consumers of data, we’ve had to do a lot more engineering and adaptation than we initially thought to work with it. Perhaps more than CMS had hoped with regulation,” Robin said. “But that’s also the reality of the complexities of contracting.” He said the differences between insurance companies underscore the need for a CMS to host a single directory with prices listed in a standard format.

That would be ideal, Corlett said, but it’s unlikely. If the CMS stays with the current fragmented approach, it should standardize the insurance index you use to explain where to post information and how to search for certain services. Requiring insurers to adopt common file naming conventions, standardize codes associated with individual actions, and organize different services into separate subfolders would help researchers, she said. She said that requiring carriers to publish smaller files would expand public access to the data.

Corlett said making these changes would not require new regulations because the technical specifications required of insurers could simply be rewritten, but the agency would benefit from public input.

Insurance companies have invested a significant amount of time and money in complying with the price transparency policy. Sissy Connolly, president and CEO of the Community Health Plans Alliance, a trade group for nonprofit insurers, said a CMS should ensure patients can use this information before it adds more rules.

Next year, insurers will be required to disclose in-person costs for 500 shared covered services via online self-service tools. The following year, insurance companies will need to include personal information for all medical services. Ultimately, insurers may also need to disclose what they pay for prescription drugs, though the government has indefinitely postponed this requirement. Connolly said many provisions of the No Surprises Act and Transparency in Coverage overlap, so the CMS should work to align them and focus on how they benefit consumers.

“You’re kind of piling on the requirements here, and it’s not clear to us that that would be very consumer-friendly,” Connolly said. “It can be very stressful, and it can be repetitive.”

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