State law already requires hospitals to give patients estimates of their charges and any applicable uninsured discounts, the board noted. And nothing prevents doctors from discussing their billed charges or other estimates with their pa- tients, Dr. Carter says. The institute also recommended state agencies regularly report on the imple- mentation of Senate Bill 1731, passed by the legislature in 2007. The law already requires insurers to give their members cost estimates upon request. Other pro- visions designed to educate patients about their out-of-network obligations and help them avoid expensive bills are still under development. (See “Adequate to Inadequate,” pages 21–25.) Other suggestions included support for requirements that:
• Hospitals and other providers help patients and their insurers, as appli- cable, with preauthorization and re- view of proposed health care services;
• Hospitals and other providers supply, upon request by an uninsured patient or patient seeking an out-of-network service, a good faith estimate of pay- ment amounts for planned treatment, and do so within two to 10 days; and
• Insurers inform their policyholders of their right to request information about out-of-pocket costs, treatment outcomes, and less costly alternatives, and how different negotiated rates may impact patients’ costs.
The full report is available online at
www.ihcqe.org/ICHQE-Report-Novem ber.pdf.
M. Shannon Stansbury, Blue Cross and Blue Shield of Texas vice president for health care delivery, said in the re- port that the health plan supported SB 1731 and is already implementing it. He also served on the institute board and agreed with physicians that “the provi- sion of health care is highly individual- ized,” making price disclosure difficult. Doing so would not help consumers and would “violate legal and contractual requirements to keep negotiated rates confidential between health plans and providers,” Mr. Stansbury wrote. Health plans and physicians can
share that information with individual enrollees or other parties to the contract. But a 2011 study by the Govern- ment Accountability Office (
www.gao .gov/
new.items/d11791.pdf ) suggests that disclosing negotiated payment rates among competing physicians and health plans may violate federal anti- trust laws. Guidance from the Federal Trade Commission (FTC) and Depart- ment of Justice indicates exchanging price information could amount to col- lusion. The report affirmed that “several health care and legal factors may make it difficult for consumers to obtain price information for the health care services they receive … include[ing] the diffi-
culty of predicting health care services in advance, billing from multiple provid- ers, and the variety of insurance benefit structures.”
Some dissenters argue that such bar- riers could be overcome to allow such disclosures. For one, antitrust laws would come into play only if physicians and others communicate with each other about their individual prices, says board mem- ber attorney Ronald T. Luke, PhD, a health care consultant and director of the Texas Association of Business. He declined to comment for this story. In the report, Mr. Luke says the leg- islature could relieve other liability con-
No small task
In addition to health care pricing, the Texas Institute for Health Care Quality and Efficiency’s first legislative report addressed a host of recommendations likely to be the subject of ongoing debates on how to reform health care delivery in Texas. The report also included recommendations to:
• Collect and publicly report on a small, focused set of out- come measures with the long-term goal of building a robust, integrated health care information system;
• Hold off on pursuing an all-payer claims database that man- dates claims reporting by insurance carriers until there is progress on setting up an integrated data collection system;
• Promote efforts by health care delivery organizations, payers, clinicians, plans, employers, consumer-groups, and associa- tions to increase the availability of information on health care quality, costs to the consumer, outcomes of care, and safety;
• Require hospitals to publicly report potentially preventable Medicaid readmission and complication rates; and
• Comprehensively study consumer behaviors, preferences, and ways to maximize their use of health care information for development of a consumer-friendly website with informa- tion on state health care performance metrics and quality and cost-effectiveness resources.
March 2013 TEXAS MEDICINE 37
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