Only two states, Maine and Massa- chusetts, received an overall passing “B” grade. That’s largely because they have so-called “all-payer claims databases,” a single, public state repository of claims processed by public and private payers that includes information on charges, payments, and services across providers. To lawmakers in those two states,
however, such existing reforms — which date back to 2003 in Maine, for example — apparently weren’t enough when they pursued newer 2014 laws, medical soci- ety officials said. The report card did not include the later measures. The Texas IHCQE also explored all- payer claims databases and found they mostly benefitted employers and third- party administrators shopping for a bar- gain on payment rates among health practitioners, not patients shopping for individualized health care, Dr. Carter notes.
TMA’s Council on Legislation also wants to make sure any approaches to price transparency are compatible with future alternative payment models, like bundled payments, Dr. Floyd adds. The physicians also caution broad price disclosures, if not carefully crafted, could backfire and lead to higher costs. Again, they highlighted Medicare as an example of what could go wrong. “Medicare is the most transparent price system we have. It covers tens of millions of patients. Fees have gone down for years, and yet the total cost of Medicare is not going down,” Dr. Carter said. “And do we really want pa- tients and physicians to be arguing over whether a test is needed or not, based on cost? To me, that’s a barrier in my ability to take care of my patients. What we want is a balanced approach.”
Workgroup to develop standard prior authorization form
Physicians are one step closer to a day when they don’t have to deal with hun- dreds of different prior authorization
forms from multiple payers. In late March, Texas Department of Insurance (TDI) Commissioner Julia Rathgeber ap- pointed a committee of health care pro- fessionals, which includes several Texas Medical Association members, to advise her on the technical, operational, and practical aspects of developing a stan- dardized form for medical services. Senate Bill 1216 by Sen. Kevin Eltife (R-Tyler) and Rep. Sarah Davis (R-Hous-
Know your price
Price transparency is likely here to stay, and TMA’s Council on Legislation is exploring options that ensure the state pursues only approaches that are meaningful for patients and feasible for physicians. Still, “physicians should realize that it’s very possible they
could be required to post their billed charges for at least a subset of services they provide,” council member Patrick Carter, MD, says. Physicians also should understand that their standard charg-
es are a “real” number, TMA officials say. “Your charge is your price, and there could be consequences for creating confusion around that number,” said Donna Kinney, director of research and data analysis in TMA’s Division of Medical Economics. For example:
• State law prohibits physicians from using variations in charg- es to discriminate against payers;
• Insurers and government payers typically pay the lesser of physicians’ billed charges or the payer’s allowed amounts; and
All articles in Texas Medicine that mention Texas Medical Association’s stance on state legislation are defined as “legislative advertising,” according to Texas Govt. Code Ann. §305.027. That law requires disclosure of the name and address of the person who contracts with the printer to publish the legislative advertising in Texas Medicine: Louis J. Goodman, PhD, Executive Vice President, TMA, 401 W. 15th St., Austin, TX 78701.
• State regulators often assess prompt-pay penalties based on those charges.
And as long as physicians do not get together to discuss
their fees or contract rates, antitrust rules do not prohibit physi- cians from posting their individual charges, TMA Vice President for Medical Economics Lee Spangler clarifies.
July 2014 TEXAS MEDICINE 41
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