ELLY GRIMM
• Leader & Times
The need for more ease and transparency in healthcare costs has long been a hot topic and recently, some action has been taken to help with just that.
Andrew Mignatti. co-founder and CEO of careviso, said such action has been needed for a long time.
“There have been some new actions from the Departments of Labor, Health and Human Services, and Treasury set to help reshape health care price transparency across the U.S. The release of four major regulatory documents – targeting prescription drug price disclosures, technical standards for health plans, and hospital price posting requirements – signals a new era of federal enforcement and public accountability,” Mignatti said. “Recent federal guidance now requires hospitals to post actual, not estimated, prices for items and services, while health plans face new technical standards for publishing pricing data. At the same time, public feedback is being sought on how to strengthen compliance and ensure price data is accurate, complete, and actionable for patients. What we've done is build up a platform for diagnostics and specialty pharmacy built into a patient's medical benefits. What our platform will do is take the patient, identify the test or medication that patient is being prescribed, and from there is answered the question of who the billing entity. A lot of times, we work with diagnostic laboratories and those facilities, and we identify the billing entity, and then we look at the patient information and figure out if the patient is in or out of network with that individual provider, and if they are, we look at the patient's benefits and then grab the machine-readable file data and use that to give actual cost estimates.”
The more focused work with everything began in 2020, Mignatti said.
“We were providing services to patients out of pocket prior to building out the platform, and what that was, was us picking up the phone and calling insurance companies and talking to them on a patient's behalf in order to get that information,” Mignatti said. “That can be very, very challenging, and if the person on the other end of the call doesn't fully understand what you're asking, it can take a lot of extra time. There are many inherent issues when you have to get on the phone and actually call these places, so we ironically made the decision around April 2020 to build that out into a platform to be able to do that in real time. And it just happened the No Surprises Act was sitting on the House floor at the time, so it allowed us to get involved in the legislation and advocate on behalf of patients.”
One of the main goals of this work, Mignatti said, is ease and transparency for patients.
“Basically, we marry the patient's benefits with the actual reimbursement the insurance company has negotiated with the provider, and we then identify if prior authorization is required and covered under their medical policy, and then we provide that result to the lab or facility to deliver that information to the patient in real time,” Mignatti said. “We've been able to grab the machine-readable files – we started building this out in 2022 – and then we use that to really provide transparent results to the lab and/or patient side. On the prior authorization side, we've developed a workflow system where, if a PA is required, we'll go ahead and gather the information, submit it to the insurance company, get the information and then provide it to the provider.”
Mignatti added such transparency is important especially in modern times.
“We work primarily in genetic testing and specialty pharmaceuticals, which are very high-dollar items in healthcare. Genetic testing can range from $1,500 to $3,000, and drugs can cost hundreds of thousands of dollars,” Mignatti said. “As a patient going in and getting these procedures done, you don't have too much of an idea of what your insurance is going to cover and what YOUR final costs will be – you know you've paid your premiums, but you have the cost share portion in terms of co-insurance and deductibles and all of that. So you don't know if your total is going to be $1,000, $5,000 or $10,000. Before the No Surprises Act was passed, it was really hard to get that, because none of that data was transparent, so with that legislation and the laws that have come out, it allows that data to be available so the patient can, before they go in, understand how everything will be broken down. And the reason that's particularly pertinent now is because when they passed these laws in 2020, it forced everyone to do this in 2022. The reality is, the data the payers are putting on their Web sites is extremely complicated, and it's not necessarily something you can just download and take on the go.”
Mignatti also gave his thoughts on why it took so long for such action to finally happen.
“I think it's because the hospitals didn't want it to happen. At the end of the day, it's not to the hospitals' benefit to understand how they get paid and what the costs are, which I find odd,” Mignatti said. “For example, if I'm an uninsured patient, the hospital charges three to five times what Medicare reimburses to the insurance company, and then they get paid at some contractual rate. That markup is irrelevant to how I actually get paid. But if I'm uninsured and go into a hospital, I'm getting charged what they bill to the insurance company, which is nowhere near what they're actually getting paid. Without that transparency and understanding, uninsured patients especially could really suffer. All of that has to change, and this transparency is going to eventually drive that down to where the hospitals can't do all of that.”
Having such action in place should have several long-term benefits, Mignatti added.
“In the long term, I think this will help drive down costs because it's competitive. Three or four years ago, people didn't know what the insurance company was contracting with competitors as far as 'This is what X hospital is charging, I can go get the exact same procedure/service at Y hospital for half the cost,'” Mignatti said. “Patients didn't really know those things. In terms of general use and what we're doing, we're using it to give patients very transparent information as far as what X or Y procedure would cost as a certain facility. A lot of other companies are in the space of selling the data from one end to the other so they can look and maybe say 'We need to be more competitive in X market, so the price needs to come down.' In the long term, that's really valuable because there could be some sticker shock if you're taken to the hospital and you had zero idea of what prices were for one procedure or another. I feel like this will help, in the long term, drive down the cost of healthcare, though it will still take some time since the data is very complex and difficult to fully understand. The portion of the data we're getting from these machine-readable files is what we call medical data, and that means everything that's not a billing capsule on the pharmaceutical side. When you go to the pharmacy and get your prescription(s), that data – the PBNs – was not made available through the No Surprises Act, so this new legislation is forcing that issue. That's important because it's not always clear how pricing is done on the PBN side in terms of the contracted rate with the insurance and the rebates and everything else. That's still not entirely transparent yet, and this second iteration of this rule is really pushing that. When that comes out, I think people will see significant change because the cost of certain pharmaceuticals is really high, and it needs to come down, but people need to understand how they're getting paid, and that's just not clear.”
Mignatti added he feels the work has been successful so far.
“From my perspective, I think the legislation has been successful, and you see the insurance companies are complying with everything, though they could make certain aspects easier to navigate, and I think some extra enforcement would help there,” Mignatti said. “Where I think things have fallen somewhat is on the hospital side – hospitals are supposed to post this information on their Web sites so people can see, but there are several hospitals that haven't done so and they're not complying. CMS was initially not fining those facilities, which led the hospitals to ignore the rule, but I think with this second iteration, there will be more enforcement, which is needed. I think most of the payers have done what they're supposed to, but there's definitely work to be done on the hospital side.”
Overall, Mignatti said, patients’ needs must come first and foremost.
“The patient needs to be at the center of things like this so they can make sure they get the care they need at an affordable rate. I think this will definitely help with that, though it will probably take more time than people would like,” Mignatti said. “I also like how this legislation was a bipartisan effort, and I feel like there's the desire to see this be successful. From a prior authorization perspective, streamlining the process and making things more accessible for patients and providers is super valuable – today, you can submit a prior authorization to insurance, which would take a week or more to get a response back about. If they're committed to streamlining that process, creating that clearinghouse providers can come to for all those requests will make things much more efficient for the providers and provide better care. We are starting to see that with some providers, which is great.”
