"From our perspective, transparency seems to be a one-way street," said Craig Becker, president of the Tennessee Hospital Association. He added that in today's increasingly "pay-for-performance" environment, providers are expected to post everything from charges to outcomes. However, payers … for the most part … have not reciprocated with their own data.

 

"Hospital charges don't mean a whole lot unless you know what your insurance actually pays and what your charge is," noted Becker. "To me, it's like 'suggested manufacturer's retail price.' You have to know what the payer pays, what the discount is and what your part is."

 

Although somewhat useful for those with no insurance, posting charges has its limits even within this subgroup. Those who qualify for charity care will have one set of fees, and those who are completely on their own must try to negotiate a rate with the provider without any real sense of what third-party payers typically reimburse.

 

Becker said for maximum impact, consumers and businesses need to have a much clearer picture of negotiated rates and out-of-pocket costs.

 

"My understanding is that BlueCross is coming up with a Web site to allow you to do that … and that's a good thing. That is something I think all insurers should do –– to let their insured know what they actually pay," he continued. He added that BlueCross BlueShield of Tennessee, as the largest commercial payer in the state, has taken a leadership role in two-way transparency. "Hopefully, they will drive the rest of the market," Becker added.

 

While most businesses would never purchase supplies or sign a vendor agreement without knowing the true costs or allotment of funds for services, healthcare remains an area where money is handed over without any real understanding of how it is allocated.

 

"It would be nice if businesses knew how much of their premium is going to providers, and how much is being held by the insurers," he said, adding that the THA has faced this dilemma. "As a small business company, I can't find out from my insurer what my experience was the past year … how much they paid out in medical claims for all my employees." Becker continued that to negotiate the best rate, it would be extremely beneficial to know his organization's experience rating. "It makes it very difficult to shop around."

 

Becker added that most carriers consider that information to be proprietary and to be competitive information so they don't want to make it public. However, he continued, "The Obama Administration certainly feels transparency is the way to go. If transparency is good for us (providers) … and we think it is … then it's got to be good for the other players," Becker said.

 

THA & Transparency

The THA isn't opposed to payments being tied to quality and outcomes. However, Becker said the underlying concern remains whether the expectations are reasonable and evidence-based or simply a way to squeeze more money out of the system by paying providers less. Again, he pointed out, quality care transparency should be a two-way street.

 

"I definitely think they (payers) need to say what their denial rates are. Right now we have a situation with a TennCare insurer who is denying payment inappropriately. You can't expect providers to stay hitched to that insurer," he said, adding both providers and consumers have a right to know how payers stack up against each other in terms of approving or denying care.

 

Ultimately, Becker concluded, transparency by all stakeholders should level the playing field. "I think we all realize there is going to be less money in the system, but we all have to take the hit," he said.