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New health insurance “transparency data” looks suspiciously wrong

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Re: New health insurance “transparency data” looks suspiciously wrong

#141

Post by lelanthran »

Timon3 wrote: post #137
lelanthran wrote: post #134

Earlier quoted context omitted.

> It also doesn’t help that the private system is incentivised to undermine the ‘free’ system at every turn. By competing on ... what? Can't be price (because "free" wins). The only other option is competing on quality. Your statement doesn't sound correct.

Competition isn't the only way for a private system to have influence on a non-private system. You understand that, right?

> Competition isn't the only way for a private system to have influence on a non-private system. You understand that, right?

I already asked what the ways are; why are you replying saying there are ways?

I literally asked "In what ways?" and you are replying "handwaving There Are Ways" ...

Re: New health insurance “transparency data” looks suspiciously wrong

#142

Post by Timon3 »

lelanthran wrote: post #141
Timon3 wrote: post #137

Earlier quoted context omitted.

Competition isn't the only way for a private system to have influence on a non-private system. You understand that, right?

> Competition isn't the only way for a private system to have influence on a non-private system. You understand that, right? I already asked what the ways are; why are you replying saying there are ways? I literally asked "In what ways?" and you are replying " handwaving There Are Ways" ...

No, you did not. You specified that you're only looking at competition, and then replied to yourself that there isn't anything else.

In case you really can't imagine alternatives: what if the private system spreads lies about the non-private system? What if they use their influence to change laws and regulations to prefer their system? What if they use their influence to make others with influence treat those using the non-private system worse?

None of these are competition in the sense you're asking for, and yet they are a natural consequence of private incentives.

Re: New health insurance “transparency data” looks suspiciously wrong

#143

Post by phkahler »

ethbr0 wrote: post #77
candiddevmike wrote: post #3

Everyone assumed there would be malicious compliance here but it's definitely eye opening just how malicious they made it. Speaks volumes for the perceived risk releasing this data, IMO. Still waiting to hear about someone using this data to negotiate down a hospital bill, seems like it's just insurance companies that can weaponize this data for better rates.

> but it's definitely eye opening just how malicious they made it As someone familiar with insurer, provider, and facility IT systems, I'd offer an alternate explanation -- the data is bad because healthcare IT is understaffed (and often incompetent). These are businesses that have squeezed most costs out, and IT is definitely a cost. Imagine banking... if there were much less competitive pressure and an inability to…

>> These are businesses that have squeezed most costs out, and IT is definitely a cost.

What's the cost of an X-ray? Did you know they used to do a FREE X-ray at the shoe store back in the day to check fit? Yeah, don't tell me they squeezed out most of the cost.

Re: New health insurance “transparency data” looks suspiciously wrong

#144

Post by phkahler »

jcrawfordor wrote: post #130
walnutclosefarm wrote: post #83

Earlier quoted context omitted.

I'm pretty sure the truth is a mix of malicious compliance and inability, but I'd weight it heavily in favor of malicious compliance, especially for the insurance data. Insurers know their costs, and when and why they pay specific charges. (My qualifications to make this statement: 15 years in healthcare IT, including UHG/Optum, and 8 years as CTO of a large clinical organization that included primary through tertiar…

I'm not so confident from my experience in healthcare IT, admittedly shorter than yours. One of the issues seems very telling, the fact that one of the listed rates from the insurer matched the portion paid to the radiologist but not the total. Problems with matching up different line items are really ubiquitous in healthcare systems because, despite the standardization that theoretically exists, there's huge variati…

>> Problems with matching up different line items are really ubiquitous in healthcare systems because, despite the standardization that theoretically exists, there's huge variation in how different accounting and analytics systems represent line items.

Maybe the problem IS the line items. You know the labor cost of tracking the fact a person was given Tylenol is way more than the cost of the pill? Just give people the incidentals and stop billing for them. Half your overhead might vanish.

BTW, yes every medication need to go on their chart. But it does not need to go through the entire finance system and to insurance.

Re: New health insurance “transparency data” looks suspiciously wrong

#145

Post by Vvector »

phkahler wrote: post #143
ethbr0 wrote: post #77

Earlier quoted context omitted.

> but it's definitely eye opening just how malicious they made it As someone familiar with insurer, provider, and facility IT systems, I'd offer an alternate explanation -- the data is bad because healthcare IT is understaffed (and often incompetent). These are businesses that have squeezed most costs out, and IT is definitely a cost. Imagine banking... if there were much less competitive pressure and an inability to…

>> These are businesses that have squeezed most costs out, and IT is definitely a cost. What's the cost of an X-ray? Did you know they used to do a FREE X-ray at the shoe store back in the day to check fit? Yeah, don't tell me they squeezed out most of the cost.

cost =/= price

Re: New health insurance “transparency data” looks suspiciously wrong

#146

Post by sl-dolt »

logicallee wrote: post #43

I've asked the author for a copy of a correct csv or xlsx file, I'll share it if the author responds. https://imgur.com/a/bTmfDEU

I'm the author. Publishing my reply to you (as I understood your question):

> No one can produce the corrected/missing rates but the insurance companies themselves. All we can do is point out when we’ve found rates/patterns that don’t make sense. E.g. https://github.com/CMSgov/price-transparency-guide/discussio...

Re: New health insurance “transparency data” looks suspiciously wrong

#147

Post by sl-dolt »

aintgonnatakeit wrote: post #10

There are two problems here: 1) Hanlon’s razor 2) The author doesn’t understand health insurance data. I’m not trying to excuse the other bad behavior, but within the data itself, he’s experiencing a combination of health insurers’ incompetence, the kludged up data models they’ve had to build to represent the output of the multiple generations of claims processing systems and other administrative processes, and the g…

I'm the author.

Take an example like this https://github.com/CMSgov/price-transparency-guide/discussio...

I don't know how closely you've worked with this data -- you clearly have some kind of expertise -- but how do you explain this?

The insurance companies had 18 months to talk to the CMS and ask for a better data model. If they're not able to explain how much things cost with 5 different negotiated types -- negotiated, percentage, derived, fee schedule, and capitation -- then they should have asked for another one.

The hospital and insurance rates are both fee-for-service base rates for items billed individually. If there's some nuance in interpreting how "fee for service" "dollar amount negotiated" goes, definitely write to me and let me know. I talked with experts in healthcare pricing before I published this.

You can write to me at alec@dolthub.com if you wanna hit me with more questions.

Re: New health insurance “transparency data” looks suspiciously wrong

#148

Post by sl-dolt »

aintgonnatakeit wrote: post #85
yunohn wrote: post #15

Earlier quoted context omitted.

But the given examples are basic procedures like “wrist x-ray” or “endoscopy”. Surely they have simpler rate calculations than the potential special cases you mention?

Let’s do wrist x-ray and keep it simple. I’m sure I’ll mess up the formatting here. When you get an x-ray, you would expect to see 3 claims (again, simplifying). —— One is the x-ray tech taking the picture. That gets a professional claim with a CPT code and is straightforward. —- One is the interpretation by a radiologist of the imaging. That is a professional claim with a CPT and a modifier. —- The last depends on t…

I'm the author. When I write articles I have to make a choice: make them readable by the public, or detailed enough to satisfy the experts. I try to strike a balance, but I can't have both.

Please take a look at the CMS Price Transparency Guide https://github.com/CMSgov/price-transparency-guide and familiarize yourself with the schema. You can also take a look at the federal ruling: https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-...

The metadata you're talking about is specified in the files themselves. I've limited my search to fee-for-service (non-capitated, non-derived, non-bundled) institutional claims.

You can write to me if you have more questions. alec@dolthub.com

Re: New health insurance “transparency data” looks suspiciously wrong

#149

Post by sl-dolt »

ElijahLynn wrote: post #16

This paragraph is missing the link at the end: At DoltHub, where we build databases like codebases, we're running a data bounty, collecting rates for popular medical procedures for all US hospitals. Then we'll release the data under CC. Find out more here.

Thanks. Will fix that.

Re: New health insurance “transparency data” looks suspiciously wrong

#150

Post by sl-dolt »

Spivak wrote: post #106

This could have been much much easier if they just required the medical equivalent of certificate transparency. Every insurance company is required to post publicly every single claim they receive, the full information of the provider(s), the name/code of the plan, the billing codes, whether it was approved or denied, how much the insurance was billed, and how much insurance actually paid (where paid doesn't mean dis…

Completely agree. There are databases like this out there (All-Payer-Claims database) but they're extremely expensive (it would cost millions to get data for the entire US) and I have no idea why.
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