Headline Heavy: Surprise Medical Bills, Transparency and Interoperability in Healthcare

The negative impacts of rising healthcare costs and the concern over data ownership certainly aren’t new topics of discussion. But as policymakers have increased their focus in these areas (transparency and interoperability), the steady stream of news has turned into a fast-moving series of waves leaving people wondering what changes will actually come as a result.


Stories about surprise medical bills always grab my attention. Last year, Vox ran an in-depth series called “I read 1,182 emergency room bills this year. Here’s what I learned.” It focused on where many of the most stunning surprise bill situations occur – the Emergency Room. These stories shed light on widely varying prices, lack of transparency and interoperability, and people being held responsible for “out of network” charges for seeking urgent care that they couldn’t have possibly planned for. What often makes the headlines here are the unbelievable charges for over the counter medications, supplies or simple treatments – $60 for an ibuprofen, $5,751 for an ice pack (no other treatment) or $629 for a Band-Aid.

A recent article by Kaiser Health News, “Surprise Medical Bills Are Driving People Into Debt: Will Congress Act To Stop Them?” provides a good overview of how politicians are framing and legislating the issue.

Our own consumer research found that 53 percent of consumers have received a surprise medical bill and we’re taking part in the conversation as policymakers consider regulatory changes to lower costs and increase protection for consumers. In fact, we’ve recently been able to meet with senate committees and staffers to share how we support our health plan clients’ efforts related to price transparency.


rain covered windowI’ll start with this: the cost of healthcare impacts all of us and the assumption that health insurance companies don’t support price transparency is inaccurate. For many years, health plans have been working with companies like ours to share cost information with their members. In our case, we use claims data and analytics to identify billing and pricing patterns to predict how much services will cost members as they plan to see healthcare providers available to them. We then show personalized out-of-pocket cost estimates based on an individual member’s benefit design and deductible status. Other important decision-making criteria such as quality scores and patient reviews can be layered on as well to help people find the best healthcare available.

Our cost estimate tools are available to tens of millions of health plan members across the country. Once you include other transparency tools offered today, there are many more millions of people who can access cost estimates through their health plan websites. The problem is that many people don’t know about them or use them.

Our research shows that even when these tools are available, less than half of consumers (46%) don’t know that they have access to cost estimation tools that would help them search for providers and see their service costs. Yet 67% of respondents said they wish they had more control over their healthcare costs.

For hospitals, the move toward price transparency is growing but there is still major work to be done. A price transparency rule took effect at the beginning of this year, but many hospitals are meeting the requirements by posting generic “list” prices, which aren’t based on what the consumer may actually be responsible for. For price transparency to be meaningful, information must be actionable and individualized so that it closely represents the actual costs. This blog by The Commonwealth Fund does a nice job of explaining this complex issue (and offers some good suggestions).

With all the work that’s been done by health plans to share out-of-pocket cost estimates, one idea for improving the information on hospital websites is to extend the reach of the payer data. By using APIs and security measures to enable authentication, a hospital could allow patients to select their own insurance plan and immediately display the same out-of-pocket estimates they have access to via their health plan’s website. It would certainly take work to get all the payers in a hospital’s service area to provide this data, but it’s not unrealistic.


Data powers insight – and in healthcare that means saving lives, delivering better care and reducing waste. But currently healthcare data is siloed – preventing key stakeholders from easily sharing information – even with their own members or patients.

Earlier this year, the U.S. Department of Health and Human Services proposed new rules related to the interoperability of healthcare data. The rules will place expectations on the industry to meet several transparency and interoperability requirements including; providing APIs for provider directories, providing consumers with direct access to their claims data online, and potentially deliver cost transparency.

While we wait for these rules to be finalized, we’re working to make sure we can support our health plan clients with APIs and new features. This is one step but the industry needs more, and our work doesn’t stop there. We want people to feel empowered to take charge of their healthcare, save money and get the care they need and we will continue to support interoperability initiatives in healthcare.

We believe federal standards for transparency and interoperability are, all told, a net positive. A well-defined playing field will be easier for health plans, providers and app developers to invest in and remove traditional barriers for innovation and collaboration. This effort can spur systemic improvements to help real people with problems like surprise bills, access to data, care coordination, etc. We look forward to these rules being finalized, and for HealthSparq to evolve and continue to serve our health plan clients and their millions of members.