Background: Some consumers have experienced difficulty getting an estimate for health care costs in advance of receiving services that is valuable in calculating possible out-of-pocket expenses or comparing choices of health care providers or facilities. Information on charges for common services is becoming more available; however, the data displaying charges does not incorporate the insurance coverage a consumer may have.

To assist with transparency, the Washington State Hospital Association developed a hospital database with information on charges and utilization for each hospital and common procedures. The database is searchable and allows comparisons of facilities. In 2013 the Centers for Medicare and Medicaid Services (CMS) released data that displays hospital average charges for the 100 most common Medicare claims, and in January 2014, CMS released data on provider charges for 30 common outpatient services.

The Washington Health Alliance, formerly the Puget Sound Health Alliance, has been working to produce health care data on cost and quality that will help inform purchasers. The most recent release of their report Community Checkup with data on quality of care, includes county-level results for the entire state.

Summary of Engrossed Substitute Bill: Health insurance carriers offering benefit plans on or after January 1, 2016, must offer member transparency tools with certain price and quality information to enable the member to make treatment decisions based on cost, quality, and patient experience.

The transparency tools must aim for best practices and include the following:

a display of cost data for common treatments for the following categories: in-patient treatments, outpatient treatments, diagnostic treatments, and office visits;
a display of the cost for prescription medications on the member website or through a link to the third party that manages the prescription benefits is encouraged;
a patient review option or method for members to provide a rating or feedback on their experience with the medical provider;
an option to allow people to access the estimated costs on a portable electronic device;
a display of the estimated cost of the treatment and the estimated out-of-pocket costs for the member, with a display of personalized benefits such as the deductible and cost sharing;
a display of quality information on providers when available; and
a display of alternatives that are more cost effective when there are alternatives available, such as using an ambulatory surgical center is encouraged.

Health insurance carriers' operating integrated care delivery systems, licensed as health maintenance organizations, may display meaningful consumer data based on the total cost of care or episode of care.

The member transparency tools must include information to allow a provider search of in-network providers, with additional information including the following: specialists; distance from the patient; the provider's contact information; the provider's education, board certification, and other credentials; malpractice history and disciplinary actions; affiliated hospitals and other providers in a clinic; and maps and driving directions.

The patient review option that allows feedback on the experience with the medical provider must be monitored for appropriateness and validity, and the site may include independently compiled quality of care ratings of providers and facilities.

The Insurance Commissioner may not expand the requirements through rulemaking.

Staff Summary of Public Testimony on Proposed Substitute as Heard in Committee: PRO: The policy objective is to reward high quality, low-cost providers with more customers and to actively engage customers in managing their health care. Consumers need additional tools to make more informed choices and this bill provides more information without requiring any paperwork from providers or hospitals. This may help drive down the cost of health care by providing consumers with more information to make informed choices. It is high time consumers had access to important information like this to inform their purchases. The Affordable Care Act now requires all individuals to have insurance, so it is only fair to make sure consumers have the information they need to make rational, informed decisions. We hope this leads to even more transparency across plans. Consumers are being faced with ever higher deductibles and cost sharing and it is important to get as much information as possible to improve decision making, especially on items that have high cost sharing such as pharmaceutical where the co-pay may be 50 percent of the cost but then it is not possible to find out which drugs are in that category until a person is enrolled in the plan. This should go even further and make that information available before purchasing the plan. Perhaps we could have the Exchange build this into their comparison information. We have a long-standing commitment to investing in transparency and helping patients and providers make informed choices. Additional information has beneficial impacts on cost and quality. We suggest amending the section that has the Office of the Insurance Commissioner completing the review. Displaying the pharmacy costs is a bit more difficult, because many plans use a pharmacy benefit manager that has separate tools and a separate platform. We might suggest amendments for functionality.

House Amendment(s):

Creates the Performance Measures Committee to recommend health performance measures and propose benchmarks to track costs and improvements in health outcomes. State agencies must use the measure set to inform and set benchmarks for purchasing decisions.
Requires transparency tools to display cost data for diagnostic tests, rather than diagnostic treatments; deletes the requirement that the tools be accessible while sitting in a doctor's office; requires tools to include information on where to find malpractice history and disciplinary actions, rather than the malpractice history and disciplinary actions themselves; and requires the tools to include directions to provider offices and hospitals, rather than maps and directions.
Removes the limitation on the Office of Insurance Commissioner to set rules for the transparency tools.
Insurance carriers must provide enrollees with the performance information required by the Affordable Care Act and related regulations.