New Health Affairs commentary says claims data and price transparency files work best together

A new Health Affairs Forefront article argues employers should pair medical claims with public price transparency data to compare insurer rates, evaluate networks, and spot cost-saving opportunities. The piece says neither source alone gives a full picture of health care prices and spending.

Why it matters: - Employers often rely on claims data to understand their health care spending, but claims alone cannot show what another insurer would have paid for the same care. - Combining claims with public price transparency files can help employers compare negotiated rates, evaluate alternative providers, and identify opportunities to lower costs. - The article says the same approach is relevant for researchers, states, and journalists seeking price information without buying proprietary claims data.

What happened: - Health Affairs Forefront published a new commentary today titled “Claims and Transparency Files are Complements in Understanding Health Care Prices.” - The article was written by Simple Healthcare’s David Muhlestein and Elvira Makk Frid. - The commentary explains how publicly available price transparency data can supplement employer claims analysis when employers are considering a new insurer or a shift in site of care. - Simple Healthcare said the work was supported by the Peterson Center on Healthcare.

The details: - Claims show the care patients received and the amounts their plans allowed. - Price transparency files reveal contracted prices, including rates for providers and services that may never appear in an employer’s claims history. - Together, the two data sources can help employers identify spending drivers, compare insurers’ negotiated rates, and evaluate alternative providers and sites of care. - David Muhlestein said claims can show what an employer’s plan paid last year, but not what another insurer would have paid for the same care. - The commentary says public files can include implausible provider-service combinations, incomplete payment formulas, and gaps between hospital and physician charges. - The commentary also says claims data are retrospective, can be delayed or incomplete, and often come with access and licensing restrictions. - Neither source alone gives a complete picture of health care prices and spending. - The authors recommend employers start with their own medical and pharmacy claims to understand where members receive care and what drives spending. - Public transparency data can then add current contracted rates, comparisons across insurers, and information about providers and care settings outside the employer’s historical experience. - These comparisons are especially useful when an employer is considering a change in insurers or networks. - The authors call for more detailed service-volume information in public reporting. - They also want clearer reporting of complex payment arrangements and better connections between facility and professional rates. - The long-term goal is for public files to become reliable enough that employers, researchers, states, and journalists can answer price-related questions without purchasing proprietary claims data. - The authors say claims should still be preserved because claims provide distinct information about utilization, patient mix, and historical spending. - Simple Healthcare says its public Search tool provides free access to health care prices, and its Roadmap product combines employer claims analysis with network benchmarking to support purchasing decisions. - More information is available at Simple Healthcare.

Between the lines: - The commentary pushes back on the idea that any one data source can fully explain health care pricing. - The practical message for employers is to use claims for history and transparency files for comparison. - That division of labor could matter most when employers are shopping for a new network or trying to shift care to lower-cost settings.

What's next: - The authors want public price reporting to become more complete and easier to use. - If those improvements happen, employers and outside analysts could rely less on proprietary claims data for some pricing questions. - For now, the article argues that the best purchasing decisions will come from using both data sources together.