Health Care Price Transparency in Missouri: Part Two

Posted on by Quin Rizer

In my last post, I discussed the push for increased price transparency in health care, and why transparency is good for consumers. For example, if you need a knee replacement, you should be able visit your local hospitals’ websites, find a price estimate for the surgery at each hospital, and make an informed decision about where to have the surgery done. I decided to try this out for my usual hospital of choice, Mercy Hospital in St. Louis. I used the online price estimation tool, and per Mercy’s suggestion searched “knee replacement.” Nothing came up:

I decided to try the same thing out at the flagship hospital for four of St. Louis’s major hospital systems. I found that the price without insurance for a knee replacement was $26,122 at Barnes Jewish and $18,766 at St. Luke’s. Using that search term in the pricing websites for both Mercy St. Louis and SSM Saint Louis University turned up no matches. I then decided to broaden my search to every hospital in Missouri.

I used the rules outlined by the Centers for Medicare and Medicaid Services (CMS) to evaluate how “transparent” each hospital’s pricing was. The rules state that each hospital needs to have a consumer-friendly way to shop for common services, as well as a comprehensive list of all services and charges in a digital file. I found that of Missouri’s 164 hospitals, only 47 fulfilled both requirements. That is a compliance rate of just 29%, which, considering the federal rule is a year and a half old, is pretty terrible.

Many of the 47 “compliant” hospitals, such as Mercy, had some sort of online form to estimate prices but, in my opinion, did not make the system all that easy or intuitive to use. Many of these sites would not accept a general term for a procedure, like “knee replacement”, but instead required a technical procedure name or hospital code. Requiring the average patient to have such specific information is not “user friendly.” Likewise, the digital files many hospitals provided are difficult to read unless you have extensive computer software and coding knowledge. The digital file Mercy provided was one of these difficult file types. After spending approximately 45 minutes using code to read Mercy’s file, I found that it was still missing key information CMS requires about negotiated rates between the hospital and insurers.

The bottom line is that Missouri hospitals, by and large, are not following the plain intent of the rules, which makes it difficult for patients to know how much their care will cost and to effectively compare prices. If you would like to try to research the prices of procedures for yourself, I have included an Excel file at the bottom of this post that has URLs for every hospital’s pricing information.

 

 

 

 

The $20,000 Discount: Municipal Checkbook Hall of Shame

Posted on by Quin Rizer

Arbyrd, Missouri is a town of just over 400 people in the southwest corner of the Missouri Bootheel. Many small towns, and not just Arbyrd, have few if any full-time government employees, and often they do not have any digital records. What is unique about Arbyrd is that the city was prepared to charge the Show-Me Institute tens of thousands of dollars to see how it spent taxpayer money.

That’s right. Last week, the Show-Me institute began an updated municipal checkbook project, which entailed obtaining the spending records of every city in Missouri. Every city that had available contact information was sent a request under Missouri’s Sunshine Law. Many cities had data already organized and were happy to share, all of which is available here. Some cities, especially those without already-digitized records, requested a fee before they would gather their data. This is allowed under law, but fees are supposed to reflect only the cost of labor and copying involved, and usually did not amount to more than $100. Arbyrd’s fee was a little more than that. According to the response I received from the Arbyrd City Clerk, our request would “require a significant amount of time and resources to complete and therefore we charge $40 per page with a minimum of 500 pages. This amounts to $20,000.”

Twenty thousand dollars! With no details explaining how a single page of paper could cost $40, Arbyd was prepared to charge us tens of thousands of dollars for information about where the city is spending taxpayer money. This clearly goes against both the letter and the spirit of the sunshine law and was met with a swift reply from Institute staff.

Unsurprisingly, days after our reply explaining that what they were doing violated the Sunshine law and that we would be contacting the Attorney General’s office, Arbyrd backed down. The mayor sent a revised offer, promising a digital copy of their spending information at no charge (we received their information on July 19). As it turns out, Arbyrd’s spending data was available in digital form, but for whatever reason their response to our initial request was to decline to provide it.

The bottom line is that all citizens, not just the most dedicated or persistent, should be able to see how their tax dollars are being spent. Cities should strive to make this information easy to access, without the need to resort to state law. Taxpayers should not have to fight for a $20,000 discount to have transparency in government.

Health Care Price Transparency in Missouri: Part One

Posted on by Quin Rizer

What makes health care so different than any other thing you might shop for? Well, it’s different in that you don’t know how much anything is going to cost until after you buy it—it would be like a grocery store without any prices on the shelves. This is obviously ridiculous, so why do we tolerate such practices when it comes to our health?

Health care price transparency was added to the Show-Me Institute’s 2022 blueprint because of its potential to dramatically improve the lives of Missourians. Price transparency arms the health care consumer with greater knowledge about what exactly procedures will cost, what prices insurers negotiate with hospitals, and how the cost of a procedure differs from hospital to hospital. This information should be easily accessible so that someone could do accurate research before ever scheduling a hospital visit.

The main benefit of price transparency is that more information is available to patients, insurers, and employers to aid in decision making. Insurers can use the information to better negotiate prices with hospitals, while patients and employers can use the information to make more informed decisions when purchasing health plans. A price tag attached to a procedure makes it much easier to weigh the costs and benefits of a service, so you know exactly what you are putting in your healthcare shopping cart.

In Missouri, the strictest price transparency rules come at the federal level. Under the guidelines of a Trump administration 2019 executive order, hospitals are required to publish a list of standard charges for 300 common procedures in a user-friendly, shoppable display. In addition, hospitals must publish a complete list of charges in a machine-readable format. “Machine readable” simply means the information can be downloaded off the hospital website into a file format that your computer could understand—like a Microsoft Excel file, as one example. The files need to include the gross charge, a discounted cash price, any payer-specific negotiated charges, and both the highest and lowest negotiated charge for any given service.

While price transparency reforms such as this one are potentially very beneficial for patients all across the nation, there are problems with compliance. The Wall Street Journal reported that, as of last December, many of the nation’s largest hospital systems were not complying with the 2019 rule, without any penalty from the Centers for Medicare and Medicaid Services. In the next post, I take a deep dive into Missouri hospitals and their compliance (or lack thereof) with price transparency rules.

Clerk with a Camera: Municipal Checkbook Hall of Fame

Posted on by Abigail Wagner

The initial response to the Show-Me Institute’s municipal checkbook Sunshine Law request from the city of Linneus, a small town with a population of less than 300 in north central Missouri, was familiar to me. Even though we had only been receiving emails about our request for less than 24 hours, I had already seen several of Missouri’s smaller cities respond in the same way.

“We don’t have any of our records on electronic format,” the email read. “Everything is done by hand on paper.” I typed up my standard response to this type of email, asking Linneus’s clerk to copy and mail the city’s expense records if she could, and to inform us what she thought the copies, work, and postal service fees would cost so we could make a budget decision before she started working. I assumed that, like several other small towns before, Linneus would send an estimate, I would note it in an ever-expanding spreadsheet, and the case would be left alone until the municipal checkbook team could decide whether we would fund the inquiry.

Linneus’s city clerk, Patricia Brandes, had a different idea. After telling me she didn’t know what the cost for over 100 copies would be at the Linneus courthouse, she sent me one of my favorite emails of the entire municipal checkbook project.

“Maybe I could try taking pictures of them with my phone and email them to you. Would that work?”

That did work. Patricia sent me the cellphone photos later that day, and you can see all 64 of them for yourself in Linneus’s folder on our online drive. Although they may not be as instantly readable as the Excel sheets and PDFs sent in by some of our state’s municipalities, the images still reveal Linneus’s dedication to transparency. Patricia turned in every page of the city’s pen-and-paper operating expense record from July 2021 to July 2022, including amounts paid and names of vendors. What’s more, she was willing to take time to think of a creative, free solution that fulfilled our request, despite the limited resources of a city as small as Linneus. That’s a clear demonstration of the culture of transparency our project hopes to find in all of Missouri’s municipalities, and reflects well on  Linneus’s city government’s commitment to serving the public.

The Suspense Isn’t Exactly Killing Me

Posted on by Susan Pendergrass

I guess we should be concerned that the Missouri Department of Elementary and Secondary Education (DESE) is keeping their district accountability system on hold for another couple of years, but does it really matter? Should we be holding our breath with anticipation as DESE fiddles, once again, with the metrics they use to determine whether school districts in the state are accredited?

Let me put it another way: If I told you that last spring, upon DESE’s recommendation, the State Board of Education reinstated fully accredited status to Kansas City Public School District, where 12 percent of students scored at a Proficient level or higher in math and 25 percent did so in English/language arts (ELA), what would be your takeaway? Would you think any more highly of the district knowing that it has DESE’s seal of approval? Or would you think instead that accreditation must not have much to do with how successful the district has been at preparing students to succeed?

DESE doesn’t appear to be very picky about which schools qualify for full accreditation. The Ferguson-Florissant School District, for example, is now fully accredited despite the fact that only 8 percent of students scored Proficient or higher in math, and 20 percent did so in ELA.

On the other hand, DESE seems to be tireless in its quest to perfect its system for evaluating school districts. It changed the test it uses four times in five years—making it difficult if not impossible to compare student test scores from consecutive years. And now, amid all the upheaval caused by the pandemic, it is replacing the Missouri School Improvement Plan (MSIP) 5 with MSIP 6. It’s an awful lot of trouble to go to just to tweak a system that has consistently accredited 99% of Missouri school districts. And that work will take time—nearly a decade will pass before school districts receive a new accreditation update from the state.

None of this is to say that the MSIP 5 shouldn’t be replaced; the Show-Me Institute has repeatedly pointed out its shortcomings. Under that system, districts needed to get at least 70 percent of their possible points to be accredited. However, there were multiple opportunities for “extra credit”—including all of the points for academic growth—and plenty of non-academic points at play. That explains why accreditation has been so easy to come by, and so far removed from the academic success of students.

Under MSIP 6, academic growth is now officially counted in the point total, but academic indicators still only comprise 48 out of 100 points. Districts can now earn points for creating a Continuous School Improvement Plan. They get points for “reflecting upon current practices and data.” They get points for having the “required documentation.” All of which is to say that districts with troublingly low academic performance are still quite likely to be able to get full accreditation.

But here’s the real kicker: DESE is going to go through the laborious calculations of MSIP 6 for each district, and then it’s going to make an accreditation recommendation to the State Board of Education. The recommendation will be based on the Accreditation Score, but also on “previous department MSIP findings” (whatever those are), on financial status, on statutory and regulatory compliance (whatever that involves), and on the employment of an “appropriately certified” superintendent. In other words, we will have State Board meetings like the one earlier this year that reinstated Kansas City Public Schools full accreditation, and the decision will be subjective.

So it doesn’t bother me that it will be a couple of more years before we are officially reminded of how stubbornly DESE and the State Board of Education refuse to face reality. What bothers me is that Missouri’s accountability system, if you can call it that, is heading in the wrong direction. It is becoming less academic, more watered down, and more about the adults in the system rather than the children in the schools.

Supreme Court Reins in Federal Bureaucracy in EPA Case

Posted on by Patrick Ishmael

One of the first things most kids learn about American government is that it has three branches: the legislative, the executive, and the judicial. Generally speaking, the legislature writes the laws, the governor or president executes those laws, and courts resolve disputes over the laws. In recent decades, however, the power to write, execute, and litigate the “law” in the federal government has often fallen to a growing administrative state in the executive branch. Is American law whatever an alphabet soup of federal agencies says it is? Sometimes, yes, and in recent years increasingly so.

Well, buried at the end of an uneventful year for U.S. Supreme Court Rulings is a little case called West Virginia v. EPA. In 2015, the Environmental Protection Agency (EPA) under the Obama administration wanted to comprehensively regulate “greenhouse gases” at American power plants under the Clean Air Act, so it adopted what it called the “Clean Power Plan rule.” The rule put pressure on dirtier coal power plants to shutter and promoted alternative energy plants. The problem with that is the Clean Air Act had only ever been used to enable the regulation and oversight of individual power-generating facilities; Congress had not authorized the EPA to unilaterally reorganize all power-generating capacity of the United States at the grid level.

After seven years of legislative wrangling, constant litigation, and a couple of presidential administrations, the Supreme Court affirmed that the EPA had indeed exceeded its mandate under the Clean Air Act. The court found that when a “major question” like nationwide energy generation is to be decided, Congress must render its decision directly or clearly authorize an agency to act on its behalf, consistent with the law. Here, Congress had not spoken directly or made such a clear delegation to the EPA to give it such expansive powers, and because it had not, the EPA’s dramatic rulemaking was invalid.

To be clear, the court’s ruling doesn’t suggest that the federal government can’t regulate “greenhouse gases,” but it does make clear that if the federal government is going to regulate them, Congress needs to clearly authorize it. That’s a win for small and accountable government; this ruling preserves the constitutional norms of our republican form of government. Each of the three branches is constrained by the Constitution; new laws must be passed through Congress, not by bureaucratic fiat.

How do you stop out-of-control regulations like this? Ideally, by requiring some form of legislative action for them to continue. Regulatory reform is a dense and oftentimes boring policy area, but if I were to suggest one change consistent with state and federal constitutional divisions of power, I think it’d be appropriate for every regulation enacted by an agency to come with a sunset date. The sunset provision would wipe the regulation clean if not adopted and passed into law by Congress or a legislature. That way, every regulation would eventually have to get an up or down vote by the people’s representatives, or else disappear.

Regardless, the Supreme Court’s finding in West Virginia is an important one that hopefully will remind lawmakers that they alone should be making “the law”—and that they can, and should, be held accountable for both the laws they pass directly and any regulations that descend from the statutes they enact.

The Scooter Ban Revisited (Or Not)

Posted on by Abigail Wagner

When I wrote about the downtown Saint Louis ban on scooters a few weeks ago, city officials were planning to return them to the streets with new restrictions after about two weeks. That two-week deadline came and went on Monday, June 27. The ban is still in effect in mid-July, and there’s no news on if the aldermen plan to even address the scooter issue any time soon.

Although policy on scooters hasn’t changed in the last month, it has become clearer that scooters weren’t as much to blame for the Saint Louis crime spike as the Post-Dispatch suggested in the article that inspired my first scooter post. An article from the same source on June 27 quoted several downtown business owners and residents who all agreed that although teenagers on scooters may have been a traffic disturbance, the real danger wasn’t young riders disobeying the rules of the road.

The owners of the downtown Insomnia Cookies location have moved closing time to midnight from 3 a.m. and no longer accept cash because of robberies by armed youths. The owner of NAPPS Natural Hair Salon has seen an increase in crime among adults who come downtown to party. Some residents report seeing children who aren’t yet teenagers carrying guns near apartment buildings. Clearly, teens on scooters aren’t the biggest threat to public safety and commerce downtown. The ban on scooters for the last few weeks has been a band-aid solution to what is often literally a bullet-hole problem.

There are changes that should be seriously considered to improve the scooter situation, such as the rider age and speed limit restrictions suggested by rental companies, which I discussed in my prior post. But a complete ban on scooters seems to be putting the cart before the horse. Safety in downtown Saint Louis is a problem with no simple solutions, but aldermen should start by finding a solution to the scooter issue that doesn’t punish law-abiding residents and visitors instead of scapegoating a useful means of public transit.

Municipal Checkbook Project Returns

Posted on by Patrick Ishmael

Four years ago, Show-Me Institute researchers sent Sunshine Law requests across Missouri, asking cities how they were spending their tax dollars. Some of the responses we received were startling, like a $35,000 bill from the city of Battlefield and $25,000 from Hollister to get their spending records. Meanwhile, much larger cities such as Springfield and much smaller cities such as Strafford gave us their records for free.

As it turns out, the ability to produce a city’s “checkbook register” isn’t dependent on city size. In fact, the willingness to share with the public how tax dollars are being spent seems far more likely to hinge on city culture than anything else.

And now with the benefit of some time having passed since our last inquiries of Missouri’s cities, we thought it was appropriate to check in and see how their cultures of transparency were holding up. The good news is spending records are already rolling in from cities across the state; the bad news is that once again, some cities are still giving us the runaround, if they respond at all.

If you don’t see your city yet on the online drive we’ve set up, there’s still the possibility it will appear there eventually; we are receiving new submissions all the time, so stand by for updates. And if you have concerns about how your municipal government is spending money in general, be sure to hit us up. My colleagues and I will be talking about both the positive and negative stories learned from this transparency project over the next few weeks, and if you have local knowledge that you think would be useful to that narrative, we’re all ears.

Missouri Supreme Court Takes Solid Step Toward Greater Transparency

Posted on by Patrick Ishmael

The run-up to the July 4 holiday weekend featured a torrent of positive developments in Jefferson City. We’ve already talked about the planned adoption of a massive income tax reform by the state’s executive and legislative branches. But earlier that week, the state’s judicial branch also broke some good policy news. The public will have extensive access to documents filed in the state’s court system from their own personal electronic devices, starting next year. According to the state supreme court’s press release:

“With the assistance of Missouri’s Court Automation Committee, a statutory entity comprised of members from all three branches of government, the judiciary has been working toward this goal for a number of years,” Chief Justice Paul C. Wilson said. “Today’s orders will ensure court documents that are currently open to the public will be truly accessible to the public. These improvements will fundamentally change the way individuals access public court documents, while balancing the need to protect confidential information and ensure the overall security and reliability of our underlying case management system.”

The rule changes will not go into effect until July 1, 2023, partially due to the constitutionally required waiting period for certain court rules. The waiting period also gives the Court the opportunity to work with The Missouri Bar to educate attorneys, court staff, parties or anyone else offering documents for filing in any Missouri state court to keep unnecessary confidential information out of otherwise public documents and, when confidential information must be included, to redact that information to protect it from disclosure.

Giving the public access to the actual documents filed in Missouri courts may seem like a narrow transparency victory, and in some respects, it is. The average Missourian will probably only take advantage of the new document transparency system a handful of times in their lives; for example, they might want to closely monitor a local court case that may impact their own lives, but may not get the scrutiny or news coverage of higher-profile litigation.

Yet enabling robust oversight of government functions, even if used intermittently at the individual level, is a key good government reform. The purpose of transparency initiatives like this one isn’t to push every Missourian to constantly watch every function of government; ain’t nobody got time for that. But such reforms empower individuals and communities with the opportunity to oversee the governing system that serves them when they do have concerns.

In general, government should have to demonstrate why certain documents can’t automatically be made public rather than require the public to ask first, as is generally required under the state’s Sunshine Law. The state court system’s shift in policy is a positive step in this rethink of what government transparency should really look like.

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