Taking the Pulse of Hospitals' Response to the New Price Transparency Rule

Over- and underreporting of prices: most hospitals are not compliant with the Hospital Price Transparency Rule

Concern has been raised about the effectiveness of the Hospital Price Transparency Rule to facilitate a clear understanding of health care prices due to poor reporting by hospitals. However, the relationship between what services the hospital provides and what prices they report is not clear. We assessed reported prices in the Turquoise Health database and compared them at the hospital level with the CMS Provider of Services File to identify if a shoppable service was provided at a hospital. We found significant mismatch between the hospital prices being reported and the services being provided. For example, 56% of hospitals providing at least 1 shoppable service that requires public price reporting did not report any prices. Of hospitals reporting prices, most hospitals (66%) reported prices for only a portion of the services they provide. In addition, 12% of hospitals reported prices for services they do not provide. Only 6% of hospitals had complete concordance with price reporting and services they actually provide. Current compliance enforcement and penalties do not appear to be adequate to achieve the goals of the Hospital Price Transparency Rule.

To be or not to be compliant? Hospitals' initial strategic responses to the federal price transparency rule

OBJECTIVE

To understand US hospitals' initial strategic responses to the federal price transparency rule that took effect January 2021.

DATA SOURCES AND STUDY SETTING

Primary interview data collected from 12 not-for-profit hospital organizations in six US metropolitan markets. All but one organization were multihospital systems; the 12 organizations represent a total of 81 hospitals.

STUDY DESIGN

Exploratory, cross-sectional, qualitative interview study of a convenience sample of hospital organizations across six geographically and compliance diverse markets.

DATA COLLECTION/EXTRACTION METHODS

In-depth, semi-structured, qualitative interviews with 16 key informants across sampled organizations between November 2021 and March 2022. Interviews solicited data about internal organizational factors and external market factors affecting strategic responses. Transcribed interviews were de-identified, coded, and analyzed using the constant comparative method.

PRINCIPAL FINDINGS

Hospitals' strategic responses were influenced internally by the degree of the regulation's alignment with organizational values and goals, and task complexity vis-a-vis available resources. We found extensive variation in organizational capabilities to comply, and all but one organization relied on consultants and vendors to some degree. Key external factors driving strategic responses were hospitals' variable perceptions about how available price information would affect their competitive position, bottom line, and reputation. Organizations with more confidence in their interpretation of the environment, including how peers or purchasers would behave, and greater clarity in their own organization's position and goals, had more definitive initial strategic responses. In the first year, organizations' strategic responses skewed toward compliance, especially for the rule's consumer shopping requirements.

CONCLUSIONS

A deeper understanding of the realities of operationalizing price transparency policy for hospitals is needed to improve its impact.

The relationship between community social risk factors and regional hospital-reported cash, negotiated, and chargemaster prices for 14 common services

BACKGROUND

Social risk factors are key drivers of the geographic variation in spending in the United States but little is known how community-level social risk factors are associated with hospital prices. Our objective was to describe the relationship between regional hospital-reported prices and social risk factors by price type (chargemaster, cash, commercial, Medicare, and Medicaid).

METHODS

This cross-sectional analysis used newly available hospital-reported prices from acute general hospitals in 2022. The prices were for 14 common services. Prices were winsorized at 98%, wage index-adjusted, standardized by service, and aggregated to hospital service areas (HSAs). For social risk, we used 23 measures across 5 domains of social risk (socioeconomic position; race, ethnicity, and culture; gender; social relationships; and residential and community context). Spearman's correlation was used to estimate associations between median prices and social risk by price type.

RESULTS

Prices were reported from 2,386 acute general hospitals in 45% (1,502 of 3,436) HSAs. Correlations between regional prices and other social risk factors varied by price type (range: -0.19 to 0.31). Chargemaster and cash prices were significantly correlated with the most community characteristics (10 of 23, 43%) followed by commercial prices (8, 35%). Medicare and Medicaid prices were only significantly correlated with 1 measure (all p < 0.01). All price types were significantly correlated with the percentage of uninsured (all p < 0.01). Chargemaster, cash, and commercial prices were positively correlated with percentage of Hispanic residents, residents with limited English proficiency, and non-citizens (all p < 0.05).

CONCLUSIONS

While regional correlations between prices and social risk factors were weak across all prices, chargemaster, cash, and commercial prices were more like closely aligned with community-level social risk factors than the two public payers (Medicare and Medicaid). Chargemaster, cash, and commercial hospital prices appeared to be higher in socially disadvantaged communities. Further research is needed to clarify the relationship between prices and community social risk factors.

Playing by the Rules? Tracking U.S. Hospitals' Responses to Federal Price Transparency Regulation

GOAL

As of January 1, 2021, the Centers for Medicare & Medicaid Services requires most U.S. hospitals to publish pricing information on their website to help consumers make decisions regarding services and to transform negotiations with health insurers. For this study, we evaluated changes in hospitals' compliance with the federal price transparency rule after the first year of enactment, during which the Centers for Medicare & Medicaid Services increased the penalty for noncompliance.

METHODS

Using a nationally representative random sample of 470 hospitals, we assessed compliance with both parts of the hospital transparency rule (publishing a machine-readable price database and a consumer shopping tool) in the first quarter of 2022 and compared its baseline level in the first quarter of 2021. Using data from the American Hospital Association and Clarivate, we next assessed how compliance varied by hospital factors (ownership, number of beds, system membership, teaching status, type of electronic health record system), market factors (hospital and insurer market concentration), and the estimated change in penalty for noncompliance.

PRINCIPAL FINDINGS

By early 2022, 46% of hospitals had posted both machine-readable and consumer-shoppable data, an increase of 24% from the prior year. Almost 9 in 10 hospitals had complied with the consumer-shoppable data requirement by early 2022. Larger hospitals and public hospitals had lower probabilities of baseline compliance with the machine-readable and consumer-shoppable requirements, respectively, although public hospitals were significantly more likely to become compliant with the consumer-shoppable requirement by 2022. Higher hospital market concentration was also associated with higher baseline compliance for both the machine-readable and consumer-shoppable requirements. Furthermore, our analyses found that hospitals with certain electronic health record systems were more likely to comply with the consumer-shoppable requirement in 2021 and became increasingly compliant with the machine-readable requirement in 2022. Finally, we found that hospitals with a larger estimated penalty were more likely to become compliant with the machine-readable requirement.

PRACTICAL APPLICATIONS

Longitudinal analyses of compliance with the federal price transparency rule are valuable for monitoring changes in hospitals' behavior and assessing whether compliance changes vary systematically for specific types of hospitals and/or market structures. Our results suggest a trend toward increased hospital compliance between 2021 and 2022. Although hospitals perceive the consumer-shopping tools as being the most impactful, the value of this information depends on whether it is comprehensible and comparable across hospitals. The new price transparency rule has facilitated the creation of new data that have the potential to significantly alter the competitive landscape for hospitals and may require hospital leaders to consider how their organizational strategies change concerning their engagement with payers and patients. Finally, greater price transparency is likely to bolster national policy discussions related to price variation, affordability, and the role of regulation in healthcare markets.

Provision of Hospital Price Information After Increases in Financial Penalties for Failure to Comply With a US Federal Hospital Price Transparency Rule

Importance

Price transparency regulations aim to help patients make informed decisions about medical care, but enforcing these rules is a policy challenge. There may be an association between financial penalties and hospital compliance for enforcing price transparency regulations.

Objective

To evaluate the association between financial penalties and acute care hospital compliance with the 2021 Centers for Medicare & Medicaid Services (CMS) Price Transparency Rule.

Design, Setting, and Participants

This cohort study uses an instrumental variable design to evaluate the responses of 4377 acute care hospitals in the US operating in 2021 and 2022 to changes in financial penalties in the context of a federal rule requiring hospitals to disclose privately negotiated prices.

Exposure

Changes in noncompliance penalties between 2021 and 2022 based on a nonlinear function of bed counts.

Main Outcomes and Measures

Whether hospitals publicly posted a machine-readable file with private, payer-specific negotiated prices at the service-code level. Negative controls were used to address confounding.

Results

The final sample included 4377 hospitals. Compliance increased from 70.4% (n = 3082) in 2021 to 87.7% (n = 3841) in 2022, with 90.2% of hospitals (n = 3948) reporting prices in at least 1 year. Noncompliance penalties increased from $109 500/y in 2021 to a mean (SD) of $510 976 ($534 149)/y in 2022. Penalties in 2022 were substantial, averaging 0.49% of total hospital revenue, 0.53% of total hospital costs, and 1.3% of total employee wages. Compliance increases were significantly positively correlated with penalty increases: a $500 000 increase in penalty was associated with a 2.9-percentage point (95% CI, 1.7-4.2 percentage points; P < .001) increase in compliance. Results were robust to controlling for observable hospital characteristics. No associations were found for preperiod (2021) compliance or ranges of bed counts where penalties do not vary.

Conclusions and Relevance

In this cohort study of 4377 hospitals, compliance with the CMS Price Transparency Rule was associated with increased financial penalties. These findings are relevant for the enforcement of other regulations designed to promote transparency in health care.

Estimating the Impact of New Health Price Transparency Policies

This analysis investigates and scores the impact of new health price transparency rules. Using a set of novel data sources, we estimate substantial savings are possible following the implementation of the insurer price transparency rule. Specifically, we estimate annual savings to consumers, employers, and insurers by 2025, assuming a robust set of tools to allow consumers to purchase medical services. We matched claims with 70 HHS defined shoppable services by CPT and DRG codes and replaced them with an estimated median commercial allowed payment multiplied by a reduced cost of 40% based on estimates found from literature for the difference in cost between negotiated and cash payment for medical services. We consider 40% to be an upper bound estimate of the potential savings based on existing literature. Several databases are used to estimate the potential benefits of insurer price transparency. Two different all-payer claim databases were used, representing the entire insured population in the US. For this analysis, only the private insurer commercial population was examined, comprised of over 200 million covered lives as of 2021. The estimated impact of price transparency will vary significantly by region and income level. The national upper bound estimate is $80.7 billion. The national lower bound estimate is $17.6 billion. For the upper bound, the region with the most significant impact in the US will be the Midwest, with $20 billion in potential savings and an 8% reduction in medical expenditure. The region with the lowest impact will be the South, with only a 5.8% reduction. Concerning income, those at lower levels of income will have the most significant impact with a -7.4% (<100% Federal Poverty Level) to -7.5% (100%-137% Federal Poverty Level) impact. Overall, the total impact could be a 6.9% reduction for the whole privately insured population in the United States. In summary, a unique set of national data resources were used to estimate the cost savings impact medical price transparency. This analysis suggests price transparency for shoppable services may yields significant savings between $17.6 to $80.7 billion by 2025. Consumers may have strong incentives to shop with the rise in the use of high deductibles, health plans, and health savings accounts. How these potential saving are to be shared by consumers, employers and health plans has yet to be determined.

Hospital And Regional Characteristics Associated With Emergency Department Facility Fee Cash Pricing

Self-pay patients are an understudied yet important and financially vulnerable population of emergency department (ED) users. As ED facility fees may be a key cost driver in patient ED bills, we leveraged newly available hospital pricing data to describe ED facility fees for self-pay patients (cash prices) and how they vary according to hospital and regional characteristics in a sample of 1,621 hospitals across the United States. The median cash price for ED facility fees ranged from $160.78 for a level 1 visit to $1,097.43 for a level 5 visit. Hospital for-profit status and a bed count of 251 or more beds were associated with higher cash prices for ED facility fees across all visit levels. Meanwhile, location in a county with a poverty rate of 16 percent or more was correlated with lower facility fee cash prices for ED visit levels 2 and up. We hope that these findings can inform targeted policy efforts to better ensure affordable ED care for vulnerable patients.

US Hospital Characteristics Associated With Price Transparency Regulation Compliance

This cross-sectional study examines associations between characteristics of US hospitals and their compliance with Centers for Medicare & Medicaid Services regulations for transparency of insurance-negotiated prices.

Use of Neuroimaging for Patients With Dizziness Who Present to Outpatient Clinics vs Emergency Departments in the US

Importance

Overuse of costly neuroimaging technology is associated with low-value care for the prevalent symptom of dizziness. Although quality improvement initiatives have focused on the overuse of computed tomography (CT) scans in emergency departments (EDs), most patients with dizziness present to outpatient clinics. To inform practice and policy, a comprehensive understanding of the uses and costs of neuroimaging across settings and episodes of care is needed.

Objective

To characterize neuroimaging use, timing, and spending as well as factors associated with imaging acquisition within 6 months of presentation for dizziness in outpatient vs ED settings.

Design, Setting, and Participants

This cross-sectional study of commercial and Medicare Advantage claims for 805 454 adults (≥18 years of age) with new diagnoses of dizziness was conducted from January 1, 2006, through December 31, 2015. Data were analyzed from October 1, 2020, to September 30, 2021.

Main Outcomes and Measures

Use of neuroimaging (CT scan, magnetic resonance imaging [MRI], angiography, and ultrasonography) and total spending on neuroimaging were measured. Kaplan-Meier analysis was performed. The associations of neuroimaging with setting, sociodemographic characteristics, and clinicians were estimated with multivariable analyses.

Results

A total of 805 454 individuals with dizziness (502 055 women [62%]; median age, 52 years [range, 18-87 years]) were included in this study; 156 969 (20%) underwent neuroimaging within 6 months of presentation (65 738 of 185 338 [36%] presented to EDs and 91 231 of 620 116 [15%] presented to outpatient clinics). The median time to neuroimaging was 0 days (95% CI, 0-2 days) after ED presentation and 10 days (95% CI, 9-10 days) after outpatient presentation. Neuroimaging was independently associated with advanced age, comorbidity, race and ethnicity, ED presentation, and outpatient clinician specialty. Across sites, a head CT scan was the most used test on presentation date (92% of tests [46 852 of 51 022]). Within 6 months of presentation, a head CT scan was the most used test (47% of all tests [177 949 of 376 149]), followed by brain MRI (25% [93 130 of 376 149]), cerebrovascular ultrasonography (15% [56 175 of 376 149]), and magnetic resonance angiography (9% [34 026 of 376 149]). Of $88 646 047.03 in total neuroimaging spending, MRI accounted for 70% ($61 730 251.95), CT scans for 19% ($16 910 506.24), and ultrasonography for 11% ($10 005 288.84). Per-test median spending ranged from $68.97 (CT scan of the head) to $319.63 (MRI of the brain) among commercially insured individuals and $43.21 (CT scan of the head) to $362.02 (MRI of the orbit, face, and neck) among Medicare Advantage beneficiaries.

Conclusions and Relevance

The findings of this cross-sectional study suggest that use of neuroimaging for dizziness is prevalent across settings. Interventions to optimize the use of neuroimaging must occur early in the patient care journey to discourage guideline-discordant use of CT scans, advocate for judicious MRI use (particularly in ambulatory settings), and account for the effects of price transparency.