The administration’s health price transparency rule went live Jan. 1. Already, President Donald Trump is declaring victory. But did it work? Are hospitals complying? Does it matter for patients?
Describing the new rules, the Centers for Medicare and Medicaid Services say on their website:
“Starting January 1, 2021, each hospital operating in the United States will be required to provide clear, accessible pricing information online about the items and services they provide in two ways:
“As a comprehensive machine-readable file with all items and services.
“In a display of shoppable services in a consumer-friendly format.
“This information will make it easier for consumers to shop and compare prices across hospitals and estimate the cost of care before going to the hospital.”
The first, the machine-readable file, applies to standard charges for all items and services, and requires hospitals to include their negotiated rates with third-party payers. Then, in the listing for shoppable services, to be provided in a consumer-friendly format, “hospitals must make public the charges associated with a total of 300 shoppable services, and CMS indicates in the Final Rule that it may increase this number once hospitals are accustomed to posting charge information. CMS specified 70 shoppable services in the Final Rule, and hospitals must post their charges for as many of these services as they provide. The remaining shoppable services will be selected by the hospital,” according to The National Law Review’s article on the topic.
First, there’s a big myth about this rule. Some experts are saying “it will allow you to shop for your health care while knowing the price first.” From what we’ve seen, it does not do that. Compliance is spotty and seems to be changing even as we speak. The data files, when they can be found, are unwieldy. Some hospitals use broadly used coding systems allowing for comparisions, while others use their own — meaning comparisons are hard if not impossible.
It would be quite difficult for the average person to first find these, and it’s even hard for health nerds like me who have been talking about the topic — and then it’s harder to understand them, and then figure out how to compare, insurer by insurer, who’s paying what. I do health data for a living, and it’s a challenge for me. That said, it is light-years beyond the administration’s last attempt at price transparency, which went into effect Jan. 1, 2019. Here’s our post about that.
We have heard of various enterprises planning to scoop up all this data and make price-shopping tools. We’ll be interested to see if those are any more actionable than the hodgepodge of different spreadsheets and tools that we’ve seen up to now, as this is being written, on Jan. 2. (We plan to update.)
An early look
From a quick look at the information we found, there’s a wide range of compliance. Some hospitals are omitting the cash prices. Some have big gaps in the data. Some are complying with the “consumer-friendly” mandate simply by directing patients to their existing “find the price” services, which seems to comply with the “consumer-friendly” mandate. Some seem to have found the same vendor to supply this service — and that vendor seems to be directing people seeking information sometimes to the right place, but sometimes from a New Hampshire hospital’s site to a Connecticut hospital’s price list. There’s more detail below.
Take a look at our first blog post about a hospital’s price transparency tools. A string of pages with some missing information, grouped by procedure code, showing what a given insurer pays a given hospital for a given procedure.
For this MRI of the lower back, without contrast, CPT code 72148, we learn that Cigna has no number at all, with no explanation. Same with Oxford. MVP paid this hospital $467, Aetna $1,788 and Empire Blue Cross $311 for that particular MRI. So how is that actionable for me as a patient?
This may tell me what different insurers pay Putnam hospital for a given procedure, but it doesn’t let me “shop” in any meaningful way, because if I have Aetna insurance, I’ll be paying the Aetna price, instead of going and asking for the MVP price. And I can’t easily compare Putnam with other hospitals in the area, because the hospitals are all apparently complying in different ways (and the spreadsheets aren’t that easy to find).
Further, it doesn’t say anything about deductible or co-insurance, and since many of us have significant deductible or co-insurance, this price list doesn’t exactly clarify but maybe even muddies the picture.
Beyond this, the rule does not affect radiology centers, breast centers, gastroenterology centers and the like — where prices for things like MRI’s, mammograms and colonoscopies can be much lower than hospital prices. In that way, it might actually increase a person’s health spending — if she thinks the hospital rates are the only ones she can choose from, then she’s missing a chance to save money.
We are partial to our search and share tool, which has cash prices, Medicare prices and insured prices contributed by community members, to represent the actual broad range of pricing. To see an example, go to this page and search for an ultrasound of the abdomen, CPT code 76700, in Zip code 70145, New Orleans.
Is it valuable?
One man who studies health cost pricing, Michal Horny, an assistant professor and health economist at Emory University, is not so sure.
He said: “When I read the final rule of the C.M.S. regulation, they actually said, whoever wrote it, they were pretty open about the fact that the regulation is not perfect, but it’s a step in the right direction, and eventually, we’ll get there.
“But now seeing how hospitals really don’t comply, even with the bare minimum, I don’t know if this will be helpful to the industry at all. It definitely will not be helpful to patients. Definitely more work needs to be done.
“Also I am really worried that the backlash from the hospital industry will be strong. It’s difficult to make change, unfortunately.”
Attention span and brainshare — and timing
This particular CMS rule has been under consideration for some time. It has also been challenged in court this year, and several challenges were turned back.
Also, considering the circumstances, it seems that some hospitals have chosen not to comply immediately, or to comply in a minimalist way. Imagine the hospital executive confronted with tides of coronavirus patients, lack of personal protective equipment for staff and a need to hire more nurses right now, and imagine how that exec would respond to a request for resources for compliance with the health cost transparency mandate?
CMS has been saying that it will audit hospitals for compliance beginning this month. Penalties are minimal, $300 a day (see related post), and there is speculation that enforcement may be lax, or hospitals may decide to accept that penalty.
For a related post on implementation, compliance, background and so on, go here. This post will be updated as we see more examples of price lists and assess them in this context.
Who’s doing what?
We had an earlier post inspecting the price lists for some Westchester and Connecticut hospitals. Find it here.
Here are some other examples.
Speare Memorial Hospital in New Hampshire has this price transparency page, announcing: “Speare Memorial Hospital has partnered with a third party to assist in coordinating its adoption of 45 CFR Part 180, CMS-1717-F2, the Centers for Medicare and Medicaid Services hospital price transparency rule (the “Rule”) requiring certain healthcare providers to disclose their pricing to patients for a number of standard provider service offerings.” On Jan. 2, w
hen we clicked on their “Price Transparency Tool” link, we wound up in Western Connecticut hospital’s Nuvance Health pricing page. It’s clearly labeled for Danbury Hospital, so that’s a bit disconcerting.
I went all the way through the price search process for a 72148 MRI of the lower back without insurance, and found out it would cost $3,666, which is an astronomical price — and also, it seems to be at Danbury Hospital, not Speare.
Downloading the “machine-readable” file, I got a document in the json open-standard file format. I’m not great with this kind of
data, but it seems to have diagnosis-related group (DRG) codes and not Current Procedural Terminology (CPT) codes. That means that you can get an idea of pricing for a shunt neural implant or an appendectomy, which you probably wouldn’t be shopping for, but you can’t find an MRI, which you might be shopping for. (Acknowledging, I might not be looking in the right place.)
The next day, Jan. 3, I went to Speare’s site again, and clicked through. This time I got an error message from a page marked for Cleverley and Associates (see screenshot). This answers another of my questions: Who are the vendors who are supplying these services? Cleverley is a consultancy working in health care on data; their front page refers to the transparency mandates.
I’m guessing that someone at Cleverley is having a very tough holiday weekend. By Jan. 4, that same clickthrough was referring to a Speare branded page (see screenshot) but the information seemed to be only marginally compliant. Wonder if the C.M.S. audit team will call anybody out for this? We’re curious, again, about what is acceptable compliance with the letter and the spirit of the mandate, and what will be unacceptable.
HCA, the giant for-profit chain, has gone on record as saying it will comply. I looked at one of their hospitals, Alaska Regional, finding it from this overall HCA Healthcare pricing page.
The pricing page says: “Alaska Regional Hospital is committed to providing meaningful information about our healthcare services, including the amount that patients may be obligated to pay for those services. The amount that patients pay is largely determined by their health insurance coverage. If a patient does not have health insurance, their financial liability will be determined by the application of our uninsured discount to the bill for non-elective services. To provide you with information that is most helpful and specific to your circumstances, please call our Service Center (800) 370-1983 to discuss any questions you may have.
“If you are interested in obtaining details around pricing, view our detailed price list (raw data file) or our average procedure price report (raw data file).” The detailed price list is “standard charges,” and has only one price per entry; it looks like a Chargemaster, and not a transparency document as described by CMS. The average procedure price report has two prices per entry; it is built on what look like diagnosis-related groups (DRG) and includes “average charge per case” and “average Medicare payment per case,” therefore not actually corresponding to the CMS request. What HCA does have is a pricing estimate service, which some experts say satisfies the CMS request for consumer-facing data, but where’s the machine-readable data with payments to various insurers, plus cash rates? I couldn’t find it.
On the HCA Houston Healthcare site, we are again directed to the Patient Payment Estimator. I told it I did not have insurance, and it asked me to call an 888 number for help. I searched for the data files, and got the same options as in Alaska:
HCA “owns and operates 186 hospitals and approximately 2,000 sites of care, including surgery centers, freestanding emergency rooms, urgent care centers and physician clinics in 21 states and the United Kingdom,” according to its Wikipedia page. We assume all the hospitals in the U.S. will follow this filing system for pricing pages.
A hospital in the Bronx
Calvary Hospital, on Eastchester Road in the Bronx, has a downloadable spreadsheet that has all the insurers’ rates listed on a spreadsheet. It’s very easy to read. Find it here.
As with the others, though, notice how hard it would be for you to comparison shop. So how valuable is this kind of transparency to an actual individual? Does it say anything here about co-insurance or deductible? Nope.
Also, it starts out looking fairly robust, but once you’re about 95 lines deep, it becomes a vast sea of blank lines. A header note points out that Calvary is dedicated to treatment and palliative care for cancer patients — and does not provide a lot of the services CMS asked for.
And then how is that actionable? If you have MVP insurance, maybe you know what MVP is supposed to charge — but how does that translate into an action? Are you supposed to dump Aetna, the high-priced payer and jump over to Empire mid-year to get a cheaper MRI? Of course you can’t do that, and you can’t go ask the hospital to give you the Empire price if you’re an MVP member. And what about that deductible? And co-insurance?
At Denver Health, the only thing we could find (on Dec. 31) was the January 2019 page representing the hospital system’s response to the January 2019 edict that hospitals post their price lists. That was the result of a Trump administration decision to adhere to an Affordable Care Act stipulation that hospitals post price lists, which we regarded as pretty meaningless. Here’s our piece about that, and here’s our piece on some reaction to that from people in health care. Here’s our piece on how Seema Verma, the Centers for Medicare and Medicaid Services administrator, had asked Twitter to help her enforce compliance — on what was a pretty meaningless edict.
The Denver Health page from that time is here. If we find a page complying with the new order, we’ll park it here.
At Baylor, Scott and White in Dallas-Fort Worth, there’s a price estimator tool. We can’t find their 2019 entry; here’s the page for the estimator tool.
At Cook Children’s Hospital in Forth Worth, Tex., the 2019 page seems to be the only one available, cataloging the charges (Chargemaster) prices, not the negotiated rate or member rate for each insurer.
Texas Health Resources, another hospital group, seems not to be in compliance; it still lists average charges by diagnosis related group (DRG), meaning things like the entire course of treatment for kidney failure or a stroke, as well as a separate listing for the Chargemaster or list prices for different Current Procedural Terminology (CPT) codes, and also an invitation to go to Texas Price Point, a Texas Hospital Association site that collects prices, apparently for hospitalizations (and not for something simple like an MRI in a hospital.
New York, city and suburbs, and Atlanta
New York City Health and Hospitals appears to have complied, with downloadable machine-readable and really big files for all its locations, on this page. For all the 72148 listings we saw, the charged price was $1,327.65, and the payment rate was $531.06, for all payers.
New York Presbyterian has a list of 320 “shoppable services” that appears to be in compliance — with a cash price and the actual payment rates for 28 different insurers. Confusingly, it is marked “confidential proprietary information,” which we assume came from the lawyers. For our 72148 MRI, Emblem receives $1,045.454725 (yes, the decimals are on the spreadsheet) while Aetna pays $4,004 — and the charge is listed as $4,004. The discounted cash price, we are told, is also $4,004. In fact, at first glance, all the “discounted cash price” listings seem to be the same as the gross charge. Sigh.
Northwell Health, just north of New York City, gives you the chance to use their “self-service price estimator tool.” It has the same imperfections of other similar tools: One price, hard to compare; no complete explanation of methodology; what if I want to compare my insurance vs. self-pay? Also, I can no longer find their charged prices price list, which my records show we could find in January of 2019. Sigh, one step forward, two steps back.
At Emory Healthcare, you can use the cost estimator. The page notes: “The cost-estimate resources below are estimates of out-of-pocket costs for the planned hospital test(s) and or procedure(s) selected and are not a guarantee of costs or the final bill. Estimates do not reflect the final costs for services rendered. Costs vary due to complications, final diagnosis, recommended treatment by the doctor that is unknown at the time of the estimate, the terms and coverages of any applicable health benefit plan/insurance, the time at which services are rendered, location, and a variety of other factors. Costs may also vary between different hospitals within Emory Healthcare, so please make sure you are viewing the estimate for your desired hospital(s).” The same page gives access to a machine-readable file, but it does not seem to have specific reimbursement rates for specific insurers broken out.
At Lake Regional in Osage Beach, Mo., the estimator tool is here. I didn’t see a machine-readable file.
Trinity Health, in Minot, N.D., has a different approach: Consumer shoppable and machine readable files are accessible on this page. The consumer shoppable one looks very much like the one from the Nuvance hospitals in our previous blog post; it’s a WordPress document. We talked about the presentation in the previous post. It seems clearly to be the same vendor, and the documents are findable with a Google search on “consumer shoppable.”
Though it’s not easy to wade through, it is clear (if you know how to read these things) that the self-pay price of $196 vs. the United HealthCare price of $1,876 presents a stark contrast. Cash is king. Or maybe not.
You can see the Trinity one here:
More New York suburbs and Indiana
Catholic Health Services of Long Island, parent of Good Samaritan, Mercy Medical and several others, has an overall page about pricing, directing people to call any one of the hospitals for financial counseling. They also offer a chargemaster, sometimes a pharmacy chargemaster and a DRG listing of average prices for all of the hospitals.
Community Healthcare System in Indiana offers a Guest Estimate tool or invites patients to sign in to MyChart for their patient estimator. I downloaded their price list, and found that it basically has the charged rate for procedures, which seems to pretty much be identical for all insurers for some procedures, while wildly different for others. These appear to be DRG figures and CPT figures, confusingly.
For some, a payment rate (expected reimbursement) is given, and for others it’s not. This data set also has a cash price, which can be the same as or as much as three times higher than the insurers’ charged rate; it also shows minimum negotiated rate and maximum negotiated rate, but does not say what insurer gets which rate. It’s a huge file and hard to manipulate because it has so many rows and cells; 50 columns and more than 56,000 rows.
For our old favorite CPT 72148, the table lists “expected reimbursement” as high as $3,007.37 (Aetna National Advantage Program) and as low as $168.63 (BX of Illinois Community Health Partners), with the cash price $2,293.20.
Florida, Kentucky, alabama and pennsylvania
Jan. 2: Baptist Health South Florida directs people to its pricing estimator, at 786-662-7181 or email at CentralPricing@BaptistHealth.net. The page also says a spreadsheet of list prices (the chargemaster) may be downloaded, though it may take 15 minutes to download. A new pricing tool is coming soon, the page adds, with this footnote: “Baptist Health South Florida has been working with Experian to launch the Price Estimator tool for Doctors Hospital. The current estimated launch date of this tool is February 2021. Please check back soon, or, if you have any questions regarding your out of pocket amount for healthcare services, please call our Centralized Pricing Office at 786-662-7181 or email CentralPricing@BaptistHealth.net.”
Jan 2: At Paul B. Hall Regional Medical Center in Paintsville, Ky., the pricing transparency page explains billing procedures and offers a downloadable Chargemaster file, which was probably put there in compliance with the Jan. 1, 2019, transparency mandate. Nothing relating to the new CMS rule was visible. Patient financial services can give estimates, the page notes.
Jan. 2: Community Health Systems is a big for-profit chain with 95 hospitals in 16 states at this writing — though they are divesting at a fairly rapid clip. Their home site doesn’t talk about transparency. But you can go to their “locations” page and then find the site of an individual hospital. Flowers Hospital in Dothan, Ala., has a pricing information page that directs patients to the online price estimator tool, where we learned that the 72148 MRI of the lower back would cost $2,506.47 for a self-pay patient. You can get a personalized estimate by calling (334) 794-5000 x 1168, Monday through Friday, or emailing PatAccEducation@Flowershospital.com. There is nothing apparent about the new mandate, though the pricing page gives you an opportunity to download the Chargemaster (presumably from the Jan. 2, 2019 mandate).
For CHS hospitals in Pennsylvania, it’s the same drill: Go to the hospital site, then “patients and visitors,” then “financial information,” then “pricing information” and you’ll see a very similar page: Referral to the patient estimate service, the online calculator, and an offer of the Chargemaster. Nothing evident about the new mandate.
New York suburbs and Michigan
Jan. 2: At Northwell Health, the chain north and east of New York City, the pricing page directs you to a series of phone numbers to call for an accurate price estimate at five Northwell locations. There’s also an online patient cost estimator, made by Experian. And there’s a Medicare rate calculator — first time I’ve seen one of those on a web site — and an opportunity to download the Chargemaster. No sign of response to the new mandate.
The price estimator page adds: “As federal regulations evolve, and additional pricing files are requested to be made available, it remains Northwell’s priority to ensure that any information posted meet the expectations of regulators and does not introduce confusion or otherwise mislead community members seeking to draw comparisons between providers. We continue to work with CMS to clarify and refine its expectations for posting machine-readable standard charges for hospital services, as we deliver a robust suite of price estimate tools and financial support resources for our patients.
“We strongly urge you to use the phone numbers and online tool listed above, or contact your insurance carrier directly, for the most accurate price estimates for your planned course of care.”
Jan. 2: At Beaumont Health in Michigan, I went to Patients and Families, then the pricing page, where I was urged to use the online calculator or call a specialist for a personalized estimate. Charges for services provided in 2021 for eight Beaumont locations are available for download, but I had to click through to a separate page. I was again urged to use the online calculator, and finally found a list of downloadable charge files.
I got one; it’s unwieldy, 67 columns and almost 25,000 rows. But it does seem to comply. Looks like the Community Health Systems one above. For that 72148 MRI of the lower back, the numbers look like this:
Charged price $3,846.00, Minimum price, $142.00, Maximum $3,187.00, Uninsured $923.00. Aetna Better Health is at $146; and several Medicare-Medicaid plans are at $142. Multiplan PPO is at $3,187. Looks like Multiplan is higher on several of the prices. It’s hard to analyze, though, without crunching all the data.
Emory Healthcare and Mass General in Boston
Horny led me to the Emory Healthcare site.
This page refers people to the online price-finder, to a set of phone numbers for getting an estimate, and to other resources. Downloadable files are also here. The files include gross charge (categorized apparently by the hospital’s own filing system, not the more common DRG or CPT systems) as well as inpatient and outpatient minimum and maximum charges. Most interesting is the discounted cash price, for about 80 common procedures. Our MRI of the lower back without contrast, 72148, does not appear, but any MRI without contrast is $550, with reading fee of $150.
Interestingly, they chose to include bariatric procedures in this small list of cash prices.
Emory prefaces its disclosure by saying: “The following information is posted in accordance with the Centers for Medicare and Medicaid Services regulation found at 45 C.F.R. § 180.50. This information is based on reasonable and good faith interpretations of the regulation. Because this information is specific to this regulation, documents may not be directly comparable to information from other public or private reports, databases or documents. Pursuant to the federal regulation, this information will be updated at least annually. The following information does not represent the amounts most patients pay. For estimates of the cost of services as applicable to you, please call us using the phone numbers provided above on this webpage.”
He also pointed me to the Massachusetts General Hospital site, part of the Partners Healthcare giant in Boston. Mass General has a cost estimator, which probably satisfies the “consumer-friendly” requirement.
The hospital also offers CMS-required hospital charge data on a separate page. The download file is prefaced by this: “Please note: Because of the size of the file, you may need special computer software/speed to open the file. The price information contained in this large file is NOT an estimate of the costs that you are responsible for paying. This file is not intended for patients and does not reflect your out of-pocket costs. If you are a patient, you can request a cost estimate by contacting Patient Billing Solutions or using our online tool to view a cost estimate of common health care services (“shoppable items”).”
Horny said the downloadable file is too big for his computer. I did not download and inspect.