Philly hospitals must now disclose prices for care, but it’s still hard to comparison shop: ‘The randomness is stunning.’
The price transparency requirement is supposed to help consumers save money on health care, but the presentation of the information is difficult to navigate.
The price for a simple knee MRI under Independence Blue Cross plans ranges from $330 at Einstein Medical Center Montgomery in East Norriton to $1,500 at Riddle Hospital in Media.
Those are the prices consumers with high-deductible plans would have to pay to scan their knee and find out how serious the source of their pain is.
And replacing that knee would cost from $12,300 to more than $44,000 under insurance plans that IBC sells to employers and individuals.
Those are the hard numbers culled from the arcane world of hospital prices that were recently released for the first time. They come courtesy of a federal rule that required hospitals to publish thousands of rates — long kept secret — that they have negotiated with insurers.
The goal is to help consumers shop for care. But the variation in prices is astounding.
“When you really dive into the structure of health-care reimbursement in America, there’s no rhyme or reason. The randomness is stunning,” said Steve Kelly, chairman of ELAP Services LLC, a Wayne company that scrutinizes claims to help employers save on health care.
Kelly said it’s too soon to know whether the disclosures, which hospitals bitterly opposed, will make a difference to consumers or to employers who sponsor plans that cover about 50% of Americans.
The stated purpose of the Hospital Price Transparency rule is to help consumers compare prices before getting services, increasing competition, and slowing growth in the ever-expanding $3.8 trillion health-care sector.
Indeed, Xavier Becerra, President Joe Biden’s pick to lead the U.S. Department of Health and Human Services, promised “robust enforcement” of the rule before a Senate committee last week. “For far too long, people have never had an idea of what they are going to pay if they walk into a hospital,” he said.
But in their current form, the disclosures won’t make it easy on consumers. The presentation is haphazard and hard to navigate, much like health care itself. In their supposedly “consumer-friendly” online tools, many hospitals require consumers to enter insurance information to see prices under specific insurance plans. That makes shopping a laborious process.
Plus, price is not all that matters. Quality is key, but the new data don’t include quality measures. Who wants a cheap, but botched, knee surgery? And numerous studies show high price is no guarantee of high quality.
Hope for change
Some experts are optimistic that the disclosures will have a major impact in the future.
“Employers, researchers, advocates can take steps to build on this to make it standardized, centralized, make it clear and more consumer-friendly,” said Patrick Keenan, director of consumer protections and policy at the Pennsylvania Health Access Network, a nonprofit advocacy group.
To help Philadelphia-area consumers and employers get a start, The Inquirer compiled a database with more than 30,000 rates negotiated between 29 hospitals in the Philadelphia region and 43 insurance companies.
The database is limited to a collection of 70 services and procedures that federal regulators required hospitals to include on their list of 300 services that can be scheduled in advance. Some hospitals don’t provide every service.
Hospitals say they support transparency.
“We’re happy to see this continue, to hopefully be more usable for the average consumer,” said Nick Barcellona, chief financial office of Temple University Health System. Temple included multiple disclaimers on its website, warning consumers to be wary of comparing price estimates for different insurers because they might not cover the exact same set of services.
Some of the confusion comes from the nature of negotiations between hospitals and insurers. The focus is generally not on individual prices or on the actual cost of providing services, but on the total revenue a hospital can expect under a particular contract. Insurers, for their part, want to maintain what they see as customary rates in the market. So percentage changes are based on whatever prices existed historically. Over time, that can lead to wild distortions.
In a statement, IBC said reimbursing providers at the same rate for services might seem logical. But “hospitals have vastly different cost structures based on where they are located and what services they provide.”
Hospitals often give discounts for patients who pay cash. And administrators were supposed to report those cash prices, but not all hospitals did.
Hospitals also vary in how they set those cash discounts. For some, that price is the Medicare rate plus 15%. Tower Health sets the cash price as the average of commercial rates.
The Inquirer database does not include children’s hospitals or specialty hospitals, such as Wills Eye in Philadelphia or Rothman Orthopedic Specialty Hospital in Bensalem.
The price information could be most valuable to consumers with annual deductibles that run into the thousands of dollars. That’s because many common services have big ranges. Prices under a popular IBC preferred provider plan for an electrocardiogram, used to diagnose heart problems, range from $30 to $460.
Most people with employer-based insurance will probably not need to shop around because they don’t pay most of the bills after satisfying the deductible. Employers have more incentive to use prices, but it would take a huge amount of effort to make them useful.
A long fight over transparency
The price disclosure is rooted in a section of the 2010 Affordable Care Act called “Bringing Down the Cost of Health Care Coverage.” The law required hospitals to publish a list of “standard charges.” The Obama administration allowed hospitals to fulfill this requirement by sharing their “chargemasters,” massive lists of highly inflated prices that almost no one pays.
The Trump administration took it further, pushing for the publication of real prices. It got its way when, on Dec. 29 a federal appeals court judge in Washington rejected a bid by hospitals to block the rule.
About a third of hospitals nationwide fully complied with the Hospital Price Transparency rule, according to an early analysis by Turquoise Health, a San Diego start-up that is compiling the data nationally.
Most health systems in the Philadelphia region have complied to some extent. The rule requires hospitals to publish prices for 300 “shoppable” services, which means they can be scheduled in advance, in a “consumer-friendly” format. It also requires them to make available a comprehensive database of all items and services in a format that can be downloaded for analysis.
Among the holdouts in the region were Grand View Hospital in Bucks County. Virtua, the largest health system in South Jersey; and Prime Health Care Services Inc., with three hospitals in the region, failed to publish anything under the new rule as of Feb. 15. Grand View did not respond to requests for comment. Virtua and Prime said they are working on a posting.
Doylestown Hospital has not published its full list of negotiated prices, providing only an interface for consumers to request prices for a specific service. In its comprehensive file, Main Line Health did not group prices into packages of services and supplies, such as those needed for a vaginal delivery of a baby.
Trinity Health Mid-Atlantic took a different tack. It posted comprehensive files, but did not show prices under individual insurance plans. Instead, Trinity, which owns St. Mary Medical Center in Langhorne, Nazareth Hospital in Northeast Philadelphia, and Mercy Fitzgerald in Darby, posted ranges for Medicare, Medicaid, and commercial insurance.
What about the consumer?
Eliza Morrison of Spring City has an Independence Personal Choice plan with an $8,000 annual deductible and said she would be glad to compare prices for health care if they were readily available.
“I don’t know what the argument would be in favor of keeping consumers in the dark about pricing,” she said.
That stance is not unusual, but even when prices are available, consumers tend not to use the information, in part because they stick with their doctors and other providers their doctors or friends recommend, experts said.
“Americans don’t make great consumers of health care,” said Andrew Cavenagh, chief executive of Pareto Health Inc., a Philadelphia company that organizes health coverage for groups of employers that pay their employees’ medical bills directly.
“Even when you provide the data in an easy-to-use form, people don’t check it,” Cavenagh said. “They go to Penn because it has the best reputation, whether or not it’s the cheapest and whether or not it’s the best for that particular procedure.” They go to a particular surgeon based on a colleague’s recommendation, he said.
Another weakness of the new disclosures is that they don’t include quality information, said Neil Goldfarb, CEO of the Greater Philadelphia Business Coalition on Health. Federal regulators are telling consumers that after they find a price they should go to a Centers for Medicare and Medicaid Services web site to find out the quality of a hospital, he said.
Goldfarb doubts that a person shopping for a knee replacement is going to check five different hospital websites and than another site for quality data. “The average consumer doesn’t understand that. They’re not going to do that,” he said.
Not that Goldfarb wants to minimize the significance of the disclosures.
He called the current effort “a big step in the right direction,” but said that “it clearly has to continue to evolve.”