In June 2019, the Trump Administration issued an executive order to support patients’ need for price and quality information about “shoppable” services. The order included
- Publicly posting standard charge information in consumer-friendly as well as machine-readable formats using consensus-based data standards.
- Developing a Health Quality Roadmap that aims to align and improve reporting on data and quality measures across Medicare, Medicaid, the Children’s Health Insurance Program, the Health Insurance Marketplace, the Military Health System, and the Veterans Affairs Health System.
- Increasing access to de-identified claims data from taxpayer-funded healthcare programs and group health plans to facilitate the development of tools that empower patients to be better informed as they make decisions related to healthcare goods and services.
In June of this year, DC District Court judge Carl Nichols rejected a lawsuit from the American Hospital Association [AHA] arguing the Trump administration did not have the authority to require the publication of negotiated prices for health services. The AHA will appeal the decision, but the rule is scheduled to go into effect in January 2021.
If history is any guide, the decision to publish prices for healthcare services is unlikely to lead large numbers of patients to use that information to guide decision-making. Sinako and Rosenthal reviewed the use of Aetna’s Member Payment Estimator in 2011-12. 3.5% of subscribers used the tool at least one during the study period. The top 20 services accounted for half of all searches (23 services are listed to account for differences across the two years):
|Vaginal delivery||Physician office consult, on request of another physician|
|MRI of lower extremity joint without dye||Cesarean section|
|MRI of lower back without dye||Vasectomy in a facility|
|Intrauterine device insertion||Upper gastrointestinal endoscopy|
|Established patient nonprimary care office visit||Cataract or lens procedure|
|MRI of brain without dye||CT scan of abdomen, pelvis and chest with dye|
|Ultrasound after 14 weeks gestation||Established primary care office visit|
|Laparoscopic cholecystectomy||MRI of neck without contrast|
|Dermatology new patient office visit||Chiropractic manipulative treatment, spinal|
|Echocardiogram||Total knee replacement|
*These procedures include a version that is considered a preventive screening service, usually fully covered by insurance. Both mammograms and colonoscopies have diagnostic versions with a different set of prices that may not be fully covered by insurance. Many have argued that patients expecting a screening procedure may not be prepared for a diagnostic one (e.g., seeing an abnormality on the screening mammogram or a polyp on the colonoscopy). I am not aware of anyone helping patients make an informed decision about screening and its associated downstream testing from a value-transparency perspective.
The authors believe health care price information is most useful to patients expecting to use medical care, who can learn the price of their potential care and incorporate the information into their care-seeking decisions (e.g., preventive screenings, childbirth, imaging, and nonemergency outpatient procedures) . The Aetna Member Payment Estimator included no information about service quality. Desai et al. found 10% of employees of two large companies across multiple US markets with access to a website with price estimates actually accessed the site. Top searches were obstetric deliveries, colonoscopy, office visits and gastric bypass surgery. They found that employees randomized to access to the website had a small increase in total outpatient spending (difference in difference $59 [confidence interval $25-$93]).
Mehrotra, Chernew and Sinaiko suggested that price transparency efforts in healthcare have failed for several reasons. All listed prices may include all associated expenses (e.g., physician fees for procedures). Out-of-pocket costs are hard to discern within complicated health insurance plans. When about five percent of patients account for half of all healthcare spending, high-cost patients may not be motivated to find the lowest cost healthcare service provider. Patients may defer to their providers or prefer to stay within a specific health system to support coordinated care. The authors suggest reference pricing (14-21% savings); tiered, narrow networks (5% savings); focus on healthcare commodities like laboratory testing, imaging, direct medical equipment and physical therapy (unknown savings); and engaging physicians directly (unknown savings).
When we think about value outside of healthcare, many products and services have at least some information about the quality of what they plan to purchase. Many of us would not consider purchasing a car, home entertainment system or a cruise without considering features, costs and other people’s experiences. Consumer Reports and its competitors provide some information about specific features, costs and a subjective indicator of a product/service’s value (e.g., Editor’s choice). Instead of validating a product or service’s features or reliability, some sites (e.g., Yelp, Amazon) display the impressions of customers who have purchased the product/service. Back in healthcare, there are a few sources of quality information for elective procedures. The CDC’s Assisted Reproductive Technology site lists success rates for each clinic within the National Assisted Reproductive Technology Surveillance System. The files include numbers of attempts and success across many criteria that could help individuals decide where they might receive assisted reproduction services. The Society of Thoracic Surgeons (STS) reports quality outcomes for adult cardiac disease (coronary artery bypass surgery [with or without valve repair], aortic valve repair and mitral valve replacement/repair), congenital heart disease (across five different categories of procedural complexity) and general thoracic surgery (lobectomy for lung cancer and esophagectomy). The STS includes information about operative mortality and major morbidity, but there does not appear to be any way to track performance by age group or specific pre-operative comorbidity.
A discerning healthcare purchaser of a specific healthcare procedure might want the following quality indicators:
- Immediate and long-term success rates
- Immediate complications (including risk of death)
- Side effects (or ongoing costs) from the treatment
Considering procedure-specific endpoints would help patients, payers and employers make more informed decisions about what they were purchasing when entering into an agreement to receive a service from a provider, medical group or medical center. The International Consortium of Health Outcomes Measurement has some condition-specific measures (e.g., cataracts, diabetes, hip & knee osteoarthritis) that they suggest tracking over time. Pairing these measurements with price information might be the best way to help patients determine a provider or health system’s value in performing a specific procedure (vasectomy, cataract, laparoscopic cholecystectomy, knee replacement). Patients who may not be sure what procedure they need (vaginal delivery or Cesarean section, screening or diagnostic colonoscopy) may need additional information about how often a provider has chosen one procedure or another when working with similar patients in the past.
Although not typically considered something prospective patients might review, bundled payments could simplify the complexity around episodes of care (pregnancy, joint replacement) by listing a single price for all associated products and services (ultrasounds, physician visits and delivery for pregnancy; pre-operative visit, surgery, and post-operative care for joint replacement). Unfortunately, the documented savings to date have been small. In one systematic review of bundled payments published in January 2020, the only decrease in Medicare episode payments was in lower extremity joint replacement episodes. There were no differences in spinal fusion procedures, revision joint arthroplasty or medical conditions. Most of the observed savings across the studies were a reduction in institutional post-acute care. The lower extremity joint replacement savings ranged between two and four percent. In a Medicare difference-in-differences study, another group found a two percent reduction in total episode spending for pneumonia, but not for congestive heart failure or chronic obstructive pulmonary disease. The cost reductions seemed to be generated from more home health visits, lower skilled nursing facility utilization and lower outpatient professional fees. The savings seemed to increase as systems spent more time in the program (years 2 and 3 saw reductions approaching 10% versus less than two percent in year 1). There was no difference in overall mortality.
For patients relying on providers to evaluate new symptoms, patient-centered value transparency might be more effective if targeted toward parts of the diagnostic cascade that might be easily pulled out of a health system. Laboratory testing and imaging (CT scans, MRIs, echocardiograms) come to mind, but some referrals (dermatology, upper gastrointestinal endoscopy) might also qualify. Many practitioners might expect their “own” specialists to review diagnostic information, but that seems to be more important for those diagnostic evaluations when a subtle finding may determine next best steps. For most laboratory tests that are not pathology slides, clinicians tend to accept the values that are generated by the performing laboratory. Although this might not be as elegant as a more formal value transparency argument, determining the value of specific diagnostic procedure might help patients make specific choices about how their diagnostic work is completed.
Patients with chronic disease or requiring surveillance for disease recurrence might use a similar approach. Laboratory testing and radiology exam prices could be posted for patients to review. Most radiology facilities share images with patients, allowing some providers to get a second interpretation of the images. Unlike episodic care or a new diagnosis, value transparency for chronic disease would also include prescribing patterns as many prescriptions are required for years. Providers who use e-visits or telehealth might be perceived as higher value than providers who only perform face-to-face evaluations.
Mandating price transparency is necessary but not sufficient to help patients make value-based healthcare decisions. Until we in the healthcare industry are willing to provide more information about differences in quality, patients will struggle to translate prices into value. There should be different approaches to addressing discrete episodes of care, evaluating new symptoms and managing chronic disease.