This article was originally published May 4, 2021.
Effective January 1, 2021 there are new rules for hospital charges
or prices and how this is communicated to customers in the United States.
Hospitals must host their negotiated prices and chargemaster (gross prices) in
a machine-readable file online. (Health and Human Services Agency
of United States, 2019) In an effort to see how compliance was
going for this gargantuan task, I surveyed a number of hospitals throughout the
country.
Methods: Data was extracted for two cardiac procedures with major
complications, installation of a shunt and a stent, through verification of the
diagnostic code and procedure description. Chargemaster is the universal guide
that US hospitals use for procedure charges. Prices were analyzed for the gross
price, cash payer or uninsured individual payor payments, and private insurance
company reimbursements. Only Virginia Hospital Center Health System provided
detailed data by each insurer contract, the rest were aggregated, based on a
median or an average, depending on what the hospital provided. A table was made
to show the variance between the self-pay and insurance reimbursed prices. Since
the hospitals are in different regions of the country the price per hospital
comparison reflects cost factors on the East coast, Midwest, and the Pacific
Northwest. All hospitals are nonprofit entities.
|
Procedures by Price
|
Ventricular shunt with major complications
|
Stent with major complications, 4 arteries
|
|
Hospital
|
Virginia
Hospital-Arlington
|
Virginia
Hospital-Arlington
|
|
Price-Chargemaster
|
$52,999.45
|
$68,262.05
|
|
Price-Self-Pay
|
$42,399.56
|
$54,609.64
|
|
Price-Insurance Contracts
|
$35,968.97 (average/all payers)
|
$27,973.02 (average/all payers)
|
|
Hospital
|
Mayo
Clinic-Rochester
|
Mayo
Clinic-Rochester
|
|
Price-Chargemaster
|
$40,370.55
|
$84,190.96
|
|
Price-Insurance Contracts
|
$17,453.37 (median value)
|
$30,194.61 (median value)
|
|
Hospital
|
University
of Washington-Seattle
|
University
of Washington-Seattle
|
|
Price-Chargemaster
|
Search did not provide
|
$158,736.00
|
|
Price-Insurance Contracts
|
Search did not provide
|
$100,004.00 (gross less discounts)
|
|
Hospital
|
Virginia
Mason Hospital-Seattle
|
Virginia
Mason Hospital-Seattle
|
|
Price-Chargemaster
|
$61,42.33
|
$101,811.59
|
|
Price-Insurance Contracts
|
Not provided
|
Not provided
|
Results Best to Worst for Transparency
1. Virginia Hospital Center Health System-Arlington (DC area)-This
east coast health system provides an extractable EXCEL file which discloses;
gross price in the chargemaster, what the uninsured might pay, and each
insurance companies payment by procedure. This was easy to use and thoroughly
complied with hospital pricing transparency and is included in the price comparison
table. https://www.virginiahospitalcenter.com/patients-visitors/billing-financial-assistance/price-transparency/
2. Mayo Clinic-Rochester-Provides a machine-readable CSV file
of its entire chargemaster file, which can be converted to EXCEL and takes 30
minutes to download, but this would allow analysis by procedure. However, the
data does not allow for discernment by insurer or by self-pay customers.
Finally, the file size is so large most individual users would not be able to
extract and save it, but analysts will love it. https://www.mayoclinic.org/patient-visitor-guide/billing-insurance/price-estimates/chargemaster
3. University of Washington Medical Center-This Seattle
hospital provides a downloadable file of its average DRG code charges per case,
but no information on insurance company prices. There was some information on average
discount per procedure offered in aggregate, but it was not possible to discern
how this would impact privately insured customers versus those without medical
insurance. This might comply with the 2021 pricing transparency ruling. I was
able to make a rough calculation of the cost at the patient level per procedure,
by calculating the aggregated discount it provided for all payors. https://www.uwmedicine.org/patient-resources/billing-and-insurance/charge-description-master-codes
4. Virginia Mason Medical Center-Seattle- Provides their chargemaster
and median insurance payor reimbursement data. Therefor this data may meet the
legal requirements of the transparency law but it will not be helpful to
consumers because it doesn’t differentiate between insurer contract prices and
what cash payers are charged. https://www.virginiamason.org/virginia-mason-standard-charges
5. Kaiser Permante Foundation Hospital-Central-Hosts a limited
tool to assess procedure costs, but does not show its entire chargemaster
schedule from which to gauge baseline costs and actual costs paid by insurers by
diagnostic code or procedure. It provides a very limited list of inpatient
procedures and I was unable to find a match for a common cardiac procedure when
I searched the EXCEL file. https://wa.kaiserpermanente.org/html/public/health-plans/hospital-charges
Analysis
Determining what you will actually end up paying for medical
procedures in the US is fraught with risks and this regulation, created under
the Trump Administration is a step towards greater transparency. The prices are
based on the Medicaid and Medicare diagnostic codes and the hospital
chargemaster data, but do not necessarily reveal all that a patient might pay.
A median charge is not the same as what you might actually pay. However, if an organization
wants to review price and quality rankings when contracting for services it is
a baseline. Each hospital has a department which advises the patient on her financial
responsibility at the time of admission. Of course, in the event of an
emergency this is moot, because your life, presumably is more important.
And this is the healthpolicymaven signing off encouraging
you not to sign blanket releases when you consent for procedures, do indicate
that for which you consent and which you decline. This is absolutely critical
now when more hospitals are Catholic owned enterprises which apply Catholic law
in their health practices, regardless of your theology. If you have specific
end-of-life instructions, make sure you have an advanced medical directive in
place, so your life is not held in the balance because of an ethics committee
decision.
This column has been in continuous publication since 2007
and does not purport to provide medical advice and does not accept remuneration from any company in the healthcare industry. Healthpolicymaven is a
trademark of Roberta Winter and her company.
References
Health and Human Services Agency of United States.
(2019, November 27). Price Transparency Requirements For Hospitals To Make
Standard Charges Public. (H. a. Department, Editor) doi:84 FR 65524
