VI. Key Issues: Financing and Delivery >> A. Health Spending >> Health Cost Containment >> Promote Competition >> Transparency (last updated 9.20.17)
- 1 Overview
- 2 Policy Problem
- 3 Overview of Transparency Tools
- 4 Private Initiatives to Improve Transparency
- 5 Public Initiatives to Improve Transparency
- 6 News
- 7 Links
This page addresses the benefits and costs of various approaches to increasing price and quality transparency to consumers. See Transparency under Health Reform for a discussion of health reform policy proposals related to increasing transparency that are under discussion and not yet adopted or implemented.
- According to survey of 1,000 working-age adults commissioned by CIGNA:
- 20% of women compare the costs of doctors and medical procedures vs. 15% of men.
- 79% of women purchase generic medications instead of name-brand drugs vs. 69% of men.
- A study involving 20 focus groups in Santa Monica, CA and Washington, DC showed:
- Patients for the most part did not want cost to play any role in decision-making;
- “There was an almost vengeful attitude toward insurance companies, the idea that “I’ve been paying in and now I’m going to get what I’m owed,” or “I’m going to get them back for all the money I’ve paid in all these years.””
- Lack of Cost Transparency (video: BC/BS of NC).
- Unknown Pricing (video: BC/BS of NC).
Overview of Transparency Tools
Private Initiatives to Improve Transparency
General Comparison Sites
- Center for Value in Improving Healthcare (CVIHC) “is providing cost and quality insights by analyzing claims data for various medical procedures. CIVHC uses the all payer claims database, which includes claims from insurers, Medicaid, and Medicare, to help make healthcare prices public…Led by the increasing deductibles and copayments that leave patients responsible for a growing share of costs, as well as by a pressing need to bring healthcare costs down, pricing transparency may for the first time let prospective patients know how much a hospital stay or procedure will cost in advance. In general, people without insurance pay the ‘rack rate,’ or the highest charge, which no insurance company or public payer pays. In addition, every insurance contract is different, and the exact same procedure may cost thousands more in one part of a state than another.” (Behavioral Healthcare, 4.17.14)
- Healthcare Blue Book. The Healthcare Blue Book is a free consumer guide to help you determine fair prices in your area for healthcare services. If you pay for your own healthcare, have a high deductible or need a service your insurance does not fully cover, we can help. The Blue Book will help you find fair prices for surgery, hospital stays, doctor visits, medical tests and much more.
- Pricing Healthcare. People love a good market, aisle after aisle lined with vendors’ tables and tents. American healthcare needs this. We’ve built a place where providers of all types can advertise bundled, cash-pay procedures, without putting contracted or government relationships at risk, and where employers of any size can supplement their network with widespread direct contracting.
Physician Comparison Sites
- FH Medical Cost Lookup. The FH Medical Cost Lookup offers information on estimated costs for healthcare professionals’ services for medical procedures, including a limited number of anesthesia services available on FH Estimate Assist®. At this time the website does not include charges for durable medical equipment or separate facility fees, which may be billed in addition to healthcare professional fees, when services are performed in a hospital, freestanding clinic, or other treatment center. Over time, the FH Medical Cost Lookup will be expanded to include this information. The data is based on 15 billion medical claims from 70 private health and dental insurers.
- PokitDok. This is a relatively new website whose mission is to provide a transparent health marketplace where consumers can shop for health services from verified providers, clear service descriptions and posted prices. Users search 3 million providers, shop for services and request quotes from providers, along with service guarantees.
- ZocDoc. Started in 2007, ZocDoc is a free service that allows patients to find a nearby doctor or dentist who accepts their insurance, see their real-time availability, and instantly book an appointment via ZocDoc.com or ZocDoc’s free apps for iPhone or Android. By revealing the ‘hidden supply’ of appointments, ZocDoc helps most patients get access to care in just 24 – 72 hours. The company’s most recent product, ZocDoc Check-In, allows patients to fill out their paperwork online in advance of their appointment, and a Spanish-language version called ZocDoc en Español is also available. More than 2.5 million people use ZocDoc each month across 1,800+ cities, covering 40 percent of the US population.
Hospital Comparison Sites
- OpsCost. Compare charges for common procedures at over 3,300 hospitals, sourced from government data and user reported bills. Users can select Location and Procedure to find the average amount billed and reimbursed by Medicare for a given procedure at the 10 nearest hospitals, sorted by distance from the location entered.
- Hospital Adviser. Consumer Reports won a RWJF transparency challenge for is Hospital Adviser app. Its app is designed to inform consumers seeking the best hospital for hip or knee replacement surgery. Consumers can include their experience and notes in one place. Chris Bailey, who is developing the app, said it’s currently in private Beta and would use feedback from users to tweak it.
Pharmaceutical Price Comparison Sites
- myDrugCosts Public provides basic information on prescription drug savings. It is available without registration from the myDrugCosts.com website.
- myDrugCosts Premium provides comprehensive information on prescription drug savings specific to your health plan. You must Sign Up to use myDrugCosts Premium.
Price tools typically are for members only.
- Aetna. Aetna members can use Aetna Navigator to find:
- Estimated average costs in your area for certain office visits, diagnostic tests, vaccines, and surgical and scope procedures (“Scope” refers to an instrument used to examine an inner part of the body and, with an attached instrument, to perform a biopsy or surgery.)
- Estimated average costs in your area for certain dental procedures (if you are enrolled in an Aetna dental plan)
- Annual estimated average costs in your area for treating specific diseases and conditions
- Costs for specific brand and generic drugs filled at participating retail drug stores or ordered through Aetna’s mail order program (if you are enrolled in an Aetna pharmacy plan)
- Cigna. Cigna allows customers to assess medical costs – including specialist, facility and related fees – according to the real-time status of their health plan deductibles and co-insurance, as well as their available health spending account funds, before choosing their physician.
- UnitedHealthcare. The myHealthcare Cost Estimator provides cost estimates to members based on available fee schedules or contracted rates (when fee schedules/contracted rates are not available, estimates are based on claims averages for the particular provider).
The following are examples of private providers who have posted their prices on-line for anyone to view:
- Surgery Center of Oklahoma. This long list of prices is sorted by body part.
Public Initiatives to Improve Transparency
These data summarize the utilization and payments for procedures and services provided to Medicare fee-for service beneficiaries by specific inpatient and outpatient hospitals, physicians, and other suppliers. These data include information for the 100 most common inpatient services, 30 common outpatient services, and all physician and other supplier procedures and services performed on 11 or more Medicare beneficiaries. Separate data are available for:
- Inpatient. The data provided here include hospital-specific charges for the more than 3,000 U.S. hospitals that receive Medicare Inpatient Prospective Payment System (IPPS) payments for the top 100 most frequently billed discharges, paid under Medicare based on a rate per discharge using the Medicare Severity Diagnosis Related Group (MS-DRG) for Fiscal Year (FY) 2011 and 2012. These DRGs represent more than 7 million discharges or 60 percent of total Medicare IPPS discharges. For these DRGs, average charges, average total payments, and average Medicare payments are calculated at the individual hospital level. Users are able to make comparisons between the amount charged by individual hospitals within local markets, and nationwide, for services that might be furnished in connection with a particular inpatient stay.
- Outpatient. The data provided here include estimated hospital-specific charges for 30 Ambulatory Payment Classification (APC) Groups paid under the Medicare Outpatient Prospective Payment System (OPPS) for Calendar Years (CY) 2011 and 2012. The Medicare payment amount includes the APC payment amount, the beneficiary Part B coinsurance amount and the beneficiary deductible amount.
- Physician and Other Supplier. The Physician and Other Supplier PUF contains information on utilization, payment (allowed amount and Medicare payment), and submitted charges organized by National Provider Identifier (NPI), Healthcare Common Procedure Coding System (HCPCS) code, and place of service.
State Hospital Databases
- Arizona. Department of Health’s website Arizona Price Compare compares prices for certain procedures across hospitals for 2011.
- California. Common Surgeries and Price Comparison is a website allowing healthcare consumers to view and compare the price of 28 common elective inpatient procedures at hospitals across California.
- Florida. The state set up a website that enables consumers to obtain data on hospitals’ charges and readmission rates.
- Maryland. The state’s Health Care Commission provides consumers with an online hospital pricing guide that lists, for each acute care hospital in Maryland, the number of cases, the average charge per case, and the average charge per day for the 15 most common diagnoses.
- New Hampshire. The state’s website gives prices for certain procedures based on age and whether the patient is insured or not.
- New Jersey. The state launched a website to help consumers make informed choices regarding price and quality of hospital services in New Jersey.
- Oregon. The Oregon Pricepoint website is sponsored and maintained by the Oregon Association of Hospitals and Health Systems and allows health care consumers to receive basic, facility-specific information about services and charges.
On 3.25.14, a Forbes blogger reported: In their “Report Card on State Price Transparency Laws,” the nonprofit Health Care Incentives Improvement Institute and Catalyst for Payment Reform, gave 45 states a failing grade with the highest grades awarded to Maine and Massachusetts, which each received a “B.” No states received an “A.” States with high grades generally share information about inpatient and outpatient services via a website that can be accessed by anybody. See also: http://medcitynews.com/2013/12/whats-needed-make-future-healthcare-prices-transparent/#ixzz2mzYUawXh
- Does ERISA Preempt State Databases? SCOTUSBlog reports (11.25.15) that the Supreme Court has accepted a case to consider whether ERISA preempts state health-care databases. “The question here is whether the Employee Retirement Income Security Act of 1973 (ERISA) preempts state statutes that provide for “all payer” health care databases – designed to provide comprehensive state-level information about the distribution of health care services provided in the state and the costs of providing them.The statute at issue here authorizes Vermont’s database, but there is nothing unusual about Vermont’s program; more than a dozen states manage similar databases. The statute obligates all providers of health care in the state to provide detailed data about their services – what services they provide, how much they cost, where they are provided, and the like. The detailed data helps Vermont to understand a variety of things of import in managing health-care expenditures: variations in cost by location and over time, variations in the use and effectiveness of procedures, variations in the choices between pharmaceuticals and more intrusive interventions and the like. The case comes to the Supreme Court because ERISA plans provide some, though obviously not all, health care in Vermont. Because Vermont’s statute requires those plans to provide data, it imposes a burden on them that they otherwise would not have, which comes in addition to the numerous reporting and disclosure obligations the plans already have for the federal Department of Labor.”
- Case Details. Links to all proceedings and orders starting 8.13.14.
- Bagley, Nicholas, and Christopher Koller. “Transparency and the Supreme Court — Can Employers Refuse to Disclose How Much They Pay for Health Care?” New England Journal of Medicine November 25, 2015. The Court will hear argument in Gobeille on December 2. If it sides with Liberty Mutual, its decision will not only thwart state efforts to shed some badly needed light on the byzantine way medical services are priced, but it will also circumscribe states’ authority to experiment with new approaches to overseeing their health care markets. In the wake of an adverse decision, individual states would be left to negotiate with national self-insured companies, most of whom would see no compelling reason to accommodate the states’ varied requests when they can reap the benefits of any successful local efforts without participating.
- U.S. Supreme Court Deals Blow to CT Health Data Collection Effort. “In a ruling that could have reverberations for a Connecticut health reform effort, the U.S. Supreme Court ruled Tuesday that certain health plans could not be required by a state to disclose data for use in a health care claims database…Close to 20 states, including Connecticut, are developing or already have databases of medical, dental and pharmacy claims that can show what health care services residents used and what was paid for them. Proponents of the databases say they can be a key tool in better understanding health care service usage and costs, including price variation and gaps in access to care.” (Connecticut Mirror, 3.1.16)
- Hospitals, Physicians Face Mounting Policy and Market Pressure to Disclose Prices. “Both conservative and liberal policy analysts long have supported the concept of giving consumers price and quality information to enable them to shop around for the best deals on healthcare services… Despite the growing clamor for transparency, providers and insurers continue to argue that the prices they charge and pay are business secrets and that publicly disclosing those rates would hurt their bargaining positions and jeopardize their finances. But even some healthcare providers are losing patience with that argument. ‘It is shocking to us, as a full-service academic medical center, to see that we have to pay 35% more when our employees end up at another hospital,’ said Steven Sonenreich, CEO of Mount Sinai Medical Center in Miami Beach. ‘We need to continue to inform the public that a lack of price transparency is driving up expenses for employees and employers.’” (Modern Healthcare, 1.18.14)
- Fight Over a State Healthcare Transparency Bill Goes Mostly Uncovered. “In Ohio, 3rd Rail Politics—a blog that pledges to show ‘the side of politics other publications ignore’—recently detailed the political hardball that has blocked the implementation and enforcement of a patient protection law. The Healthcare Price Transparency Law, written by Republican state Rep. Jim Butler and passed in 2015, would require the state’s hospitals, doctors and other healthcare providers to disclose their prices for non-emergency services—a rule that should appeal to anyone who has experienced “sticker shock,” a 3rd Rail blogger wrote. But the law has yet to take effect—and it might not, if the state’s biggest healthcare stakeholders have their way. ‘The hospital association is fighting the hardest to avoid this, and their strategy is to divert the effort,’ says Butler. ‘They don’t want their patients to shop for healthcare.’… Prices of medical procedures can vary widely, and the Health Care Cost Institute (HCCI) proved as much in Ohio. HCCI evaluated claims data from four of the country’s largest insurers and found that Ohio residents pay more than 30 percent above the national average for common medical procedures including CT scans, breast ultrasounds, abdominal ultrasounds, and thyroid tests. (State residents also pay 10 percent more for many other services that are shoppable.) There were also meaningful differences within the state: When Health Affairs published a study comparing price variations for medical services, its blog editor noted that a pregnancy ultrasound in Cleveland costs three times more, on average, than the same procedure costs in nearby Canton.” (Columbia Journalism Review, 4.6.17)
- Transparency (Health Affairs search)
- Castlight Health enables employers, their employees, and health plans to take control of health care costs and improve care. Named #1 on The Wall Street Journal’s list of “The Top 50 Venture-Backed Companies” for 2011 and one of Dow Jones’ 50 Most Investment-Worthy Technology Start-Ups, Castlight Health helps the country’s self-insured employers and health plans empower consumers to shop for health care.
- Castlight Health. Health Care Transparency 101: What Employers Need to Know Now
- Castlight Health. Infographic: The Case for Health Care Transparency. April 11, 2013.
- Public Citizen. Shedding Light on Health Care Prices: Patient Perspectives on Health Care Price Transparency Efforts. 8.3.16.