Transparency in Coverage Data and Variation in Prices for Common Health Care Services.
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ABSTRACT:
SUBMITTER: Chartock BL
PROVIDER: S-EPMC10611987 | biostudies-literature | 2023 Oct
REPOSITORIES: biostudies-literature
Publications
Transparency in Coverage Data and Variation in Prices for Common Health Care Services.
Chartock Benjamin L BL Simon Kosali K Whaley Christopher M CM
JAMA health forum 20231006 10
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Project description:Competition in health care markets should lead to lower prices and less dispersion, with consumer choice as the driving mechanism. Several studies document price variation, suggesting room for improvement; however, they relied on selected data from insurers who provide access to data, limiting generalizability. We document the nature of price variation in the private US market across geography, payer, and provider by leveraging a new dataset, implementing a descriptive analysis using the most comprehensive data available: Transparency-in-Coverage. We measured health care prices in 3 ways: percentile distribution prices for common services, state-level and insurer-level facility fee price indices, and regression-adjusted mean inpatient and outpatient prices. Variation is large: the mean facility fee for a foot X-ray, for example, is $86 at Anthem and $190 at UnitedHealth. Pricing does not appear to be uniform; there is just 22% correlation between an insurer's inpatient price and outpatient facility price. And there is little difference in ordering of high-price states depending on alternative measures, such as relative to Medicare. Results suggest greater consideration of policies to address high and variable prices for US health care.
| S-EPMC11798183 | biostudies-literature
Project description:ObjectiveTo compare methods of price measurement in health care markets.Data sourcesTruven Health Analytics MarketScan commercial claims.Study designWe constructed medical prices indices using three approaches: (1) a "sentinel" service approach based on a single common service in a specific clinical domain, (2) a market basket approach, and (3) a spending decomposition approach. We constructed indices at the Metropolitan Statistical Area level and estimated correlations between and within them.Principal findingsPrice indices using a spending decomposition approach were strongly and positively correlated with indices constructed from broad market baskets of common services (r > 0.95). Prices of single common services exhibited weak to moderate correlations with each other and other measures.ConclusionsMarket-level price measures that reflect broad sets of services are likely to rank markets similarly. Price indices relying on individual sentinel services may be more appropriate for examining specialty- or service-specific drivers of prices.
| S-EPMC4693848 | biostudies-literature
Project description: Not available
| S-EPMC11415782 | biostudies-literature
Project description:BackgroundInternationally, the clinical outcomes of routine mental health services are rarely recorded or reported; however, an exception is the English Improving Access to Psychological Therapies (IAPT) service, which delivers psychological therapies recommended by the National Institute for Health and Care Excellence for depression and anxiety disorders to more than 537 000 patients in the UK each year. A session-by-session outcome monitoring system ensures that IAPT obtains symptom scores before and after treatment for 98% of patients. Service outcomes can then be reported, along with contextual information, on public websites.MethodsWe used publicly available data to identify predictors of variability in clinical performance. Using β regression models, we analysed the outcome data released by National Health Service Digital and Public Health England for the 2014-15 financial year (April 1, 2014, to March 31, 2015) and developed a predictive model of reliable improvement and reliable recovery. We then tested whether these predictors were also associated with changes in service outcome between 2014-15 and 2015-16.FindingsFive service organisation features predicted clinical outcomes in 2014-15. Percentage of cases with a problem descriptor, number of treatment sessions, and percentage of referrals treated were positively associated with outcome. The time waited to start treatment and percentage of appointments missed were negatively associated with outcome. Additive odd ratios suggest that moving from the lowest to highest level on an organisational factor could improve service outcomes by 11-42%, dependent on the factor. Consistent with a causal model, most organisational factors also predicted between-year changes in outcome, together accounting for 33% of variance in reliable improvement and 22% for reliable recovery. Social deprivation was negatively associated with some outcomes, but the effect was partly mitigated by the organisational factors.InterpretationTraditionally, efforts to improve mental health outcomes have largely focused on the development of new and more effective treatments. Our analyses show that the way psychological therapy services are implemented could be similarly important. Mental health services elsewhere in the UK and in other countries might benefit from adopting IAPT's approach to recording and publicly reporting clinical outcomes.FundingWellcome Trust.
| S-EPMC5820411 | biostudies-literature
Project description:BackgroundThe goal of this study is to estimate the association between hospital system market share and negotiated prices. Hospital system consolidation has led to many highly concentrated markets where systems can leverage their market share to negotiate higher commercial prices. Recently, the Centers for Medicare & Medicaid Services, under its Transparency in Coverage initiative, required health insurers to release all negotiated commercial prices, providing, for the first time, publicly available, nationally representative data on commercial rates. We utilize this newly available data on negotiated prices of healthcare services to show that a hospital with 10% higher market share charges 880-1,180 more per admission.Study designWe used commercial price data for national networks of three large, national insurers and performed a linear regression based on more than 1.3 million negotiated rates across 1,784 hospitals to estimate the association between a hospital's system-level market share and commercial negotiated rates, adjusting for service (DRG), health system, and area level time-invariant characteristics.ResultsWe find that a one percentage point increase in hospital system market share is associated with an $88 to $118 higher negotiated rate per admission. All else equal, a hospital that is part of a system with a 10-percentage point higher market share can expect from $880 to $1,180 more per admission relative to a hospital with lower system market share (5.4% to 6.2% of the median price).ConclusionThese findings confirm that higher hospital system market share is strongly associated with higher commercial negotiated prices and should aid policymakers and decisionmakers in assessing the impact of various policy options aimed at reducing provider consolidation in the healthcare market.Trial registrationNot applicable.
| S-EPMC11619101 | biostudies-literature
Project description:ObjectiveTo measure commercial price variation for cancer surgery within and across hospitals.BackgroundSurgical care for solid-organ tumors is costly, and negotiated commercial rates have been hidden from public view. The Hospital Price Transparency Rule, enacted in 2021, requires all hospitals to list their negotiated rates on their website, thus opening the door for an examination of pricing for cancer surgery.MethodsThis was a cross-sectional study using 2021 negotiated price data disclosed by US hospitals for the 10 most common cancers treated with surgery. Price variation was measured using within-hospital and across-hospital ratios. Commercial rates relative to cancer center designation and the Herfindahl-Hirschman Index at the facility level were evaluated with mixed effects linear regression with random intercepts per procedural code.ResultsIn all, 495,200 unique commercial rates from 2232 hospitals resulted for the 10 most common solid-organ tumor cancers. Gynecologic cancer operations had the highest median rates at $6035.8/operation compared with bladder cancer surgery at $3431.0/operation. Compared with competitive markets, moderately and highly concentrated markets were associated with significantly higher rates (HHI 1501, 2500, coefficient $513.6, 95% CI, $295.5, $731.7; HHI >2500, coefficient $1115.5, 95% CI, $913.7, $1317.2). National Cancer Institute designation was associated with higher rates, coefficient $3,451.9 (95% CI, $2853.2, $4050.7).ConclusionsCommercial payer-negotiated prices for the surgical management of 10 common, solid tumor malignancies varied widely both within and across hospitals. Higher rates were observed in less competitive markets. Future efforts should facilitate price competition and limit health market concentration.
| S-EPMC10840891 | biostudies-literature
Project description:BackgroundThe implementation of the primary health care (PHC) approach requires essential health system inputs, including structures, policies, programs, organization, and governance. Effective health system governance (HSG) is crucial in PHC systems and services, as it can significantly influence health service delivery. Therefore, understanding HSG in the context of PHC is vital for designing and implementing health programs that contribute to universal health coverage (UHC). This scoping review explores how health system governance contributes to delivering PHC services aimed at achieving UHC.MethodsWe conducted a scoping review of published evidence on HSG in the delivery of PHC services toward UHC. Our search strategy focused on three key concepts: health system governance, PHC, and UHC. We followed Arksey and O'Malley's scoping review framework and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist to guide our methodology. We used the World Health Organization's framework on HSG to organize the data and present the findings.ResultsSeventy-four studies were included in the final review. Various functions of HSG influenced PHC systems and services, including:1) formulating health policies and strategic plans (e.g., addressing epidemiological and demographic shifts and strategic financial planning), 2) implementing policy levers and tools (such as decentralization, regulation, workforce capacity, and supply chain management), 3) generating intelligence and evidence (including priority setting, monitoring, benchmarking, and evidence-informed decision-making), 4) ensuring accountability (through commitments to transparency), and 5) fostering coordination and collaboration (via subnational coordination, civil society engagement, and multisectoral partnerships). The complex interplay of these HSG interventions operates through intricate mechanisms, and has synergistic effects on PHC service delivery.ConclusionPHC service delivery is closely linked to HSG functions, which include formulating strategic policies and plans responsive to evolving epidemiological and demographic needs, utilizing digital tools, decentralizing resources, and fostering multisectoral actions. Effective policy implementation requires robust regulation, evidence-based decision-making, and continuous monitoring. Accountability within health systems, alongside community engagement and civil society collaboration, is vital for realizing PHC principles. Local health institutions should collaborate with communities-end users of these systems-to implement formal rules and ensure PHC service delivery progresses toward UHC. Sociocultural contexts and community values should inform decision-making aligning health needs and services to achieve universal access to PHC services.
| S-EPMC11870385 | biostudies-literature
Project description:BackgroundIncreasing health care expenditure in the United States has put policy makers under enormous pressure to find ways to curtail costs. Starting January 1, 2021, hospitals operating in the United States were mandated to publish transparent, accessible pricing information online about the items and services in a consumer-friendly format within comprehensive machine-readable files on their websites.ObjectiveThe aims of this study are to analyze the available files on hospitals' websites, answering the question-is price transparency (PT) information as provided usable for patients or for machines?-and to provide a solution.MethodsWe analyzed 39 main hospitals in Florida that have published machine-readable files on their website, including commercial carriers. We created an Excel (Microsoft) file that included those 39 hospitals along with the 4 most popular services-Current Procedural Terminology (CPT) 45380, 29827, and 70553 and Diagnosis-Related Group (DRG) 807-for the 4 most popular commercial carriers (Health Maintenance Organization [HMO] or Preferred Provider Organization [PPO] plans)-Aetna, Florida Blue, Cigna, and UnitedHealthcare. We conducted an A/B test using 67 MTurkers (randomly selected from US residents), investigating the level of awareness about PT legislation and the usability of available files. We also suggested format standardization, such as master field names using schema integration, to make machine-readable files consistent and usable for machines.ResultsThe poor usability and inconsistent formats of the current PT information yielded no evidence of its usefulness for patients or its quality for machines. This indicates that the information does not meet the requirements for being consumer-friendly or machine readable as mandated by legislation. Based on the responses to the first part of the experiment (PT awareness), it was evident that participants need to be made aware of the PT legislation. However, they believe it is important to know the service price before receiving it. Based on the responses to the second part of the experiment (human usability of PT information), the average number of correct responses was not equal between the 2 groups, that is, the treatment group (mean 1.23, SD 1.30) found more correct answers than the control group (mean 2.76, SD 0.58; t65=6.46; P<.001; d=1.52).ConclusionsConsistent machine-readable files across all health systems facilitate the development of tools for estimating customer out-of-pocket costs, aligning with the PT rule's main objective-providing patients with valuable information and reducing health care expenditures.
| S-EPMC11015359 | biostudies-literature
Project description:ObjectivesEffective coverage (EC) is a measure of health systems' performance that combines need, use and quality indicators. This study aimed to assess the extent to which the Kenyan health system provides effective and equitable maternal and child health services, as a means of tracking the country's progress towards universal health coverage.Methods and resultsThe Demographic Health Surveys (2003, 2008-2009 and 2014) and Service Provision Assessment surveys (2004, 2010) were the main sources of data. Indicators of need, use and quality for eight maternal and child health interventions were aggregated across interventions and economic quintiles to compute EC. EC has increased from 26.7% in 2003 to 50.9% in 2014, but remains low for the majority of interventions. There is a reduction in economic inequalities in EC with the highest to lowest wealth quintile ratio decreasing from 2.41 in 2003 to 1.65 in 2014, but maternal health services remain highly inequitable.ConclusionsEffective coverage of key maternal and child health services remains low, indicating that individuals are not receiving the maximum possible health gain from existing health services. There is an urgent need to focus on the quality and reach of maternal and child health services in Kenya to achieve the goals of universal health coverage.
| S-EPMC5396138 | biostudies-literature
Project description:PurposeThe American Society of Clinical Oncology Cancer Survivorship Committee established a task force to determine which survivorship care services were being denied by public and private payers for coverage and reimbursement.MethodsA quantitative survey instrument was developed to determine the clinical practice-reported rates of coverage denials for evidence-based cancer survivorship care services. Additionally, qualitative interviews were conducted to understand whether coverage denials were based on payer policies, cost-sharing, or prior authorization.ResultsOf 122 respondents from 50 states, respondents reported that coverage denials were common ("always," "most of the time," or "some of the time") for maintenance therapies, screening for new primary cancers or cancer recurrence. Respondents reported that denials in coverage for maintenance therapies were highest for immunotherapy (41.74%) and maintenance chemotherapy (40.17%). Coverage denials for new primary cancer screenings were highest for Hodgkin lymphoma survivors needing a PET/CT scan (49.04%) and breast cancer survivors at a high risk of recurrence who needed an MRI (63.46%), respectively. More than half of survey respondents reported denials for symptom management and supportive care services. Fertility services, dental services when indicated, and mental health services were denied "always" or "most of the time" 23.1%, 22.5%, and 12.8%, respectively. Respondents reported they often had a process in place to automatically appeal denials for evidence-based services. The denial process, however, resulted in greater stress for the patient and provider.ConclusionOur study demonstrates that additional advocacy with payers is needed to ensure that reimbursement policies are consistent with evidence-based survivorship care services.
| S-EPMC10874319 | biostudies-literature