| 摘要 | The Trump administration’s new proposed regulation on hospital price transparency is an important step toward consumer-friendly price information. For the first time, it introduces into federal price transparency requirements the concepts of service standardization, consumer-friendly organization and terminology, and bundling, all of which are crucial for the marketplace to become more price competitive.
However, as the administration acknowledges, this regulation by itself will not fully address the opacity of today’s market. Further disruptive changes will be necessary to give consumers usable pricing information. Among other things, meaningful transparency requires even stricter standardization of the services being priced and “all in” pricing that matches how consumers think about the services they need.
In addition, reform of the nation’s insurance payment system must be integrated into the price transparency effort to ensure consumers are price sensitive across a wider range of services. Suppliers of services will only compete on price when significant numbers of consumers have strong incentives to seek out low-cost alternatives.
Disclosing Privately Negotiated Rates
The new price disclosure provision is included as a proposed requirement in the administration’s annual rule governing hospital outpatient services. It will go into effect, if finalized, in 2020 unless threatened lawsuits by hospitals are successful in delaying it. The new rule supplements an existing requirement, from a rule published last year, which forced hospitals to post online all of their chargemaster rates starting in January of this year.
Hospitals, and insurers, are balking at the new rule because it forces them to disclose confidential price information that they view as fundamental to their business operations and financial viability. Hospitals responded to the requirement that went into effect this year by posting online their chargemaster rates for the thousands of codes used in today’s insurance billing system. Most of the information now available online is indecipherable to the lay consumer but can be used by technology companies to refine price transparency tools. The new proposal would require supplementing the existing chargemaster rates with the actual rates paid by insurers for those same codes.
The industry argues that public disclosure of these heretofore confidential rates would backfire and increase prices; hospitals would be less willing to make selective pricing concessions for fear of having to extend them to all payers. Put another way, transparency could undermine the ability of the insurers with the most leverage to get deeper discounts than their competitors from hospitals.
That’s possible, but it assumes that payers do not already have a good idea of the discounts their competitors have secured with hospitals, which may not be true in many cases. Moreover, given the opacity, dysfunction, and high costs prevalent in the current marketplace, it is worth taking the risk of disrupting existing business practices to facilitate both new private-sector strategies and better public oversight of the market. Disclosure is likely to expose true outliers, and possibly abusive pricing practices, that are harming consumers enrolled in plans with weak leverage.
Transparency might also help generate new business opportunities to build networks that steer patients based on differential pricing patterns exposed by the new data. It would also lead facilities to lower prices in some cases to avoid embarrassing disclosures.
Like the posting of chargemaster rates, the unveiling of privately negotiated rates for thousands of billing codes is unlikely to be of much direct use to consumers, but that is not the point of the effort, as noted by the administration. The real aim is to enable more outside scrutiny of pricing across competing facilities and thus facilitate strategies in the private sector to lower overall costs of care.
Prices For “Shoppable” Services
A major innovation in the new rule is the introduction of a short list of “shoppable” services for which hospitals must disclose relevant prices in a consumer-friendly manner. Shoppable medical services are defined as those that can be scheduled in advance by the patient.
Hospitals would be required to post their privately negotiated rates for a list of 300 shoppable services. In the regulation, the Centers for Medicare and Medicaid Services (CMS) specifies 70 of the services that must be included in every hospital’s pricing list; hospitals are free to choose the other 230 themselves. (In the event a hospital does not provide all 70 of the services on CMS’s list, it is required to specify other services to ensure it provides pricing for a total of 300 items.)
CMS’s list of 70 services includes common physician services, laboratory and pathology services, radiology services, and medical and surgical procedures. Requiring all hospitals to disclose pricing for these services is the necessary first step toward facilitating apples-to-apples price comparison across facilities.
The shoppable services proposal also takes a step toward “all in” pricing by requiring hospitals to couple pricing for primary services with the ancillary services that usually accompany them. The primary services and the ancillary services would be grouped together to make it easy for consumers to see the expected comprehensive price for the primary services. This is a particularly relevant requirement for medical and surgical procedures, which usually come with additional charges for radiology, pathology, an operating room, and therapy services.
Facilitating The Consumer Role
The administration’s proposal is encouraging because, while it is only a first step, it is consistent with a strategic framework that would allow consumers to play a more active role in the market for medical services.
As deductibles have risen in recent years, consumers have used less services but have not engaged in meaningful price shopping before getting care, despite the growing prevalence of price transparency tools. Major barriers have been the fragmentation price data and the lack of standardization of what is being priced. The administration’s proposed regulation begins to address both issues.
Fragmented Price Data
Consumers want to know the “all in” price for the services they need and do not have the time or expertise to gather up pricing information from multiple billing parties. It would be much better for consumers if pricing were set based on definitions of services that cover an episode of care, rather than based on billing conventions. For instance, consumers can understand pricing that is set for an elective surgery that covers the surgeon’s fee, the facility fee, anesthesia, lab tests, follow-up care, and whatever else might be necessary to successfully care for the patient while providing the service. Hospitals and clinicians are unlikely to change their business practices to make pricing of this kind available to consumers unless it is required in federal regulations.
The Need For Standardized Bundles
Standardization is also critical. Consumers need to know that when they are comparing prices between competing suppliers, there is not a substantial difference in the services covered in the various prices. If one price includes follow-up care and lab tests, and the others do not, consumers will not have confidence that they know how to assess the overall value of what is being provided. Consumers will hesitate to make care decisions based on price unless they are certain they are making apples-to-apples comparisons.
The administration’s proposal introduces bundled pricing and standardization into the transparency framework, but only tentatively. As noted, at least 70 of the 300 shoppable services will be identical (or nearly so), which is a first step toward a uniform federal pricing list. The rule also requires hospitals to post private-payer rates for ancillary services related to the primary services on the CMS list, which is a first step toward “all in” pricing that would be easier and more meaningful for consumers to use.
Unfortunately, hospitals can vary the ancillary services that are grouped together under different primary services. This makes it difficult if not impossible for consumers to ascertain fully comparable pricing. Even small barriers to transparent pricing can be enough to discourage an active consumer role.
The Missing Price-Sensitive Consumer
While the administration’s rule is a welcome first step, it would not usher in a major shift in the consumer role, in large part because consumers are not sensitive to price differences in many cases. Even with high deductibles, patients with expensive conditions often expect to satisfy their deductibles no matter how much they shop for lower-price care, so it is not possible for them to reduce their out-of-pocket spending. Moreover, insurers have already negotiated preferential pricing with preferred hospitals and physicians for enrollees in private coverage, and the consumers in these plans correctly assume they will minimize their own expenses if they simply stay in-network when getting care. For them, price shopping will not make much of a difference.
The prices posted by hospitals will be meaningful, and competitive, only when they are relevant to greater numbers of consumers. In the administration’s proposed regulation, hospitals are not being asked to specify a price for a group of consumers who are ready to use that information to make care decisions. Rather, hospitals are disclosing prices that are either only rarely used by direct-pay consumers (chargemaster rates) or available to enrollees who have little incentive to worry about pricing matters (private-pay rates). In this context, these prices may or may not bear much resemblance to the prices that would be disclosed if large numbers of consumers were price sensitive and likely to act on the prices being posted by the hospitals.
Greater numbers of consumers could be made price sensitive for a wider array of medical services through a system of universal reference-based payments. As has been documented by previous research, reference-based payments by insurers provide strong incentives for patients to seek out lower-price care. Consumers would be price sensitive for the shoppable services on the CMS list if their insurers were required to make reference-based payments for those services for all out-of-network care. Consumers could stay in-network and get the negotiated rates secured by their insurers or go out of network and use a reference-based payment to cover at least part of the cost of the services they receive. Ideally, consumers should be allowed to keep 100 percent of the savings when selecting out-of-network providers with prices below the reference-based payments made by their insurers.
Would it work? On the one hand, one must assume that private insurers are already getting the most preferential rates available for their enrollees, as they represent large groups of consumers and thus have more leverage than individual patients. On the other hand, there’s no reason to believe that the high cost of hospital-based care has no room for cost cutting. Standard, bundled pricing, along with reference-based payments would open new opportunities for entrepreneurial providers to attract market share with aggressive price reductions.
Summing Up
The administration’s proposed regulation is unpopular with the hospital and insurance industries because it disrupts the status quo and requires adjustments to their current business models. Given the strain high costs are placing on employers, workers, and taxpayers, some disruption is called for to facilitate new strategies and perhaps new policy initiatives to help bring costs under better control.
While the administration’s proposal is a welcome development, it doesn’t fully address the barriers that limit the consumer role today. Easily accessible price information is a necessary condition of a functioning market, but it is not sufficient in the case of medical services. The prices also need to be based on standardized, episode-based services that are defined in ways that are meaningful to consumers. The administration’s proposal is an acknowledgement that these are important considerations that will require further regulatory steps and possibly even changes in current law.
For more analysis on price transparency in health care, read the longer paper on this topic here. |
