The Need for Price Transparency in Healthcare

The United States spends $3.6 trillion each year on healthcare. That’s an average of $11,000 per person, and the Centers for Medicare and Medicaid Services (CMS) projects spending will rise to $6.2 trillion, or about $18,000 per person, by 2028.

It’s no secret most U.S. consumers are frustrated with the high cost of healthcare. In addition to $500 for the average outpatient visit, most inpatient stays run more than $22,000, resulting in this nation spending almost twice as much as the average developed country. Hospitals are one of the worse culprits, with approximately 45 percent of all spending by health insurers going to these facilities.

Addressing Complex Costs

Unlike many other services and products in the U.S., prices for healthcare often are not clear to consumers. While rules implemented under the Affordable Care Act (ACA) require hospitals to publish the standard dollar amount for the services they provide and prices have to be listed on hospitals’ websites in a machine-readable or computer-friendly format, much of the data is still too complex for patients to understand. More than 50 percent of Americans report trying to find out the price of healthcare before receiving it, but most of the prices do not take into consideration insurer-negotiated rates.

A key effort to address the high cost of healthcare for Americans has been promoting price transparency, the goal of which is to reduce healthcare costs and spur competition among providers by enabling patients to shop for healthcare services. Approximately 90 percent of U.S. residents believe the government should require hospitals and insurers to disclose prices. Without this transparency, patients can receive the same healthcare services but end up paying drastically different prices. Perhaps it’s for reasons like this that about 75 percent of patients would rather pay $50 out of pocket than not know the cost of a primary care visit, and almost half say having a clear estimate of financial responsibility will affect whether they see a certain provider.

Promoting a Myriad of Benefits

A key advantage of price transparency in healthcare is reducing costs and increasing affordability for patients, but there are a multitude of others for both providers and patients, including the elimination of surprise medical bills causing great stress, more educated healthcare purchasing decisions leading to better outcomes, easier comparison of hospital products and services, and more profitable revenue collection. For providers, offering price transparency also promotes patient engagement, which the World Health Organization (WHO) defines as “the process of building the capacity of patients, families, careers, as well as health care providers, to facilitate and support the active involvement of patients in their own care, in order to enhance safety, quality and people-centeredness of healthcare service delivery.” Patients who are fully engaged in their care are also more likely to maintain treatment plans.

Implementing an Initiative

The primary initiative from the U.S. government designed to address this issue is the CMS Final Rule on Price Transparency, which is scheduled to go into effect on January 1, 2021. According to the Department of Health & Human Services (HHA), the final rule will require hospitals to make their standard charges public in two ways:

Comprehensive Machine-Readable File: Hospitals will be required to make public all hospital standard charges (including the gross charges, payor-specific negotiated charges, the amount the hospital is willing to accept in cash from a patient, and the minimum and maximum negotiated charges) for all items and services on the internet in a single data file that can be read by other computer systems. The file must include additional information such as common billing or accounting codes used by the hospital (such as Healthcare Common Procedure Coding System (HCPCS) codes) and a description of the item or service to provide common elements for consumers to compare standard charges from hospital to hospital.
Display of Shoppable Services in a Consumer-Friendly Manner: Hospitals will be required to make public payor-specific negotiated charges, the amount the hospital is willing to accept in cash from a patient for an item or service, and the minimum and maximum negotiated charges for 300 common shoppable services in a manner that is consumer-friendly and update the information at least annually.

According to the rule, hospitals must list standard prices for 300 “shoppable services,” as well as the lowest prices they will accept from consumers paying out of pocket. Shoppable services are defined by CMS as those that can be scheduled by a healthcare consumer in advance. Hospitals and health systems that don’t comply with one or more of the rule’s requirements face a monetary penalty of up to $300 per day.

At Tripment, we believe that healthcare can be done better, and it starts with price transparency and healthcare consumerism. Contact us to learn more about the services we provide for both providers and patients.

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