Abstract
Background:
While transthoracic echocardiography (TTE) is responsible for more Medicare spending than any other cardiovascular imaging procedure, little is known about its commercial cost footprint. The 2021 Hospital Price Transparency Final Rule mandated US hospitals publish their insurer-negotiated and self-pay prices for services. This study sought to characterize and assess factors contributing to variation in TTE prices.
Methods:
We used a commercial database containing hospital-disclosed prices to characterize variation in TTE prices within and across hospitals. We linked this price data to hospital and regional characteristics using Medicare Facility IDs.
Results:
1949 hospitals reported commercial prices. Among reporting hospitals, median commercial and self-pay prices were 2.93- and 3.06-times greater than the median Medicare price ($1313 and $1422, respectively, versus $464). Within hospitals, the 90th percentile payer-negotiated rate was 2.78 (IQR 1.80–5.09) times the 10th percentile rate (within-center ratio). Across hospitals within the same hospital referral region (HRR), the median price at the 90th percentile hospital was 2.47 (IQR 1.69–3.75) times that at the 10th percentile hospital (across-center ratio). On univariate analysis, for-profit (p=0.04), teaching (p<0.01), investor-owned (P<0.01), and higher-rated hospitals (p<0.01) charged higher prices, whereas rural referral centers (p=0.01) and disproportionate share hospitals (DSH) (p<0.01) charged less. On multivariate analysis, the association between these characteristics and TTE prices persisted, except investor ownership and rural referral centers.
Conclusions:
Self-pay and commercial TTE prices were higher than Medicare prices and varied significantly within and across hospitals. For-profit, teaching, and higher-rated hospitals had higher prices, in contrast to DSH hospitals. Better understanding the relationship between this cost variation and quality of care is critical given the impact of cost on healthcare access and affordability.
Introduction
Cardiovascular imaging comprises a large portion of overall healthcare spending in the US. Transthoracic echocardiography (TTE) is responsible for more Medicare spending than any other cardiovascular imaging procedure.1 In 2019, over 7.5 million TTEs were performed among Medicare fee-for-service patients, costing Medicare more than $900 million.1
These costs are set against a backdrop of rising healthcare expenditures in the US. Mounting healthcare costs are outpacing wage growth, leading to increasing concern about the impact on access and affordability.2,3 Data suggest that patients with cardiovascular disease with significant financial burden experience decreased quality of life and worse outcomes due to financial toxicity, which can lead to medication nonadherence, delayed or forgone care, and food insecurity.4–7 Despite the impact of healthcare costs on equity and financial toxicity, little is known about the actual rates charged by providers and how they vary across hospitals.8
To promote cost transparency, the 2021 Hospital Price Transparency Final Rule mandated hospitals publicly disclose insurer-negotiated and self-pay rates for all medical services.9 We sought to characterize the variation in TTE cost both within and across US hospitals using self-reported hospital prices compiled in a commercial database.10 We evaluated the association between TTE costs and hospital, regional, and market characteristics. We hypothesized that insurer-negotiated and self-pay TTE prices would be significantly higher than the Medicare rate and that prices would vary widely across payers and hospitals irrespective of regional cost of living indices.
Methods
Price Transparency Legislation
In January 2021, a Congressional mandate termed the federal Hospital Price Transparency Final Rule required all US hospitals release a publicly available, machine-readable file containing pricing information on all items and services. The requirements under the new legislation include disclosure of standard charges, including the gross (“chargemaster”) price, discounted cash (“self-pay”) price, and private insurer negotiated (“commercial”) prices). Hospitals not compliant with this rule are subject to daily fines.
Data Source
This study used the Turquoise Health database, a commercial data source containing basic hospital characteristics and self-reported prices from 4,691 US hospitals. This database uses automated data scripts to extract price information from each hospital’s machine-readable file. We included hospitals reporting prices for common procedural terminology (CPT) code 93306 (transthoracic echocardiography with Doppler, complete). The data were queried on May 7th, 2022 and reflect cross-sectional pricing data compiled from 2021–2022. To assess the reliability of these data, we randomly selected and reviewed machine-readable files from 100 hospitals and found 100% accuracy. We excluded hospitals with the following identifiers: psychiatric, children’s, rehabilitation, imaging center, acute care - Department of Defense, Veterans Affairs, and missing CMS certification number (CCN), as these hospitals likely differ in their operational structure and requirement to report data. We also excluded hospitals with fewer than 2,000 discharges annually. eTable 1 summarizes the cohort creation process. This study was deemed to be institutional review board exempt as it involved analysis of publicly available, de-identified data.
Data Linkages and Variables
We linked the Turquoise Health data to hospital characteristics via each hospital’s Medicare Facility ID (eTable 1). Using the Medicare Provider of Service (POS) file, we extracted the hospital type, ownership structure, inpatient bed number and location.11 Using the HCAHPS and Medicare Hospital Compare databases, we captured hospital ratings in terms of patient experience, effectiveness of care, overall rating, and mortality.12,13 Using the American Hospital Association (AHA) Survey, we extracted each hospital’s teaching status, urban/rural locality, admissions, discharges and bed utilization, facility resources and staffing, special designations (critical access, rural referral center, sole community provider, disproportionate share hospital ratio (DSH)), and revenue sharing models.14 DSH is a measure of a hospital’s share of indigent patients and is calculated by adding together the percentage of Medicare inpatient days attributable to patients receiving both Medicare Part A and Supplemental Security Income (SSI), and the percentage of total inpatient days attributable to patients eligible for Medicaid but not on Medicare Part A.15 Geographic practice cost indexes (GPCIs) were collected via the Medicare GPCI Fee Schedule.16
In addition to hospital-level data, we examined health system characteristics. For applicable hospitals, we captured the parent health system’s hospital count, number of inpatient beds, staffing levels, annual inpatient admissions and discharges, and geographic footprint via the Agency for Health Research and Quality’s (AHRQ) Compendium of U.S. Health Systems file.17
To examine associations with regional factors, each hospital was sorted by zip code into a specific Hospital Referral Region (HRR), as designated by the Dartmouth Atlas.18 There are a total of 306 HRRs in the US, each of which represents a distinct and validated hospital market. Census-based, population-weighted characteristics for every HRR are provided in the Dartmouth Atlas, including population size, median income, poverty rate, race breakdown, healthcare infrastructure and accessibility, and Medicare spending. Regional levels of market consolidation were calculated using data from the Medicare Claims Carrier File and Provider Enrollment, Chain, and Ownership System and quantified via the Herfindahl-Hirschman Index (HHI), a metric which ranges from 0 to 1, with higher numbers denoting more consolidation and less competition.
Statistical Analyses
We compared hospital characteristics between hospitals that reported TTE prices and those that did not via standardized mean differences. We considered a standardized mean difference of 0.1 a substantial difference.
To minimize the impact of outliers, we Winsorized individual prices below the 1st percentile and above the 99th percentile. Categorical variables were compared using the chi-square test and continuous variables using the two-sample T-test. To quantify the variation in commercial rates within each hospital for TTE, we calculated the ratio between the 90th and the 10th percentile payor-negotiated rate (within-hospital ratio).19 To quantify the variation in rates between hospitals but within a given HRR, we calculated the ratio between the 90th percentile hospital median payer-negotiated rate and the 10th percentile hospital price.19
We evaluated the association between median hospital commercial price and hospital-related characteristics. For categorical hospital characteristics, we used two-sample t-tests and analysis of variance (ANOVA) tests with the Tukey test. Non-parametric variables were analyzed using the Kruskal-Wallis test. Continuous characteristics were analyzed via linear regression.
A multivariable linear regression model was generated based on factors meeting a p-value threshold of <0.1 on univariate analysis as well as pre-selected variables of interest: hospital bedcount, annual inpatient admissions, US News and World Reports Top 50 Cardiology Hospitals, health system hospital count, urban versus rural location, HRR hospital market HHI, HRR median income, HRR % black population, HRR hospitals beds per 1,000 people, and HRR Medicare spending per capita. For a detailed breakdown of the covariates tested in the univariate and multivariate analysis, see eTable 2. Statistical analyses were performed using R (Version 4.1.1, R Foundation for Statistical Computing, Vienna, Austria) and Graphpad Prism (Version 9.4.0, GraphPad Software, San Diego, California USA). A p-value of <0.05 was considered significant for two-sided comparisons.
Results
A total of 6,715 hospitals were included in the Turquoise database. After applying the exclusion criteria (eFigure 1), 3,333 hospitals remained, with 1,949 hospitals (58.5%) reporting at least one payor-negotiated price for transthoracic echocardiography (Table 1). Reporting hospitals differed from non-reporting hospitals with regard to hospital type, teaching status, number of beds, rural location, region, HHI index, health system hospital count, physicians, and number of beds, and investor ownership. For-profit and major investor-owned hospitals were more likely to report commercial prices, as were hospitals with lower bed counts and number of physicians in the overarching health system.
Table 1:
Characteristics of Hospitals Reporting and Not Reporting Commercial Prices for TTE
| Hospital Characteristic | Characteristic Category | Reporting | Not Reporting | P-value | Standardized Difference¥ | Cramer’s V Effect Size† |
|---|---|---|---|---|---|---|
| Hospital Type | Government | 235 (12.1) | 152 (11.1) | <0.0001 | +0.03 | 0.128 |
| Not-for-profit | 1229 (63.4) | 899 (65.7) | −0.03 | |||
| For-profit | 354 (18.2) | 156 (11.4) | +0.19 | |||
| Unspecified | 122 (6.3) | 162 (11.8) | −0.19 | |||
| Teaching Status | Major teaching | 150 (7.7) | 100 (7.2) | <0.0001 | +0.02 | 0.112 |
| Minor teaching | 578 (29.7) | 375 (27.1) | +0.06 | |||
| Non-teaching | 1120 (57.5) | 754 (54.5) | +0.06 | |||
| Unspecified | 101 (5.2) | 155 (11.2) | −0.22 | |||
| Hospital Beds | <250 | 1023 (52.4) | 639 (46.1) | <0.0001 | +0.13 | 0.155 |
| 250–500 | 372 (19.1) | 201 (14.5) | +0.12 | |||
| >500 | 180 (9.2) | 94 (6.8) | +0.09 | |||
| Unspecified | 376 (19.3) | 452 (32.6) | −0.31 | |||
| Urban/Rural | Urban | 1597 (81.9) | 1088 (78.6) | <0.0001 | +0.08 | 0.115 |
| Rural | 251 (12.9) | 141 (10.2) | +0.08 | |||
| Unspecified | 101 (5.2) | 155 (11.2) | −0.22 | |||
| Region | New England (CT, MA, ME, NH, RI, VT) | 120 (6.2) | 24 (1.7) | <0.0001 | +0.23 | 0.185 |
| Middle Atlantic (NJ, NY, PA) | 207 (10.6) | 160 (11.6) | −0.03 | |||
| South Atlantic (DC, DE, MD, VA, WV, NC, SC, GA, FL) | 370 (19.0) | 238 (17.2) | +0.05 | |||
| East North Central (OH, IN, IL, MI, WI) | 336 (17.2) | 235 (17.0) | +0.01 | |||
| East South Central (KY, TN, AL, MS) | 172 (8.8) | 75 (5.4) | +0.13 | |||
| West North Central (MN, IA, MO, ND, SD, NE, KS) | 229 (11.7) | 112 (8.1) | +0.12 | |||
| West South Central (AR, LA, OK, TX) | 206 (10.6) | 221 (16.0) | −0.16 | |||
| Mountain (MT, ID, WY, CO, NM, AZ, UT, NV) | 138 (7.1) | 102 (7.4) | −0.01 | |||
| Pacific (WA, OR, CA, AK, HI) | 171 (8.8) | 217 (15.7) | −0.21 | |||
| Regional Level of Hospital Consolidation (HHI Index) | ≤0.10 | 758 (38.9) | 575 (41.6) | 0.0086 | −0.06 | 0.064 |
| 0.10–0.20 | 570 (29.2) | 330 (23.9) | +0.12 | |||
| 0.20–0.30 | 321 (16.5) | 230 (16.6) | 0.00 | |||
| 0.30–0.50 | 231 (11.9) | 184 (13.3) | −0.04 | |||
| >0.50 | 69 (3.5) | 63 (4.6) | −0.05 | |||
| Part of Multi-Hospital Health System | Yes | 1825 (93.6) | 1286 (92.9) | 0.4382 | +0.03 | 0.014 |
| No | 124 (6.4) | 98 (7.1) | −0.03 | |||
| Health System Hospital Count | 2–10 | 670 (35.2) | 524 (39.4) | 0.0021 | −0.09 | 0.069 |
| 10–50 | 865 (45.4) | 521 (39.2) | +0.13 | |||
| >50 | 370 (19.4) | 284 (21.4) | −0.05 | |||
| Health System Physicians | <5000 | 1608 (82.1) | 1001 (72.3) | <0.0001 | +0.24 | 0.117 |
| ≥5000 | 350 (17.9) | 383 (27.7) | −0.24 | |||
| Health System Number of Beds | ≤2000 | 956 (48.8) | 699 (54.0) | <0.0001 | −0.10 | 0.082 |
| 2001–10000 | 721 (36.8) | 375 (29.0) | +0.17 | |||
| >10000 | 281 (14.4) | 220 (17.0) | −0.07 | |||
| Major Investor Owned | Yes | 373 (19.1) | 177 (12.8) | <0.0001 | +0.17 | 0.084 |
| No | 1576 (80.9) | 1207 (87.2) | −0.17 |
There was significant variation in TTE pricing across price categories (Figure 1). Compared with a median Medicare price of $464 (IQR $445-$493), the median commercial and discounted self-pay prices were $1,313 (IQR $744-$1948) and $1422 (IQR $836-$2,189) respectively, representing a 2.83- and 3.06-fold markup from the Medicare rate. The median chargemaster price was $2,497 (IQR $1,731-$3,576), corresponding to a 5.38-fold markup.
Figure 1. Price Variation in Medicare, Chargemaster, Self-Pay, and Commercial Rates.
The median number of payers per individual hospital was 20 (IQR 8–42).
Within hospitals, rates negotiated across individual payors varied substantially (Figure 1). The 90th percentile payor-negotiated rate was 2.78 (IQR 1.80–5.09) times the 10th percentile price (within-center ratio). This was also true across hospitals. Within the same hospital referral region (HRR), the median price at the 90th percentile hospital was 2.47 (IQR 1.69–3.75) times that at the 10th percentile hospital (across-center ratio). Figure 2 illustrates the variation in commercial rates across the US by state, with the median price across states of $1,398 (IQR $1,064-$1,661) and a range of $391 to $2,991 (for variation by HRR, see eFigure 2).
Figure 2.
Comparison of Median Hospital Commercial Price for TTE by State
We performed univariate and multivariable analyses of hospital, health system, and regional level predictors of TTE price. In the univariate analysis, hospital type, teaching status, rural referral center status, major investor ownership, and DSH status were significantly associated with TTE price (Table 2). There was a significant difference in median price between for-profit hospitals ($1,194; IQR $710–1,902) and not-for-profit and government hospitals ($1,339; IQR $772–1,931 and $1,282; IQR $749–2,237, respectively) (p=0.038). Prices were overall higher among major-investor owned hospitals than non-investor owned hospitals (median $1,313 [IQR $776–2,369 vs. median $1,313 [IQR $730–1,917], p<0.0001). eTable 2 includes a full summary of the variables tested.
Table 2.
Univariate Analysis of Factors Associated with TTE Commercial Price
| Categorical Variables (% Reporting) | # of Hospitals (%) | Mean Price ± STD) | Median Price (IQR) | P-Value |
|---|---|---|---|---|
| Hospital Type (93.3) | ||||
| For-Profit | 354 (18.2) | 1668±1211 | 1282 (749–2237) | 0.03806 |
| Not-For-Profit | 1229 (63.4) | 1429±827 | 1339 (772–1931) | |
| Govt | 235 (12.1) | 1348±874 | 1194 (710–1902) | |
| Teaching Status (94.8) | ||||
| Major Teaching | 1120 (60.6) | 1485±884 | 1355 (817–1947) | 0.00019 |
| Minor Teaching | 578 (31.3) | 1358±937 | 1141 (628–1872) | |
| Non-Teaching | 150 (8.1) | 1510±921 | 1337 (829–2010) | |
| Urban vs Rural (94.8) | ||||
| Urban | 1597 (81.9) | 1423±693 | 1371 (862–1859) | 0.38850 |
| Rural | 251 (12.9) | 1466±957 | 1273 (725–1977) | |
| Rural Referral Center (80.7) | ||||
| Rural Referral Center | 305 (19.4) | 1350±890 | 1207 (696–1803) | 0.01395 |
| Non-Rural Referral Center | 1268 (80.6) | 1493±968 | 1295 (736–2025) | |
| Sole Community Provider (80.7) | ||||
| Sole Community Provider | 75 (4.8) | 1621±961 | 1626 (756–2224) | 0.15160 |
| Non-Sole Community Provider | 1497 (95.2) | 1457±954 | 1272 (725–1948) | |
| Major Investor Owned (100.0) | ||||
| Major Investor Owned | 373 (19.1) | 1749±1270 | 1313 (776–2369) | <0.0001 |
| Not Major Investor Owned | 1576 (80.9) | 1396±814 | 1313 (730–1917) | |
| Bedcount (100.0) | ||||
| ≤250 | 1340 (68.8) | 1472±885 | 1338 (780–1938) | 0.08803 |
| 250–500 | 424 (21.8) | 1457±885 | 1156 (639–1994) | |
| ≥500 | 185 (9.5) | 1422±865 | 1293 (743–1948) | |
| DSH (100.0) | ||||
| <0.25 | 1036 (53.2) | 1513±916 | 1379 (843–1974) | <0.0001 |
| 0.25–0.5 | 759 (38.9) | 1445±917 | 1249 (726–1978) | |
| ≥0.5 | 154 (7.9) | 1227±1037 | 860 (523–1682) | |
| USNWR Top Cardiology Hospital (100.0) | ||||
| 1–50 | 18 (1.6) | 1580±724 | 1652 (993–2029) | 0.16220 |
| Not Ranked | 1918 (98.4) | 1462±932 | 1307 (741–1947) | |
| Hospital Overall Rating (81.9) | ||||
| 1 | 81 (5.1) | 1268±1013 | 942 (455–1718) | <0.0001 |
| 2 | 313 (19.6) | 1482±1103 | 1154 (648–1992) | |
| 3 | 470 (29.4) | 1338±869 | 1220 (735–1881) | |
| 4 | 500 (31.3) | 1477±913 | 1338 (768–1973) | |
| 5 | 1656±925 | 1615 (1074–2176) | ||
| Continuous Variables (% Reporting) | R2 | |||
| HRR Median Income (100.0) | <0.01 | |||
| HRR Index (100.0) | <0.01 | |||
| Poverty Rate (100.0) | <0.01 | |||
| % Black (100.0) | <0.01 | |||
| Hospital Beds per 1K (100.0) | <0.01 | |||
| Hospital FTE per 1k (100.0) | 0.02000 | |||
| Docs per 1k (100.0) | <0.01 | |||
| Medicare $ per Capita (100.0) | <0.01 | |||
| Admission (80.7) | <0.01 | |||
| Total Medicare Discharges (80.7) | <0.01 | |||
| Total Medicaid Discharges (80.7) | <0.01 | |||
| Hospital Count (100.0) | 0.05000 |
In a multivariable model, several characteristics remained significantly associated with median TTE price. Factors associated with higher prices included for-profit status (+$322 versus non-profit; p=0.02), major teaching status (+$255 versus minor teaching; p=0.017), number of health system hospitals (+$61 per 10 hospitals; p<0.001), and CMS overall rating (5-star rating: +$483.2 versus 1-star; p<0.001). Factors associated with lower prices included DSH ratio (-$4 per 1%; p=0.023) which was collinear with number of Medicaid discharges (-$54 per 1000 discharges; p<0.001).
Discussion
In this cross-sectional study of hospital price transparency data, we observed substantial variation in TTE pricing within and across hospitals. Higher prices were associated with for-profit status, teaching hospitals, overall CMS rating, and health system size, whereas lower prices were associated with higher DSH status. Commercial and self-pay prices were 2.83- and 3.06-fold greater than the Medicare rate, respectively.
In response to rising healthcare costs, US policymakers have increasingly turned toward price transparency under the belief that patients will make better decisions with detailed cost information. The 2021 Federal Hospital Price Transparency Rule required hospitals disclose the rates they negotiate with private payers and uninsured patients. While known that hospital list prices generally exceed Medicare allowable cost, the magnitude of cost differences across payers was unavailable prior to the price transparency legislation. Previous estimates have used charge-to-cost ratios that are generally unavailable for specific procedures, such as an echocardiogram.20 This analysis provides greater granularity regarding the markup of echocardiography costs for non-Medicare patients.
Compliance with the price transparency rule was poor at 58.5%, but higher than reported in previous studies, which sampled data from early to mid-2021 (20–33%), though these studies required compliance across more than one procedure.21,22 Despite being 1.5 years into the price transparency requirement, a large number of hospitals remain non-adherent. One potential explanation is the penalty for non-adherence has remained relatively lenient at $300 per day in 2021. Congress revised this in 2022 to a maximum of $5500 per day, which amounts to a maximum of $2,007,500 per hospital per calendar year.23 Actual enforcement is also unclear--CMS has issued hundreds of warnings, but as of June 2022, only 2 hospitals have been issued fines.24,25 Characteristics of hospitals more likely to report commercial prices included for-profit status, investor ownership, bed count ≤500, and system physician count <5,000. Academic teaching status, urban location, and regional level of market consolidation were not associated with greater compliance. These results differ from data reported by Haque et al., which showed greater adherence in urban areas and unconcentrated health markets and no association with hospital ownership or size; however, in that study, compliance was assessed across 300 shoppable services.22 Further research is warranted to assess whether this study’s observations apply to a broader set of cardiovascular tests beyond TTE and the reasons which underlie the association with hospital ownership and size, which appear to be counterintuitive.
In addition to considerable markups from the Medicare rate, we observed substantial price variation between insurers in the same hospital and across hospitals. We demonstrate that not only do patients across the country pay drastically different rates for TTE but so too do patients receiving care at the same hospital. By including all US hospitals, these data significantly extend the scope of previous assessments by Oseran et al., which observed substantial within-hospital variation (largest IQR $470-$3,022) and between-hospital variation ($204-$2,588), but was limited to the top 20 US News and World Report hospitals.26 Our report of a within-center ratio of 2.78 also aligns with previous reports of general radiology services, including CT and MRI (mean of 3.8 across 13 shoppable services).27 Other analyses have demonstrated commercial rates can be higher than discounted cash rates.28 Our findings bolster the need for policy reform as unchecked price variability may create artificial cost hotspots in an ecosystem in which there are often limited options to guide patients in plan selection.29–31 This may be particularly detrimental to vulnerable populations with limited or no coverage, who may be deterred from accessing care, may be less likely to compare prices, and will bear an outsized financial burden.32–34 Greater price transparency may lead to decreased price variation; nonetheless, even with greater enforcement, there is still uncertainty as to whether increased consumer price transparency will produce appreciable change, with limited experiments having merited modest results thus far.35
In addition to surveying prices from the most comprehensive list of hospital providers to-date, this study was also the first to assess for hospital, system, and regional factors predictive of commercial TTE prices. Multiple hospital characteristics, including for-profit status and major investor ownership, were associated with higher TTE cost. After adjustment for hospital characteristics, investor ownership was associated with lower prices. Although it is not exactly clear what underpins these relationships, one can speculate that for-profit and investor-owned hospitals may have stronger incentives to charge higher prices. Surprisingly, consolidation was not associated with higher echocardiography prices, as posited recently by Oseran et al., despite prior literature that has shown the opposite for other medical services.26,36–37 This may be reflective of limited competition and consumer shopping when it comes to echocardiograms.
Increased prices for a given service may be acceptable if the service is also higher quality. Previous studies have demonstrated better outcomes in for-profit hospitals and PE-backed hospitals20,38. We did not have any data regarding echocardiography quality, though we did include global measurements of hospital quality tracked by CMS. In our univariate analysis, we found estimates of patient experience, hospital overall rating and effectiveness of care were significantly associated with increased TTE cost, though mortality was not. The relationship with hospital overall rating remained significant in the multivariable analysis. One can surmise that hospitals with higher perceived and/or objective global ratings may be able to leverage their system-wide bargaining position to achieve higher prices across the full organization rather than each individual department. Indeed, negotiations between hospitals and private payers commonly occur at the organizational level rather than at the specialty or procedural level. To this end, hospitals belonging to larger health systems had significantly higher TTE costs. Of note however, although we observed an absolute difference in the median price between US News and World Report Top 50 Cardiology hospitals and unranked hospitals, this was not statistically significant. Without objective measures of echocardiography quality, it is difficult to make well-founded inferences between price and quality and more research will need to be done to interrogate these factors.
While higher quality care can merit higher reimbursement, one can argue that hospitals which serve underserved and/or indigent populations should be comparatively better reimbursed. Indeed, this is the express purpose of such CMS designations as rural referral center, sole community hospital, and DSH hospital, whereby federal law stipulates that Medicaid programs should make additional payments to qualifying hospitals which take care of a greater proportion of patients with difficult access to care or are dependent on Medicare or Medicaid. Our data show that the opposite is occurring on the commercial side, which may be related to the limited ability of safety net hospitals, which are resource-constrained, to negotiate effectively with commercial payers. Such an effect may worsen health inequities related to cardiovascular care and should be a focus of attention of policymakers amidst the already widening disparity gaps in the US.
This study had several limitations. As a cross-sectional study, we did not assess price changes over time. Given only select hospitals report their price, our study may have underestimated the variation in TTE prices if non-reporting hospitals have higher prices or more substantial variation across payers. On a related note, missing data related to hospital characteristics may influence the associations identified in this analysis. Missingness was higher among noncompliant hospitals. In addition, the costs reported pertain only to facility fees and do not include professional fees. It is ostensible that these may trend the same way and could magnify the differences reported here. Finally, since the legislation only pertains to hospitals, we were unable to assess TTE prices at freestanding clinics.
Conclusions
The 2021 Hospital Price Transparency Rule has opened the door for evaluation of insurer-negotiated and cash pay prices for medical services rendered at US hospitals. However, there is still a need for more price transparency data, including costs at non-compliant hospitals and prices charged by insurers to beneficiaries. We demonstrated a large markup in commercial and uninsured rates for TTE. We found substantial price variation within and across hospitals with unclear association with quality of care, which may complicate access and affordability of care, especially for vulnerable populations. We also showed that hospitals that care for more vulnerable patients may be less well reimbursed, which may further deepen existing inequities. Taken together, these data and insights provide a critical lens with which to assess and improve the value of our care.
Supplementary Material
Table 3:
Multivariable Analysis of Factors Associated with TTE Commercial Price
| Median TTE Commercial Price | ||
|---|---|---|
| Hospital/Health System Factors | Estimate | P-value |
| For-Profit | Reference | - |
| Not-For-Profit | −322.0±137.8 | 0.020* |
| Govt | −165.2±164.3 | 0.315 |
| Major Investor Ownership | −375.6±144.0 | 0.009** |
| Major Teaching | Reference | - |
| Minor Teaching | −254.7±106.4 | 0.017* |
| Non-Teaching | −107.5±115.5 | 0.352 |
| Total Hospital Beds (per 100 beds) | +16.1±16.7 | 0.334 |
| Annual Inpatient Admissions (per 1,000 admissions) | −4±2.9 | 0.249 |
| DSH Ratio (Per 1%) | −4.2±1.8 | 0.023* |
| CMS Overall Hospital Rating 1 | Reference | - |
| CMS Overall Hospital Rating 2 | +196.1±123.8 | 0.114 |
| CMS Overall Hospital Rating 3 | +161.3±121.9 | 0.186 |
| CMS Overall Hospital Rating 4 | +283.5±123.8 | 0.022* |
| CMS Overall Hospital Rating 5 | +483.2±137.1 | <0.001*** |
| USNWR Top 50 | +108.2±200.1 | 0.589 |
| Total Health System Hospitals (per 10 hospitals) | +60.7±7.8 | <0.001*** |
| Not Rural Referral Center | +106.8±6.5 | 0.093 |
| Urban Hospital Location | +801.0±661.5 | 0.221 |
| Regional Factors | ||
| HRR Hospital Market HHI (per 0.1 units) | −14.2±21.1 | 0.501 |
| HRR Median Income (per $1,000) | +4.7±2.7 | 0.080 |
| HRR % Black Population (per 1%) | −3.3±2.9 | 0.250 |
| HRR Hospital Beds per 1,000 people | +10.9±7.4 | 0.884 |
| HRR Medicare Spending per Capita (per $1,000) | −3.5±2.6 | 0.894 |
Footnotes
Disclosures: None
References
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