Abstract
This cross-sectional study assesses list prices, cash prices, and negotiated rates for emergency department services.
Introduction
Health care costs are a source of financial hardship for many US residents.1 Contributing to this problem is a lack of price transparency, which prevents patients from shopping for health care services and health insurers from negotiating rates.2 The Centers for Medicare and Medicaid Services Hospital Price Transparency rule requires hospitals to disclose list prices and negotiated rates for specific services. Among these services are emergency department (ED) visits, which have recently seen a substantial and disproportionate increase in facility fees (80% of ED visit costs).1,3 In this study, we compared list prices, cash prices, and negotiated payer rates for the facility fees of ED visits at low-, moderate-, or high-level medical decision-making (billing code levels 3-5), corresponding with Current Procedural Terminology (CPT) codes 99283 to 99285.
Methods
This cross-sectional study analyzed billing rates for quarter 4 of 2022 using a publicly available dataset (Turquoise Health). This dataset consists of facility fees disclosed by all hospitals in compliance with the Hospital Price Transparency rule (approximately 5750 of 6330 total hospitals are compliant); numbers of ED visits are not included. The Mayo Clinic Institutional Review Board deemed this study exempt from ethics review and informed consent because it was not human participant research. We followed the STROBE reporting guideline.
CPT codes 99283 to 99285 were selected, and prices and rates were categorized as list price, cash price, private insurance, Medicare Advantage, and Managed Medicaid (eMethods in Supplement 1). Prices and rates were recorded directly; no conversions were required. The main outcome was the comparison of cash prices and negotiated rates for private insurance, Medicare Advantage, and Managed Medicaid to list prices for CPT codes 99283 to 99285.
Comparisons were performed using log-γ regression and reported as percent differences with 95% CIs. Regression models were both unadjusted and adjusted for hospital state, rating, and size. Two-sided P < .05 indicated statistical significance. Statistical analysis was performed using R 4.2.2 (R Core Team).
Results
A total of 489 847 ED visit facility fees were reported, including 159 232 (32.5%), 161 537 (33.0%), and 169 078 (34.5%) with CPT codes 99283, 99284, and 99285, respectively (Table). The median (IQR) facility list prices for these CPT codes were $696 ($359-$1292), $1189 ($589-$2106), and $1784 ($863-$3194), respectively (Figure). After adjusting for hospital state, rating, and size, Managed Medicaid rates were the lowest relative to list prices across all complexity levels for CPT codes 99283, 99284, and 99285 (−74.8%, −78.4%, and −79.5%; all P < .001), followed by Medicare Advantage rates (−72.5%, −72.6%, and −72.7%; all P < .001), cash prices (−37.0%, −37.2%, and 39.7%; all P < .001), and private insurance rates (−36.1%, −39.0%, and −39.4%; all P < .001). There was more variation in list prices, private insurance rates, and cash prices compared with Medicare Advantage and Managed Medicaid rates. Both hospital rating and size were associated with increased prices and rates (3.2% and 19.9%, respectively, for CPT code 99285).
Table. Summary of Price and Rate Categories, Hospital Characteristics, and Prices and Rates by Emergency Department Billing Code Level.
| CPT code and billing code level, No. (%) | |||
|---|---|---|---|
| 99283, Level 3 (n = 159 232) | 99284, Level 4 (n = 161 537) | 99285, Level 5 (n = 169 078) | |
| Price and rate categories | |||
| List price | 7372 (4.6) | 7557 (4.7) | 7753 (4.6) |
| Cash price | 6464 (4.1) | 6609 (4.1) | 6797 (4.0) |
| Private insurance rate | 110 853 (69.6) | 111 446 (69.0) | 117 589 (69.5) |
| Medicare Advantage rate | 24 993 (15.7) | 25 976 (16.1) | 26 506 (15.7) |
| Managed Medicaid rate | 9550 (6.0) | 9949 (6.2) | 10 433 (6.2) |
| Hospital rating | |||
| 1 | 6278 (3.9) | 7115 (4.4) | 6732 (4.0) |
| 2 | 20 725 (13.0) | 20 980 (13.0) | 22 030 (13.0) |
| 3 | 32 263 (20.3) | 33 097 (20.5) | 34 451 (20.4) |
| 4 | 36 004 (22.6) | 36 544 (22.6) | 37 439 (22.1) |
| 5 | 19 903 (12.5) | 20 322 (12.6) | 21 643 (12.8) |
| Unknown or not rated | 44 059 (27.7) | 43 479 (26.9) | 46 783 (27.7) |
| Hospital size (No. of beds) | |||
| ≤100 | 68 348 (42.9) | 67 915 (42.0) | 71 724 (42.4) |
| 101-250 | 37 425 (23.5) | 38 969 (24.1) | 39 469 (23.3) |
| ≥251 | 51 774 (32.5) | 53 187 (32.9) | 56 161 (33.2) |
| Unknown | 1685 (1.1) | 1466 (0.9) | 1724 (1.0) |
| Price and rate, median (IQR), $ | |||
| List price | 696.00 (358.86-1291.50) | 1189.0 (589.00-2106.30) | 1783.50 (863.08-3194.00) |
| Cash price | 420.30 (238.48-729.73) | 699.00 (386.87-1235.00) | 1058.80 (570.00-1863.20) |
| Private insurance rate | 517.00 (258.55-853.10) | 838.00 (417.94-1441.75) | 1280.47 (614.55-2239.66) |
| Medicare Advantage rate | 231.60 (208.00-276.00) | 367.14 (329.30-443.00) | 527.14 (466.01-646.00) |
| Managed Medicaid rate | 178.89 (84.86-282.59) | 272.88 (147.06-438.46) | 334.97 (197.38-632.00) |
Abbreviation: CPT, Current Procedural Terminology.
Figure. List Prices, Cash Prices, and Negotiated Rates for Private Insurance, Medicare Advantage, and Managed Medicaid.
Upper and lower ends of the boxes represent upper (75%) and lower (25%) quartiles, respectively; horizontal line inside boxes represent the median; and whiskers represent the minimum and maximum. CPT indicates Current Procedural Terminology.
Discussion
In a national comparison to list prices for ED visit facility fees, prices and rates ranked from highest to lowest were for private insurance, cash price, Medicare Advantage, and Managed Medicaid. These list and cash prices were similar to those in previous national studies but significantly lower than in a Florida study.4,5 Negotiated rates were also similar to rates in a recent study that was not specific to ED visits; however, that study did not indicate whether Medicare Advantage and Managed Medicaid plans were included.6 This information is important given that Medicare Advantage rates are capped at traditional Medicare fee-for-service rates, even if the hospital is out of network.
Study limitations included data quality within the public dataset, hospital compliance with disclosing data, and data availability for quarter 4 of 2022. Future research should explore the role of transparency in changing prices and rates over time, hospital and payer characteristics, more pricing categories, and both affordability and access for patients.
eMethods.
Data Sharing Statement
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eMethods.
Data Sharing Statement