Analysis of Price Transparency for Oncologic Surgery Among National Cancer Institute–Designated Cancer Centers in 2020

Abstract

This cross-sectional analysis reviews hospital chargemasters for a range of cancer surgeries to determine hospitals’ legal compliance with disclosure requirements and the specific prices disclosed.

In January 2019, the Centers for Medicare and Medicaid Services (CMS) began legally requiring hospitals to publish chargemasters online to promote price transparency.¹ Hospital chargemasters list gross charges for all items and services, which are the undiscounted prices hospitals bill patients who are uninsured, self pay, or have out-of-network insurance.

Understanding the cost of care is important for patients with cancer, who often suffer considerable financial burdens. However, a recent analysis² examining price transparency for radiation therapy has raised concerns about the utility of public chargemasters. We therefore sought to investigate the information available to patients with cancer seeking surgical care at National Cancer Institute (NCI)–designated cancer centers.

Methods

We performed a cross-sectional analysis of hospital charges for inpatient cancer operations at NCI-designated cancer centers in March 2020. We excluded centers exempt from the Medicare Inpatient Prospective Payment System, because service pricing fundamentally differs for these hospitals. We systematically reviewed the public websites of each center to determine if a chargemaster was available. We then extracted Medicare Severity–Diagnosis-Related Group (MS-DRG) level charges (which hospitals were required to disclose) for cancer operations across 13 major disease areas (eMethods in the Supplement) as available. Institutional review board approval was not required by Mass General Brigham because this study analyzed publicly available data, and informed consent was likewise not required.

We examined hospital charges for cancer operations by disease area and MS-DRG–specified case severity (without complications or comorbidities [CC], with CC, or with major CC [MCC]). We used descriptive statistics to characterize the proportion of cancer centers publicly disclosing hospital charges. We calculated the markup ratio³ between hospital charges and estimated Medicare payment amounts, which are based on the expected cost of care delivery, including hospital-specific factors, such as local wage indices (eMethods in the Supplement).⁴ We performed all analyses using R version 4.0.3 (R Foundation for Statistical Computing).

Results

In March 2020, 43 of 52 included NCI-designated cancer centers (82.7%) publicly disclosed MS-DRG–level charges for at least 1 inpatient cancer operation. Among these cancer centers, rates of disclosure varied by disease area. Whereas all centers (N = 43; 100.0%) disclosed charges for chest cases without CC or MCC, only 14 (of 43; 32.6%) disclosed charges for prostate cases without CC or MCC (Table).

Table. Hospital Charges for Oncologic Surgery at National Cancer Institute–Designated Cancer Centers, Stratified by Disease Area and Case Severity.

Disease area	No. of cancer centers	Hospital charge, median (interquartile range), $	Charge, $
			Minimum	Maximum
Bladder
Without CC or MCC	38	96 212 (67 433-141 460)	42 957	302 202
With CC	36	122 904 (98 068-178 835)	51 125	294 772
With MCC	33	191 532 (140 259-247 954)	68 491	488 707
Bowel
Without CC or MCC	40	63 778 (44 595-85 766)	28 135	320 708
With CC	37	87 139 (63 642-112 540)	35 204	250 205
With MCC	37	186 191 (134 914-233 999)	68 880	532 979
Breast
Without CC or MCC	35	74 530 (48 333-123 195)	18 195	274 391
With CC or MCCa	30	93 141 (61 555-128 497)	35 025	320 378
Foregut
Without CC or MCC	42	59 538 (44 734-75 873)	24 349	250 490
With CC	37	97 764 (82 173-150 235)	40 057	285 580
With MCC	37	214 035 (160 582-277 799)	71 360	622 454
Head/neck
Without CC or MCC	40	74 385 (51 226-111 045)	34 244	263 150
With CC or MCCa	37	118 329 (81 244-144 154)	51 445	306 382
Kidney/ureter
Without CC or MCC	42	64 089 (51 560-85 684)	21 546	177 390
With CC	37	90 181 (63 455-106 391)	28 439	203 656
With MCC	37	137 221 (103 214-203 584)	45 489	402 343
Chest
Without CC or MCC	43	71 679 (52 123-90 081)	19 765	262 227
With CC	37	91 565 (66 167-116 106)	52 966	279 023
With MCC	38	177 169 (135 067-274 151)	80 969	590 026
Pancreas/liver
Without CC or MCC	40	86 224 (63 831-127 814)	38 427	288 120
With CC	37	110 480 (82 840-163 444)	49 240	267 906
With MCC	38	199 969 (139 051-294 193)	84 266	572 792
Pelvic exenteration
Without CC or MCC	32	58 522 (37 041-90 945)	20 022	193 625
With CC or MCCa	32	91 199 (53 683-155 409)	18 065	447 809
Prostate
Without CC or MCC	14	40 833 (22 168-45 276)	14 872	119 916
With CC	20	62 614 (49 341-71 726)	14 428	138 866
With MCC	13	83 800 (50 969-186 469)	43 900	294 130
Rectal
Without CC or MCC	30	59 452 (42 751-80 046)	18 951	175 056
With CC	30	84 929 (57 352-107 829)	26 126	373 998
With MCC	22	129 483 (95 764-204 325)	23 947	976 242
Thyroid/parathyroid
Without CC or MCC	40	53 598 (35 956-75 208)	15 435	128 821
With CC	37	68 501 (50 410-101 170)	22 365	216 049
With MCC	35	120 676 (91 923-157 556)	45 514	316 611
Uterine/adnexa
Without CC or MCC	38	61 076 (40 505-88 618)	18 962	213 822
With CC	36	87 672 (52 838-124 614)	33 418	272 375
With MCC	35	133 195 (94 149-205 513)	31 406	468 505

Abbreviations: CC, complications or comorbidities; MCC, major complications or comorbidities.

^aIn Medicare fiscal year 2020, cases with CC or MCC were grouped into single Medicare Severity–Diagnosis-Related Group code (with CC or MCC) for breast, head/neck, and pelvic exenteration operations.

The median markup ratio between hospital charges and Medicare reimbursement ranged between 3.73 (interquartile range [IQR], 2.07-5.42; for prostate surgery with a MCC) and 6.57 (IQR, 3.55-9.05; breast surgery without a CC or MCC) across disease areas (Figure, A). Within disease areas, markup ratios varied substantially between hospitals. For example, there was an approximately 20-fold difference in markup ratios between hospitals for rectal operations with MCC (20.5) and pelvic operations with MCC (22.0; Figure, B).

Figure. Markup Ratios for Oncologic Surgery.

A, Distribution of markup ratios for oncologic surgery among National Cancer Institute–designated cancer centers, stratified by disease area and case severity. B, Maximum variation in markup ratios for oncologic surgery among National Cancer Institute–designated cancer centers, stratified by disease area and case severity.

^aIn Medicare fiscal year 2020, cases with complications or comorbidities (CC) or major complications or comorbidities (MCC) were grouped into single Medicare Severity–Diagnosis-Related Group code (with CC or MCC) for breast, head/neck, and pelvic exenteration operations. Markup ratios and maximum variation in markup ratios for these disease areas are duplicated in CC and MCC columns for internal consistency.

Discussion

In this study, we found wide variation in the disclosure of charges for inpatient cancer operations by NCI-designated Cancer Centers as required by law. Among centers disclosing charges, there was substantial variation in markup ratios, which reflect hospital billing for charges in excess of estimated Medicare reimbursement. Our findings build on prior work suggesting that chargemasters listing undiscounted prices may provide limited benefit to patients with cancer and could potentially deter them from seeking care.²

Recent action by the CMS could help address these concerns. In January 2021, the agency began requiring hospitals to additionally disclose payer-specific negotiated charges and discounted cash prices.⁵ However, the American Hospital Association has requested that the new US presidential administration rescind the law after unsuccessfully mounting legal challenges to enactment.⁶ While we recognize concerns about the potential burden of compliance during the ongoing COVID-19 pandemic, our findings underscore the need for better financial information to help patients make informed treatment decisions.

Our study has limitations. Our cross-sectional analysis of inpatient oncologic operations may not reflect current charge disclosure practices or charge variation for other service types. Further research will be necessary to examine price transparency for cancer care amid ongoing reforms.

Supplement.

eMethods.

eReferences.