Payer-Negotiated Prices in the Diagnosis and Management of Thyroid Cancer in 2021

Abstract

This study examines price availability and variation for thyroid cancer care at National Cancer Institute (NCI)–Designated Cancer Centers following a 2021 CMS policy reform requiring hospitals to disclose commercial payer-specific negotiated prices for all items and services.

Thyroid cancer is among the most common malignancies in the US, with a 3.6% annual increase in incidence over the past 50 years.¹ Treatment regimens for thyroid cancer are well-established, with excellent survival outcomes. However, costs of thyroid cancer care can vary substantially by hospital and impose significant financial burdens on patients²; among patients with cancer, bankruptcy rates are highest for those with thyroid cancer.³

The Centers for Medicare & Medicaid Services (CMS) recently implemented price transparency reforms to promote informed hospital selection by patients and cost-based competition among hospitals. Effective January 1, 2021, hospitals must disclose commercial payer-specific negotiated prices for all items and services.⁴ We characterized price availability and variation for thyroid cancer care at National Cancer Institute (NCI)–Designated Cancer Centers.

Methods

We performed a cross-sectional analysis of commercial payer-negotiated prices of services for thyroid cancer at NCI-Designated Cancer Centers. We restricted analysis to cancer centers providing adult clinical care and participating in the Medicare Inpatient Prospective Payment System. We reviewed each center’s website to extract (as available) prices for 14 services that are integral to thyroid cancer management, including laboratory tests, radiology studies, medical and surgical treatments, and inpatient care (Supplement).

To compare prices between centers, we first normalized the median price for each service at each center to the estimated center-specific 2021 Medicare payment amount, which accounts for factors affecting the cost of care delivery (Supplement).² We then determined the ratio between the maximum and minimum normalized median prices for each service across centers (“across-center ratio”). To compare negotiated prices between payers at each center, we calculated the ratio between the maximum and minimum negotiated prices (“within-center ratio”) for each service.

All available prices were current as of March 25, 2021. We performed all analyses using R, version 4.0.4. The Mass General Brigham Institutional Review Board did not require approval because the study used publicly available data and involved no patient records.

Results

Of 71 NCI-Designated Cancer Centers, 52 (74.3%) met inclusion criteria. A total of 26 of 52 centers (50.0%) disclosed commercial payer-negotiated prices for any items or services. Disclosure differed by service type (Table); whereas 25 centers (48.1%) disclosed prices for thyroid-stimulating hormone testing or neck ultrasonography, only 8 (15.4%) disclosed professional fees for total thyroidectomy.

Table. Variation in Negotiated Rates for Commonly Performed Services in the Management of Thyroid Cancer at National Cancer Institute–Designated Cancer Centers.

Service	No. (%) of centersa	Payer-negotiated price, $b				Across-center ratioc	Median (IQR) within-center ratiod
		Median (IQR)	Mean (SD)	Minimum median	Maximum median
Laboratory tests
Thyroid-stimulating hormone	25 (48.1)	76 (42-138)	97 (77)	17	373	22.2	3.9 (2.4-8.1)
Parathyroid hormone	23 (44.2)	161 (112-278)	213 (167)	41	775	18.8	4.2 (2.3-7.0)
Fine-needle aspiration biopsy	18 (34.6)	413 (298-804)	783 (816)	169	2919	16.1	4.8 (2.3-10.2)
Radiology
Neck ultrasonography	25 (48.1)	395 (269-628)	448 (242)	82	939	12.4	3.5 (2.1-5.3)
Thyroid uptake scan	17 (32.7)	596 (458-738)	587 (270)	56	1165	21.3	4.6 (2.6-6.5)
Neck computed tomography	24 (46.2)	871 (422-1121)	1067 (1014)	108	4845	44.7	4.1 (2.5-6.3)
Neck magnetic resonance imaging	20 (38.5)	1495 (890-1891)	1597 (1068)	224	5130	24.0	3.4 (2.3-6.2)
Whole-body thyroid scan	22 (42.3)	1047 (867-1896)	1436 (850)	248	3735	17.9	3.4 (2.2-5.6)
Treatment
Radioactive iodine	24 (46.2)	723 (342-1312)	1344 (2181)	161	10 790	70.1	4.6 (2.4-7.7)
Surgical procedures
Hemithyroidectomye	7 (13.5)			2429	16 547	6.4	−5.0
Total thyroidectomye	8 (15.4)			3052	23 262	7.2	−5.0
Inpatient care for thyroid, parathyroid, and thyroglossal procedures
With major complications or comorbidities	11 (21.2)	49 614 (40 471-55 875)	51 060 (26 241)	7884	111 045	13.6	2.8 (1.0-3.6)
With complications or comorbidities	14 (26.9)	26 796 (19 890-30 478)	27 422 (10 294)	9698	49 425	5.0	3.8 (2.2-6.6)
Without complications or comorbidities	14 (26.9)	20 200 (15 225-31 477)	24 054 (14 285)	9811	63 204	3.7	3.0 (1.5-4.7)

Abbreviation: IQR, interquartile range.

^aExcludes Medicare Prospective Payment System–exempt cancer centers (n = 11).

^bMedian, mean, minimum, and maximum prices were calculated based on the median payer-negotiated prices at each included center (not normalized to Medicare).

^cRatio calculated as the maximum median Medicare-normalized price divided by the minimum median Medicare-normalized price among all centers.

^dRatio for each center calculated as the maximum payer-negotiated rate divided by the minimum payer-negotiated rate.

^eMedians and means were not calculated because there were less than 10 centers.

Normalized payer-negotiated prices varied widely across centers (Table). For instance, across-center ratios were 70.1 (raw median price range, $161-$10 790) for radioactive iodine treatment and 44.7 (raw median price range, $108-$4845) for neck computed tomography. Within centers, negotiated service prices varied widely across payers; for example, median (interquartile range) within-center ratios were 4.8 (2.3-10.2) for fine-needle aspirate biopsy and 4.6 (2.6-6.5) for thyroid uptake scan.

Discussion

Half of NCI-Designated Cancer Centers disclosed payer-negotiated prices for thyroid cancer services as required by law.⁴ Although CMS has audited hospitals since January 2021,⁵ this high nondisclosure rate may be attributable to the modest repercussions of nonadherence (ie, maximum $300 daily penalty).

Among centers disclosing negotiated prices, there was considerable variation in disclosure by service type. Although approximately 15% of centers disclosed surgeon professional fees for thyroid resection, nondisclosure may be legal: CMS requires hospitals to disclose negotiated rates for hospital-employed physicians,⁴ but physicians practicing at hospitals are often employed by affiliated physician organizations (eg, faculty practice plans). Among services with disclosed prices, negotiated rates varied widely between cancer centers and across payers at the same center. This may reflect differences in cancer center market power, particularly for commoditized services, such as imaging.

Limitations of this study include potential lack of generalizability to other hospital or service types. Furthermore, the study was conducted shortly after implementation of price transparency requirements and may thus underestimate future disclosure rates as cancer centers overcome obstacles to adherence or respond to CMS penalties.

Nonetheless, these findings suggest that CMS should consider more stringent penalties for nondisclosure and more inclusive definitions of physician employment to enhance disclosure and promote transparency. Inconsistent disclosure could otherwise hinder efforts by patients and payers to take cost into account when selecting hospitals and physicians.

Section Editor: Jody W. Zylke, MD, Deputy Editor.

Supplement.

eMethods