Compliance With Price Transparency Rules at US National Cancer Institute–Designated Cancer Centers

Abstract

This cross-sectional study analyzes whether cancer centers have complied with Centers for Medicare & Medicaid Services regulations for price transparency.

In an effort to contain health care costs, the Centers for Medicare & Medicaid Services (CMS) began requiring hospitals to disclose prices negotiated with insurers on January 1, 2021. Existing analysis of transparency efforts via chargemaster lists has shown substantial variation in prices and limited utility when comparing prices for oncological services.¹ We analyzed compliance with mandated release of payer-negotiated prices at National Cancer Institute–designated cancer centers (NCI-CCs), including Medicare Prospective Payment System–exempt cancer centers (excluded from standard Medicare fee-for-service limitations based on diagnosis-related group), and evaluated pricing variability of available rates.

Methods

We performed a cross-sectional analysis of compliance with CMS price transparency efforts. US National Cancer Institute–designated cancer centers were deemed compliant if they had (1) a machine-readable file with all required items and services and (2) a display of 300 shoppable services in a consumer-friendly format. Compliance with the January 2019 CMS ruling requiring standard prices via chargemaster list was also evaluated. Data were collected from March 1 to June 1, 2021, via targeted searches for the term price transparency on public websites assessing for machine-readable files with mandated elements, patient-facing price transparency tools, and chargemaster lists. Radiotherapy to bone metastasis and colonoscopy with polyp or tumor removal were evaluated as examples of fully encapsulated treatments with sufficient data on price specifics. Descriptive statistics were used to evaluate compliance. The institutional review board of Memorial Sloan Kettering Cancer Center deemed this study exempt from review and waived the requirement for informed consent consistent with its policy on nonhuman participant research that uses publicly available data.

Results

Of 63 evaluated NCI-CCs, 21% (n = 13) had a complete machine-readable file; 38% (n = 24) had at least a partial machine-readable file with incomplete data or incorrect formatting. Two-thirds (65%, n = 41) had a patient-facing price transparency tool, and 70% (n = 44) had a chargemaster list. Of 11 Medicare Prospective Payment System–exempt cancer centers, 27% (n = 3) had a complete machine-readable file, 45% (n = 5) had a price transparency tool, and 73% (n = 8) had a chargemaster list. Of 11 NCI-CCs with complete pricing for radiotherapy to bone metastasis (Table), the range was $297.00 to $33 411.34, with a mean price 3.78 times the Medicare maximum allowable rate of $2476.89. Of 7 NCI-CCs with complete pricing for colonoscopy with polyp or tumor removal, the range was $297.00 to $6316.00, with a mean price 2.05 times the Medicare maximum allowable rate of $1036.95.

Table. Payer-Negotiated Rate Ranges for Oncological Services^a.

Oncological treatment (CPT code)	Negotiated rate, mean (range), $			Medicare maximum allowable, $
	Minimum	Maximum	Maximum total
Colonoscopy with polyp/tumor removal (45384)	890.46 (297.00-1545.11)	3371.19 (1371.00-6316.00)	NA	1036.95
Single fraction radiotherapy to a bone metastasis (77334, 77295, 77300, 77412, 77336)b	2149.84 (297.00-3492.42)	13 273.65 (4304.19-33 411.34)	16 182.48 (5072.01-37 183.30)	2476.89

Abbreviations: CPT, Current Procedural Terminology; NA, not applicable.

^a Payer-negotiated rate is the amount a specific commercial payer or insurer contracts to pay for health care services provided by a health care professional or medical facility; these prices may vary across a payer’s different plan types. Required elements for the Centers for Medicare & Medicaid Services’ transparency rules include gross charges, discounted cash price, payer-specific negotiated charge, and minimum and maximum negotiated charges.

^b Quantity 4 was used for CPT code 77300 given the estimated use of 4 fields for radiotherapy.

Discussion

Greater price transparency, specifically through better pricing information available to patients on the internet, may improve affordability via lower and more uniform prices.² This study found that only one-fifth of NCI-CCs are compliant with CMS rules and that variability in negotiated rates is large, with some centers charging up to 8 times the Medicare maximum allowable rate. Although patient-facing price transparency tools are available in two-thirds of NCI-CCs, it remains unclear whether these tools will accurately estimate out-of-pocket costs given the complexities of cancer treatment and insurance plan design. Previous work has shown that these tools were used by few eligible patients and were not associated with substantial cost savings.³ Although price transparency may not immediately translate to improved affordability for patients, availability of data may help inform health policy to contain costs.⁴

The findings of the present study are not unique to cancer centers; a recent analysis of 100 US hospitals found that 83 were noncompliant with federal requirements for price transparency.⁵ In April 2021, CMS began sending notices documenting rule violations and requesting corrective action plans. Given the civil monetary penalties “not in excess of $300 per day” (maximum of $109 500 annually) for noncompliance, it is perhaps unsurprising why so few centers are transparent. Recent work has reported a wide range in the levels of compliance and rates for oncology services.⁶ Many NCI-CCs will likely continue to keep their pricing opaque given the potential reduction in reimbursement that may follow true transparency. Limitations of this study include the possibility of price transparency information posted after the final search date and generalizability of pricing for the cancer services assessed when compared with other cancer treatments. Additionally, this study focused on services and transparency at NCI-CCs, which may limit comparisons to non-NCI centers. Most NCI-CCs are poorly compliant with the 2021 CMS price transparency rules, potentially stymieing efforts to limit proliferating cancer treatment costs and improve affordability for patients.