Assessment of Prices for Cardiovascular Tests and Procedures at Top-Ranked US Hospitals

Abstract

This cross-sectional study describes variation in prices for common cardiovascular tests and procedures, both between and within top-ranked US hospitals.

In the US, routine cardiovascular tests and procedures are performed frequently, but little is known about the price of these procedures across hospitals and payers.¹ In 2021, the Hospital Price Transparency Final Rule took effect and requires hospitals to post payer-specific negotiated prices for all items and services. The public availability of these data creates a unique opportunity to understand variation in hospital pricing,² which to our knowledge has not been described for cardiovascular tests and procedures. In this cross-sectional study, we characterize variation in prices for common cardiovascular tests and procedures, both between and within top-ranked US hospitals.

Methods

We searched the websites of the 20 top-rated hospitals by US News & World Report in 2021 for pricing files through September 15, 2021. We chose these hospitals because they likely have resources to comply with the law and because we wanted to compare prices across hospitals with similar characteristics. Additional information is available in eMethods and eTables 1 and 2 in the Supplement.

We extracted payer-specific and self-pay cash prices for noninvasive (transthoracic echocardiogram, nuclear stress test) and invasive (right heart catheterization [RHC], diagnostic coronary angiogram, percutaneous coronary intervention [PCI], and pacemaker implantation) cardiovascular tests/procedures using Current Procedural Terminology codes. To examine between-hospital price variation, we determined the median negotiated price for a specific cardiovascular test/procedure across all payers at each hospital, then compared median prices across institutions. To evaluate within-hospital price variation, we compared the IQR of prices for each test/procedure across payers at each hospital. We included both commercial and public (eg, Medicare and Medicaid) payers. Institutional review board approval was not required because we used publicly available data and did not use patient information. Analyses were performed from December 1, 2021, to January 15, 2022.

Results

Of the top 20 US hospitals, 19 (95%) hospitals posted a machine-readable file to their websites, 16 (80%) reported prices for some cardiovascular tests/procedures, and only 7 (35%) reported prices for all cardiovascular tests/procedures. Across hospitals, the number of insurance plans publicly listed for each test/procedure ranged from 1 to 432.

Across hospitals, the median price ranged from $204 to $2588 for an echocardiogram and from $463 to $3230 for a stress test (Figure 1). The median price ranged from $2821 to $9382 for an RHC, $2868 to $9203 for a coronary angiogram, $657 to $25 521 for a PCI, and $506 to $20 002 for pacemaker implantation (Figure 2). Self-pay cash prices exhibited a similar variation.

Figure 1. Prices for Noninvasive Cardiovascular Tests at the Top 20 US Hospitals in 2021.

Whiskers extend to the minimum and maximum payer-specific negotiated prices, and in some instances, the median price is similar to the 25th percentile (eg, transthoracic echocardiogram at the Hospital of the University of Pennsylvania [HUP]) because a large number of insurers have similar negotiated prices. The limited variation in prices across payers at Johns Hopkins Hospital (Hopkins) may be related to Maryland’s All-Payer Model. Rush University Medical Center (Rush) did not report specific Current Procedural Terminology codes; therefore, study tests and procedures were identified based on written description. Self-pay cash prices were extracted from hospitals with payer-specific prices for some tests and procedures. Self-pay cash prices were identified based on the following labels: “self-pay,” “cash price,” and “discounted cash price.” Mayo Clinic Hospital; NewYork-Presbyterian Hospital (NYPH); NYU Langone Health; University of California, San Francisco Medical Center; Stanford University Medical Center; Houston Methodist Hospital (Houston); and Vanderbilt University Medical Center did not post prices for echocardiograms. Mayo Clinic Hospital; NYU Langone Health; University of California, San Francisco Medical Center; Stanford University Medical Center; HUP; and Vanderbilt University Medical Center did not post prices for stress tests. Barnes indicates Barnes-Jewish Hospital; BWH, Brigham and Women’s Hospital; Cedars, Cedars-Sinai Medical Center; Cleveland, Cleveland Clinic Hospital; Mayo AZ, Mayo Clinic Hospital in Arizona; MGH, Massachusetts General Hospital; Michigan, University of Michigan Hospital; Northwestern, Northwestern Memorial Hospital; Sinai, Mount Sinai Medical Center; and UCLA, Ronald Reagan UCLA Medical Center.

Figure 2. Prices for Invasive Cardiovascular Tests and Procedures at the Top 20 US Hospitals in 2021.

Whiskers extend to the minimum and maximum payer-specific negotiated prices, and in some instances, hospitals listed payer-specific prices for a small number of insurers (eg, 1 plan for a percutaneous coronary intervention at Mount Sinai Medical Center [Sinai]). Rush University Medical Center (Rush) did not report specific Current Procedural Terminology codes; therefore, study tests and procedures were identified based on written description. Self-pay cash prices were extracted from hospitals with payer-specific prices for some tests and procedures. Self-pay cash prices were identified based on the following labels: “self-pay,” “cash price,” and “discounted cash price.” Cleveland Clinic Hospital (Cleveland); Ronald Reagan UCLA Medical Center (UCLA); Johns Hopkins Hospital (Hopkins); NewYork-Presbyterian Hospital; NYU Langone Health; University of California, San Francisco Medical Center; Stanford University Medical Center; Mayo Clinic Hospital in Arizona (Mayo AZ); and Vanderbilt University Medical Center did not post prices for right heart catheterization. UCLA; Hopkins; NewYork-Presbyterian Hospital; NYU Langone Health; University of California, San Francisco Medical Center; Stanford University Medical Center; Hospital of the University of Pennsylvania (HUP); Barnes-Jewish Hospital (Barnes); and Vanderbilt University Medical Center did not post prices for percutaneous coronary intervention. Cleveland; Hopkins; NewYork-Presbyterian Hospital; NYU Langone Health; University of California, San Francisco Medical Center; Stanford University Medical Center; Mayo AZ; and Vanderbilt University Medical Center did not post prices for coronary angiogram. Hopkins; NewYork-Presbyterian Hospital; NYU Langone Health; University of California, San Francisco Medical Center; Stanford University Medical Center; HUP; Barnes; and Vanderbilt University Medical Center did not post prices for pacemaker implantation. BWH indicates Brigham and Women’s Hospital; Cedars, Cedars-Sinai Medical Center; Houston, Houston Methodist Hospital; Mayo, Mayo Clinic Hospital; MGH, Massachusetts General Hospital; Michigan, University of Michigan Hospital; and Northwestern, Northwestern Memorial Hospital.

Within hospitals, the largest IQR of payer-specific prices was $470 to $3022 for an echocardiogram and $776 to $3473 for a stress test. The largest IQR was $3143 to $12 926 for an RHC, $4011 to $14 486 for a coronary angiogram, $11 325 to $23 392 for a PCI, and $8474 to $22 694 for pacemaker implantation.

Discussion

There is marked variation in prices for common cardiovascular tests and procedures, both between and within highly ranked US hospitals. For example, we observed a 10-fold difference in the median price of an echocardiogram and a greater than 3-fold difference in the median price of a diagnostic coronary angiogram across top hospitals.

The between- and within-hospital price variation we observed is likely more associated with market dynamics rather than true differences in care quality because we focused on a group of similar hospitals. Even within the same institution—where tests and procedures should require similar resources and be of similar quality—prices across payers varied substantially. One potential reason for this variation is physician and payer consolidation, which has been shown to affect hospital pricing,³ without consistent improvements in quality. As the US health care system becomes increasingly concentrated,⁴ efforts to track changes in hospital prices and ensure that they reflect care quality will be important.

This study has limitations. First, the findings are conditional on the quality and accuracy of data posted by hospitals. Second, pricing files were not standardized across institutions and, often, did not specify whether prices included professional fees or reflected the inpatient or outpatient care setting. Third, because we lack data on utilization rates and the number of patients covered by each insurance plan, we were unable to estimate average prices weighted by payer mix, the more relevant measure to understand the effect of prices on total spending. Policies that ensure that prices more closely reflect quality may help improve the value of cardiovascular care in the US.

Supplement.

eMethods

eTable 1. Hospital Compliance with the Requirement to Post Payer-Specific and Self-Pay Cash Prices for Available Tests and Procedures

eTable 2. Availability of Inpatient vs Outpatient Payer-Specific Negotiated Price Data, by Hospital