S. J. Masoud1, M. Cerullo1 1Duke University Medical Center, Department Of Surgery, Durham, NC, USA 2Yale University School Of Medicine, Department Of Surgery, New Haven, CT, USA
Introduction: The Centers for Medicare and Medicaid Services (CMS) price transparency rule aims to facilitate cost-conscious decision-making. Where hospital charges for complex cancer operations like pancreaticoduodenectomy (PD) show marked variation and sensitivity to operative volume, real-world pricing amidst a fragmented reimbursement landscape remains opaque. Novel platforms enable investigation of hospital and market factors mediating transparency and cost. Herein, we hypothesized greater price transparency and decreased prices for PD performed in high volume centers.
Methods: The Leapfrog Hospital Survey was used to identify hospitals performing PD, their quality ratings, and procedural volume. Hospital pricing and financial performance were derived from the Turquoise Health Research Dataset and CMS Medicare Cost Reports. Herfindahl-Hirschman Index (HHI) estimated hospital referral region competition. Modified Poisson regression evaluated associations between quality indicators and price disclosure. Two-part models were used to query average marginal effects of hospital factors on PD prices.
Results: Of 452 Leapfrog Hospitals, 295 (65.2%) disclosed PD prices. Disclosing hospitals had higher charge-to-cost ratios (5.93 vs. 4.78, p<0.01) and net hospital margins (-1.03% vs. -5.62% , p=0.02), but did not differ by Leapfrog ratings or HHI market concentration. In multivariate analysis, teaching affiliation (IRR 1.43, 95% CI 1.18-1.74, p<0.01), for-profit status (IRR 1.50, 95% CI 1.30-1.73, p<0.01), and annual volume over 20 PDs (IRR 1.39, 95% CI 1.13-1.71, p<0.01) predicted price disclosure. PD list price decreased an average $262 with increasing net margins (95% CI $28 vs. $496, p=0.03), but non-profit status conferred uniform increases in list ($19276, 95% CI $2689 – $35863, p=0.02), commercial ($11012, 95% CI $3422 – $18601, p<0.01), Medicare ($7732, 95% CI $3799 – $11665, p<0.01), and self-pay prices ($9783, 95% CI $131 – $19435, p=0.05). Teaching hospitals had higher list price ($21409, 95% CI $7360 – $35458, p<.01) and Medicare rates ($4420, 95% CI $860 – $7980, p<0.02). Intermediate (HHI 1500-2500), relative to low market concentration, predicted decreases of $9829 (95% CI $381 – $19277, p=0.04) and $7266 (96% CI $2513 – $12019, p<0.01) for commercial and Medicare payment, respectively.
Conclusion: Nationwide analysis of Leapfrog hospitals demonstrated high rates of non-disclosure for PD pricing. Price transparency was noted in hospitals with higher overall revenues, operative volume, and academic affiliation, but did not track with Leapfrog quality measures. Drivers of PD prices were non-profit and academic status, and low market concentration, rather than quality and volume metrics. Our analysis suggests an extant disconnect between price transparency and cost-effectiveness. Policy changes may be required to broadly incentivize price disclosure, and translate price transparency into increased value for patients.