Background 

The Centers for Medicare and Medicaid Services (CMS) recently implemented price transparency legislation. As total joint arthroplasty (TJA) procedures are widely used, expensive, and generally are predictable in terms of cost and expected outcomes, these procedures are a proxy for assessing how hospitals provide price transparency for their services as a whole. Furthermore, cost estimates for TJA procedures represent some of the most commonly sought-after price transparency information among the orthopaedic surgery patient population.

Questions/purposes 

We asked: (1) Are hospitals compliant with federal rules mandating transparency in pricing for primary TJA? (2) Are hospitals providing these data in a user-friendly format? (3) Is there a difference in prices quoted based on Current Procedural Terminology (CPT) codes compared with Diagnosis Related Group (DRG) codes?

Methods 

Our cross-sectional retrospective analysis used the CMS’s Hospital Compare database. This database includes information for 5326 Medicare hospitals nationally. We excluded children’s, psychiatric, Veterans Affairs, and active military base hospitals as well as hospitals performing fewer than 100 TJAs annually. A total of 1719 hospitals remained after this selection process. Random sampling stratified across practice setting, hospital size, TJA volume, type, ownership, and Census region was performed to identify 400 facilities for our final analysis. Included hospitals were located predominately in urban areas (79% [317 of 400]) and were mostly medium-sized facilities (43% [171 of 400]). Most hospitals were classified as acute care (98% [392 of 400]) versus critical access. Three reviewers thoroughly searched each hospital website for a machine-readable file providing the following five datapoints: gross charges, payer-specific negotiated charges, deidentified minimum negotiated charges, deidentified maximum negotiated charges, and discounted cash prices. Hospitals that provided all five datapoints through a machine-readable file were considered compliant. Additionally, we considered hospitals with any gross price information pseudocompliant. The consumer-friendliness of the website was assessed based on the following criteria: (1) languages other than English were offered, (2) it took less than 15 minutes to locate pricing information, (3) a phone number or email address was provided for questions, and (4) there was a description of procedure in common terms. Pricing information was recorded and compared for CPT codes 27447 and 27130 and DRG codes 469 and 470. Data were sourced from December 1 through 20, 2021, to assess compliance in the first year since the legislation was implemented.

Results 

Only 32% (129 of 400) of the sampled hospital websites were compliant with all six requirements under the CMS rule for transparency in pricing. When segregating by individual procedures, 21% (84 of 400), 18% (72 of 400), 18% (71 of 400), and 19% (74 of 400) of hospitals provided CMS-compliant pricing information for CPT codes 27447 and 27130 and DRG codes 469 and 470, respectively. For each code, rates of pseudocompliance were 36% (143 of 400), 31% (125 of 400), 34% (135 of 400), and 50% (199 of 400) for the included codes, respectively. Most included hospitals provided at least some of their pricing data in a user-friendly format. Prices quoted using a DRG search were higher overall than prices quoted using a procedure-specific CPT code.

Conclusion 

Although the CMS implemented a price transparency mandate at the beginning of 2021, our analysis demonstrated that most hospitals either do not provide TJA price estimates or are noncompliant when presenting related information. Specifically, approximately half of evaluated hospitals provided a gross charge for any TJA code, and less than one-third of these institutions were fully compliant with all CMS mandates for these procedures.

Clinical Relevance 

Given the potential influence compliance and price sharing may have on empowering patients’ healthcare decisions and reducing healthcare expenditures, hospitals should use our analysis to identify where their compliance is lacking and to understand how to make their pricing information more readily available to their patients. In addition to ensuring that all six CMS mandates are met, this should include providing information in easy-to-understand formats and making related services identifiable across all levels of health literacy. Furthermore, we advocate for the use of CPT codes and layman terms when identifying provided services as well as a price estimator tool that allows for the download of a machine-readable file specific to the procedure of interest.

中文翻译：

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不到三分之一的医院为全关节置换术提供合规的价格透明度信息

背景 

医疗保险和医疗补助服务中心 (CMS) 最近实​​施了价格透明度立法。由于全关节置换术 (TJA) 手术被广泛使用、昂贵且通常在成本和预期结果方面是可预测的，因此这些手术可以作为评估医院如何为其整体服务提供价格透明度的指标。此外，TJA 手术的成本估算代表了骨科手术患者群体中最常见的一些价格透明度信息。

问题/目的 

我们询问：(1) 医院是否遵守要求初级 TJA 定价透明的联邦规则？(2) 医院是否以用户友好的格式提供这些数据？(3) 与诊断相关组 (DRG) 代码相比，基于当前程序术语 (CPT) 代码的报价是否存在差异？

方法 

我们的横断面回顾性分析使用了 CMS 的医院比较数据库。该数据库包含全国 5326 家医疗保险医院的信息。我们排除了儿童医院、精神科医院、退伍军人事务部医院和现役军事基地医院以及每年执行 TJA 少于 100 次的医院。经过此次遴选，最终剩下 1719 家医院。我们对实践环境、医院规模、TJA 数量、类型、所有权和人口普查区域进行了分层随机抽样，以确定 400 个设施用于我们的最终分析。纳入的医院主要位于城市地区（79% [400 家中的 317 家]），并且大多是中型设施（43% [400 家中的 171 家]）。大多数医院被归类为急症护理（98% [400 家中的 392 家]）与重症护理。三名评审员彻底搜索了每个医院网站，寻找提供以下五个数据点的机器可读文件：总费用、付款人特定的协商费用、未识别的最低协商费用、未识别的最高协商费用和折扣现金价格。通过机器可读文件提供所有五个数据点的医院被认为是合规的。此外，我们认为提供任何总价格信息的医院都是伪合规的。该网站的消费者友好性根据以下标准进行评估：(1) 提供英语以外的语言，(2) 查找价格信息的时间不超过 15 分钟，(3) 提供电话号码或电子邮件地址(4) 有通用术语的程序描述。记录并比较了 CPT 代码 27447 和 27130 以及 DRG 代码 469 和 470 的定价信息。数据来源于 2021 年 12 月 1 日至 20 日，以评估自立法实施以来第一年的合规性。

结果 

在抽样医院网站中，只有 32%（400 家中的 129 家）符合 CMS 定价透明度规则的所有六项要求。按个别程序进行分类时，21%（400 家中的 84 家）、18%（400 家中的 72 家）、18%（400 家中的 71 家）和 19%（400 家中的 74 家）的医院提供了 CPT 代码 27447 的符合 CMS 的定价信息和 27130，DRG 代码分别为 469 和 470。对于每个代码，所包含代码的伪合规率分别为 36%（400 个中的 143 个）、31%（400 个中的 125 个）、34%（400 个中的 135 个）和 50%（400 个中的 199 个）。大多数医院都以用户友好的格式提供了至少一些定价数据。使用 DRG 搜索的报价总体高于使用特定程序 CPT 代码的报价。

结论 

尽管 CMS 在 2021 年初实施了价格透明度要求，但我们的分析表明，大多数医院要么不提供 TJA 价格估算，要么在提供相关信息时不合规。具体而言，大约一半的接受评估的医院对任何 TJA 代码都收取总费用，其中不到三分之一的机构完全遵守这些程序的所有 CMS 要求。

临床相关性 

鉴于合规性和价格共享可能对赋予患者医疗保健决策权和减少医疗保健支出产生潜在影响，医院应使用我们的分析来确定其合规性不足的地方，并了解如何使患者更容易获得其定价信息。除了确保满足所有六项 CMS 要求外，还应包括以易于理解的格式提供信息，并使相关服务在各个级别的健康素养中都可识别。此外，我们提倡在识别所提供的服务时使用 CPT 代码和外行术语，以及允许下载特定于感兴趣程序的机器可读文件的价格估算工具。