Payers have been required to post pricing information online for covered items and services since July, but several limitations exist to providing the true cost of care to patients, according to researchers at Elevance Health.
In an article published May 19 in Health Affairs, the researchers noted that as other researchers and software developers continue to analyze price transparency data, it is important to use data from additional sources to gain a more accurate picture of the cost of care. In addition, Elevance researchers said CMS' data publication mandate does not account for certain institutional and contractual structures that can affect pricing.
To demonstrate some of the limitations with payers' public data, the researchers compared new in-network pricing data to medical claims data at Elevance Health, specifically analyzing colonoscopy codes in Colorado in August 2022.
Six limitations with payer price transparency data:
- Within the August pricing data, Colorado providers listed prices for colonoscopies that did not occur that month. Only about 1 percent of individual providers in Colorado had a claim for a colonoscopy in August. Researchers should confirm actual care utilization using claims data, according to the article.
- Not all providers listed in Colorado's colonoscopy pricing data actually provide colonoscopies in the state. One reason for that could be a health system operating locations across multiple states. The researchers recommend using ZIP codes associated with individual providers to accurately see prices in a specific area.
- The pricing data lists the cost for each service once, but utilization does not follow the same pattern. Within the claims data, the researchers found a higher percentage of colonoscopies took place at providers that charged more. They recommend supplementing price data with usage data and weighting the prices by use.
- In the pricing and claims data, there were fewer unique facilities and fewer prices per facility compared to the number of professionals and prices per professional, even though the cost for the patient usually is the facility and professional prices combined. The researchers said this could be because providers can practice in multiple locations or places of service, and recommended differentiating between professional and facility prices when making comparisons.
- In the pricing and claims data, colonoscopies were cheaper and more common at ASCs compared to hospital outpatient settings, but more prices were negotiated at hospitals. The researchers recommend limiting analysis to places of service that are procedure-specific and stratifying results by place of service when possible. They noted that stratification by place of service is difficult using facility prices, and public provider data should be used to determine place of service.
- Individual providers can have multiple prices for the same colonoscopy, so pricing data alone does not provide all the information that is needed. A patient's insurance coverage can also affect the final price of a procedure.
Read the full study here.