Finding hospital prices can be complicated for patients, even with transparency rule in play
Price-shopping for a medical procedure could save you hundreds or even thousands of dollars — especially if you're paying cash for it.
Take a mammogram as one example. One Oklahoma City hospital charges a cash price of about $40 for a mammogram of both breasts. Less than two miles away, another hospital has a cash price of over $500.
Many patients may not realize how greatly prices for routine medical procedures can vary, depending on what insurance coverage they have and where they have the procedure done.
More:I write about health for a living. Here's how it went when I tried 4 hospital price tools
A federal rule aimed to bring more transparency to the process. By putting hospital prices in patients' hands, Americans should be empowered to shop around for their medical services. And it could help them avoid sticker shock, too.
But over a year and a half since the rule went into effect, not all hospitals are meeting its requirements. And many patients may not know what information is available to them.
An Oklahoman review of hospitals’ price estimator tools and downloadable data files of their items and services found that what’s available is a complicated and inconsistent patchwork of information, leaving gaps for consumers to fill in themselves. Add to that the fact that hospitals' price estimates often exclude the costs of physicians' or practitioners' fees, and you're left with a process that's still opaque to patients.
The federal price transparency rule, enforced by the Centers for Medicare and Medicaid Services (CMS), requires hospitals to post both a consumer-friendly list of common services and procedures and their prices, as well as a database of every item and service a facility provides, including their cash prices and negotiated prices with insurance plans.
Over a year and a half since the rule went into effect, hospitals in Oklahoma and across the U.S. have responded to its requirements with varying degrees of completeness.
The four major health systems in Oklahoma — OU Health, SSM Health, Mercy and Integris Health — have each posted a file of their services, and each have a price estimator tool on their websites.
In The Oklahoman's analysis of hospitals' databases, prices were missing for several procedures we spot-checked. The "consumer-friendly" tools, on the other hand, often ask patients to fork over their insurance details before it's possible to access a cost estimate.
More:Want to price shop for medical procedures? 5 steps for patients to get started
Wading through the files and tools, you can find great variation in what a certain procedure costs from hospital to hospital, as well as differences even in the same facility.
For example, at OU Medical Center in Oklahoma City, the discounted cash price for a total knee replacement is $13,763.79.
If you have insurance, your insurance company could be billed anywhere from $3,071 to upwards of $112,000 for that same knee replacement, and it would depend on your deductible and the particulars of your insurance plan on how much of that you may have to pay out of pocket.
Or, if you need a sleep study done and wanted to pay cash, you could pay about $952 at OU Medical Center, about $3,200 at Mercy Hospital Oklahoma City, or about $4,500 at SSM Health St. Anthony.
Measuring hospitals’ compliance
So which Oklahoma hospitals are meeting the requirements of the price transparency rule? Depends on whom you ask.
CMS, the agency tasked with enforcing the rule, has not fined any Oklahoma hospital for deficiencies in compliance with the rule.
Two Oklahoma City hospitals — Mercy Hospital Oklahoma City and SSM Health St. Anthony Oklahoma City — told The Oklahoman they had received warning notices from CMS about compliance with the rule in 2021 but have since corrected those issues. An Integris Health spokeswoman said the system hadn't received any warnings or notices from CMS, and OU Health declined to comment.
More:Finding out how long a flu shot lasts and when is the best time to get one
SSM Health St. Anthony provided copies of its letters to and from CMS to The Oklahoman. An email from CMS dated Feb. 14, 2022, said the agency found that the hospital had rectified the issues CMS had noted in its warning letter, and CMS closed the inquiry into the hospital's compliance.
Mercy also provided The Oklahoman with an August 2021 letter from CMS citing issues with the price transparency rule. A spokeswoman said the hospital came into full compliance and was never fined.
A recent report estimates only 16% of U.S. hospitals are fully meeting the requirements of the rule, but other analyses paint a more positive picture. Only two hospitals in the country, both in Georgia, have faced fines for lack of compliance with the rule.
Patient Rights Advocate, a nonprofit promoting health care price transparency, spot-checked 48 Oklahoma hospitals between May and July of this year, and its analysis found that only three were fully complying with the CMS rule’s requirements: OU Medical Center, Hillcrest Hospital South in Tulsa and Jefferson County Hospital in Waurika.
Hospital name | Patient Rights Advocate assessment | Turquoise Health medical services file rating (out of 5) | Centers for Medicaid and Medicare action, if any |
SSM Health St. Anthony Hospital | N/A (not included) | 5 | Notice received, issues corrected |
Integris Baptist Medical Center | Noncompliant | 3 | None |
University of Oklahoma Medical Center | Compliant | 5 | Declined to comment |
Mercy Hospital Oklahoma City | Noncompliant | 3 | Notice received, issues corrected |
Hospitals are primarily falling short when it comes to the data file of prices, said Cynthia Fisher, founder and chairman of Patient Rights Advocate. Many are missing large swaths of data, or not clearly naming the plan for the price listed, she said.
Of the 2,000 hospitals reviewed in the group’s August report, only 16% were fully complying with the rule. That’s only a slight bump from about six months earlier, when about 14% of the hospitals reviewed were compliant.
Turquoise Health, a health tech startup founded on the heels of hospital price transparency legislation, tracks and aggregates thousands of hospitals’ pricing files and provides a platform for patients to look up hospital pricing in one place.
Out of roughly 6,000 hospitals in the U.S., Turquoise found that 4,500 to 5,000 have posted a downloadable data file of their pricing.
Instead of marking hospitals compliant or noncompliant, like the Patient Rights Advocate report, Turquoise grades hospitals on a five-star scale based on how complete the facility’s price database is. The rating doesn’t factor in hospitals’ price estimator tools.
Of the hospitals Turquoise has found a file for, at least 70% have either a four or five-star rating, which is “very reasonable completeness,” said Marcus Dorstel, vice president of operations at Turquoise Health.
“There’s definitely a spectrum of compliance and completeness in those files,” he said. “Within that spectrum, and within the data that we’re seeing, I think we view it a lot more positively than [the Patient Rights Advocate] report.”
CMS ultimately makes the call on whether hospitals are meeting the rule’s requirements or not.
As of late July, CMS had issued 368 warning notices to hospitals out of compliance with the rule across the U.S. The agency issued 188 requests for corrective action plans to hospitals that had previously received a warning notice.
Two hospitals, both in Georgia, have been fined since the law went into effect.
A CMS spokesperson declined to tell The Oklahoman whether any Oklahoma hospitals were among those who received warnings or notices requesting corrective action. The Oklahoman’s Freedom of Information Act request for that information is still pending.
Patti Davis, president of the Oklahoma Hospital Association, a trade group that represents Oklahoma hospitals, cautioned consumers from placing too much weight on any one analysis of hospitals’ compliance with the rule.
“Different groups might come out with different reports, and the most important thing is to know that not all reports are created equal, and not all of them are measuring the same thing,” she said. “We're going to go by what's required by federal law in terms of that being the guideposts that our hospitals use.”
Davis said hospitals in Oklahoma are doing their best to comply with a “relatively new rule.” Some struggled to meet the rule’s demands when they first took effect in January 2021, as many hospitals were facing surging COVID-19 hospitalizations and staffing shortages.
More:COVID-19 cancellations cost Oklahoma Shakespeare in the Park thousands in losses
It’s a “work in progress,” Davis said, adding that hospitals’ transparency measures will improve over time.
Ahead of the curve
The prices most hospitals post in their estimator tools and in their total files come with significant caveats.
They don’t include fees for which patients may be billed separately — like physicians’ fees, fees from an anesthesiologist or for other professional services.
The Surgery Center of Oklahoma is an outlier here. Since 2009, the center has posted its prices online, and they’re all-inclusive figures so there are no surprises, said Dr. Keith Smith, managing partner of the Surgery Center of Oklahoma.
More:Oklahoma County received over $154 million in ARPA funding. What has it spent so far?
Patients in Oklahoma and beyond its borders make use of the Surgery Center’s posted prices, Smith said. About 40% of its patients come from out of state.
Others, instead of traveling to Oklahoma, show the Surgery Center’s prices to their local hospitals.
“The hospital has a choice,” Smith said. “They can either price-match, or they can watch the patient walk out the door.”
Some patients use the prices after their own surgery or procedure elsewhere to contest what they were charged.
Smith is a believer in competitive, free markets and and isn’t for government mandates, so he’s not a fan of the CMS rule — it’s been ineffective so far, he said. But there’s a silver-lining to the rule, he said.
“I’m reluctant to even admit this, but it changed the narrative,” he said. “I’m not the one with the tinfoil hat on my head who’s posting prices. Now, people who don’t post prices have some explaining to do.”
Help us report: Have you used a hospital price transparency tool in Oklahoma?
We want to hear from Oklahomans: Have you used a price transparency tool to estimate the cost of your medical care? How did it go?
If you want to help us report, here’s how you can do that.
Have you had a recent non-emergency medical procedure in Oklahoma? It could be anything from a surgery to routine lab work.
If so, take a look at your bill for that medical service, then look up your procedure on the site that corresponds to your health system. Here’s where you can find that information for the four major health systems in Oklahoma City:
When you input your information, does the total come out close to what you were billed? Were there other charges that weren’t included?
Send us what you find. We won’t publish your information without your permission.
This article originally appeared on Oklahoman: Do Oklahoma hospitals follow price transparency rule? It's complicated
