In push for pricing transparency, state’s hospitals stumble

By: - July 27, 2021 6:15 am
Closeup of a drip line in a hospital

The percentage who said they don’t believe COVID-19 poses a serious health risk has dropped considerably since June, from 50 percent to 24 percent. (Getty Images)

This story was updated June 27, 2021 at 8 a.m. to include a comment from HCA NH, which includes Frisbie Memorial Hospital, Parkland Medical Center, and Portsmouth Regional Hospital.

Under a new federal law, hospitals are required to post prices for hundreds of procedures on their websites and make those costs easy for patients to compare. Only two of the state’s 31 hospitals have complied, according to a report from a patients’ rights advocacy group.

But not even those – Androscoggin Valley Hospital in Berlin and Exeter Hospital – make price shopping among hospitals as easy as the state’s NH HealthCost website, the first of its kind in the country when the state Department of Insurance launched it in 2007. 

The state’s site was credited in a 2019 study of X-ray, CT scan, and other imaging costs with creating a competitive market that saved customers $7.9 million over five years and insurance companies $36 million. States across the country have called seeking help duplicating it, and it has consistently earned New Hampshire an A from a national group that studies states’ health pricing transparency laws. The only other state to do so is Maine, which is using New Hampshire’s model.

“Nobody had much confidence that the state would be able to do this very well,” said Tyler Brannen, the life and health director at the Insurance Department who built the site, which now also provides dental cost estimates. “The number of people who told me we couldn’t do it when we started was huge.”

It’s easy to see why.

The disclosure and technical requirements are significant, and the advocacy group said the penalties for hospitals – even at $300 a day – are too low to force compliance. (It recommends $300 per day, per bed.) Almost 95 percent of the country’s 6,002 hospitals are falling short by “undermining the rule with incomplete information, burdensome access restrictions,” and other barriers, according to the report issued by Patient Rights Advocate this month.

The new federal pricing transparency requirement for hospitals, an initiative of the Trump administration that took effect Jan. 1, is an effort to create the same kind of competition – and savings – the state’s search tool accomplished. 

A map showing state grades for price transparency
The 2020 comparison of state price transparency laws. (Source: Catalyst for Payment Reform and The Source on Healthcare Price and Competition, at the University of California Hastings College of Law.)

Hospitals are required to publish detailed pricing on 300 of the most common services in two ways: a “consumer-friendly” display and a digital “machine-readable” file. The communications office at the Center for Medicaid and Medicare Service overseeing the new requirements said both versions are required to tell patients the total cost of a service; the discount they’ll get if they are uninsured and pay cash; and the maximum and minimum charges allowed under contracts they’ve negotiated with insurance companies.

Because there are suggested but no standard formatting requirements, hospitals have taken varying approaches to creating those search tools, and so far most are difficult to navigate or short on pricing information – or both. Like the report, a recent piece on the Kaiser Health News site shows New Hampshire is not unique. 

“I have spent hours toggling among multiple spreadsheets, each containing thousands of numbers, in an effort to compare prices for 20 common outpatient procedures,” wrote Bernard Wolfson about his search of two California hospital websites. “After three months of glazed eyes and headaches from banging my head against walls of numbers, I am throwing in the towel. It was a fool’s errand. My efforts ultimately yielded just one helpful piece of advice: Don’t try this at home.”

The complex and at times indecipherable pricing information raises a question: Will this new federal rule accomplish its goal of lowering health care costs?

“I think any effort to make information about price and services transparent to patients is a good idea,” said attorney Lucy Hodder, director of Health Law and Policy programs at the UNH School of Law. “We access many of our health services from hospital systems so starting with their prices makes sense. I would say some of our hospitals were already doing a pretty good job of putting their most common services up on their website and available for the patient, but we can do better. I think the transparency tools most hospitals have posted are really difficult to use.”

The challenge of using the hospitals’ search tools is best appreciated when compared to the state’s NH HealthCost site, which is not only easy to use but likely provides more accurate estimates. That’s because a 2005 state law allows the state to collect from the commercial insurance companies it regulates detailed claims showing all the health services a patient gets –  and pays for – when undergoing a single procedure. “If you want to get a mammogram, you want there to be a radiologist to read it,” Brannen said. (Hospitals are supposed to bundle those costs together as well, but on most sites there was no way to tell if they had.)

Three clicks and little data entry on the NH HealthCost site gives patients with and without insurance the estimated cost of a colonoscopy at 36 hospitals, as well as the estimated price they will pay, on one screen. (There is also an option to search by insurance provider.) Clicking the hospital name produces a detailed breakdown of that hospital’s prices and, in some cases, quality of care scores and patient ratings. 

 Screenshot of patient ratings of Portsmouth Regional Hospital on the NH HealthTrust website.
Patient ratings of Portsmouth Regional Hospital on the NH HealthCost website. (Screenshot)

In a search on NH HealthCost last week, St. Joseph Hospital in Nashua had the highest price for a colonoscopy for a patient with Anthem insurance at $5,653 and the Concord Endoscopy Center charged the least at $1,670. But “quality of care” information was available for only the first. (Seven of 10 patients would recommend the hospital, and nurses and doctors communicate well.) 

That search is far less easy to do through the hospitals’ pricing tools. And, those sites don’t provide quality ratings, which experts say is necessary for patients to make an informed choice. 

Elliot Hospital in Manchester and Southern New Hampshire Medical Center in Nashua hired the same company to create their pricing tools. Those tools returned no results for colonoscopy when searched one way and more than 4,000 results, seemingly of all hospital services, when searched another. That search result included prices but no information about whether the price was for insured or uninsured patients as required.

The ability to publish pricing for patients in an understandable way is very complicated,” said Dawn Fernald, spokeswoman for SolutionHealth, which owns the hospitals. “This regulation that went into effect in early 2021 was also very complicated. We are also working on developing our own, more meaningful price estimate tool for patients to use but it is not ready for publication.”   

Dartmouth-Hitchcock owns and shares a billing system with  Cheshire Medical Center in Keene. Both sites made it easy to find some pricing for a colonoscopy (about $7,700), but the charges were not differentiated by insurance carriers or self-paying patients. Only one of the two sites said the colonoscopy estimate did not include the cost of some related services, like lab tests. 

No one at Dartmouth-Hitchcock could be reached for comment.

Frisbie Memorial Hospital in Rochester, Parkland Medical Center in Derry, and Portsmouth Regional Hospital use the same “patient payment estimator.” Searching colonoscopy is easy; pricing is less so. Insured patients must enter their insurance information; uninsured patients must call a toll-free number to get an estimate, contrary to the rules. Those with insurance must enter their name and insurance policy information, something not required by other sites.

Ryan Lawrence, director of marketing and communications at Parkland Medical Center, said all three hospitals have been working since January to comply with the new rules by adding a “patient payment estimator” option and the machine-readable file with prices by insurance carrier. Lawrence said the hospitals will be updating the site to include pricing for self-paying patients.

“In our experience, each uninsured individual comes to us with unique financial circumstances and is best served by an individualized discussion with a financial counselor so they can be informed of all available discounts and financial assistance,” Lawrence said in a email. “Based on this experience, we have guided uninsured individuals to our financial representatives to provide the most accurate representation of the individual’s estimated financial obligation. Although we continue to prefer that uninsured individuals speak with financial representatives, we are updating the online price estimator tool to ensure that uninsured individuals can also use the tool to receive a price estimate online.”

Both hospitals deemed compliant by Patient Rights Advocate, Androscoggin Valley Hospital and Exeter Hospital, require patients to enter detailed insurance information, including deductible met and co-pay, making the pricing estimate more personal to the patient. But neither allow patients to enter the simple term “colonoscopy,” and instead use more medically technical terms patients may not recognize.

Hodder said price transparency should be the start, not the only goal. She’d like to see the state’s hospitals and their communities think more broadly about what medical services are most important to them and focus on the value of those services. Is it vascular surgery or substance misuse services or mental health treatment, or both? How do we make those services sustainable in our communities?

“I think providers want to demonstrate their value, but no one is asking them to partner in a comprehensive way,” she said.

Our stories may be republished online or in print under Creative Commons license CC BY-NC-ND 4.0. We ask that you edit only for style or to shorten, provide proper attribution and link to our web site. Please see our republishing guidelines for use of photos and graphics.

Annmarie Timmins
Annmarie Timmins

Senior reporter Annmarie Timmins is a New Hampshire native who covered state government, courts, and social justice issues for the Concord Monitor for 25 years. During her time with the Monitor, she won a Nieman Fellowship to study journalism and mental health courts at Harvard for a year. She has taught journalism at the University of New Hampshire and writing at the Nackey S. Loeb School of Communications.