Health care prices

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Unlike most markets for consumer services in the United States, the health care market generally lacks transparent market-based pricing.[1][2] Patients are typically not able to comparison shop for medical services based on price, as medical service providers do not typically disclose prices prior to service.[1][2][3] Government mandated critical care and government insurance programs like Medicare also impact market pricing of US health care. According to the New York Times, "the United States is far and away the world leader in medical spending, even though numerous studies have concluded that Americans do not get better care."[2]

Price transparency issues[edit]

In a market with transparent pricing, the price of a particular service is openly advertised.[1][4] For example, companies that provide automotive oil changes often advertise their prices, and consumers have access to these prices when choosing a service provider. In contrast, in the US medical industry, patients generally do not have access to pricing information until after medical services have been rendered. A study conducted by the California Healthcare Foundation[5] found that only 25% of visitors asking for pricing information were able to obtain it in a single visit to a hospital.[6]

Since the majority (85%) of Americans have health insurance, they do not directly pay for medical services.[7] Insurance companies, as payors, negotiate health care pricing with providers on behalf of the insured. Hospitals, doctors, and other medical providers have traditionally disclosed their fee schedules only to insurance companies and other institutional payors, and not to individual patients. Uninsured individuals are expected to pay directly for services, but since they lack access to pricing information, price-based competition may be reduced. The introduction of high-deductible insurance has increased demand for pricing information among consumers. As high-deductible health plans rise across the country, with many individuals having deductibles of $2500 or more, their ability to pay for costly procedures diminishes, and hospitals end up covering the cost of patients care. Many health systems are putting in place price transparency initiatives and payments plans for their patients so that the patients better understand what the estimated cost of their care is, and how they can afford to pay for their care over time.

Organizations such as the American Medical Association (AMA) and AARP support a "fair and accurate valuation for all physician services".[8][9] Very few resources exist, however, that allow consumers to compare physician prices (one exception is[10]) The AMA sponsors the Specialty Society Relative Value Scale Update Committee, a private group of physicians which largely determine how to value physician labor in Medicare prices. Among politicians, former House Speaker Newt Gingrich has called for transparency in the prices of medical devices, noting it is one of the few aspects or U.S. health care where consumers and federal health officials are "barred from comparing the quality, medical outcomes or price".[11][12][13]

Recently, some insurance companies have announced their intention to begin disclosing provider pricing as a way to encourage cost reduction.[7] Other services exist to assist physicians and their patients, such as Healthcare Out Of Pocket,[14] Accuro Healthcare Solutions, with its CarePricer software.[15] Similarly, medical tourists take advantage of price transparency on websites such as MEDIGO and Purchasing Health]], which offer hospital price comparison and appointment booking services.[16]

Government-mandated critical care[edit]

In the US and most other industrialized nations, emergency medical providers are required to treat any patient that has a life-threatening condition, irrespective of the patient's financial resources. In the US, the Emergency Medical Treatment and Active Labor Act requires that hospitals treat all patients in need of emergency medical care without considering patients' ability to pay for service.[17]

This government mandated care places a cost burden on medical providers, as critically ill patients lacking financial resources must be treated. Medical providers compensate for this cost by passing costs on to other parts of the medical system by increasing prices for other patients and through collection of government subsidies.[18]

Medicare and Medicaid[edit]

Medicare was established in 1965 under President Lyndon Johnson as a form of medical insurance for the elderly (age 65 and above) and the disabled. Medicaid was established at the same time to provide medical insurance primarily to children, pregnant women, and certain other medically needy groups.

Medicare and Medicaid are managed at the Federal level by the Centers for Medicare and Medicaid Services (CMS). CMS sets fee schedules for medical services through Prospective Payment Systems (PPS) for inpatient care, outpatient care, and other services.[19] As the largest single purchaser of medical services in the US, Medicare's fixed pricing schedules have a significant impact on the market. These prices are set based on CMS' analysis of labor and resource input costs for different medical services.

As part of Medicare's pricing system, relative value units (RVUs) are assigned to every medical procedure.[20] One RVU translates into a dollar value that varies by region and by year; in 2005 the base (not location adjusted) RVU equaled roughly $37.90. Major insurers use Medicare's RVU calculations when negotiating payment schedules with providers, and many insurers simply adopt Medicare's payment schedule. The AMA-sponsored committee in charge of determining RVUs of medical procedures that inform Medicare's payment to physicians has been shown to grossly inflate their figures.[21]

See also[edit]


  1. ^ a b c Rosenberg, Tina (July 31, 2013). "Revealing a Health Care Secret: The Price". New York Times. Retrieved August 1, 2013. 
  2. ^ a b c Rosenthal, Elisabeth (June 2, 2013). "The $2.7 Trillion Medical Bill - Colonoscopies Explain Why U.S. Leads the World in Health Expenditures". New York Times. Retrieved August 1, 2013. 
  3. ^ The perils of transparent pricing: the time for speculation is over: transparent pricing is becoming a reality for hospitals. | Health Care > Health Care Professionals from
  4. ^ Price transparency: Definition and Much More from
  5. ^ California Healthcare Foundation
  6. ^ Price Check: The Mystery of Hospital Pricing -
  7. ^ a b US Census Press Releases
  8. ^ "RBRVS: Resource-Based Relative Value Scale". American Medical Association. Retrieved May 3, 2011. 
  9. ^ "AARP: Creating a New Health Care Paradigm". AARP. Retrieved May 3, 2011. 
  10. ^ " a way to compare physician prices". Avalon Business Systems. Retrieved December 7, 2015. 
  11. ^ Newt Gingrich and Wayne Oliver (April 19, 2011). "With Health Care, Taxpayers Deserve To Know What They're Paying For". Retrieved May 3, 2011. 
  12. ^ Brendon Nafziger (May 2, 2011). "Gingrich calls for medical device price transparency". DotMed. Retrieved May 3, 2011. 
  13. ^ Leigh Page (May 3, 2011). "Newt Gingrich Backs Price Transparency for Medical Devices". Becker's ASC Review. Retrieved May 3, 2011. 
  14. ^ Compare Provider Chargers
  15. ^ Patient Estimates - Accuro Healthcare Solutions
  16. ^ Patient Estimates - MEDIGO
  17. ^
  18. ^ Analysis of the Joint Distribution of Disproportionate Share Hospital Payments: Executive Summary
  19. ^ Medicare
  20. ^ AMA (RBRVS) RBRVS: Resource-Based Relative Value Scale
  21. ^ Peter Whoriskey and Dan Keating (July 20, 2013). "How a secretive panel uses data that distort doctors’ pay". The Washington Post. Retrieved March 23, 2014. 

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