醫(yī)療市場價格和質(zhì)量透明度的障礙

1、ContentsPreface iii HYPERLINK l _TOC_250016 Summary vi HYPERLINK l _TOC_250015 Acknowledgments xi HYPERLINK l _TOC_250014 Abbreviations xii HYPERLINK l _TOC_250013 Introduction 1 HYPERLINK l _TOC_250012 Methods 2 HYPERLINK l _TOC_250011 Health Care Professionals 4 HYPERLINK l _TOC_250010 Overview 4

2、HYPERLINK l _TOC_250009 How Are Prices Set? 4Medicare 5Medicaid 5Veterans Health Administration 6Commercial Health Plans 6Out-of-Pocket Prices for Insured and Self-Pay Patients 7Variation 7 HYPERLINK l _TOC_250008 What Influences the Level of Consumer Price and Quality Transparency? 8Government 8Com

3、mercial Payers 10Data Availability 10 HYPERLINK l _TOC_250007 What Is the Relationship Between Price, Quality, and Advertising? 11 HYPERLINK l _TOC_250006 Hospitals 12 HYPERLINK l _TOC_250005 How Are Hospital Prices Set? 12Medicare 13Medicaid 13Veterans Health Administration 14Commercial Health Plan

4、s 14Out-of-Pocket Price for Insured and Self-Pay Patients 15State Rate-Setting Models 16 HYPERLINK l _TOC_250004 What Influences the Level of Consumer Price and Quality Transparency? 16Government 16Commercial Payers 18Data Availability 19 HYPERLINK l _TOC_250003 What Is the Relationship Between Pric

5、e, Quality, and Advertising? 20 HYPERLINK l _TOC_250002 Pharmaceuticals 22 HYPERLINK l _TOC_250001 Overview 22 HYPERLINK l _TOC_250000 How Are Prices Set? 22Health Plans 23Government 23Pharmacies 24Out-of-Pocket Price for Insured and Self-Pay Patients 25What Influences the Level of Consumer Price an

6、d Quality Transparency? 26Government 26Commercial Payers 27Data Availability 28What Is the Relationship Between Price, Quality, and Advertising? 28Medical Devices 30Overview 30How Are Prices Set? 31What Influences the Level of Consumer Price and Quality Transparency? 31Government 31Commercial Payers

7、 32Data Availability 32What Is the Relationship Between Price, Quality, and Advertising? 32Discussion and Conclusions 33Appendix: Search Terms for the Targeted Literature Review 37References 40SummaryIn most markets, buyers know the price of goods or services before they purchase them. In the U.S. h

8、ealth care market, prices are generally opaque to consumers and not often known to them before they receive care. This is partially due to the fact that the U.S. health care system is complex, with multiple payers paying different prices for similar services and negotiated rates between commercial i

9、nsurers and providers that are not publicly disclosed. A further complication is that consumers do not usually pay the full price of their care; instead, they typically pay a flat fee (copay) or a portion of the price (coinsurance), based on their health insurance coverage.In June 2019, President Do

10、nald Trump issued an executive order called Improving Price and Quality Transparency in American Healthcare to Put Patients First with the intention of promoting consumer price and quality transparency initiatives in health care to facilitate better- informed consumer decisionmaking. As part of this

11、 effort, the administration sought to inform policymakers and the public about how prices are currently set in health care markets, how the government and private payers can aid or limit price and quality transparency, and the extent to which providers can use advertising to promote price and qualit

12、y information.To that end, the Office of the Assistant Secretary for Planning and Evaluation asked the RAND Corporation to conduct an environmental scan to synthesize existing knowledge on these topics.How Are Health Care Prices Set?Physicians and HospitalsPublic payers, such as Medicare and Medicai

13、d, typically set prices for physicians and hospitals prospectively; providers have little direct bargaining leverage other than deciding not to serve these patient populations. The majority of care provided to veterans covered by the Veterans Health Administration is provided in Veterans Health Admi

14、nistration facilities, which are federally funded and employ salaried health care providers. Commercial health plans, in contrast, negotiate with physicians and hospitals to determine prices, including prices for their Medicare Advantage or Medicaid managed care plans. Some research has shown substa

15、ntial variation in negotiated prices, while other research suggests more moderate variation in some markets. Insured consumers rarely pay the full negotiated price of their care, typically paying a smaller copayment or coinsurance amount. Although the government does not directly affect prices paid

16、by commercial health plans, commercial prices tend to be positively correlated with Medicare fee-for-service prices.PharmaceuticalsIn the case of pharmaceuticals, Medicaid receives mandated rebates from drug manufacturers for dispensed prescriptions, and the Veterans Health Administration negotiates

17、 prices in exchange for including a manufacturers drug on a limited formulary. Commercial health plans, including those that cover Medicare Part D enrollees, negotiate both the prices paid to pharmacies and any discounts and rebates received directly from drug manufacturers. Self-pay prices faced by

18、 consumers in pharmacies (either because of uninsurance or because of full prices on a high-deductible plan) are set by individual pharmacies. Big-box stores (e.g., Walmart, Target) and pharmacy chains (e.g., CVS, Walgreens) can use heavily discounted prices of certain generic drugs to drive traffic

19、 to their stores.Medical DevicesMost medical devices are not purchased directly by Medicare, Medicaid, or private insurers. Rather, these items (ranging from latex gloves to expensive imaging equipment) are purchased by providers and considered in the price of bundled or fee-for-service payments. Fo

20、r durable medical equipment, such as crutches or blood sugar monitors that are generally used by patients at home, Medicare uses a competitive bidding process to determine prices.Price and Quality Transparency InitiativesRecent federal consumer transparency efforts have focused primarily on hospital

21、 price transparency. A 2018 federal rule requires that hospitals release their chargemaster data for all items and services in a machine-readable format, and a 2019 final federal rule requires hospitals to disclose payer-specific negotiated rates for all items and services and to disclose payer- spe

22、cific negotiated rates in a consumer-friendly manner for “shoppable” services, which are those that can be scheduled in advance by a consumer. The government also issued a final rule in 2020 that requires commercial insurers to provide online price transparency tools to their members and to disclose

23、 negotiated prices for all covered services. The federal government also promotes quality transparency by providing quality information about physicians and hospitals to consumers via the Care Compare online tool (previously known as Physician Compare and Hospital Compare).State governments have als

24、o pursued various consumer price transparency efforts. In particular, a number of states have established or are in the process of establishing all-payer claims databases (APCDs). These databases form the basis for various price transparency tools intended for consumer use. One standout example is t

25、he state of New Hampshire, which has used its APCD data to create an extensive online price transparency tool that provides provider- specific pricing to consumers, taking into account their insurance status.Most commercial insurers have also rolled out price transparency tools for their members to

26、help estimate the costs of various services. However, these tools could be of limited value, as they can be difficult to navigate and do not always provide accurate pricing.Barriers to Price and Quality TransparencyA key limitation of recent government consumer price transparency initiatives aimed a

27、t hospitals is that they have focused on charges and negotiated prices. Charges are the “l(fā)ist” price of care, and they are generally not related in any systematic way to the actual amounts paid by public or private insurers. Negotiated prices, in contrast, are much more relevant and represent the ac

28、tual price of care paid by the insurer to the hospital. In price transparency efforts aimed at consumers of health care, the out-of-pocket (OOP) price paid by the consumer is probably the most relevant.There are also some regulatory barriers to price transparency. First, in Gobeille v. Liberty Mutua

29、l Insurance Company, 2016, the Supreme Court determined that the Employee Retirement Income Security Act of 1974 (ERISA) preempts state APCD reporting requirements for self- insured employers. This undermines many state price transparency initiatives that rely on APCD data. Second, Statement 6 from

30、the Federal Trade Commission and Department of Justices 1996 Statements of Antitrust Enforcement Policy in Health Care is intended to limit the sharing of price data for anticompetitive reasons, but it could be cited by those opposed to current price transparency initiatives to note that sharing pri

31、ce data could have anticompetitive effects in some markets. Finally, the Health Insurance Portability and Accountability Act protects patients rights to privacy over their medical information, but it makes the sharing and disclosure of health data (for transparency or other reasons) more cumbersome.

32、On the part of insurers and providers, a potential barrier to price transparency is contract language that prohibits the disclosure of negotiated prices. However, there are efforts in Congress to pass legislation that would disallow or limit the effect of such clauses in contracts. State and federal

33、 governments have also passed legislation to prohibit the use of “gag clauses” that prevent pharmacists from telling patients about lower-cost drug options.Finally, consumer information on the Centers for Medicare & Medicaid Services (CMS) Care Compare website has some important limitations. Price a

34、nd quality data are not explicitly linked, so consumers might assume that a higher price means higher quality. Price data on hospitals are very limited and are not included for physicians, and both price and quality data might not include enough variation to enable meaningful comparisons between pro

35、viders.Advertising Price and Quality InformationOur literature search identified only a handful of articles that addressed advertising price and quality information. The available literature suggests that hospitals and physicians do not typically include pricing and quality information in their adve

36、rtisements. Data on the amount thathospitals and physicians spend on advertising are lacking, as is information about the substance of advertising. One barrier to advertising price information could be clauses in provider-insurer contracts that prohibit the disclosure of negotiated prices. Furthermo

37、re, providers might be concerned that publicizing price data could lead to a “race to the bottom” on prices, in which all insurers demand the lowest prices offered by a provider.Pharmaceutical companies conduct a substantial amount of direct-to-consumer advertising, but they have historically not ad

38、vertised price or quality information. However, pharmaceutical advertisements do sometimes offer discounts or coupons, and, more recently, some advertising has directed consumers to pricing information via a web link.The literature search did not identify any articles that addressed advertising by d

39、evice manufacturers.Conclusions and RecommendationsIn an effort to help consumers make better-informed health care choices, federal policymakers sought to identify potential barriers to price and quality transparency. Findings of this environmental scan show that consumer price transparency is being

40、 pursued by federal and state governments, as well as by commercial insurance companies. The findings also highlight potential barriers to meaningful transparency that could be addressed:First, policymakers could consider initiatives aimed at OOP price transparency given the focus of federal price t

41、ransparency initiatives on consumers. For example, policymakers can continue to pursue initiatives such as a 2020 federal rule that requires insurers to provide online price transparency tools to their members that would display OOP prices. Such efforts would also address shortcomings of existing in

42、surer price transparency tools, which are offered by most private plans but do not always offer accurate pricing information.Second, existing tools that promote quality transparency, such as Care Compare, could be improved upon to allow meaningful comparisons between providers. In particular, CMS co

43、uld consider the following:presenting detailed, provider-specific pricing information for a wide range of servicespresenting the full variation in quality scores rather than limiting information to differences from the national meanexplicitly linking detailed quality and price data by presenting bot

44、h pieces of information together.Third, policymakers can continue to pursue legislation that would limit or prohibit clauses in provider-insurer contracts that do not allow for the disclosure of negotiated prices. Such contract language presents a key barrier to price transparency. Similar clauses i

45、n contracts between private insurers and pharmacies that prohibited pharmacists from informing patients when paying for adrug out of pocket would be less expensive than paying the copay through their insurance are no longer permitted following 2018 legislation.Fourth, the federal government could co

46、nsider regulations that would require drug manufacturers to submit cost effectiveness or comparative effectiveness data on their drugs in order for those drugs to be covered by Medicare, similar to requirements in other countries. This data could be made public to consumers to allow for more informe

47、d decisionmaking.Fifth, states could work together with federal agencies, such as the Department of Labor (DOL), to address the issue of ERISA preemption undermining state APCDs. The DOL could require the collection of APCD data from self-funded health plans. This would be a significant undertaking,

48、 however, as the DOL currently does not collect any data similar to APCDs.Finally, states can work to improve price transparency and quality transparency:States that have not yet established APCDs could do so.States that do have APCDs but do not have online price transparency tools for consumers can

49、 create them.States that do have APCDs and online price transparency tools can work to improve the breadth and quality of the data provided.States can provide consumers with detailed quality information on providers in conjunction with online transparency tools.The barriers to consumer price and qua

50、lity transparency identified through this work generally represented limitations of existing tools. Efforts to achieve price and quality transparency have the potential to allow consumers to make better-informed decisions about their health care, particularly if the challenges and barriers outlined

51、in this report are addressed.AcknowledgmentsWe gratefully acknowledge the support and assistance of several people in writing this report. We thank our Office of the Assistant Secretary for Planning and Evaluation project leads, Joel Ruhter and Ann Conmy, as well as Christie Peters for their input a

52、nd guidance. We also thank several colleagues at RAND for their assistance: Christine Eibner for serving in a senior advisory role on this project, Vishnupriya Kareddy and Nabeel Shariq Qureshi for excellent research assistance, Jody Larkin and Orlando Penetrante for assisting with the literature se

53、arch, and Kayla Howard for administrative assistance. We are also grateful to Christopher Whaley (RAND) and Zachary Brown (University of Michigan) for their thoughtful reviews of this work.AbbreviationsACAAffordable Care ActAMPAverage Manufacturer PriceAPCAmbulatory Payment ClassificationAPCDall-pay

54、er claims databaseASPaverage sales priceASPEOffice of the Assistant Secretary for Planning and Evaluation CalPERSCalifornia Public Employees Retirement SystemCBOCongressional Budget OfficeCMSCenters for Medicare & Medicaid ServicesDMEdurable medical equipmentDOJDepartment of JusticeDOLDepartment of

55、LaborDRGdiagnosis-related groupERISAEmployee Retirement Income Security Act of 1974FDAU.S. Food and Drug AdministrationFFSfee-for-serviceFTCFederal Trade CommissionGAOU.S. Government Accountability OfficeGDDPgeneric drug discount programHCCIHealth Care Cost InstituteHMOhealth maintenance organizatio

56、nIPPSInpatient Prospective Payment SystemMAMedicare AdvantageMACMaximum Allowable CostOOPout-of-pocketOPPSOutpatient Prospective Payment SystemPhRMAPharmaceutical Research and Manufacturers of America RVUrelative value unitVHAVeterans Health AdministrationWACWholesale Acquisition CostIntroductionIn

57、June 2019, President Donald Trump signed an executive order called Improving Price and Quality Transparency in American Healthcare to Put Patients First. The purpose of the order was to make consumers aware of price and quality of health care services to help them make more-informed decisions about

58、health care use. To improve price and quality transparency, the administration wanted to inform policymakers and the public of the ways in which the government and the private sector could aid or impede price and quality transparency.The Office of the Assistant Secretary for Planning and Evaluation

59、(ASPE) asked the RAND Corporation to synthesize existing knowledge on how health care prices are set in the United States, how the government affects prices, the level of price variation in health care markets, ways in which the government and commercial insurers can aid or impede price and quality

60、transparency to consumers, and the extent to which health care providers advertise price and quality information to consumers.In response to ASPEs request, RAND researchers conducted an environmental scan of existing literature to synthesize and summarize existing knowledge related to consumer price