兰德-医疗市场价格和质量透明度的障碍（英文）-2021.4-64页_320kb

Summary of Barriers to Price and Quality Transparency in Health Care Markets

Core Content

This report, conducted by RAND Health Care in response to a request from the Office of the Assistant Secretary for Planning and Evaluation (ASPE), explores the challenges and barriers to price and quality transparency in the U.S. health care system. It examines how prices are set in various health care markets—health care professionals, hospitals, pharmaceuticals, and medical devices—and evaluates the extent to which price and quality information is available to consumers and used in marketing.

The U.S. health care system is known for its opacity in pricing, with consumers often unaware of the actual cost of care before receiving it. This is due to a complex network of payers, including public programs like Medicare and Medicaid, and private insurers, each negotiating different rates for the same services. Additionally, consumers typically pay a copayment or coinsurance rather than the full price, further obscuring the true cost of care.

In June 2019, President Trump issued an executive order to improve price and quality transparency in health care, aiming to empower consumers with more information to make informed decisions. The report highlights both federal and state efforts to increase transparency, including the release of hospital chargemaster data, the creation of all-payer claims databases (APCDs), and the development of online price transparency tools by insurers.

Main Viewpoints

1. Price Setting Mechanisms

• Health Care Professionals: Prices are set through Medicare’s fee-for-service (FFS) system, which uses a relative value unit (RVU) system to determine payments. Medicaid and private insurers also influence pricing, with commercial plans often aligning with Medicare FFS prices.
• Hospitals: Prices are negotiated between hospitals and insurers, and public payers like Medicare and Medicaid set rates prospectively. Out-of-pocket (OOP) prices are more relevant to consumers than negotiated or chargemaster prices.
• Pharmaceuticals: Prices are influenced by Medicaid rebates, VHA formulary negotiations, and commercial insurer contracts. Self-pay prices are set by individual pharmacies, and some chains use discounts to attract customers.
• Medical Devices: Medicare uses competitive bidding for durable medical equipment (DME), while other devices are purchased by providers and included in bundled or FFS payments.

2. Barriers to Transparency

• Regulatory Barriers: ERISA preempts state APCD reporting for self-insured employers, limiting the effectiveness of state-level transparency initiatives. FTC and DOJ antitrust statements may also be used to argue against price transparency.
• Contractual Barriers: Provider-insurer contracts often include clauses that restrict the disclosure of negotiated prices, hindering consumer access to accurate cost information.
• Data Limitations: Existing transparency tools often lack detailed price data, and price and quality information are not explicitly linked, leading to consumer misconceptions.
• Advertising Limitations: Providers rarely include price or quality information in their advertisements, and there is limited research on how they use such data in marketing strategies.

3. Consumer Use of Price and Quality Information

• Consumers generally do not use price or quality information effectively due to limited access and poor data presentation.
• Price transparency tools, such as those provided by insurers, are often inaccurate or difficult to navigate.
• The Care Compare tool, which provides quality data for hospitals and physicians, lacks price information and does not fully enable meaningful comparisons.

Key Recommendations

• Expand OOP Price Transparency: Policymakers should focus on providing out-of-pocket price information, as this is most relevant to consumers. The 2020 federal rule requiring insurers to provide OOP price transparency is a step in the right direction.
• Improve Quality Transparency Tools: Enhance the Care Compare tool by including detailed price data and presenting full variations in quality scores. This would allow for more meaningful comparisons between providers.
• Limit Contractual Restrictions: Legislation should be introduced to restrict or eliminate clauses in provider-insurer contracts that prevent the disclosure of negotiated prices.
• Require Comparative Effectiveness Data: The federal government could mandate drug manufacturers to provide cost-effectiveness or comparative effectiveness data for Medicare coverage, similar to practices in other countries.
• Address ERISA Preemption: States and federal agencies should collaborate to overcome the limitations imposed by ERISA, potentially by requiring self-funded health plans to report data to APCDs.
• Enhance State-Level Transparency Initiatives: States should establish APCDs and online price transparency tools, and improve the breadth and quality of data they provide to consumers.

Conclusion

The report underscores the need for greater transparency in health care pricing and quality, emphasizing that current initiatives have limitations. Addressing these barriers could empower consumers to make more informed decisions and drive competition and efficiency in the health care market. The findings suggest that a multi-faceted approach involving federal and state policies, regulatory changes, and improvements in data availability and presentation is essential to achieving meaningful transparency.

Key Information

• Funding: The research was funded by ASPE and conducted by RAND Health Care.
• Scope: The environmental scan covered four health care markets: health care professionals, hospitals, pharmaceuticals, and medical devices.
• Methodology: A targeted literature search was performed across three databases (PubMed, Business Source Complete, and EconLit) and gray literature sources, identifying 1,095 articles and 56 from gray literature.
• Limitations: The literature search did not identify articles on how physician ethical codes might affect transparency, and there is limited research on pharmaceutical and device advertising.
• Targeted Search Terms: The appendix lists the search terms used to identify relevant articles, including terms related to price transparency, quality transparency, and advertising in health care.