{"id":47979,"date":"2020-07-07T17:52:51","date_gmt":"2020-07-07T16:52:51","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=47979"},"modified":"2020-07-10T17:46:29","modified_gmt":"2020-07-10T16:46:29","slug":"american-patients-cant-shop-their-way-to-a-low-cost-system","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2020\/07\/07\/american-patients-cant-shop-their-way-to-a-low-cost-system\/","title":{"rendered":"American patients can\u2019t shop their way to a low cost healthcare system"},"content":{"rendered":"<p class=\"standfirst\">Hospital price transparency is a distraction from policies that could reduce costs without burdening patients, say Jamie Daw and Adam Sacarny<\/p>\n<p><!--more--><span style=\"font-weight: 400\">The prices that hospitals charge privately insured patients in the US have long been shrouded in secrecy. These prices\u2014which are negotiated between hospitals and private insurers\u2014<\/span><a href=\"https:\/\/healthcostinstitute.org\/hcci-research\/hmi-2019-service-prices\"><span style=\"font-weight: 400\">vary widely<\/span><\/a><span style=\"font-weight: 400\">: the price for the same blood test could vary 39-fold within Tampa, Florida and the cost of a cesarean delivery varies by up to $24 000 in San Francisco, California.<\/span><\/p>\n<p><span style=\"font-weight: 400\">A recent federal court decision stands to shine a light on opaque hospital pricing in the US. In a lawsuit brought forward by the American Hospital Association, <\/span><a href=\"https:\/\/ecf.dcd.uscourts.gov\/cgi-bin\/show_public_doc?2019cv3619-35\"><span style=\"font-weight: 400\">a federal judge upheld<\/span><\/a><span style=\"font-weight: 400\"> a regulation issued by the Trump administration that will soon require hospitals to post a wealth of information on payment rates online.<\/span><\/p>\n<p><span style=\"font-weight: 400\">This policy seems intuitive: in other sectors of the economy, consumers usually know the price of a service or product before they purchase it. By comparing prices, consumers can shop around and save money. In turn, sellers anticipate that behavior and are incentivized to keep prices low. Who wouldn\u2019t want a virtuous circle like that in healthcare?\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">The Trump administration argues that hospital price transparency will encourage value in healthcare by helping patients and employers find lower prices, while pressuring hospitals to cut them further. However, the potential effects\u2014and who stands to benefit\u2014are not so straightforward.<\/span><\/p>\n<p><span style=\"font-weight: 400\">Firstly,<\/span> <span style=\"font-weight: 400\">giving consumers information on prices doesn\u2019t necessarily mean that they will respond by seeking lower cost services. Studies have consistently found that patients <\/span><a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/25466414\/\"><span style=\"font-weight: 400\">tend not to use price transparency tools<\/span><\/a><span style=\"font-weight: 400\">, and their <\/span><a href=\"https:\/\/jamanetwork.com\/journals\/jama\/fullarticle\/2518264\"><span style=\"font-weight: 400\">effects on healthcare spending<\/span><\/a><span style=\"font-weight: 400\"> are small or nonexistent. Why?<\/span> <span style=\"font-weight: 400\">Shopping for healthcare services is often complicated or impossible.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">Many of the most expensive services are for emergencies where there is little scope for patients to shop. Even when a patient has time to compare prices for non-urgent procedures or tests, the complexity of healthcare payment systems and insurance products makes it next to impossible for a patient to preemptively calculate what they would personally pay for an encounter. Establishing that amount requires patients to know the cost-sharing parameters of their insurance plan, the set of services they will use during the encounter, and how aggressively the hospital will bill for those services.<\/span><\/p>\n<p><span style=\"font-weight: 400\">Insurance also obscures patients\u2019 incentives to shop by insulating them from healthcare prices. While patients can be given strong incentives to shop\u2014and an increasing number of American workers are <\/span><a href=\"https:\/\/www.cdc.gov\/nchs\/products\/databriefs\/db317.htm\"><span style=\"font-weight: 400\">enrolled in high deductible health plans<\/span><\/a><span style=\"font-weight: 400\"> with this aim\u2014these incentives are created by hoisting financial risk on patients. This <\/span><a href=\"https:\/\/www.healthaffairs.org\/doi\/full\/10.1377\/hlthaff.2010.0584\"><span style=\"font-weight: 400\">financially burdens<\/span><\/a><span style=\"font-weight: 400\"> American families and <\/span><a href=\"https:\/\/econpapers.repec.org\/article\/oupqjecon\/v_3a132_3ay_3a2017_3ai_3a3_3ap_3a1261-1318..htm\"><span style=\"font-weight: 400\">can result in<\/span><\/a><span style=\"font-weight: 400\"> patients <\/span><a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/28971921\/\"><span style=\"font-weight: 400\">forgoing appropriate care<\/span><\/a><span style=\"font-weight: 400\">.<\/span><\/p>\n<p><span style=\"font-weight: 400\">Beyond the challenges posed by patient shopping, the empirical evidence supporting price transparency is weak. It could even backfire. Economists have pointed out that in sectors with low competition, price transparency can facilitate collusion and lead to higher prices. This fear was borne out in Denmark when authorities began publishing the prices of ready-mixed cement. <\/span><a href=\"https:\/\/onlinelibrary.wiley.com\/doi\/abs\/10.1111\/1467-6451.00057\"><span style=\"font-weight: 400\">Prices proceeded to converge and rise<\/span><\/a><span style=\"font-weight: 400\">, and the authorities eventually abandoned the idea. The most hopeful evidence in the US healthcare system comes from New Hampshire, where <\/span><a href=\"http:\/\/www-personal.umich.edu\/~zachb\/zbrown_eqm_effects_price_transparency.pdf\"><span style=\"font-weight: 400\">prices for medical imaging fell by 3%<\/span><\/a><span style=\"font-weight: 400\"> after the state established a price transparency website. But even effects of this magnitude, while beneficial, would only make a tiny dent in lowering US healthcare costs.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">Price transparency efforts reflect a broad trend for American policy makers to turn to consumer-driven strategies to reduce healthcare costs. These strategies are built on the assumption that patients ought to be responsible for navigating their way to high quality, low cost healthcare. However, the challenges faced by patients in assessing the complex cost-quality tradeoffs in healthcare limit the potential for price transparency to have the impact that the administration advertises.<\/span><\/p>\n<p><span style=\"font-weight: 400\">Perhaps more troubling is that these efforts could distract policy makers from addressing the main drivers of US healthcare prices, such as rapid and ongoing consolidation. Concentrated hospital markets are becoming the norm in the US and are strongly <\/span><a href=\"https:\/\/isps.yale.edu\/research\/publications\/isps15-027\"><span style=\"font-weight: 400\">associated with higher prices<\/span><\/a><span style=\"font-weight: 400\">. Antitrust actions, such as preventing hospital mergers, could reduce and reverse consolidation, likely leading to lower prices.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">Another option for policy makers is to assume a greater regulatory role over healthcare prices, including introducing <\/span><a href=\"https:\/\/www.healthaffairs.org\/do\/10.1377\/hblog20140826.041002\/full\/\"><span style=\"font-weight: 400\">price caps<\/span><\/a><span style=\"font-weight: 400\"> and an <\/span><a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/22068405\/\"><span style=\"font-weight: 400\">all-payer rate setting<\/span><\/a><span style=\"font-weight: 400\">. A Supreme Court decision made it <\/span><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC5602770\/\"><span style=\"font-weight: 400\">much more difficult<\/span><\/a><span style=\"font-weight: 400\"> for state governments to collect the data that would undergird these efforts. As a result, the information released under the transparency rule may end up being more useful for states considering new price regulations than for patients shopping for healthcare services.<\/span><\/p>\n<p><span style=\"font-weight: 400\">If we want to reduce prices without burdening patients with financial risk, then policy makers need to address the emerging causes of rising healthcare costs directly. Efforts to control costs are most likely to succeed when policy makers tackle the structural drivers behind the most expensive health system in the world.<\/span><\/p>\n<p><b><i><img loading=\"lazy\" decoding=\"async\" class=\"alignleft wp-image-47984\" src=\"https:\/\/blogs.bmj.com\/bmj\/files\/2020\/07\/jamie_daw.jpg\" alt=\"\" width=\"128\" height=\"119\" \/>Jamie Daw <\/i><\/b><i><span style=\"font-weight: 400\">is an assistant professor of health policy and management at Columbia University Mailman School of Public Health. She studies health insurance and access to care in the US and Canada. Twitter: <a href=\"https:\/\/twitter.com\/jamie_daw\">@jamie_daw\u00a0<\/a><\/span><\/i><\/p>\n<p><b>Competing interests<\/b><i><span style=\"font-weight: 400\">: <\/span><\/i><span style=\"font-weight: 400\">None declared.<\/span><\/p>\n<p><b><i><img loading=\"lazy\" decoding=\"async\" class=\"alignleft wp-image-47985\" src=\"https:\/\/blogs.bmj.com\/bmj\/files\/2020\/07\/adam_Sacarny.jpg\" alt=\"\" width=\"128\" height=\"119\" \/>Adam Sacarny <\/i><\/b><i><span style=\"font-weight: 400\">is an assistant professor of health policy and management at Columbia University Mailman School of Public Health. His research studies the relationship between healthcare payment policy, provider and patient decision making, and clinical quality. Twitter: <a href=\"https:\/\/twitter.com\/asacarny\">@asacarny<\/a><\/span><\/i><\/p>\n<p><b>Competing interests<\/b><i><span style=\"font-weight: 400\">: <\/span><\/i><span style=\"font-weight: 400\">None declared.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Hospital price transparency is a distraction from policies that could reduce costs without burdening patients, say Jamie Daw and Adam Sacarny [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/bmj\/2020\/07\/07\/american-patients-cant-shop-their-way-to-a-low-cost-system\/\">More&#8230;<\/a><\/p>\n","protected":false},"author":1,"featured_media":47981,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1357],"tags":[],"class_list":["post-47979","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-us-health-care"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.6 - 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