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Ruchika Talwar: Hi, everyone. Welcome to UroToday. My name's Ruchi Talwar, and as I've mentioned in our prior videos, I'm kicking off a health policy center of excellence by highlighting some amazing new articles in the urologic literature. Today I'm really excited to have Dr. Gul with us. Dr. Gul is an Assistant Professor of Urology at Washington University, St. Louis. Dr. Gul, thanks so much for joining us.

Zeynep Gul: Thank you for having me. It's so great to be here.

Ruchika Talwar: We're going to dive right in. I was really excited to read your paper that was published in JAMA Network Open, "Large Variations in the Prices of Urologic Procedures at Academic Medical Centers One Year after the Implementation of the Price Transparency Final Rule". So can you tell me a little bit about what the Price Transparency Final Rule is?

Zeynep Gul: Yes, of course. So the Price Transparency Final Rule requires that hospitals disclose standard charges for at least 300 shoppable services. Basically, CMS has 70 services that they require be included, and then the hospital has to choose an additional minimum of 230. And then the shoppable service is just any service that a consumer or patient can shop for before, so a non-emergent procedure. And the standard charges or the prices that have to be listed is the gross charge on the hospital's charge master, the discounted cash price, the maximum negotiated commercial price, and the minimum negotiated commercial price.

Ruchika Talwar: Got it. Yeah. So really important information in an attempt to improve price transparency as well as minimize surprise billing because we all know that patients, even those who are insured, often end up getting a bill at the end of their hospital stay for things that they didn't even realize they were being charged for. So a little bit about your specific purpose in this study as it relates to surgeries, tell me a bit about what brought you all to do this analysis and what your aim was.

Zeynep Gul: So we wanted to see what compliance with the legislation is like among academic medical centers and as urologists for urologic procedures. So we chose five common urologic procedures, two of which are on CMS's list of services, that's a prostate biopsy and a laparoscopic prostatectomy. And then we compared variability in price across hospitals and across commercial insurance types, so Medicare, medicaid, commercial, and cash price.

Ruchika Talwar: Got it. Got it. So tell me a bit about your results.

Zeynep Gul: So I guess there's three or four main findings. The first one is that overall compliance was very low. So like I mentioned, laparoscopic prostatectomy is a required procedure and only 29% of hospitals had a cash price for that. So that means that at most 29% of hospitals are compliant. And that was a whole year after the rule had been in effect. The second was that there was a big variation in the price of procedures across hospitals. We had a huge quartile ranges for the price of our procedures, and there was a statistically significant difference in the price of all five procedures across the four insurance types.

But when we looked at the different commercial insurance types like Aetna, Blue Cross Blue Shield, there was no significant price difference among those. And then I think last kind of bigger interesting thing is that at 16% of hospitals, the discounted cash price was the lowest price listed. I mean, that means that basically that in certain situations, the price that the consumer sees may not be exactly the same as the cash price, but in certain situations, total healthcare expenditures could probably be reduced if patients omitted their insurance information and just decide to pay out of pocket.

Ruchika Talwar: Right. That's total healthcare spending, but perhaps maybe not for the patient depending on what kind of insurance structure they have, co-insurance, et cetera. But I certainly know that that's definitely consideration. Some patients don't think about when they're considering things like their deductibles, et cetera. So I think really important findings and things as urologists we don't even approach with our patients. It may not make sense to pay for everything around a robotic prostatectomy out of pocket, but if you're talking about something like a prostate biopsy and we're considering a deductible, maybe something worth considering. Now the rate of hospitals that actually listed their prices was shockingly low. Why do you think that is?

Zeynep Gul: I think there's kind of two buckets. The first is that the law hasn't had the intended effect, and that's probably related to the cost. So maybe it's too costly for hospitals to implement this policy, to make these consumer-friendly tools. Maybe the penalties aren't high enough. So the fine by CMS depends on the size of the hospital, but it's anywhere between $300 and $5,500 a day for non-compliance. So maybe that's not enough or enforcement isn't strict enough. So far, only two hospitals have been fined. So I mean, I feel pretty confident in saying that enforcement isn't that strict.

Ruchika Talwar: Yeah.

Zeynep Gul: It's going to be hard. And then second is there could be a gain to hospitals by not posting their prices. It may allow hospitals to kind of collude and set up their prices together. Or maybe hospitals are concerned that if a patient is just online, looking for a non-emergent procedure and it's something expensive that could kind of deter patients from having this non-necessary surgery or at least non-urgent surgery. And I think there's a little bit of evidence from that just because we found that prices are listed less often for more expensive procedures.

Ruchika Talwar: Interesting. What are your thoughts on the large variation that you saw in pricing?

Zeynep Gul: Right. No, that's a good question. So I think that some of it could be that the nature and the quality of the care could be different, and that's reflected in the price. If you think of, I don't know, two cars, like a Honda and a Mercedes or something, I think people expect and understand for the most part at least why the Mercedes costs more. So to the extent that the quality is better and that the market's not perfectly competitive, maybe hospitals are incurring different prices, and that's reflected and the specialization that we're seeing among hospitals and these different quality standards, the more you have that, the more it isolates the hospitals from the general competition pool. And if there's less competition, then you have more control over your pricing. So I think that's one reason.

The other is, look, we're talking about the law and problems with the law, so the low compliance, but also patients, they're only going to price shop and look around for prices if the cost savings from that makes sense for them, if it's better saving than the cost of your time spent searching. I tried a couple of the price tools myself, and it's not so easy. A lot of them require you would've already seen the physician or they want a bunch of personal information. So it's not easy to do in and of itself. Hospitals are definitely, I think, setting up some obstacles to make it more difficult. And so if you can't use the tool, then it's not going to work.

Ruchika Talwar: Yeah, I've heard that a lot with regards to this information in terms of looking up pricing of procedures or more commonly services like a CT scan. Although the information is posted, sometimes it's really difficult for patients to understand what they're seeing or know where to look. And I think you need to have some underlying health literacy to know you even have the option to look. So it is complicated. Although it's a resource that I think in theory could do a lot of good, I think, as you've mentioned, the implementation can be challenging and then knowing how to apply it to a specific patient situation.

Zeynep Gul: No, I totally agree. I mean, I think it's a necessary and big step to require it, the kinks kind of have to be worked out still a little bit.

Ruchika Talwar: Yeah. And what are your thoughts on price variations geographically? Does this sort of spotlight some of those inequities in access to care? For example, if you're in a saturated market like a northeastern city with let's say six hospitals within a five-mile radius, did you get the sense that there was any sort of price competition in that scenario versus perhaps where I am at Vanderbilt where we're the only major medical center for serving an absurd number of states in some cases?

Zeynep Gul: We didn't really look at that, but there is a study that kind of did, and they were looking at hospital factors associated with being compliant. And it is true that hospitals in more competitive markets were more compliant. And so I think that is a reflection of what you're saying and it makes sense. Kind of like we're saying, if you can isolate yourself either geographically or by your reputation from the general competition, then you have more control of the prices. So I absolutely think that's true.

Ruchika Talwar: Yeah. So we've touched on how transparent pricing can help patients. What are your thoughts on how this sort of transparent pricing mechanism can help physicians as they counsel or discuss treatment plans with patients?

Zeynep Gul: I think it gives us a lot to think about. Like you kind of touched on too, I don't think it's something I consider really when I'm talking to patients and I don't even really know well as I should WashU services and how to access them. But I think it gives us a lot of information that we really should or need to convey to the patients because you do need some sort of amount of literacy or exposure and knowledge. So I think that's a huge opportunity for physicians right now in general to help move things forward. And I guess in a larger scale, one of the main reasons CMS decide to pass the law is that the idea that if prices are listed and people are shopping around for prices, that'll drive general prices down. And so healthcare expenditures are obviously a big concern in America. And so I think that was one big impetus for the law as well.

Ruchika Talwar: Yeah. Yeah, I totally agree. I think, again, going back to the law in theory versus the law and practicality, we have a bit of work to do, but I think it's a great start. And as you mentioned, from a physician perspective, financial toxicity really is at front and center of not just cancer care, but care in general. So things like prescription drug pricing, it's a little easier to provide resources to patients. I mean, I'm not saying we do as good of a job as we should, but perhaps it's a little easier to say to a patient, "I know your insurance may not cover X drug. Here is a website you can go to or here is a resource you can use." I think it's really challenging here, and I'm guilty of this too, when patients ask me, "What do you think? Is there a way that I could have this procedure done closer to me?" Or, "Do you estimate any sort of financial burden this may have?"

Often I would just say, "I'm not sure, but I can get you in touch with, whoever, financial counselor," whatever resource we have in our office. But now it's really helpful to know that at least I can, for motivated patients, give them a way to take charge of their healthcare and say, "Actually, you may be able to find that prices are listed on this website, and perhaps it's easier for you if you're engaged to shop around a bit." And I also wonder, I've heard stories of patients who actually have these conversations with the healthcare system. If they know they're going to be paying a cash pay price, certain health systems do provide discounts. So I always wonder if there's any room for negotiation. I can't tell you I've ever tried.

Zeynep Gul: No, I'm sure that at some level there is, because there is a discounted cash price rate, so not the price that's listed.

Ruchika Talwar: Yeah.

Zeynep Gul: One kind of way that hospitals get around that is if you don't disclose a preset discounted cash price, if there is room for negotiation, if everyone's not going to get the same discounted price, then you can just list the gross charge. So another way to maybe muddy the waters a little bit. But I do think the prices are set oftentimes based on patients, based on their information, which is not how it's supposed to be, but it's true. I'm just going to those resources and tools, they they want you to come in, they want to know all this stuff about you.

Ruchika Talwar: Yeah. Interesting. Well, congratulations on a great study. I thought it was a really great conversation starter. These are things that we should be bringing to the forefront more often. And honestly, physicians should know where to send their patients if these kinds of discussions do come up in the clinic. So I applaud you on that. Thanks so much for your work, and thanks again for joining us today.

Zeynep Gul: Thank you. I'm so glad we got to start the discussion here together.

Ruchika Talwar: Great. And to our audience, thanks again for tuning in. We hope you'll continue to join us on this Health Policy Spotlight series.