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Displaying Medicare allowable fees in the electronic health record at the time of order entry did not significantly reduce the number of inpatient lab tests at three Philadelphia hospitals.
In a study involving 98,529 patients and 142,921 admissions, Medicare payment information popped up randomly in the EHR when standard tests including complete blood cell counts, metabolic panels, and liver function tests were ordered. The costs of the labs varied depending on their extent. The message mentioned that “the dollar amount represents Medicare reimbursement for the test. Actual costs to the consumer may vary by patient insurance status.” Just over a third of the patients were actually on Medicare; most had private insurance.
The idea of the study was to see if cost information would curb unnecessary testing, and save money. “There is growing interest in using price transparency to influence medical decision-making toward higher value care,” Mina Sedrak, MD, and her colleagues said in a paper presented at the annual meeting of the Society of General Internal Medicine.
It didn’t work out that way. Four tests ordered per patient day when the messages appeared, and 2.34 when they did not. With messaging, the mean lab fee per patient day was $38.85, versus $27.59 without it. In an adjusted analyses comparing the intervention to the control group, there were no significant changes in overall test ordering (0.05 tests ordered per patient day, P = .06) or associated fees when pricing information was displayed ($0.24 per patient day; P = .47).
In a subset analysis, the investigators did find a small decrease orders for the most expensive labs and a small but significant increase in orders for the least expensive ones when physicians aware of cost (top quartile of tests based on fee value: -0.01; P = .04; bottom quartile: 0.03, P = .04).
Despite the overall negative results, there’s still a likely role for cost information in value improvement programs; what the study shows is that there’s a better way to use it, according to Dr. Sedrak, currently of the City of Hope Comprehensive Cancer Center in Duarte, Calif., and colleagues.
The investigators made several suggestions when reviewing their work.
“First, the price transparency intervention in this study was always displayed regardless of the clinical scenario. The presence of this information for appropriate tests may have diminished its impact when tests were inappropriate. Future efforts may consider more selective targeting of price transparency.” It might also be a good idea to price out different testing options for providers, and use actual charges and other more on-point forms of cost estimates, they said, instead of Medicare fees that have little to do with what many patients are actually charged. Targeting only the most expensive tests might also help (JAMA Intern Med. 2017 April 21. doi: 10.1001/jamainternmed.2017.1144).
The investigators also noticed a problem when labs are ordered to repeat automatically; clinicians did not see the price information every day, and so missed cost information “when it would be most salient.”
The mean age in the study was 54.7 years; 52% of the patients were white, 39% black, and 57% women. The mean length of stay was about 6 days, and over 80% of the patients were discharged home.
The authors evaluated what happens when one randomizes which tests have price information; other studies examine what happens when one randomizes which physicians have price information. All contemporary studies conclude the same – no effect of price information on physician ordering behavior.
One possible conclusion is that making health care prices available at the point of care is not an effective strategy to decrease wasteful spending, yet we believe this is not the case.
The disconnect suggests that current price transparency initiatives are not enough to infuse clinical care with price information and encourage consumers and physicians to consider the value of health care decisions. This does not mean we should give up on increased price transparency in health care. Rather, a more thoughtful approach to the design, point of delivery, and context for health care price information is needed to achieve the promise of price transparency.
Little has been done to deliver [out-of-pocket cost] information to patients at the time when patients are making health care decisions. Also, if both patients and physicians could see prices for episodes or bundles of care, then it could allow them to assess value together. Future interventions need to deliver price and quality information together.
Anna Sinaiko, PhD, is a research scientist at the Harvard School of Public Health, Boston. Alyna Chien, MD, is an assistant professor of pediatrics at the Harvard Medical School and a healthcare quality researcher. They made their comments in an editorial, and had no relevant disclosures (JAMA Intern Med. 2017 April 21. doi: 10.1001/jamainternmed.2017.1676 ).
The authors evaluated what happens when one randomizes which tests have price information; other studies examine what happens when one randomizes which physicians have price information. All contemporary studies conclude the same – no effect of price information on physician ordering behavior.
One possible conclusion is that making health care prices available at the point of care is not an effective strategy to decrease wasteful spending, yet we believe this is not the case.
The disconnect suggests that current price transparency initiatives are not enough to infuse clinical care with price information and encourage consumers and physicians to consider the value of health care decisions. This does not mean we should give up on increased price transparency in health care. Rather, a more thoughtful approach to the design, point of delivery, and context for health care price information is needed to achieve the promise of price transparency.
Little has been done to deliver [out-of-pocket cost] information to patients at the time when patients are making health care decisions. Also, if both patients and physicians could see prices for episodes or bundles of care, then it could allow them to assess value together. Future interventions need to deliver price and quality information together.
Anna Sinaiko, PhD, is a research scientist at the Harvard School of Public Health, Boston. Alyna Chien, MD, is an assistant professor of pediatrics at the Harvard Medical School and a healthcare quality researcher. They made their comments in an editorial, and had no relevant disclosures (JAMA Intern Med. 2017 April 21. doi: 10.1001/jamainternmed.2017.1676 ).
The authors evaluated what happens when one randomizes which tests have price information; other studies examine what happens when one randomizes which physicians have price information. All contemporary studies conclude the same – no effect of price information on physician ordering behavior.
One possible conclusion is that making health care prices available at the point of care is not an effective strategy to decrease wasteful spending, yet we believe this is not the case.
The disconnect suggests that current price transparency initiatives are not enough to infuse clinical care with price information and encourage consumers and physicians to consider the value of health care decisions. This does not mean we should give up on increased price transparency in health care. Rather, a more thoughtful approach to the design, point of delivery, and context for health care price information is needed to achieve the promise of price transparency.
Little has been done to deliver [out-of-pocket cost] information to patients at the time when patients are making health care decisions. Also, if both patients and physicians could see prices for episodes or bundles of care, then it could allow them to assess value together. Future interventions need to deliver price and quality information together.
Anna Sinaiko, PhD, is a research scientist at the Harvard School of Public Health, Boston. Alyna Chien, MD, is an assistant professor of pediatrics at the Harvard Medical School and a healthcare quality researcher. They made their comments in an editorial, and had no relevant disclosures (JAMA Intern Med. 2017 April 21. doi: 10.1001/jamainternmed.2017.1676 ).
Displaying Medicare allowable fees in the electronic health record at the time of order entry did not significantly reduce the number of inpatient lab tests at three Philadelphia hospitals.
In a study involving 98,529 patients and 142,921 admissions, Medicare payment information popped up randomly in the EHR when standard tests including complete blood cell counts, metabolic panels, and liver function tests were ordered. The costs of the labs varied depending on their extent. The message mentioned that “the dollar amount represents Medicare reimbursement for the test. Actual costs to the consumer may vary by patient insurance status.” Just over a third of the patients were actually on Medicare; most had private insurance.
The idea of the study was to see if cost information would curb unnecessary testing, and save money. “There is growing interest in using price transparency to influence medical decision-making toward higher value care,” Mina Sedrak, MD, and her colleagues said in a paper presented at the annual meeting of the Society of General Internal Medicine.
It didn’t work out that way. Four tests ordered per patient day when the messages appeared, and 2.34 when they did not. With messaging, the mean lab fee per patient day was $38.85, versus $27.59 without it. In an adjusted analyses comparing the intervention to the control group, there were no significant changes in overall test ordering (0.05 tests ordered per patient day, P = .06) or associated fees when pricing information was displayed ($0.24 per patient day; P = .47).
In a subset analysis, the investigators did find a small decrease orders for the most expensive labs and a small but significant increase in orders for the least expensive ones when physicians aware of cost (top quartile of tests based on fee value: -0.01; P = .04; bottom quartile: 0.03, P = .04).
Despite the overall negative results, there’s still a likely role for cost information in value improvement programs; what the study shows is that there’s a better way to use it, according to Dr. Sedrak, currently of the City of Hope Comprehensive Cancer Center in Duarte, Calif., and colleagues.
The investigators made several suggestions when reviewing their work.
“First, the price transparency intervention in this study was always displayed regardless of the clinical scenario. The presence of this information for appropriate tests may have diminished its impact when tests were inappropriate. Future efforts may consider more selective targeting of price transparency.” It might also be a good idea to price out different testing options for providers, and use actual charges and other more on-point forms of cost estimates, they said, instead of Medicare fees that have little to do with what many patients are actually charged. Targeting only the most expensive tests might also help (JAMA Intern Med. 2017 April 21. doi: 10.1001/jamainternmed.2017.1144).
The investigators also noticed a problem when labs are ordered to repeat automatically; clinicians did not see the price information every day, and so missed cost information “when it would be most salient.”
The mean age in the study was 54.7 years; 52% of the patients were white, 39% black, and 57% women. The mean length of stay was about 6 days, and over 80% of the patients were discharged home.
Displaying Medicare allowable fees in the electronic health record at the time of order entry did not significantly reduce the number of inpatient lab tests at three Philadelphia hospitals.
In a study involving 98,529 patients and 142,921 admissions, Medicare payment information popped up randomly in the EHR when standard tests including complete blood cell counts, metabolic panels, and liver function tests were ordered. The costs of the labs varied depending on their extent. The message mentioned that “the dollar amount represents Medicare reimbursement for the test. Actual costs to the consumer may vary by patient insurance status.” Just over a third of the patients were actually on Medicare; most had private insurance.
The idea of the study was to see if cost information would curb unnecessary testing, and save money. “There is growing interest in using price transparency to influence medical decision-making toward higher value care,” Mina Sedrak, MD, and her colleagues said in a paper presented at the annual meeting of the Society of General Internal Medicine.
It didn’t work out that way. Four tests ordered per patient day when the messages appeared, and 2.34 when they did not. With messaging, the mean lab fee per patient day was $38.85, versus $27.59 without it. In an adjusted analyses comparing the intervention to the control group, there were no significant changes in overall test ordering (0.05 tests ordered per patient day, P = .06) or associated fees when pricing information was displayed ($0.24 per patient day; P = .47).
In a subset analysis, the investigators did find a small decrease orders for the most expensive labs and a small but significant increase in orders for the least expensive ones when physicians aware of cost (top quartile of tests based on fee value: -0.01; P = .04; bottom quartile: 0.03, P = .04).
Despite the overall negative results, there’s still a likely role for cost information in value improvement programs; what the study shows is that there’s a better way to use it, according to Dr. Sedrak, currently of the City of Hope Comprehensive Cancer Center in Duarte, Calif., and colleagues.
The investigators made several suggestions when reviewing their work.
“First, the price transparency intervention in this study was always displayed regardless of the clinical scenario. The presence of this information for appropriate tests may have diminished its impact when tests were inappropriate. Future efforts may consider more selective targeting of price transparency.” It might also be a good idea to price out different testing options for providers, and use actual charges and other more on-point forms of cost estimates, they said, instead of Medicare fees that have little to do with what many patients are actually charged. Targeting only the most expensive tests might also help (JAMA Intern Med. 2017 April 21. doi: 10.1001/jamainternmed.2017.1144).
The investigators also noticed a problem when labs are ordered to repeat automatically; clinicians did not see the price information every day, and so missed cost information “when it would be most salient.”
The mean age in the study was 54.7 years; 52% of the patients were white, 39% black, and 57% women. The mean length of stay was about 6 days, and over 80% of the patients were discharged home.
Key clinical point:
Major finding: There were no significant changes in overall test ordering (0.05 tests ordered per patient day, P = .06) or associated fees when pricing information was displayed ($0.24 per patient day; P = .47).
Data source: Analysis involving 98,529 patients and 142,921 admissions of the effect of Medicare reimbursement information on lab test ordering
Disclosures: This study was funded by the University of Pennsylvania Health System. The senior investigator Mitesh Patel, MD, an assistant professor of medicine at the University of Pennsylvania, Philadelphia, is a principal at Catalyst Health, a technology and behavioral change consulting firm. The authors had no other disclosures.