We found that prices for the most common gastroenterology and hepatology procedures significantly vary across the top 25 GI hospitals in the US. For EGD and colonoscopy, the standard deviation across the study was greater than the average reported self-pay price with standard deviations of $7800 and $8325, respectively. Furthermore, there was a 51-fold difference found in the price for an EGD and greater than an 80-fold difference for a colonoscopy. In the analysis, significant outliers were found in multiple procedures. Interestingly, these outliers were not the same institution with repeat occurrences. Instead, it was multiple hospitals with one or two significantly elevated prices. Therefore, we suspect the degree of variation in prices demonstrated was not secondary to a few hospitals with high prices rather variation was present systematically.
Considering the Hospital Price Transparency Final Rule, hospitals must legally post prices for all tests and procedures. Despite these hospitals being chosen for their exemplary care as well as their well-funded programs, only two of the 25 hospitals in this study met this requirement. Of the procedures of interest, EGD, CT abdomen with contrast, and complete abdominal ultrasound were the only tests to have prices available at all institutions. Colonoscopy prices similarly was reported in 24 of 25 hospitals. Ultimately, 92% of the hospitals included in this review failed to meet the requirement of providing prices for all procedures despite legal requirements for reporting.
We also found that transparency is limited by accessibility to this data. Some hospitals used simple patient-friendly websites with easy access to procedure information including price estimates, while others did not have this information available at all, or it was behind multiple menus of a website. These unfriendly forms may meet legal requirements for public display of pricing but ultimately undercut the objective of transparency for patients.
The inaccessibility aforementioned largely impacted this analysis. Individual insurance plans, Medicare, and Medicaid prices had substantial barriers to information gathering. For example, the large majority of individual insurance plans are locked behind payer ID. Additionally, Medicare estimates provided by the US Federal Government include national averages and do not include true prices regarding procedures. Lastly, Medicaid is a state implemented program which results in variability of out-of-pocket costs state by state. Overall, all of these factors and other barriers to collecting data outside of cash pay price became unsurmountable for a national price analysis.
These gastroenterology tests and procedures place a significant economic burden on the US. Annual healthcare expenditures for gastroenterology are estimated to be 135 billion annually in the United States4. This is greater than heart disease, trauma, or mental illness expenditures5. The vast disparity in prices negatively impacts patient burden and our health care system as a whole. An estimated 11 million colonoscopies and 6.1 million upper endoscopies are estimated annually4. The 80-fold and 50-fold difference in prices equates to billions spent across our system due to facility selection alone. In this study, the grouping of hospitals is likely of similar quality. However, prices for self-pay vary significantly. Reasons for this are complex, and could include market variability, non-clinical related costs such as facility fees, among others. Policies to make negotiated prices for tests/procedures more transparent and easily trackable are needed, especially as the US health care system becomes more complex and new tests/procedures become available. This is a complex issue but given the significant variation in pricing for standardized procedures, this is worth further evaluation with the intention of not only lowering costs but understanding how prices are set and the dynamics at play regarding reimbursement and actual payment. Given the significant expenditures that occur in US health care, making prices more consistent for patients regardless of their pay source is needed.
This study has several limitations. First, the findings are a direct representation of the quality and accuracy of data posted by hospitals. Data within the chargemaster websites for each hospital was variable, which limited the ability to make as many price comparisons as possible across different institutions. Second, our analysis was restricted to self-pay, so we could not make comparisons in cost between different payer sources. Although the chargemaster data is publicly available, unique patient insurance information is needed to obtain prices for different insurance providers, which was not possible for the purposes of this study. Finally, prices do not specify whether professional fees are included and did not account for variations in pricing between inpatient/outpatient or screening/diagnostic tests.
The data presented brings up new areas for analysis in the push for more price transparency in the United States. One of the most interesting applications would be the analysis of smaller or more localized hospital systems in the United States. Given the large resources of the hospital system included in the analysis, investigating if smaller hospitals with relatively less resources are also struggling to provide transparency to their patient populations would provide interesting insight into transparency implementation. Additionally, these results should be compared to the costs that private insurers, Medicare, and Medicaid pay as well as the individual patient. Lastly, the transparency of the prices provided should be compared on an annual basis to affirm the further implementation of the Hospital Transparency Final Rule.
This study demonstrated the high variation in the cost of gastroenterology tests and procedures across the top 25 hospitals in the United States. Although price transparency laws have enabled access to some reported prices, their limitations in accessing this data for all procedures. Further studies will be needed to confirm these findings in private insurers and the government-directed health insurance programs