'Stunning Variation' in CV Test, Procedure Costs Revealed at Top US Hospitals

Marilynn Larkin

July 22, 2022

Wide variation in the cost of common cardiovascular (CV) tests and procedures, from stress tests to coronary interventions, was revealed in a cross-sectional analysis based on publicly available data from 20 top-ranked hospitals in the United States.

The analysis also suggested a low level of compliance with the 2021 Hospital Price Transparency Final Rule among the 20 centers.

"The variation we found in payer-negotiated prices for identical cardiovascular tests and procedures was stunning," Rishi K. Wadhera, MD, MPP, MPhil, Beth Israel Deaconess Medical Center, Boston, told theheart.org | Medscape Cardiology.

"For example, there was a 10-fold difference in the median price of an echocardiogram, and these differences were even larger for common procedures" such as percutaneous coronary intervention (PCI) and pacemaker implantation, he said. "It’s hard to argue that this variation reflects quality of care, given that we looked at a top group of highly ranked hospitals."

"Even more striking was how the price of a cardiovascular test within the very same hospital could differ across commercial insurance companies," he said. "For example, the price of a stress test varied 5-fold in one hospital, and in another hospital, more than 4-fold for a coronary angiogram."

Wadhera is senior author on the study published online as a research letter on July 18 in JAMA Internal Medicine, with lead author Andrew S. Oseran, MD, MBA, also from Beth Israel Deaconess Medical Center.

Difficulties With Data, Interpretation

The researchers looked at payer and self-pay cash prices for noninvasive and invasive CV tests and procedures at the US News & World Report 2021 top 20–ranked US hospitals, based in part on Current Procedural Terminology codes.

Price differences among the hospitals were derived from median negotiated prices for each test and procedure at the centers across all payers. The interquartile ratio (IQR) of prices for each test or procedure across payers was used to evaluate within-hospital price variation.

"Only 80% of the hospitals reported prices for some cardiovascular tests and procedures," Wadhera said. "For the most part, even among the hospitals that did report this information, it was extremely challenging to navigate and interpret the data provided."

Further, the team found that only seven of the 20 hospitals reported prices for all CV tests and procedures. Centers that did not post prices for some tests or procedures are named in the report's Figure 1 and Figure 2.

The number of insurance plans listed for each test or procedure ranged from one to 432 in the analysis. Median prices ranged from $204 to $2588 for an echocardiogram, $463 to $3230 for a stress test, $2821 to $9382 for right heart catheterization, $2868 to $9203 for a coronary angiogram, $657 to $25,521 for a PCI, and $506 to $20,002 for pacemaker implantation, the report states.

A similar pattern was seen for self-pay cash prices.

Within-hospital variation also ranged broadly. For example, the widest IQR ranges were $3143-$12,926 for a right heart catheterization, $4011-$14,486 for a coronary angiogram, $11,325-$23,392 for a PCI, and $8474-$22,694 for pacemaker implantation.

The report cites a number of limitations to the analysis, among those, the need to rely on the hospitals themselves for data quality and accuracy.

"More Needed Besides Transparency"

"As a means to better understand healthcare costs, many opined that full price transparency would leverage market dynamics and result in lower costs," observed Clyde W. Yancy, MD, MSc, professor of medicine and chief of cardiology at Northwestern Medicine in Chicago. The findings, "by an expert group of outcomes scientists, make clear that more is needed besides price transparency to lower cost," he told theheart.org | Medscape Cardiology.

That said, he added, "There are sufficient variations and allowances made for data collection that it is preferable to hold the current findings circumspect at best. Importantly, the voice of the hospitals does not appear."

Although "price variation among the top 20 hospitals is substantial," he observed, "without a better assessment of root cause, actual charge capture, prevailing market dynamics — especially nursing and ancillary staff costs — and the general influence of inflation, it is too difficult to emerge with a precise interpretation."

Across the 20 hospitals, "there are likely to be 20 different business models," he added, with negotiated prices reflecting "at least regional, if not institutional, variations."

"These are complex issues. The several-fold price differences in standard procedures are a concern and an area worth further study with the intention of lowering healthcare costs," Yancy said. "But clearly our next efforts should not address lowering prices per se, but understanding how prices are set, the connection with reimbursement and actual payments."

Wadhera discloses receiving personal fees from Abbott and CVS Health unrelated to the current study; disclosures for the other authors are in the report. Yancy is deputy editor of JAMA Cardiology.

JAMA Intern Med, 2022. Published online July 18. Research letter

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