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Clinical Research

Less Than One-third of Hospitals Provide Compliant Price Transparency Information for Total Joint Arthroplasty Procedures

Burkhart, Robert J. BS1; Hecht, Christian J. II BS1; Acuña, Alexander J. MD1; Kamath, Atul F. MD1

Author Information
Clinical Orthopaedics and Related Research: June 23, 2022 - Volume - Issue - 10.1097/CORR.0000000000002288
doi: 10.1097/CORR.0000000000002288
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Abstract

Introduction

A lack of price transparency has been identified as a leading cause for substantial healthcare spending in the United States [4, 11, 46]. Similarly, incomplete or absent price sharing may result in surprise billing and associated financial stress for patients receiving medical services [1, 16, 21, 34, 40, 43]. In response to these concerns, as well as growing patient financial responsibility, the Hospital Price Transparency Final Rule was passed to promote cost containment and price transparency [12, 13]. However, although related requirements went into effect on January 1, 2021, early evidence has suggested noncompliance with this rule [3, 15, 22, 25, 44]. Notably, Gondi et al. [22] found that of the 100 hospitals sampled in their analysis, 83% were noncompliant with at least one of the price transparency mandates.

Total joint arthroplasty (TJA) is one of the highest-volume surgical procedures in the United States [27, 49] and remains the most common inpatient procedure for Medicare beneficiaries [18, 47]. Previous analyses have demonstrated large variation in TJA pricing [7, 23, 41] and limited price transparency before the new rule [35, 45]. For example, in their analysis of THA pricing, Mahomed et al. [35] found that between 2012 and 2016, the percentage of hospitals unable or unwilling to provide any price increased from 14% to 44%. However, no previous analysis that we know of has evaluated TJA pricing information in light of the novel Centers for Medicare and Medicaid Services (CMS) rule. Additionally, because TJA procedures are widely utilized, expensive, and generally are predictable in terms of cost and expected outcomes, these procedures may be seen as an optimal proxy for assessing how hospitals provide price transparency for their services as a whole. Furthermore, with millions of Americans managing endstage hip and knee osteoarthritis [2, 29], cost estimates for TJA procedures likely represent some of the most commonly sought-after price transparency information among the orthopaedic surgery patient population.

Therefore, we asked: (1) Are hospitals compliant with federal rules mandating transparency in pricing for primary TJA? (2) Are hospitals providing these data in a user-friendly format? (3) Is there a difference in prices quoted based on Current Procedural Terminology (CPT) codes compared with Diagnosis Related Group (DRG) codes?

Materials and Methods

Study Design and Setting

We conducted a cross-sectional survey of all Medicare hospitals in the United States using the Hospital Compare Database provided by the CMS [14]. This publicly available tool provides information such as the facility identification, address, hospital type (such as acute care hospital or critical access hospital), ownership, hospital size (small = 0-100 beds, medium = 100-300 beds, large > 300 beds), and quality measure scores for each Medicare hospital. To identify which of these institutions are performing TJA, we linked publicly available inpatient discharge data with this hospital information using each facility’s unique CMS certification number. Specifically, we used the Inpatient Utilization and Payment Public Use Files to evaluate case volume at each CMS hospital. This produced a national sample of Medicare hospitals performing TJA to assess compliance with the CMS’s Hospital Price Transparency Final Rule. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines [52].

Hospital Selection

The Hospital Compare database provided information for all Medicare hospitals in the United States (n = 5326). Per previous methods [3, 5], we excluded children’s hospitals and psychiatric hospitals. Similarly, we excluded Veterans Affairs hospitals and active military base hospitals because they are not required to report prices under the CMS rule. Using each facility’s unique CMS certification number, we linked publicly available inpatient discharge data with this hospital information to identify institutions performing TJA. We excluded hospitals performing fewer than 100 TJAs because this cutoff has been used to segregate low-volume and high-volume centers [17]. A total of 1719 hospitals remained after this selection process (Fig. 1). Random sampling stratified across practice setting, hospital size, TJA volume, type, ownership, and Census region was performed to identify 400 (24%) facilities to be included in our analysis. Hospitals from similar healthcare systems were included given that the price transparency legislation requires individualized pricing per healthcare institution.

F1
Fig. 1.:
This STROBE flow chart shows the hospital selection process.

Characteristics of Included Hospitals

The Medicare hospitals were located predominately in urban areas (79% [317 of 400]) and distributed across US census regions. Hospitals ranged in size from small (22% [86 of 400]), medium (43% [171 of 400]), and large (36% [143 of 400]). Most were classified as acute care (98%) versus critical access. The most common hospital ownership type was private volunteer nonprofit (54% [214 of 400]) followed by proprietary (15% [60 of 400]), government (13% [53 of 400]), church (10% [38 of 400]), and other (9% [35 of 400]). Seventy-three percent (293 of 400) of hospitals performed 100 to 500 TJA procedures annually, 21% (85 of 400) of hospitals performed 500 to 1000, and 6% (22 of 400) of hospitals performed more than 1000 TJA procedures (Table 1).

Table 1. - Characteristics of hospitals in the analyzed sample
Characteristic Hospitals meeting inclusion criteria (n = 1719) Sampled hospitals (n = 400) p value
Practice setting 0.14
 Urban 81 (1397) 79 (317)
 Rural 19 (322) 21 (83)
Hospital size 0.11
 Small 19 (328) 22 (86)
 Medium 40 (680) 43 (171)
 Large 41 (711) 36 (143)
TJA volume per year 0.35
 100-500 75 (1291) 73 (293)
 500-1000 18 (316) 21 (85)
 > 1000 7 (112) 6 (22)
Hospital type 0.10
 Acute care 96 (1656) 98 (392)
 Critical access a 4 (63) 2 (8)
Hospital ownership 0.60
 Government 11 (195) 13 (53)
 Proprietary 16 (271) 15 (60)
 Private volunteer nonprofit 53 (909) 54 (214)
 Church volunteer nonprofit 9 (155) 10 (38)
 Other 11 (189) 9 (35)
United States Census region 0.79
 Midwest 27 (469) 28 (113)
 Northeast 16 (277) 15 (58)
 South 36 (621) 38 (151)
 West 20 (352) 20 (78)
Data presented as % (n).
aMedicare Critical Access Hospitals are specially designated rural hospitals by the CMS for ensuring that rural communities have access to hospital services.

CMS Price Transparency Requirements

Under the CMS price transparency rule, each hospital must provide a list of standard charges for all services and items provided by their facility online in a downloadable, machine-readable format [12, 13]. For each included item or service, the following five datapoints are required: gross charges, payer-specific negotiated charges, deidentified minimum negotiated charges, deidentified maximum negotiated charges, and discounted cash prices. Additionally, each item or service must be identifiable by any code used by the hospital for billing, including CPT, Healthcare Common Procedure Coding System, or DRG codes. Furthermore, this information must be available free of charge to patients, without any personal identifying information required for access.

Data Collection

We thoroughly searched hospital websites for dropdown menus or links related to pricing information. Similarly, search functions on each website were used to identify price transparency information using the following standardized search terms: “price transparency,” “estimator tool,” “price estimator,” “cost estimator,” and “cost transparency.” We recorded the identification of a machine-downloadable file or consumer-friendly price estimator tool.

For hospitals with available downloadable files, we thoroughly explored each document to identify price information related to TJA procedures. Specifically, we searched each file for CPT/Healthcare Common Procedure Coding System codes 27447 (arthroplasty, knee, condyle and plateau; medial and lateral compartments with or without patella resurfacing; TKA) and 27130 (arthroplasty, acetabular and proximal femoral prosthetic replacement; THA), as well as DRG codes 469 (major joint replacement or reattachment of the lower extremity with a major complication or comorbidity) and 470 (major joint replacement or reattachment of the lower extremity without a major complication or comorbidity). In the absence of CPT/Healthcare Common Procedure Coding System or DRG codes, the file was searched for the following standardized keywords: “total hip,” “total knee,” “major joint,” “arthroplasty,” “replacement,” “knee,” or “hip.” When a machine-readable document was unavailable, the price estimator was used to identify price information using similar methodology.

If insurance status was required to access pricing information, each reviewer selected options related to an insurance status of uninsured. If personal information was required to access pricing information, the name John Doe and a January 1, 1980, birthdate were used. Additional username, password, or insurance policy number requirements are not aligned with the CMS mandate; therefore, they were considered unavailable during the search process. Additional datapoints collected during the search process included information related to consumer-friendliness and usability. All data were sourced between December 1 and 20, 2021.

Primary and Secondary Study Outcomes

Our primary study goal was to determine whether hospitals are compliant with federal rules mandating transparency in pricing for primary TJA. To assess hospital compliance, three reviewers (RJB, CJH, AJA) thoroughly searched each hospital website utilizing dropdown menus and search functions for a link to a publicly available machine-downloadable file listing TJA price information for the following five datapoints: gross charges, payer-specific negotiated charges, deidentified minimum negotiated charges, deidentified maximum negotiated charges, and discounted cash prices. Hospitals that provided all five datapoints through a machine-readable file were considered compliant. Additionally, we considered hospitals that provided some type of gross price information pseudocompliant.

Our secondary study goal was to determine whether hospitals are providing these data in a consumer-friendly format. Per previous methods, consumer-friendliness was defined based on internet search [5, 42, 50]. To assess the usability of the pricing features on hospital websites, reviewers documented whether the following criteria were met: (1) languages other than English were offered, (2) it took fewer than 15 minutes to locate pricing information, (3) a phone number or email address provided for questions, and (4) there was a description of procedure in common terms.

Finally, our third study goal was to determine whether differences exist in quoted prices based on CPT codes compared with DRG codes. Reviewers searched the machine-downloadable file for CPT codes 27447 and 27130 and DRG codes 469 and 470, and they recorded pricing information. When a machine-readable document was unavailable, we used the price estimator to identify price information using similar methodology.

Ethical Approval

Because our analysis used publicly available data, this study was exempt from institutional review board approval.

Statistical Analysis

Previous analyses looking at price transparency during the early months following the new legislation demonstrated compliance rates of approximately 20% [3, 5, 22]. We expected that by the end of 2021, compliance would increase to at least 27% among hospitals nationally [3]. Therefore, we performed an a priori statistical power analysis for sample size estimation. Using a two-tailed, one-sample binomial test with an alpha of 0.05 and power of 0.80, the projected sample size needed was approximately 312. Therefore, we decided that a sample size of 400 was adequate to detect meaningful differences in hospital compliance. This additionally represents the largest study to date evaluating price transparency among hospitals [3, 5, 6, 9, 19, 22].

Interrater intraclass correlation tests were then performed for 20 hospitals to ensure reliability between reviewers. Based on an absolute-agreement, two-way mixed effects model, the ICC was calculated as 0.85 (95% confidence interval [CI] 0.68 to 0.94). This indicated good reliability between reviewers [31].

We evaluated the proportion of hospitals compliant with each portion of the CMS ruling for each TJA code. Chi-square tests were conducted to evaluate differences in compliance rates based on the included hospitals’ characteristics. Descriptive statistics were used to report prices listed for each of the five required price values. To evaluate differences in listed median prices between more granular TJA codes (27447 and 27130) and the more general DRG codes 469 and 470, we conducted two-tailed Mann-Whitney U tests. A p value of 0.05 was identified as significant. SPSS Statistics Version 28.0.0.0 (IBM Corp) was used for all statistical analyses.

Results

Compliance With CMS Rule

Only 32% (129 of 400) of the sampled hospital websites were compliant with all six requirements under the CMS rule for transparency in pricing (Supplementary Table 1; https://links.lww.com/CORR/A840). When segregating by individual procedures, 21% (84 of 400) and 18% (72 of 400) of hospitals provided CMS-compliant pricing information for CPT codes 27447 and 27130, respectively. Similarly, 18% (71 of 400) and 19% (74 of 400) of hospitals provided CMS-compliant price transparency information for DRG codes 469 and 470, respectively (Fig. 2). For each code, rates of pseudocompliance were 36% (143 of 400) 31% (125 of 400), 34% (135 of 400), and 50% (199 of 400), for the included codes, respectively. A total of 8% (32 of 400) of hospitals provided compliant information for all four of the included codes. An additional 15% (58 of 400) of hospitals were considered pseudocompliant for all four codes.

F2
Fig. 2.:
This chart shows the proportion of hospitals that were compliant with the CMS rule.

Additionally, most included hospitals had machine-readable files (87% [347 of 400]) per the CMS rule (Table 2). However, personalized information was required to receive estimates for 21% (82 of 400) of hospitals. Proportions of compliance were comparable when evaluating differences between hospital type (acute care: 32% [124 of 392]) versus critical access: 63% [5 of 8]; p = 0.06), ownership (government: 36% [19 of 53] versus proprietary: 33% [20 of 60] versus private volunteer nonprofit: 32% [69 of 214] versus church volunteer nonprofit: 21% [8 of 38] versus other: 37% [13 of 35]; p = 0.57), TJA volume (100-500: 31% [91 of 293] versus 500 to 1000: 37% [31 of 85] versus more than 1000: 32% [7 of 22]; p = 0.64), US Census region (Midwest: 35% [39 of 113] versus Northeast: 43% [25 of 58] versus South: 32% [45 of 141] versus West 26% [20 of 78]; p = 0.15), and practice setting (urban: 30% [95 of 317] versus rural: 41% [34 of 83]; p = 0.06). In contrast, the proportion of compliant hospitals differed according to bed size, with large hospitals demonstrating the lowest proportion (22% [31 of 143] versus small: 43% [37 of 86] versus medium: 36% [61 of 171]; p = 0.002).

Table 2. - User-friendly characteristics for 400 sampled hospital websites
Variable Total
Pricing tool 81 (322)
CMS document 87 (347)
Personal information required 21 (82)
Language
 English 95 (381)
 English and Spanish 1 (5)
 English and other 0.5 (2)
Description of procedure 3 (13)
Time from initial query
 < 5 min 32 (127)
 5-15 min 52 (207)
 > 15 min 17 (66)
Physician fees 5 (18)
Hospital fees 6 (25)
Phone number 33 (131)
Procedure search function
 Nothing 4 (14)
 CPT 9 (35)
 DRG 2 (7)
 Keywords 4 (16)
 Combination (CPT, DRG, keywords) 82 (328)
Data presented as % (n).

Usability of Hospital’s Pricing Tools

Most included hospitals provided at least some of their pricing data in a user-friendly format. Pricing tools were available on 81% (322 of 400) of hospital websites. Most hospitals only provided price transparency information in English (95% [381 of 400]) and a phone number to call for assistance was offered by 33% (131 of 400) of hospital websites. Although it took less than 15 minutes to record most (84% [334 of 400]) of the price estimates, more than 15 minutes was needed to extract pricing information for 17% (66 of 400) of the queried websites (Table 2). Furthermore, many of the machine-readable documents and price estimator tools were difficult to access, requiring multiple intermediary webpages and search inquiries to locate them. Similarly, markedly large files (> 3 GB) provided in nontraditional file formats required additional software to read for 6% (25 of 400) of hospitals. Of note, 4% (14 of 400) of hospital websites did not have CPT codes, DRG codes, or keywords as procedure search functions to locate the pricing of procedures.

Price Comparison by DRG Compared With CPT

Prices quoted using a DRG search were higher overall than prices quoted using a procedure-specific CPT code (Fig. 3). For CPT code 27447, gross charges were available through either a machine-readable document or price tool for 47% (188 of 400) of hospitals. Listed estimates ranged from USD 649 to USD 317,968, with a median (IQR) of USD 30,000 (57,000). Only 41% (165 of 400) of websites provided pricing information for CPT code 27130, with a median (IQR) of USD 27,000 (53,000).

F3
Fig. 3.:
This box-and-whisker plot demonstrates extracted pricing information for CPT and DRG codes related to total joint arthroplasty.

For the less granular DRG codes 469 and 470, gross charges were provided by 39% (154 of 400) and 56% (224 of 400) of websites, respectively. Gross charges listed for DRG code 469 had a median (IQR) of USD 65,000 (88,000). Additionally, median (IQR) price estimates extracted for DRG code 470 were USD 49,000 (54,000) (Fig. 3).

When comparing used TJA codes, higher median (IQR) prices were noted for DRG codes 469 and 470. Specifically, for CPT code 27130, gross charges (USD 27,000 [53,000] versus USD 65,000 [8000]; p < 0.001), cash discount prices (USD 16,000 [28,000] versus USD 33,000 [55,000]; p < 0.001), as well as negotiated minimum (USD 5310 [20,000] versus USD 18,000 [22,000]; p < 0.001) and maximum (USD 23,000 [44,000] versus USD 53,000 [68,000]; p < 0.001) prices were lower than the costs listed for both DRG 469 and 470. This was similarly demonstrated when comparing CPT code 27130 to DRG 469 with gross charges (USD 27,000 [53,000] versus USD 49,000 [54,000]; p < 0.001), cash discounted prices (USD 16,000 [28,000] versus USD 30,000 [39,000]; p < 0.001), as well as negotiated minimum (USD 5310 (20,000) versus USD 12,000 [23,000]; p < 0.001) and maximum (USD 23,000 [44,000] versus USD 38,000 [58,000]; p < 0.001) prices all being lower for CPT code 27130. For CPT code 27447, median (IQR) gross charges (USD 30,000 [57,000] versus USD 65,000 [88,000]; p < 0.001), cash discounted prices (USD 16,000 [29,000] versus USD 33,000 [55,000]; p < 0.001), as well as negotiated minimum (USD 4882 [27,000] versus USD 18,000 [22,000]; p < 0.001) and maximum (USD 28,000 [46,000] versus USD 53,000 [68,000]; p < 0.001) prices were all lower than the costs listed for DRG 469. Likewise, compared with DRG 470, CPT code 27447 had lower gross charges (USD 30,000 [57,000] versus USD 49,000 [54,000]; p < 0.001), cash discounted prices (USD 16,000 [29,000] versus USD 39,000 [55,000]; p < 0.001), as well as negotiated minimum (USD 4882 [27,000] versus USD 12,000 [3000]; p < 0.001) and maximum (USD 28,000 [46,000] versus USD 38,000 [58,000]; p < 0.001) prices.

Discussion

Despite legislation aimed at reducing national rates of surprise billing and increasing the affordability of healthcare, recent data have demonstrated noncompliance with price transparency mandates at the national level. Given that TJA remains one of the highest-volume orthopaedic procedures with generally reproducible costs and outcomes, we evaluated TJA price transparency to further determine rates of compliance among a national sample of hospitals. We found that fewer than one-third of sampled institutions were compliant with the new CMS rule when considering any of the evaluated TJA codes. Although pricing information was generally available, it frequently did not meet requirements established by the CMS and was oftentimes difficult to access. Furthermore, we found substantially lower prices provided for CPT codes pertaining to TJA than for more general DRG codes. These findings serve to help hospitals nationally understand current deficits in price transparency compliance as well as ways of improving accessibility of price information for their patients. Specifically, our findings emphasize that need for all six of the legislation’s mandates to be addressed during internal audits of compliance. This information should encourage standardized methods of informing patients about the available price information as well as efforts aimed at ensuring that computer and health literacy do not limit the ability of patients to access this information. Furthermore, we advocate for the use of CPT codes and layman terms when identifying provided services as well as a price estimator tool that allows for the download of a machine-readable file specific to the procedure of interest.

Limitations

This study has some limitations. First, some hospitals have intentionally restricted access to the machine-readable documents and price estimator tools, placing them in abstruse locations and delisting them from search engines [36]. Related to this notion, we are unable to comment on the accessibility of these files by the traditional patient population seeking TJA pricing. The authors recognize that hospitals frequently provide different quoted prices and charges based on the insurance status of the patient. However, because part of the price transparency legislation includes providing payer-specific charges, our analysis found that these more granular price estimates were not available from most hospitals. Additionally, although professional fees for surgeons and anesthesiologists remain important components of each patient’s total hospital charges, related price estimates are not required under the CMS mandate and therefore were not evaluated. Additionally, we were unable to determine whether cost knowledge would influence TJA pricing across institutions because additional factors such as surgeon reputation and referrals have been demonstrated to have a higher influence on where patients received their TJA care [8]. However, we contend that evaluating price transparency for a high-volume procedure such as TJA remains an appropriate surrogate for understanding the current nature of compliance among healthcare institutions across the United States. Furthermore, it is unclear whether various amendments to the legislation, such as delaying the enforcement of certain provisions, will affect proportions of compliance [51]. It is possible that hospitals have delayed compliance with the hope that related requirements may change or that current delays in enforcement may continue. Although it is unclear whether legislation will change, the low rates of compliance demonstrated in our analysis should encourage hospitals to provide related information to avoid penalties expected to be enforced starting July 1, 2022 [30]. Despite these limitations, our analysis demonstrated that most hospitals in our national sample were noncompliant with current CMS price transparency directives.

Compliance With CMS Rule

Only 32% (129 of 400) of the sampled hospital websites were compliant with all six requirements under the CMS rule for transparency in pricing for all four evaluated codes. Previous studies have demonstrated that pricing information for TJA was scarcely available before the new CMS rule [32, 35, 45]. Of note, Mahomed et al. [35] found that only 6.7% of 120 hospitals surveyed in 2016 were able to provide THA prices—a substantial decrease from 15.8% in 2012. Our analysis builds from these previous findings by evaluating price transparency for TJA procedures after the first year of the new mandate in the largest national sample to date. Importantly, by individually evaluating each of the six mandates required under the new legislation, we are able to highlight specific areas for hospitals to improve as well as considerations for future enforcement efforts. Notably, although previous studies considered hospital websites compliant because they had a related file for download and provided prices from at least one insurer [20, 28], we found that the high availability of machine-readable documents (87% [347 of 400]) did not correlate with compliance. Additionally, although gross charges were generally more available compared with related cash, minimum, and maximum prices, less than half of hospitals were compliant across all required mandates. Therefore, as current efforts, or lack thereof, for providing this information are insufficient, hospitals should ensure that available pricing information addresses each of the new legislation’s mandates to avoid future penalties. Related to this notion, CMS may consider tiering related penalties, which currently may reach up to USD 5500 daily for certain hospitals, based on how many of the mandates are met by hospitals [26]. Furthermore, as various explanations behind this noncompliance have been proposed, including lack of infrastructure for implementation and the inability to provide accurate data [24, 38], we believe that utilizing third-party companies to ensure compliance, as well as to assess the reductions in healthcare spending associated with price transparency, may further help hospitals that are currently unable or unwilling to provide charge data achieve compliance.

Usability of Hospital’s Pricing Tools

Most hospitals provided at least some of their pricing data in a user-friendly format. However, as accessibility remains an essential tenant of price transparency [10, 21, 53], we believe our findings may be used to further improve the user-friendliness of presented charges. Generally, this may be done by providing price estimates in more languages, making estimates available without requiring personalized information, and ensuring that estimates can be achieved in a reasonable time. Specifically, although price tools themselves are not considered compliant under the new mandates, the ability to search by CPT, DRG, or keyword allows for quicker identification of the service of interest compared with downloading large files. Hospitals should therefore consider embedding the machine-readable file into price tools to be downloaded once the procedure has been identified. Similarly, to ensure that literacy regarding computers and various file formats does not impact patient access to this information, we suggest using files compatible with Microsoft Excel (Microsoft) when providing machine-readable documents. Importantly, although some pricing information was provided, previous analyses have suggested that consumers are frequently unaware that these price estimates are available [33, 37, 48]. Therefore, hospitals should indicate where to access related information on their home pages or through user-friendly search tools on their website. CMS and other policymakers may consider increasing penalties if related information is purposefully hidden, as has been recently discovered [36].

Price Comparison by DRG Compared With CPT

Prices quoted using a DRG search were higher overall than prices quoted using a procedure-specific CPT code. Although using DRG codes is acceptable under the new rule, we believe there are several reasons why they should not be used when providing related price estimates. To start, healthcare institutions traditionally use DRG codes when evaluating billing charges rather than the actual reimbursements providers will receive or that patients will be responsible to cover. Additionally, as the DRG system is weighted based on various patient demographics, comorbidity burden, and outcome data for all patients receiving care at the respective institution, wide variations are often demonstrated in how much hospitals are reimbursed through these codes. This likely explains why prices pertaining to included DRG codes had substantial ranges and were markedly higher than their CPT equivalents. Furthermore, DRG codes 469 and 470 are nongranular [39] and use medical jargon that may not be familiar to patients seeking price information for the specific joint that requires surgery. Therefore, we believe our findings should encourage hospitals to use CPT codes, in conjunction with searchable layman terms, to help patients find their specific procedure more easily while additionally receiving a more accurate assessment of TJA costs at the evaluated institution.

Conclusion

Although the CMS implemented a price transparency mandate at the beginning of 2021, our analysis demonstrated that most hospitals either do not provide TJA price estimates on their websites or are noncompliant when presenting related information. Specifically, approximately half of evaluated hospitals provided a gross charge for any TJA code, and less than one-third of these institutions were fully compliant with all CMS mandates for these procedures. Given the potential influence compliance and price sharing may have on empowering patients’ healthcare decisions and reducing healthcare expenditures in the United States, hospitals should use our analysis to identify where their compliance is lacking and to understand how to make their pricing information more readily available and comprehendible for the patients that they serve. In addition to ensuring all six CMS mandates are met, hospitals should provide information in easy-to-understand formats, and they should make related services identifiable across all levels of health literacy. Future analyses are needed to evaluate whether the estimated TJA prices provided by hospitals aligns with the actual charges provided to insurers and patients. Additionally, as penalties begin in July 2022, additional studies will be needed to understand whether they will affect national rates of compliance.

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