KSHB 41 reporter Elyse Schoenig covers the cities of Shawnee and Mission. She also focuses on issues surrounding the cost of health care, saving for retirement and personal debt. Share your story idea with Elyse.
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Medical costs have long been a mystery.
It's why a report from a nonprofit is trying to add clarity in the hopes patients know how much you'll pay when you need health care.
Federal regulations on hospital compliance
The hospital price transparency rule started in 2021. The Centers for Medicare & Medicaid Services (CMS) determines whether a hospital is compliant. The law first established hospitals must post:
- standard charges for all items and services
- prices for the 300 most common services through something like a price estimator tool
In July of 2024, the rules were updated to add more format consistency and more information.
"Even for hospitals that are compliant, fully, by everyone's standard, it's still hard to shop around for medical care," Chris Garmon, an associate professor of health administration at UMKC, said.
He said the most important piece for patients to use and understand is the price estimator tool.
"That makes it a whole lot easier for you to search for the surgery you need and how much it's going to cost you," he said.
The nonprofit's study
PatientRightsAdvocate.org is a nonprofit that assesses the transparency of hospitals' online pricing.
KSHB 41 went through the group's most recent report released in November of 2024.
They assessed 2,000 hospital websites across the U.S. Nineteen of those websites were hospitals in the greater Kansas City area.
It’s important to note: the nonprofit and the hospitals don't view the federal guidelines the same. The nonprofit puts an extra level of scrutiny on the federal guidelines.
"I would say we go further than a first-level look and we look at the entire file to see if every single insurance plan the hospital accepts is posted, and if the majority of prices are in the data field," Cynthia Fisher, PatientRightsAdvocate.org founder and chairman, said.
Fifteen of the hospitals the nonprofit looked at in the Kansas City area did not meet their standards.
KSHB 41 reached out to those hospitals, who said they are in compliance with federal law.
Patient takeaways
Garmon recommends patients look for those price estimator tools. But he also points to data that federal law and reports don’t conduct: the quality of your care.
"Are they five-star or four-star hospitals? What are the mortality rates and complication rates for the procedures you’re considering? Are they a high-quality hospital or not? And ask your physician, how many of these procedures have they performed in the last year?” Garmon said.
CMS' response
KSHB 41 also reached out to the CMS on this report. A spokesperson responded saying in part, "CMS does not comment or speculate on external reports," and that "CMS is aware of several outside efforts to assess hospital compliance, with findings of alleged compliance ranging from approximately 5% to nearly 85%, depending on the date of review and the organization’s methodological approach, including how closely the organization adheres to the regulatory requirements. We regularly review such reports which are used to inform our enforcement."
Read the full statement from CMS below:
CMS does not comment or speculate on external reports; however, CMS is committed to ensuring consumers have the information they need to make fully informed decisions regarding their health care. We appreciate the overwhelming support for CMS price transparency initiatives, which include Hospital Price Transparency (HPT) [cms.gov], Transparency in Coverage (TIC) [cms.gov], and the No Surprises Act [cms.gov] (NSA). We believe that price transparency can stimulate provider competition, empower healthcare consumers, and result in lower healthcare costs, and that transparency in healthcare pricing is integral to supporting a transition to value-based care.
CMS is aware of several outside efforts to assess hospital compliance, with findings of alleged compliance ranging from approximately 5% to nearly 85%, depending on the date of review and the organization’s methodological approach, including how closely the organization adheres to the regulatory requirements. We regularly review such reports which are used to inform our enforcement.
A recent Health and Human Services Office of the Inspector General released a report [oig.hhs.gov] determined that, in the spring of 2023, over 95% of 100 hospitals sampled by the OIG had taken steps to comply and 63% of hospitals fully met requirements. The OIG’s results are generally consistent with the website assessment performed by CMS in fall 2022 which found that 70% of 600 general acute care hospitals with greater than 30 beds were fully compliant with the regulatory requirements.
As we updated the hospital price transparency requirements in the CY2024 OPPS/ASC final rule, CMS directly addressed similar stakeholder comments.
Specifically, In the CY2024 OPPS/ASC final rule [federalregister.gov], we acknowledged and agreed with commenters that, although critical for determining an individual’s out-of-pocket obligation, hospital standard charges do not represent either an individual’s out-of-pocket obligation or a “real, guaranteed price.” However , we note that individualized estimates in dollars may be obtained directly, in many circumstances, from providers and payers through other Federal price transparency efforts such as those implementing the NSA and TIC requirements. As such, we strongly encouraged individual consumers to avail themselves of hospital and payer price estimator and comparison tools, and to seek out ‘good faith estimates’ from hospitals which, in order to comply with separate requirements implementing the NSA, may provide up-front pricing that can be used to dispute final charges that are substantially in excess of the up-front amounts. Additionally, as we stated in the CY 2020 HPT final rule, we continue to encourage hospitals to provide consumers with cost information in a consumer-friendly manner.
Furthermore, we stated that we understood the desire for individual patients to access hospital prices in dollars and cents, but that we believe the policies finalized in the CY2024 OPPS/ASC final rule [federalregister.gov] are consistent with our authority under the law (section 2718(e) of the Public Health Services Act) and will greatly improve the transparency of payer-negotiated rates, including whether the hospital’s standard charges should be interpreted by the user as a dollar amount, or if the standard charges established by the hospital can only be expressed as a percentage or algorithm. Additionally, we stated that we believe that the display of hospital standard charges, in the way the hospital has established them, either as a dollar amount or algorithm, squarely aligns with the regulatory requirements. We also discussed a new requirement, beginning Jan. 1, 2025, for hospitals to include in their machine-readable files an “estimated allowed amount” which is designed to provide contextual information to the payer-specific negotiated charge when it can only be expressed as a percentage or algorithm. Finally, we stated that we would continue to educate interested parties about CMS price transparency initiatives in general and the intent and limitations of the hospital price transparency regulations for consumers in particular.
Enforcement of HPT regulation is a process. As described in the this Health Affairs article [healthaffairs.org], should a hospital be identified as potentially noncompliant (for example, through complaints made by individuals or entities to CMS, analyses related to compliance, or an audit), the CMS compliance team begins a comprehensive compliance review. That process frequently involves direct hospital engagement and discourse, which can be time consuming. Should deficiencies be found, a warning letter is sent, and should those deficiencies not be remedied, CMS will request a corrective action plan. If the deficiencies remain unresolved, CMS may issue a civil monetary penalty.
Information on all of the CMS enforcement activities and outcomes related to a hospital's compliance with the HPT regulations can be found here: data.cms.gov/provider-characteristics/hospitals-and-other-facilities/hospital-price-transparency-enforcement-activities-and-outcomes [data.cms.gov]. These data can be sorted by state and enforcement action. This dataset is also updated quarterly and currently contains information from Jan. 1, 2021, to Oct. 31, 2024 (Q3 2024).