Findings From a National Employer-led Hospital Price Transparency

Findings From a National Employer-led Hospital Price Transparency Study Gloria Sachdev, President and CEO, Employers Forum of Indiana [email protected] Chapin White, Senior Policy Researcher, (adjunct) RAND Corp [email protected] Rand 2.0 Authors: Chapin White, Ph.D., Senior Policy Researcher, RAND Corp Christopher Whaley, Ph.D., Policy Researcher, RAND Corp Master Slide Deck for Public Use Last updated 5-30-19 The contents represent the views of the authors and not the organization or its funders ABOUT THE EMPLOYERS FORUM OF INDIANA Healthcare coalition formed in 2001 Members include self-funded employers, health plans, health systems, and other interested parties Aim is to improve the value payers and patients receive for their health care expenditures www.employersforumindiana.org Members of the Employers Forum of Indiana Anthem Blue Cross and Blue Shield AON American Health Network Assured Partners Barnes and Thornburg Castlight Health Chrysler (FCA) Columbus Regional Hospital Community Health

Network Cummins Inc. Deaconess Hospital Eli Lilly and Company Encore Health Eskenazi Health Fort Wayne Community Franciscan Alliance Gregory & Appel Healthcare Options Indiana Farm Bureau Indiana State Teachers Union Indiana Health Information Exchange Indiana Rural Health Association Indiana University Indiana University Health Ivy Tech JA Benefits LHD Benefit Advisors Mercer Merck (affiliate) Monarch Beverage OneAmerica OneBridge Ortho Indy Our Health Inc. Parkview Health Purdue University Roman Catholic Archdiocese of Indianapolis Roche & Genentech

St. Vincent Health State of Indiana Suburban Health Organization The Henriott Group Tippecanoe School Corp. TrueRx United Healthcare Young at Heart QUESTIONS the Forum Aimed to Answer Part A: -Are hospital prices high in Indiana? -How do prices compare among our hospitals? -Where can we find good value? -What is our trend? Part B: -How do our prices compare to those in other states? Partnership between the Employers Forum of Indiana and RAND FORUMs Role: RANDs Role: commission and partner with RAND Corp to conduct Round 1.0, Round 2.0, and Round 3.0 analyses per MOU co-develop study design co-recruit nationally for study participation conduct all study analyses

prepare study final reports and supplemental material co-develop study design co-recruit nationally for study participation BACKGROUND Study funded by the National Institute for Health Care Reform (NIHCR), using claims data from automakers and UAW Source: White, C., Bond, A. M., & Reschovsky, J. D. (2013). High and Varying Prices for Privately Insured Patients Underscore Hospital Market Power (No. 27). Retrieved from http://nihcr.org/wp-content/uploads/2015/03/HSC_Research_Brief_No._27.pdf. The Problem: Employer premiums have risen, and so have employee contributions. *Estimate is statistically different from estimates for the previous year shown (p<.05). SOURCE: KFF Employer Health Benefits Survey, 2018; Kaiser/HRET Survey of Employer-Sponsored Health Benefits. 1999-2017 7 Use trending back to baseline. Use trending back to baseline. Inpatient

Outpatient 1.20 1.20 1.15 1.15 1.10 1.10 1.05 1.05 1.00 1.00 0.95 0.95 0.90 0.90 2012 2013 2014 2015 2016 Price Utilization and Intensity 2012 2013 2014 2015 2016

Price Utilization and Intensity Health Care Cost Institute. (2018). 2016 Health Care Cost and Utilization Report. Retrieved from http://www.healthcostinstitute.org/report/2016-health-care-cost-utilization-report/. Prices are from Appendix Table A3,, utilization and intensity is estimated by dividing spending (from Appendix Table A1) by prices. QUESTION-PART A: ARE HOSPITAL PRICES HIGH IN INDIANA? PRICE TRANSPARENCY ANALYSIS Aim: To develop a fair method to compare hospital prices for public reporting The best method the Forum believed was to convert allowable payments made by employers to what Medicare would have paid for the exact service, thus report relative prices For Example: the report shows that employers paid Hospital A 200% or 2X on average what Medicare would have paid and Hospital B was paid 350% or 3.5X on average what Medicare would have paid THE RATIONALE FOR USING MEDICARE TO LEVEL SET ALL COMMERCIAL HOSPITAL PAYMENTS

Medicare is the Largest Health Insurer in the World Medicare makes numerous adjustments in price to assure FAIR payments are made to a hospital and their methods are published: type & intensity of service/patient acuity hospitals location disproportionate share of medically underserved medical education provided RAND 1.0 EMPLOYER HOSPITAL PRICE STUDY: INDIANA ONLY Study was funded by RWJF and RAND Corp was contracted to do the study analyses Study time period was July 2013 to June 2016 ~225,000 covered lives in Indiana 120 community hospitals in Indiana All hospital inpatient and outpatient services Total paid claims was $695 million Full report of study findings: freely downloadable from RANDs website: https://www.rand.org/pubs/research_reports/RR2106.html

RAND STUDY 1.0 STUDY FINDINGS Indiana Commercial Hospital Allowable Prices Paid as a Percent of What Medicare Would Have Paid for the Same Services 272 % 217% 358 % Source: White, 2017, Hospital Prices in Indiana. RAND 1.0 STUDY FINDINGS Relative Prices are Trending Up Away From Medicare Source: White, 2017, Hospital Prices in Indiana. QUESTION, PART B: HOW DO INDIANA HOSPITAL PRICES COMPARE TO OTHER STATES? AIM: Develop a way to benchmark hospital prices in Indiana and across U.S. for the first time Solution: Invite employers across the country to participate in a National Hospital Price

Transparency Study, called RAND 2.0 We had a short amount of time to enroll folks in RAND 2.0 RAND 3.0 study enrollment is ongoing as demand for price transparency is high RAND 2.0 National Hospital Price Transparency Findings Official Study Title: Prices Paid To Hospitals By Private Health Plans Are High Relative To Medicare And Vary Widely-Findings From An Employer-led Transparency Initiative authored by Chapin White and Christopher Whaley, RAND Corporation RAND 2.0 Study was Published on May 9, 2019 We have created a home page that includes everything about these studies: www.employerPTP.org RAND 1.0 and 2.0 National Hospital Price Transparency Report Rand 2.0 Supplement Database RAND 2.0 Interactive Map Tool Master Power Point slide deck which you are welcome to use as you wish News/media Sign up for RAND 3.0, FAQ and agreements You may also find the full report and supplement database on the RAND website: https://www.rand.org/pubs/research_reports/RR3033.html

Our Study Made National & Local Newsover 30 News Outlets, including: Many Hospitals Charge Double or Even Triple What Medicare Would Pay The New York Times, May 9, 2019 Study: Employers Pay 240% More Than Medicare For Hospital Care Forbes, May 9, 2019 What Employers Pay Hospitals Varies Widely, Study Finds Wall Street Journal, May 9, 2019 Employer Health Plans Pay Hospitals 241% of What Medicare Would Pay Modern Healthcare, May 9, 2019 Private Insurers Paid Hospital 241% of what Medicare Would Have HealthLeaders, May 9, 2019 Private Plans Pay Hospital Prices 241% Higher Than Medicare, RAND Finds AJMC, May 9, 2019 Private Insurers Pay Hospitals 2.4 Times What Medicare Pays Beckers Hospital Review, May 9, 2019 Market Muscle: Study Uncovers Differences Between Medicare And Private Insurers Kaiser Health News, May 9, 2019 Study: Indiana hospitals charge private health plans 311% of what Medicare would pay Indianapolis Business Journal, May 9, 2019 INTERACTIVE MAP OF US HOSPITAL PRICES employerptp.org RAND 2.0 SUPPLEMENTAL STUDY DATABASE SUPPLEMENTAL INFORMATION, TABLE 1 FREELY AVAILABLE Number Total Total of Private Simulate Relative Stand. Number Private Simulate Relative Stand. Hospital Outpt. Allowed d price for price per

of Allowed d price for price per Hospital Compar service Outpt. ($ Medicare Outpt. Outpt. Inpt. Inpt. ($ Medicare Inpt. Inpt. name e Star s millions Outpt. Services service stays millions Inpt. services stay Parkview Regional Medical Center Eskenazi Health Indiana Universit y Health 3 3486 3 4

5494 3 6121 4 30.1 1.0 33.5 5.8 .3 7.0 $353.9 515% 3 2401 $249.9 332% 8 375 $359.2 475% 9 4431 18.1 2.1

52.8 Total Private Inpt. and Outpt. (# millions) 6.5 $17,35 280% 9 48.2 1.3 $14,67 157% 9 3.1 $24,95 21.1 249% 4 86.2 Simulate d Inpt. and Outpt. ($ millions) Relative price for

Inpt. and Outpt. services 12.3 392% 1.6 189% 28.2 306% Source: Derived from Supplement, White, 2019, Prices Paid to Hospitals by Private Health Plans are High Relative to Medicare and Vary Widely-Findings from an Employer-Led Transparency Initiative. Line of service information for inpatient and outpatient services in tables 4 and 5 RAND 2.0 National Hospital Price Study of 25 states Conducted by RAND, commissioned by Employers Forum of Indiana Services Hospital inpatient, hospital outpatient States CO, FL, GA, IL, IN, KS, KY, LA, MA, ME, MI, MO, MT, NH, NC, NM, NY, OH, PA, TN, TX, VT, WA, WI, WY Years 2015-2017 Hospitals Allowed amount (2015-7) Claims (2015-7) Data sources

Funders 1598 short-stay general medical/surgical $12.9 billion in payments ($6.3 billion inpatient, $6.6 billion outpatient) 330,000 claims inpatient, 14.2 million outpatient line items 2 all payer claims databases, many health plans, ~45 self-funded employers RWJF, NIHCR, THFI, self-funded employers (not health plans or hospitals) 20 Source: White, 2019, Prices Paid to Hospitals by Private Health Plans are High Relative to Medicare and Vary Widely-Findings from an Employer-Led Transparency Initiative OUR APPROACH Obtain claims data from -Self-funded employers -APCDs -health plans Measure prices in two ways to a -Relative Medicare benchmark -price per casemix weight Create a public hospital price report -Will be posted

online, freely downloadable -named facilities and systems -inpatient prices and outpatient prices Create private hospital price reports for self-funded employers -Optional for employers Two Ways Hospital Prices are Measured 1. Relative prices h 2. Price per casemix weight adjusted for casemix local wages teaching uncompensated care comparable across service

lines adjusted for casemix not comparable across service lines Across 25 States: Employer Health Plans Pay Hospitals 241% of What Medicare Would Pay and Overall Trend in Increasing Source: White, 2019, Prices Paid to Hospitals by Private Health Plans are High Relative to Medicare and Vary Widely-Findings from an Employer-Led Transparency Initiative Commercial Relative Price TREND Varies at the State Level: Comparison of 5 States Source: White, 2019, Prices Paid to Hospitals by Private Health Plans are High Relative to Medicare and Vary Widely-Findings from an Employer-Led Transparency Initiative Across 25 States: Average Relative Hospital Prices, 2017 Percent Employer Health Plans Pay Hospitals Relative to What Medicare Would Pay Source: White, 2019, Prices Paid to Hospitals by Private Health Plans are High Relative to Medicare and Vary Widely-Findings from an Employer-Led Transparency Initiative Indiana: TOTAL Hospital Commerc ial Pric es Relative to Medicare, 2017 (i npa tie nt plus outpa tie nt) 417% 417% 370% 311% 311% 285% 257% 160 160%

% Al ita sp o lh ls l ta To 187% 187% 264% 284% 290% 295% 298% 301% 267% 189% )

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Indiana: INPATIENT Commercial Prices Relative to Medicare, 2017 303% 303% 282% 236% 267% 253% 236% 220% 188% 157% 185% 190% 194% 197% 222% 228% 198% 167% 135% 77 77%

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In m D Co CHS Co ( al He th ** RAND 2.0 Study period (2015-2017) averages as study does not provide 2017 relative prices for these two hospitals only Source: Derived from Supplement, White, 2019, Prices Paid to Hospitals by Private Health Plans are High Relative to Medicare and Vary Widely-Findings from an Employer-Led Transparency Initiative Indiana: OUTPATIENT Commercial Prices Relative to Medicare, 2017 542% 542% 483% 403% 451% 403% 366% 325% 221% 221% 332% 379% 380%

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al He th tw Ne k or v rk Pa w ie th al e H ** RAND 2.0 Study period (2015-2017) averages as study does not provide 2017 relative prices for these two hospitals only Source: Derived from Supplement, White, 2019, Prices Paid to Hospitals by Private Health Plans are High Relative to Medicare and Vary Widely-Findings from an Employer-Led Transparency Initiative Single Health-System: Indiana vs. Michigan TOTAL Relative Inpatient plus Outpatient Prices 2017 350% 300% 312% 299% 284%

250% 200% 155% 150% 146% 145% 100% 50% % 2015 2016 Indiana 2017 Michigan Source: Derived from Supplement, White, 2019, Prices Paid to Hospitals by Private Health Plans are High Relative to Medicare and Vary Widely-Findings from an Employer-Led Transparency Initiative F r an c i sc an A l l i an c e A sc e n si o n H e al t h I n d i an a Un i ve r si t y H e al t h C o m m u ni t y He al t h Ne t wo rk

P ar kvi e w H e al t h 311% 302% 294% 417% 389% 370% 354% 2017 347% 2016 318% 319% 314% 312% 299% 284% 298% 297%

280% 2015 383% INDIANA HEALTH SYSTEMS TREND OF TOTAL COMMERCIAL PRICES RELATIVE TO MEDICARE A l l h o sp i t al s I n d i an a Source: Derived from Supplement, White, 2019, Prices Paid to Hospitals by Private Health Plans are High Relative to Medicare and Vary Widely-Findings from an Employer-Led Transparency Initiative Our Goal is to Improve Value, Where Value Includes Cost and Quality BEST Value = High Quality Cost where Cost = Price x Quantity QUALITY: CMS CREATED PUBLICLY AVAILABLE HOSPITAL COMPARE WEBSITE MEANT FOR CONSUMERS QUALITY: CMS HOSPITAL COMPARE MEDICARE.GOV 1. Heart attack 2. Heart failure 3. Heart bypass 4. Pneumonia 5. Chronic Obstructive Pulmonary Disease

6. Total knee/hip replacement Best Quality Using CMS Hospital Star Ratings and BEST PRICE Using RAND 2.0 Study Findings: Across 25 States GOAL! < 150% 150-250% > 250% Source: White, 2019, Prices Paid to Hospitals by Private Health Plans are High Relative to Medicare and Vary Widely-Findings from an Employer-Led Transparency Initiative Takeaway #1: Price transparency is the new normalHospital Shopping Should be a Team Sport Patients Employer s Policy Makers Physician s Health Plans Takeaway #2: Markets Need Information, Buyers Need Options Chaos behind a veil of secrecy (Uwe Reinhardt) Where theres mystery theres margin

We urgently need transparency in both cost and quality: Prices vary significantly by state Prices vary even more so among hospitals within states Outpatient prices are more variable than inpatient prices and consume a greater share of the employers dollar The devil is in the details: you need cost and quality information at the level of the individual provider Takeaway #3: Commercial Payment Models Do Not Need to be So Complex How does Medicare pay? base payment * facilityspecific adjustments * casemix + outliers + bonuses: one number comparison of hospital prices! How do self-funded employers pay? mix of DRGs, per diems, fixed rates, discounted charges, P4P, shared savings ... Multiple-of-Medicare contracting simplifies shopping bakes in value-based payment (RBB, bundling, pay-forperformance) stabilizes price trend States examples: Montana, North Carolina, and Oregon Takeaway #4: There are Numerous Strategies Available to Drive Value Benefit Design Levers

Narrow/Tiered networks can be built on a foundation of contracting Reference based benefits a multiple of Medicare pricing so prices are comparable Centers of Excellence Direct employer to hospital contracting Prohibit anti-gag clause between carriers and hospitals Policy Levers Prohibit anti-tiering/-narrow/-tying network contracts Revise profit/not-for-profit hospital status Limit/cap on out-of-network charges THANK YOU! For The Most Current Information Including Enrolling In RAND 3.0 Study, Please Visit www.employerPTP.org EXTRA SLIDES TO BE SHARED IF HELPFUL MICHIGAN Hospital Systems: Relative Prices (2017) and Operating Margins (2015-17) Relativ e price for inpatie nt and outpatie nt hospital care Relative prices Operating margins

250% 200% 150% 100% 50% 8.2% 0% -6.7% 5.9% 2.2% 4.1% 5.7% 8.0% 7.5% 5.4% 7.5% -0.1% -50% Source: Derived from Supplement, White, 2019, Prices Paid to Hospitals by Private Health Plans are High Relative to Medicare and Vary Widely-Findings from an Employer-Led Transparency Initiative Profit Margin information obtained from www.hospitaldatasets.org ( MICHIGAN: There Are Good, Moderately Priced Hospitals Hospital Compare Star Ratings, 2018

(Share of Hospitals Within Price Group) Best Quality Using CMS Hospital Star Ratings and BEST PRICE Using RAND 2.0 Study Findings 100% 80% 60% 5 stars (highest) 4 stars 40% 3 stars 2 stars 20% 1 star (lowest) 0% 1: Low (<145%) 2: Medium (145160%) 3: High (>=160%) Hospital Price Group (Relative to Medicare, 2015 -7) Price Source: Derived from Supplement, White, 2019, Prices Paid to Hospitals by Private Health Plans are High Relative to Medicare and Vary Widely-Findings from an Employer-Led Transparency Initiative CMS Star Ratings: https://data.medicare.gov/data/hospital-compare COLORADO: TOTAL Hospital Commercial Prices Relative to Medicare, 2017 (inpatient plus outpatient) 311%

314% 319% 319% 320% 327% 274% 269% 246% 196% 159% Source: Derived from Supplement, White, 2019, Prices Paid to Hospitals by Private Health Plans are High Relative to Medicare and Vary Widely-Findings from an Employer-Led Transparency Initiative COLORADO: INPATIENT Commercial Prices Relative to Medicare, 2017 260% 228% 221% 233% 240% 246% 266%

250% 193% 174% 125% Source: Derived from Supplement, White, 2019, Prices Paid to Hospitals by Private Health Plans are High Relative to Medicare and Vary Widely-Findings from an Employer-Led Transparency Initiative COLORADO: OUTPATIENT Commercial Prices Relative to Medicare, 2017 454% 435% 395% 350% 396% 403% 407% 350% 275% 251% 170% Source: Derived from Supplement, White, 2019, Prices Paid to Hospitals by Private Health Plans are High Relative to Medicare and Vary Widely-Findings from an Employer-Led Transparency Initiative Volume of Claims per State is Important Private Claims Volume in RAND 2.0 Study Colorado > $ 5 Billion Michigan > $ 1 Billion Indiana > $1 Billion

Pennsylvania < $12 million thus no hospital-specific breakdowns possible Theres a wealth of information when sufficient claims are available for analysis. COMMENTS FROM AMERICAN HOSPITAL ASSOCIATION (AHA) Medicare payment covers 87% of hospital cost Medicare Payment Advisory Commission (MedPAC) says hospitals are not efficient because commercial payment is so high that hospitals do not have the incentives to be efficient. 1.0/0.87 = 115% of Medicare is breakeven on hospital costs so paying a bit more is reasonable. https://www.aha.org/news/headline/2019-05-09-aha-responds-rand-study-prices-paid-hospitals-private-health-plans MedPAC report, Marc 2019 http://www.medpac.gov/-documents-/reports So why are most hospitals Losing Money on Medicare? Strong market power leads hospitals to reap higher revenues from private payers. This in turn leads these hospitals to have weaker cost controls. The weaker cost controls lead to higher costs per unit of service. As a result, hospitals have a narrower margin on their Medicare business. Jeffrey Stensland, PhD Sr. Principal Policy Analyst Medicare Payment Advisory Committee 48 The Health Market Place: Providing a Failing

Value-Proposition Twenty years of wage stagnation on the middle class has been 95% caused by exploding healthcar e costs . - WSJ March 5th, 2019 National Price Transparency Conference 49 Edging Out Salary Growth & Economic Development March 5th, 2019 National Price Transparency Conference 50 PLANS FOR A NATIONAL HOSPITAL PRICE TRANSPARENCY STUDY, RAND 3.0 The more states and the more hospitals per state that participate in RAND 3.0, the more valuable it becomes to employers as it helps inform their local strategy towards paying for value Cost to participate in the study, 2 options: 1. No charge to APCDs or TPAs 2. For employers, who in addition to contributing to the public report, wish to have a PRIVATE employer-level report, the charge is $0.20 per member, with a minimum of $1,000 and a max of $15,000, payable to RAND Corp. 3. No charge for employers who wish to contribute claims data to RAND for the PUBLIC report

RAND 3.0 Study Timeline Month, Year March, 2019 July, 2019 October, 2019 Milestone Begin recruitment of self-funded employers, APCDs, and health plans Have agreements in place between RAND and employers, DUAs in place between RAND and health plans/APCDs, and authorizations sent by self-funded employers to their TPAs Data delivery complete November, 2019 Data testing and analysis, drafting of public report First Quarter, 2020 Public report finalized and made public online, private employerlevel reports distributed ACKNOWLEDGEMENTS Robert Wood Johnson Foundation National Institute for Health Care Reform The Health Foundation of Greater Indianapolis, Inc. IBM Watson Health Economic Alliance for Michigan Center for Improving Value in Health Care (CIVHC) New Hampshire Comprehensive Health Care Information System Colorado Business Group on Health Houston Business Coalition on Health New Mexico Coalition for Healthcare Value

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