In the US, vast differences in pricing exist for the same medical services across the country, with no correlation shown between price and quality (Sinaiko 2017). Previous studies on price transparency in medicine have shown that many patients would like to know “the price of medical services in advance and are willing to look for ‘better-value care’” (Sinaiko 2017). Prior studies have shown that up to 30% of all laboratory testing in the US is wasteful (Zhi 2013). As a result, many health systems have considered increasing price transparency during order entry in an attempt to influence physician ordering behavior (Riggs 2014). However, recent data shows that displaying the Medicare allowable fees did not have an impact on how clinicians ordered these tests in an inpatient setting.
Does increasing price transparency for inpatient laboratory tests in the electronic health record at time of order influence clinician ordering behavior?
All patients admitted and discharged across 3 hospitals during the pre-intervention or intervention periods, both lasting concurrent 365 day periods. Patients admitted in one period and discharged in another or after the study concluded were excluded.
Primary: Number of tests ordered per patient day
Secondary: Number of tests performed per patient day, associated fees per patient day.
Multi-hospital randomized clinical trial
- In the year prior to the study, when cost information was not displayed:
- 2.31 tests ordered on average totaling $27.77 in the control group
- 3.93 tests ordered on average totaling $37.84 in the intervention group
- After the intervention, when cost information was displayed for the intervention group:
- 2.34 tests ordered on average totaling $27.59 in the control group
- 4.01 tests ordered on average totaling $38.85 in the intervention group.
- Across 142,921 admissions, there was no statistical difference in number of tests ordered or fees per patient-day when comparing time periods
- A slight but significant decrease in test ordering was observed for patients admitted to the Intensive Care Unit
- A slight but significant decrease in orders for the most expensive quartile of tests and a slight but significant increase in orders for the least expensive tests
- Randomized clinical trial
- Strength of randomization increases its validity
- The only study thus far on price transparency interventions to risk-adjust for patient comorbidities, predicting for 10 year mortality.
- 2-year length of study. Longest previously was 6 months
- One hospital system in one large northeast city, may not be easily generalizable to other hospitals in other cities
- Different group of ordering clinicians with different patient populations, so likely not wholly generalizable to the EM population
- Randomization occurred at the level of the test, not the site or the clinician because of EHR limitations
- Ubiquitous display of the costs for the duration of the study
- Tests in the intervention group had a higher baseline order rate than those in the control group
- Used Medicare maximum reimbursable fees, not patient out of pocket expenses
“In the year-long randomized clinical trial, we found that displaying Medicare allowable fees for inpatient laboratory testing in the EHR did not lead to a significant change in overall clinician ordering behavior or associated fees. Future efforts should consider testing the impact of different ways to target and frame price transparency.”
This study shows no effect of price information on physician ordering behavior. Interests exist both from patients and physicians to provide higher value care, but existing price transparency initiatives have not satisfied this need and efforts to improve these interventions likely need to be refocused.
Potential Impact To Current Practice
Likely none at this point, though with further research, this could lead to better price transparency using a common denominator for both physicians and patients by providing out-of-pocket expenses or recommending similar but lower priced or higher value tests, instead of coupling the labs with esoteric costs.
Displaying Medicare allowable fees in the EHR at time of order entry didn’t lead to a significant change in clinical ordering behavior, suggesting price transparency alone may not drive value decisions in in health care and that further transparency interventions may benefit from better targets, frames or with a different approach.
Riggs K and DeCamp M. Providing Price Displays for Physicians: Which Price is Right? JAMA 2014: 312(16): 1631-1632. PMID: 25335141
Sinaiko AD, Chien AT. Achieving the Promise of Price Transparency. JAMA Intern Med. 2017;177(7):946-947.PMID: 28430828
Zhi M et al. The Landscape of Inappropriate Laboratory Testing: A 15-Year Meta-Analysis. PLOS ONE. 2013:8(11): e78962.PMID: 24260139