字幕表 動画を再生する 英語字幕をプリント - [Narrator] At a hospital in Modesto, California, the price for a routine knee replacement surgery might be about $16,000 or $53,000 or even $81,000. How is a hospital able to charge such an extreme range of prices for the same surgery? The vast price differences are driven in part by the secret rates hospitals negotiate with health insurers, for everything from an MRI to open-heart surgery. - It depends on the leverage that the hospital has. It depends on the leverage the insurer has. Depends on sort of who's good at negotiating. And until recently, those rates tended to be secret. - [Narrator] But they're not so secret anymore. Thanks to federal rules that required hospitals to make their prices public in 2021. Sutter Health is one of hundreds of hospital systems now revealing their negotiated rates. - People didn't know what their competitors were paying and that limited, the negotiations in some ways. - [Narrator] So, how exactly are these rates set? Here's what goes into the secret price negotiations between hospitals and insurance companies. To understand how U.S. hospitals set their prices. Let's take a look at publicly available data from Sutter Health's Memorial Medical Center. This chart shows the prices for billing code DRG 470 which is a routine hip or knee replacement surgery. The different price tags depend on the insurance plan, covering the procedure. If you look at the lowest and most expensive rates, you can see there's a pricing spread of more than $64,000. Still, the data doesn't represent the full range of pricing. The exact costs of certain insurance plans are not available on the hospital's website. - One takeaway has definitely been the broad range of prices that are paid for the same service in the same hospital. You see this in Sutter's data, but you see it across the board in lots of other hospitals' data. - [Narrator] So, how do hospitals and insurance companies come up with these numbers? Hospitals typically have a sticker price, often called the chargemaster rate. This can be a starting point for negotiations with insurance companies. At Sutter Health Memorial, the chargemaster price for a routine hip or knee replacement is set at $92,262 but there isn't an exact formula for how this cost is calculated. - A lot of factors influence chargemaster prices. Hospitals typically will tweak them to meet their financial targets. The chargemaster rates are not typically really tied to estimates of cost or value for the service provided. Some hospitals are now trying to drill down and say, "Okay, how much does it really cost to do this particular procedure?" But that's not historically been the case. Insurers would rather have rates that are not actually tied to the chargemaster and when they are negotiating more successfully, they're not paying a rate that's a discount off the chargemaster, they're paying a rate set in some other way. - [Narrator] Hospitals will often tweak chargemaster rates based on their own financial targets. Then insurers will often negotiate discounts off these rates. - Insurance companies tend to have more leverage in the negotiations if they can deliver a lot of patients. If they have a lot of market share in that area. And also, if they're willing to design a plan that has a limited number of hospitals or a limited network so that the hospital knows that its competitors are not going to be in that plan or not as favored as they are. And in that case, a hospital will tend to offer a better rate. - [Narrator] Insurers are essentially buying in bulk using their large membership to get better deals. Meanwhile, prestigious or large hospital systems could have greater leverage in negotiations. - What gives a hospital leverage or negotiating cloud is basically being a must have system, meaning that the insurer really needs to have that hospital system to have a good plan that will attract customers. In the markets where Sutter Health has hospitals, I think it would probably be difficult for an insurer to create a strong network that included no Sutter Health facilities. They have some important facilities and they are a powerful presence in their markets. - [Narrator] In a statement, a spokesperson from Sutter Health said, "It is the insurance companies not the health systems who hold leverage in these negotiations. Sutter negotiates on behalf of our patients to help ensure they can receive access to the clinicians and facilities who can meet their healthcare needs". Meanwhile, insurance companies have generally said their contract negotiations with hospitals achieve large overall savings for their members. And comparing individual prices is not indicative of cost-competitiveness. The full impact of the contracts between hospitals and insurers can be difficult to see directly because the details of the negotiations often remain secret. For instance, some contracts include restrictive provisions sometimes called anti-steering clauses. These clauses can prevent insurers from directing patients to less expensive or better quality hospitals and doctors. - Hospitals, when they have a lot of leverage in a very powerful in their market, they can sometimes win favorable contract terms so they could get provisions in contracts that said an insurer can't exclude their hospitals from any of its plans, that all of its plans must include that hospital systems, facilities. - [Narrator] Insurance plans offered under government programs like Medicare and Medicaid tend to get the lowest rates because they're tied to prices mandated by federal and state agencies. You can see this in the knee and hip replacement surgery prices we showed you earlier. - So, you'll see that all of the Medicare plans are clustered around exactly that same number, because it is related to what Medicare itself pays for that service. But then you'll see a big range of prices. You'll see some around $53,000. You see one as high as around $81,000. And those are the negotiated rates that the different insurers are paying. - [Narrator] Because Medicaid and Medicare plans tend to get lower rates. Some hospitals say they need to rely on the higher paying privately insured patients for their revenue. - There was a study that looked at more than 2,800 hospitals over 10 years. And they found that hospitals that boosted their margins didn't cut their costs. They actually improved their revenue by raising the rates they charged to private insurers. - [Narrator] A spokesperson from Sutter Health said, "The rates paid by Medicaid and Medicare plans generally don't cover the costs of care". The prices, health insurance companies negotiate affect consumers directly. Throughout of pocket charges like deductibles and indirectly by pushing up premiums for health coverage. For instance, high deductible plans can leave patients responsible for thousands of dollars in costs before their coverage kicks in. Total spending on private health insurance in the U.S. has increased by about 40% over the past decade, according to federal figures. - Patients who don't have any insurance at all can sometimes be asked to pay a cash price that is higher than what insurers pay it varies. But some of these patients may also, if they're low income, get financial assistance in which case they get, discounts based on that, or may have the whole bill forgiven. - [Narrator] Despite the federal rules requiring hospitals to make their prices public, some hospitals still haven't fully revealed their rates. On July 1st, the second phase of the federal pricing transparency effort took effect. Health insurers now have to reveal the prices they pay to all healthcare providers, not just hospitals but also doctor groups, surgery centers, and labs. - When the federal government created these rules, one of the ideas was to help people shop for services. That's one question, will people look at these prices and try to shop for care based on them? The belief is that now that those prices are becoming more transparent, we'll see a narrower range of prices because insurers and hospitals both will say, "Hey, I see that other person's getting a better rate. I want that rate". And that will tend to narrow the big variation. (light gentle music)
B1 中級 米 Same Surgery, Different Prices: Why Hospital Bills Vary So Much | WSJ(Same Surgery, Different Prices: Why Hospital Bills Vary So Much | WSJ) 15 0 林宜悉 に公開 2022 年 08 月 21 日 シェア シェア 保存 報告 動画の中の単語