Value of Price Transparency Questioned

Publishing testing prices in electronic ordering systems for inpatients may not lead to significant changes in clinician ordering behavior or associated fees, according to a study published April 21 in JAMA Internal Medicine. However, small changes were seen in ordering for patients in the intensive care unit and in higher fee tests. The authors say this suggests that more targeted price transparency interventions may have more impact.

"The price transparency intervention in this study was always displayed regardless of the clinical scenario," explain the authors led by Mina Sedrak, M.D., from the City of Hope Cancer Center in Duarte, Calif. "The presence of this information for appropriate tests may have diminished its impact when tests were inappropriate."

The study was conducted as part of the Pragmatic Randomized Introduction of Cost data through the Electronic health record (PRICE) trial. It assessed the effect of displaying Medicare allowable fees for 30 inpatient laboratory tests on clinician ordering behavior over a one-year period at three Philadelphia hospitals, representing 98,529 patients and 142,921 hospital admissions.

The 30 tests in the intervention were selected from a list of 30 high volume and 30 more expensive tests based on 2014 charges. Tests were then grouped by tests that could be ordered individually, as a panel, or as tests with similar alternatives in order to avoid situations where clinicians would have price transparency for only a part of a group. (For example, basic metabolic panels of varying sizes, as well as the individual tests they comprised, were grouped together.) Finally, stratified randomization occurred with the top quartile of higher volume tests followed by the top quartile of the more expensive tests followed by the remaining tests. At implementation, clinicians were told this was part of a health system–wide initiative to improve high value care and they were required to acknowledge a 1-time message within the electronic health record system.

The researchers found that there were no significant changes in overall test ordering behavior. In the intervention period, the mean number of tests ordered per patient-day was 2.34 in the control group and 4.01 in the intervention group versus 2.31 and 3.93, respectively in the one-year pre-intervention period. However, a small but significant decrease in test ordering was seen in patients with ICU stays and amongst the top quartile of the most expensive tests.

"Because health care decisions are changing more rapidly in this [ICU] setting, clinicians may be less likely to rely on repeating orders and therefore may have been exposed to the intervention more often," write the authors. "Future efforts might also consider pairing price transparency information with changing the default setting in the EHR so clinicians cannot order repeating laboratory testing for an extended duration."

Takeaway: Overall, studies examining price transparency's effect on test ordering remain inconclusive. This study suggests future efforts examine interventions without standing orders and targeting pricing information to clinical situations where a test may be unnecessary.