The Centers for Medicare & Medicaid Services (CMS) took an important first step toward increasing the transparency of hospital finances when it required hospitals to post their charge information, effective January 2019. But, these charges are not prices paid — they are typically the starting point against which commercial payers negotiate discounts.
States with all-payer claims databases (APCDs) have an important tool that allows them to go a step further – they can analyze the differential between “charges” and “prices paid.” This is an increasingly important distinction, particularly as 90 percent of hospital marketplaces are highly concentrated. Research shows that such concentration diminishes the capacity of health plans to negotiate rates and has increased hospital costs from 20 to 40 percent without gaining improvements in efficiency or quality .
New Hampshire Comprehensive Health Care Information System’s APCD releases data that allows the comparison of the difference between what is charged by hospitals and what health plans and consumers pay. The statewide report of charges and allowed amounts for common hospital services in New Hampshire, available at the NH HealthCost website, shows how charges compare to allowed amounts. Analysis of this data, shown in the table, illustrates that the actual amount paid for a service can vary greatly from what is charged, sometimes by more than 100 percent.
|Service Category||Median Price Charged||Median Price
Allowed or Paid
|Percentage Difference between Median Price Charged and Amount Paid|
|Biopsy skin lesion||$ 189.00||$ 69.12||-173%|
|Total hip arthroplasty||$ 37,195.00||$ 20,193.17||– 84%|
|Total knee arthroplasty||$ 14,543.50||$ 5,824.55||-150%|
|Nasal endoscopy dx||$ 1,119.16||$ 437.85||-156%|
|Diagnostic colonoscopy||$ 2,553.00||$ 1,800.61||-42%|
|Fetal non-stress test||$ 369.00||$ 261.34||-41%|
|Low back disk surgery||$ 10,615.75||$ 6,559.99||-62%|
|CT head/brain w/o dye||$ 2,030.56||$ 685.86||-196%|
|Chest x-ray||$ 366.00||$ 146.95||-149%|
|X-ray exam of knee 3||$ 399.00||$ 189.53||-111%|
|MRI joint of lower extremity||$ 2,598.00||$ 1,392.21||-87%|
|Comprehensive metabolic panel||$ 86.92||$ 56.15||-55%|
|Lipid panel||$ 106.00||$ 68.44||-55%|
|Glucose blood test||$ 43.00||$ 12.44||-246%|
|Eye exam new patient||$ 264.65||$ 140.25||-89%|
|Speech/hearing therapy||$ 313.45||$ 157.70||-99%|
|Comprehensive hearing test||$ 235.00||$ 188.85||-24%|
|Cardiovascular stress test||$ 1,154.00||$ 662.88||-74%|
|Office/outpatient visit new||$ 288.50||$ 188.27||-53%|
|Emergency dept. visit||$ 2,300.00||$ 1,374.67||-67%|
Importantly, the charges and prices paid vary by procedure, hospital, and payer and the data that shows these price differences is available through APCDs. NH HealthCost and similar websites in Maine, Colorado, Massachusetts, and Washington all are valuable resources to enhance transparency by identifying the price for services and the variation of those prices within each state.
Working together, CMS and state APCDs can provide important data to fuel conversations about hospital charges and payments, and the policy issues that the data raises.
The Affordable Care Act’s amendment to section 2718(e) of the Public Health Service Act requires each hospital operating within the United States to make public a list of standard charges for items and service provided by the hospital including for diagnostic-related groups. CMS published proposed rules for FY 2015 reminding hospitals of their obligation to comply, and again for FY 2019, ultimately finalizing the rules to improve the public accessibility of charge information in a machine-readable format effective January 2019. https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-16766.pdf.
Josephine Porter is director of the University of New Hampshire’s Institute for Health Policy and Price and co-chairs the All-Payer Claims Database Council (APCD Council).
Trish Riley is executive director of the National Academy for State Health Policy.
Consumer out-of-pocket spending on health care costs, including “surprise” medical bills – often incurred for costly, out-of-network care — is on the rise and state lawmakers are responding with legislation to protect consumers.
Surprise bills happen when consumers receive unexpected charges for medical care that they assumed would be comprehensively covered by their insurance plans. This often occurs when consumers unknowingly receive services from providers or facilities that are not covered within their insurance network, such as a specialist who contracts to work in a hospital, but does not participate in that hospital’s network.
Surprise bills can leave consumers on the hook for up to thousands of dollars in unexpected medical costs. This issue is pervasive throughout the health care system and affects consumers regardless of whether they are covered through individual insurance markets, such as an Affordable Care Act marketplace, or their employer. (For background on surprise billing, read NASHP’s report Answering the Thousand-Dollar Debt Question.)
Generally, state laws that address surprise billing fall into four categories:
- Laws that cap or limit charges for services that are delivered out-of-network, especially for emergency care;
- Laws designed to improve cost transparency in service costs and/or provider networks;
- Laws that set up an arbitration process to resolve surprise bills that focus on achieving a resolution between providers and insurers without burdening consumers); and
- State investments in committees to study the impact of surprise billing on state consumers.
Several states took action during the 2018 legislative session to address surprise billing, ranging from New Jersey, whose new law captures most of the above strategies, to California, New Hampshire, and New York, which passed laws to restrict “balance billing” (when providers charge patients for the difference between for what they charge and the insurer’s allowed amount.)
Below is a summary of new state laws designed to protect consumers from surprise bills.
- California AB 2593: California took aggressive action in 2017 to curb surprise billing in the state and its newest law adds to those protections by prohibiting air ambulance providers from charging consumers more than in-network costs, even if the consumer receives services from an out-of-network air ambulance provider. (It is currently awaiting governor’s signature)
- Missouri SB 982: The law requires insurers to pay providers for all emergency services “necessary to screen and stabilize an enrollee” and any additional services authorized by the insurer. Consumers cannot be held liable for cost-sharing for these services, beyond what is allowed under their insurance plans, even if the provider is out-of-network. The law also outlines a specific process for arbitration between insurers and providers to settle costs owed in cases where out-of-network care is provided to consumers.
- New Hampshire HB 1809: This law prohibits specific providers (those performing anesthesiology, radiology, emergency medicine, or pathology services) from balance billing a consumer for services in cases where the provider is out of the consumer’s network but delivers services at a hospital or ambulatory surgical center that is in the consumer’s network. New Hampshire also passed a law to establish a committee to study the balance billing practices of ambulance providers in the state. A report on the committee’s findings is due Nov. 1, 2018.
- New Jersey Chapter 32: This is of the most comprehensive surprise billing laws drafted to date. It requires:
- Health care facilities to provide clear and public information regarding the insurance plans it contracts with, the network status of providers who provide services in that facility, and the costs of services in that facility;
- Providers to share information about the insurance plans they participate in and the health care facilities they are affiliated with;
- Insurers to update and maintain accurate information about their provider networks; and
- Insurers to provide consumers with clear information regarding out-of-network health care benefits.
The law also prohibits out-of-network balance billing in the case of emergency services and sets up a process of arbitration for insurers and providers to resolve billing disputes. Notably, the law includes provisions that attempt to guarantee similar protections for consumers covered by self-insured plans, over which the state has limited authority.
- New York Chapter 57: The state’s Health and Mental Hygiene Budget includes a provision to protect survivors of sexual assault from being balance billed by a hospital, a sexual assault examiner, or a licensed health care provider.
- Oregon Chapter 43: By July 2020, Oregon’s Department of Consumer and Business Services will provide a report to the state legislature on all consumer complaints received by the state related to out-of-network providers working at in-network facilities.
Other states have actively considered bills to outlaw surprise bills and additional legislation is expected during the 2019 legislative sessions. The National Academy for State Health Policy (NASHP) will continue to monitor these bills and other efforts to address surprise billing.
On the federal level, in mid-September a group of nonpartisan US senators unveiled a draft bill that also tackles surprise billing. It adds a cap on out-of-network billing rates, prohibits surprise billing in emergency situations, and requires patients to receive notice before they receive out-of-network medical care.
The NH Citizens Health Initiative has convened a multi-payer, multi-stakeholder medical home project since January 2008. Payments to pilot practices began on June 1, 2009, and ended on December 31, 2011. While Medicaid helped design the program, it did not join as a participating payer. Further information on the program is available online here. The NH Citizens Health Initiative is supported by the New Hampshire Department of Insurance, as well as a variety of other funders. The NH Citizens Health Initiative is also leading a multi-year, multi-stakeholder accountable care organization (ACO) pilot. Further information is available here.
The Center for Medical Home Improvement in New Hampshire has received support from the Special Medical Services Program in the New Hampshire Health and Human Services Division to help build medical homes for children with special health care needs. Further information is available online here.
Last updated: April 2014
As states seek to improve quality of care and health outcomes while reducing costs, many have turned to accountable care models. One key aspect of accountable care models is that organizations or structures assume responsibility for the care and outcomes of a defined population across a continuum of care and across different parts of the health system. These models generally hold providers accountable through payments linked to value and performance measurement. This webinar will feature an overview of the opportunities in accountable care models for improving population health, as well as state examples. State officials will discuss the role of both health care financing and public health agencies; and how they are working with providers and community agencies to achieve the goals of accountable care models, particularly in improving health across whole populations.
- Moderator: José Montero, MD, MHCDS, Director, Division of Public Health Services, New Hampshire Department of Health and Human Services
- Diane Rydrych, MA, Director, Division of Health Policy, Minnesota Department of Health
- Eduardo Sanchez, M.D., M.P.H., FAAFP is Deputy Chief Medical Officer (CMO) for the American Heart Association (AHA).
- Jeanene Smith, MD, MPH, Chief Medical Officer, Oregon Health Authority
|Click for the Slides||4.4 MB|
In New Hampshire
- In July of 2011 there were a total of 135,092 beneficiaries enrolled in New Hampshire’s Medicaid program, with none of these beneficiaries enrolled in managed care. However, beginning on December 1, 2013, the state transitioned from fee-for-service to a Medicaid care management program under a Section 1932(a) State Plan Amendment. Physical and behavioral health services are provided under the managed care program, while oral health services remain fee-for-service. Children must enroll in a managed care organization (MCO) and will receive physical and behavioral health services under the EPSDT benefit through the MCO. New Hampshire’s Department of Health and Human services has contracted with three MCOs.
Last updated May 2014
Regulations in New Hampshire define medically necessary as:
“health care services that a licensed health care provider, exercising prudent clinical judgment, would provide, in accordance with generally accepted standards of medical practice, to a recipient for the purpose of evaluating, diagnosing, preventing, or treating an acute or chronic illness, injury, disease, or its symptoms, and that are:
|Initiatives to Improve Access
|Reporting & Data Collection||
Managed care organizations in New Hampshire are required to report on measures sets that include:
In the first year of operation of the managed care program, the Adolescent Well Care Visits HEDIS measure is a performance incentive measure for managed care organizations.
||Behavioral health benefits are included in New Hampshire’s new managed care program. Managed care organizations are required to contract with Community Mental Health Centers to deliver behavioral services to Medicaid beneficiaries, including children with a severe emotional disturbance. Clinicians providing community mental health services to Medicaid-enrolled children must be certified in the use of Child and Adolescent Needs and Strengths Assessment.|
|Support to Providers and Families||
New Hampshire provides resources on Medicaid for families of eligible children, and it provides resources on managed care for beneficiaries
The state also provides a Medicaid Managed Care Question and Answer for providers.
Managed care contracts in New Hampshire require that managed care organizations (MCOs) implement comprehensive care management programs that at a minimum contain certain elements, including:
The contracts require that in coordinating care MCOs “ensure that services provided to children are family driven and based on the needs of the child and the family.” Care coordination services for children are required to:
MCOs are expected to develop relationships with resources in the community, including schools and juvenile justice systems.
National media in recent months have featured the high and variable costs of common health care services. In this webinar you’ll hear from leaders in Virginia, Massachusetts, and New Hampshire on what they’ve done to address the issue and improve price transparency.
In a recent report, Catalyst for Payment Reform (CPR) and the Health Care Incentives Improvement Institute (HCI3) identified these states as among the highest performing in the nation when it comes to health care price transparency. After an overview of the issue from CPR and HCI3, the webinar’s discussion will turn to price transparency efforts in the three states, barriers they faced in reaching current levels of transparency, how challenges were managed or overcome, and other lessons for states interested in pursuing this work.
- François de Brantes, Executive Director, Health Care Incentives Improvement Institute
- Andréa E. Caballero, Program Director, Catalyst for Payment Reform
- Áron Boros, Executive Director, Massachusetts Center for Health Information Analysis
- Tyler Brannen, Health Policy Analyst, New Hampshire Insurance Department
- Michael Lundberg, Executive Director, Virginia Health Information
|Click to View Webinar Presentation Slides||12.2 MB|
NASHP’s Accountable Care Activity map is a work in progress; state activity pages will be launched in waves throughout Fall 2012.
At this time, we have no information on accountable care activity that meets the following criteria: (1) Medicaid or CHIP agency participation (not necessarily leadership); (2) explicitly intended to advance accountable or integrated care models; and (3) evidence of commitment, such as workgroups, legislation, executive orders, or dedicated staff.
If you have information about accountable care activity in your state, please email firstname.lastname@example.org.
Last updated: October 2012
New Hampshire’s state government has not yet released a formal HIE Strategic Plan. A pre-ARRA planning document from the New Hampshire Citizens Health Initiative exists and presents options for the future of HIE in New Hampshire.
In 2009, New Hampshire enacted legislation to require the reporting of 28 listed adverse events in hospitals and ambulatory surgical centers. Beginning January 1, 2010, hospitals and surgical centers will be required to report to the Commissioner of the Department of Health and Human Services (DHHS) when any of the 28 adverse events occur. Deidentified reports must be made within 15 working days of the discovery of such an event. The legislation requires DHHS to establish a non-punitive system of reporting that will include the mandatory completion of root cause analyses and corrective action plans. The Commissioner will also be required to publish an annual report summarizing the adverse events of the past year, and he or she will be charged with recommending updates to the initial list of 28 events to the legislature.
|Authorizing statutes or regulations||New Hampshire House Bill 592, 2009 session|
|Authorizing statutes or regulations||New Hampshire Code of Administrative Rules, Title He-P, Part 802 (proposed)|