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Table.  Variation in Negotiated Rates for Commonly Performed Services in the Management of Thyroid Cancer at National Cancer Institute–Designated Cancer Centers
Variation in Negotiated Rates for Commonly Performed Services in the Management of Thyroid Cancer at National Cancer Institute–Designated Cancer Centers
1.
Lim  H, Devesa  SS, Sosa  JA, Check  D, Kitahara  CM.  Trends in thyroid cancer incidence and mortality in the United States, 1974-2013.   JAMA. 2017;317(13):1338-1348. doi:10.1001/jama.2017.2719PubMedGoogle ScholarCrossref
2.
Xiao  R, Miller  LE, Workman  AD, Bartholomew  RA, Xu  LJ, Rathi  VK.  Analysis of price transparency for oncologic surgery among National Cancer Institute–Designated Cancer Centers in 2020.   JAMA Surg. 2021. doi:10.1001/jamasurg.2021.0590PubMedGoogle Scholar
3.
Ramsey  S, Blough  D, Kirchhoff  A,  et al.  Washington State cancer patients found to be at greater risk for bankruptcy than people without a cancer diagnosis.   Health Aff (Millwood). 2013;32(6):1143-1152. doi:10.1377/hlthaff.2012.1263PubMedGoogle ScholarCrossref
4.
Medicare and Medicaid Programs: CY 2020 hospital outpatient PPS policy changes and payment rates and ambulatory surgical center payment system policy changes and payment rates. Fed Regist. 2019;84(229):65524-65606. Accessed March 1, 2021. https://www.govinfo.gov/content/pkg/FR-2019-11-27/pdf/2019-24931.pdf
5.
Centers for Medicare & Medicaid Services. Special edition: monitoring for hospital price transparency. Published December 18, 2020. Accessed March 1, 2021. https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-12-18-mlnc-se
Research Letter
June 4, 2021

Payer-Negotiated Prices in the Diagnosis and Management of Thyroid Cancer in 2021

Author Affiliations
  • 1Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear, Boston
  • 2Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
  • 3Division of Otolaryngology–Head and Neck Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
JAMA. 2021;326(2):184-185. doi:10.1001/jama.2021.8535

Thyroid cancer is among the most common malignancies in the US, with a 3.6% annual increase in incidence over the past 50 years.1 Treatment regimens for thyroid cancer are well-established, with excellent survival outcomes. However, costs of thyroid cancer care can vary substantially by hospital and impose significant financial burdens on patients2; among patients with cancer, bankruptcy rates are highest for those with thyroid cancer.3

The Centers for Medicare & Medicaid Services (CMS) recently implemented price transparency reforms to promote informed hospital selection by patients and cost-based competition among hospitals. Effective January 1, 2021, hospitals must disclose commercial payer-specific negotiated prices for all items and services.4 We characterized price availability and variation for thyroid cancer care at National Cancer Institute (NCI)–Designated Cancer Centers.

Methods

We performed a cross-sectional analysis of commercial payer-negotiated prices of services for thyroid cancer at NCI-Designated Cancer Centers. We restricted analysis to cancer centers providing adult clinical care and participating in the Medicare Inpatient Prospective Payment System. We reviewed each center’s website to extract (as available) prices for 14 services that are integral to thyroid cancer management, including laboratory tests, radiology studies, medical and surgical treatments, and inpatient care (Supplement).

To compare prices between centers, we first normalized the median price for each service at each center to the estimated center-specific 2021 Medicare payment amount, which accounts for factors affecting the cost of care delivery (Supplement).2 We then determined the ratio between the maximum and minimum normalized median prices for each service across centers (“across-center ratio”). To compare negotiated prices between payers at each center, we calculated the ratio between the maximum and minimum negotiated prices (“within-center ratio”) for each service.

All available prices were current as of March 25, 2021. We performed all analyses using R, version 4.0.4. The Mass General Brigham Institutional Review Board did not require approval because the study used publicly available data and involved no patient records.

Results

Of 71 NCI-Designated Cancer Centers, 52 (74.3%) met inclusion criteria. A total of 26 of 52 centers (50.0%) disclosed commercial payer-negotiated prices for any items or services. Disclosure differed by service type (Table); whereas 25 centers (48.1%) disclosed prices for thyroid-stimulating hormone testing or neck ultrasonography, only 8 (15.4%) disclosed professional fees for total thyroidectomy.

Normalized payer-negotiated prices varied widely across centers (Table). For instance, across-center ratios were 70.1 (raw median price range, $161-$10 790) for radioactive iodine treatment and 44.7 (raw median price range, $108-$4845) for neck computed tomography. Within centers, negotiated service prices varied widely across payers; for example, median (interquartile range) within-center ratios were 4.8 (2.3-10.2) for fine-needle aspirate biopsy and 4.6 (2.6-6.5) for thyroid uptake scan.

Discussion

Half of NCI-Designated Cancer Centers disclosed payer-negotiated prices for thyroid cancer services as required by law.4 Although CMS has audited hospitals since January 2021,5 this high nondisclosure rate may be attributable to the modest repercussions of nonadherence (ie, maximum $300 daily penalty).

Among centers disclosing negotiated prices, there was considerable variation in disclosure by service type. Although approximately 15% of centers disclosed surgeon professional fees for thyroid resection, nondisclosure may be legal: CMS requires hospitals to disclose negotiated rates for hospital-employed physicians,4 but physicians practicing at hospitals are often employed by affiliated physician organizations (eg, faculty practice plans). Among services with disclosed prices, negotiated rates varied widely between cancer centers and across payers at the same center. This may reflect differences in cancer center market power, particularly for commoditized services, such as imaging.

Limitations of this study include potential lack of generalizability to other hospital or service types. Furthermore, the study was conducted shortly after implementation of price transparency requirements and may thus underestimate future disclosure rates as cancer centers overcome obstacles to adherence or respond to CMS penalties.

Nonetheless, these findings suggest that CMS should consider more stringent penalties for nondisclosure and more inclusive definitions of physician employment to enhance disclosure and promote transparency. Inconsistent disclosure could otherwise hinder efforts by patients and payers to take cost into account when selecting hospitals and physicians.

Section Editor: Jody W. Zylke, MD, Deputy Editor.
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Article Information

Accepted for Publication: May 11, 2021.

Published Online: June 4, 2021. doi:10.1001/jama.2021.8535

Corresponding Author: Roy Xiao, MD, MS, Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, 243 Charles St, Boston, MA 02114 (roy_xiao@meei.harvard.edu).

Author Contributions: Dr Xiao (guarantor) had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Xiao and Rathi contributed equally to this work.

Concept and design: Xiao, Rathi, Gross, Sethi.

Acquisition, analysis, or interpretation of data: Xiao, Rathi, Ross, Sethi.

Drafting of the manuscript: Xiao, Rathi, Sethi.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Xiao, Sethi.

Administrative, technical, or material support: Xiao, Sethi.

Supervision: Rathi, Sethi.

Conflict of Interest Disclosures: Dr Gross reported receiving grants from the National Comprehensive Cancer Network (Pfizer/AstraZeneca), from Johnson & Johnson for support for new models of clinical trial data sharing, and from Genentech and personal fees from Flatiron for travel/speaking. Dr Ross reported receiving grants from the US Food and Drug Administration, Johnson & Johnson, the Medical Devices Innovation Consortium, the Agency for Healthcare Research and Quality, the National Institutes of Health/National Heart, Lung, and Blood Institute, and the Laura and John Arnold Foundation. No other disclosures were reported.

References
1.
Lim  H, Devesa  SS, Sosa  JA, Check  D, Kitahara  CM.  Trends in thyroid cancer incidence and mortality in the United States, 1974-2013.   JAMA. 2017;317(13):1338-1348. doi:10.1001/jama.2017.2719PubMedGoogle ScholarCrossref
2.
Xiao  R, Miller  LE, Workman  AD, Bartholomew  RA, Xu  LJ, Rathi  VK.  Analysis of price transparency for oncologic surgery among National Cancer Institute–Designated Cancer Centers in 2020.   JAMA Surg. 2021. doi:10.1001/jamasurg.2021.0590PubMedGoogle Scholar
3.
Ramsey  S, Blough  D, Kirchhoff  A,  et al.  Washington State cancer patients found to be at greater risk for bankruptcy than people without a cancer diagnosis.   Health Aff (Millwood). 2013;32(6):1143-1152. doi:10.1377/hlthaff.2012.1263PubMedGoogle ScholarCrossref
4.
Medicare and Medicaid Programs: CY 2020 hospital outpatient PPS policy changes and payment rates and ambulatory surgical center payment system policy changes and payment rates. Fed Regist. 2019;84(229):65524-65606. Accessed March 1, 2021. https://www.govinfo.gov/content/pkg/FR-2019-11-27/pdf/2019-24931.pdf
5.
Centers for Medicare & Medicaid Services. Special edition: monitoring for hospital price transparency. Published December 18, 2020. Accessed March 1, 2021. https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-12-18-mlnc-se
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