Carle, OSF hospitals on advocacy group's list of those not fully compliant on price transparency

Aug. 8—URBANA — Carle Health says a new report by a patient advocacy group is incorrectly claiming that five of its Illinois hospitals aren't fully complying with a federal law requiring price transparency.

"We are fully compliant," Carle spokeswoman Brittany Simon said Monday.

Under a federal rule that took effect in 2021, hospitals are required to post all their prices per item online so patients can shop around and hopefully avoid surprise bills.

Two-and-a-half years after the rule took effect, the level of compliance among the nation's hospitals is disputed.

A report last month by the Patient Rights Advocate group states only 36 percent of hospitals reviewed in a sample study of 2,000 of the more than 6,000 U.S. hospitals are fully compliant.

The five Carle Health hospitals included in the review — Carle Foundation Hospital in Urbana, Carle BroMenn Medical Center in Normal, Carle Health Methodist and Carle Health Proctor hospitals in Peoria, and Carle Health Pekin Hospital in Pekin — were all said to be noncompliant, in that not all of 13 various factors were met.

Only one OSF HealthCare hospital was included among Illinois hospitals, OSF St. Francis Medical Center in Peoria, which was also said to be partly noncompliant — though OSF spokeswoman Shelli Dankoff disagrees. All OSF's hospitals are in compliance, she said.

The American Hospital Association responded last month by calling the Patient Rights Advocate reports on price transparency "intentionally misleading."

The hospital association and the Centers for Medicare and Medicaid Services reported that, as of last year, 70 percent of hospitals had complied with both federal requirements — to provide a comprehensive, machine-readable file with all items and services, and to display "shoppable services" in a consumer-friendly format.

Patient Rights Advocate contends that while most hospitals have posted files, "the wide-scale noncompliance of 64 percent of hospitals is due to most hospitals' files being incomplete or not having prices clearly associated with both payer and plan."

Carle declined an interview about its posted pricing, which, for example, lists both the gross charge and cash price for a semi-private room at Carle Foundation Hospital as $3,040, along with variations in that price under different health plans and both the minimum and maximum prices that have been negotiated with payers.

Requiring the minimum and maximum negotiated prices to be posted is intended to let consumers — and employers making health plan decisions — see the variations within the same hospital for the same services, drugs and items, according to Patient Rights Advocate.

"We've seen joint replacements vary by $65,000, easily," said Cynthia Fisher, founder and chair of the organization.

Her group looks at whether hospitals are posting what the law requires, such as the gross charges, the discounted prices for paying cash, the minimum and maximum negotiated prices and data for every insurance carrier and plan the hospital accepts, Fisher said.

Patients have the right to see this information, she said.

"In every other market, if we buy a gallon of milk in that grocery store, it's priced the same for everybody," she said.

Getting back to that semiprivate room at Carle Foundation Hospital, clearly not everybody is paying the same price. The minimum negotiated price is $912 and the maximum is $2,736, according to data posted on the hospital website updated less than a month ago.

"What I can share is that Carle is committed to helping patients make informed choices about their care and meets all required steps to provide the most accurate and current information for their decision-making," Simon said. "Carle patients have access to our standard charges and a price estimator tool in conformity with price transparency requirements."

Dankoff said OSF has provided all the standard charge data elements required by the Centers for Medicare and Medicaid Services.

"The data elements are provided in a consumer-friendly web-based patient estimation tool and also disclosed in a comprehensive single machine-readable file," she said.

Meanwhile, an analysis of hospital price transparency data released in February by the Kaiser Family Foundation concluded the federal rules aren't specific enough to ensure hospitals provide comparable data.

Data shared by hospitals to comply with the law "are messy, inconsistent and confusing, making it challenging if not impossible for patients or researchers to use them to compare prices across hospitals or payers," the organization said.

Inconsistencies include how data connects specific services with prices, especially for care episodes that may combine multiple items into one charge, according to Kaiser Family Foundation.

Fisher said it's just the beginning for consumers being able to make valid comparisons for their health care services, and it's not just all about price. Quality and outcome data also needs to be transparent, she said.

"You have to think about quality, price and outcomes — but you have to start somewhere," she said.

In addition to its posted data, Dankoff said OSF encourages everyone to use its web-based patient estimator tool or reach out in advance of a test or procedure to get a tailored estimate.

Simon said patients searching for a specific service can use the cost estimator tool, or search by CPT (current procedure terminology) or DRG (diagnosis related group) code.

"While compliant with offering these details, we have not seen a high usage of the transparency tools by the community in relation to the amount of patients served," she said.