Study finds big price gaps for the same doctor visit by insurance plan

A new peer-reviewed analysis of 5.6 million negotiated rates finds physicians often accept widely different prices for the same office-based service depending on the patient’s insurer. The findings add fresh evidence that health plan design can affect what employers, insurers, and patients pay for routine care.

Why it matters: - The study suggests healthcare costs are shaped not only by which provider a patient sees, but also by which insurance plan the patient carries. - The price gaps could affect affordability for employers, benefit designers, policymakers, and patients trying to understand network costs. - The analysis adds to the case for using federal price-transparency data to compare negotiated commercial rates across insurers.

What happened: - A new research article in the Interactive Journal of Medical Research examined negotiated commercial prices for office-based services. - David Muhlestein, PhD, JD, CEO of Simple Healthcare, and Yuvraj Pathak, PhD, VP of Strategy and Research at Simple Healthcare, led the analysis. - The researchers reviewed about 5.6 million negotiated rates from Transparency in Coverage files released by UnitedHealthcare, Aetna, Cigna, and Blue Cross Blue Shield plans. - The study focused on the 20 most commonly performed office-based services. - For the same provider and same service, the average gap between the highest and lowest negotiated rate was equal to 40% of Medicare payment for that service.

The details: - The pricing variation was measured within the same provider, not just across different doctors or facilities. - The data set came from federally required Transparency in Coverage files. - The analysis covered commercial negotiated rates, not Medicare prices themselves. - The study points to large differences in what insurers pay for identical office-based care.

Between the lines: - The findings suggest insurer contracts can materially change the price of routine care, even when the clinical service is unchanged. - Employers may need to look beyond provider choice and examine how plan design and network contracts affect negotiated rates. - The result also shows why transparency data matters: it can surface price variation that patients and buyers usually cannot see. - David Muhlestein said Transparency in Coverage data is giving researchers an unprecedented view into how healthcare prices are negotiated.

What's next: - Employers and benefits consultants may use this kind of analysis to compare network options and steer members toward lower-cost plans. - Insurers may face more scrutiny over how much prices vary across plans for the same physician and service. - Policymakers and researchers are likely to continue using Transparency in Coverage files to study commercial pricing and healthcare affordability. - Simple Healthcare says it will keep building products on top of federal price-transparency data for plan sponsors, advisors, and consumers.

The bottom line: - The same doctor visit can cost very different amounts depending on the insurance card in a patient’s wallet.