Ep. 29: The Social Science of Hospital Pricing with Dr. Morgane Mouslim & Dr. Morgan Henderson of the Hilltop Institute
5:58PM Oct 17, 2022
Speakers:
Dr. Ian Anson
Campus Connections
Alex Andrews
Dr. Morgan Henderson
Dr. Morgane Mouslim
Keywords:
umbc
hilltop
hospital
hospitals
research
henderson
prices
data
maryland
institute
medicaid
question
social sciences
students
researchers
files
payer
services
community
project
Hello and welcome to Retrieving the Social Sciences, a production of the Center for Social Science Scholarship. I'm your host, Ian Anson, Associate Professor of Political Science here at UMBC. On today's show, as always, we'll be hearing from UMBC faculty, students, visiting speakers, and community partners about the social science research they've been performing in recent times. Qualitative, quantitative, applied, empirical, normative. On Retrieving the Social Sciences we bring the best of UMBCs social science community to you.
Some impressive institutions call Maryland home. Not only do we have UMBC, of course, worldwide leader in the social sciences and inclusive excellence and 16 over one NCAA tournament upsets. We also have a whole host of fantastic hospitals that provide research and cutting edge medical care. Of course, we have Johns Hopkins Hospital, the University of Maryland Hospital System, the Kennedy Krieger Institute, and the list goes on. But you know, when we find ourselves in need of services at these top notch facilities, one question likely stands out in all of our minds. Just how much are we going to end up paying for that care that we receive?
As it turns out, the answer to this question is not simple. Answering it is an important social science prerogative though, and researchers at UMBC are working on it right now. I recently had the opportunity to talk with Dr. Morgan Henderson and Dr. Morgane Mouslim about their work on the subject of hospital pricing. Both of these social scientists work at the Hilltop Institute, a nonpartisan research organization at UMBC that is dedicated to improving the well being of people and communities. Dr. Henderson is a principal data scientist at the Hilltop Institute, and an affiliate Assistant Professor in the UMBC Department of Economics, while Dr. Mouslim is a policy analyst at the Hilltop Institute. Let's listen in to our recent conversation to learn more about the Institute, its work in the field of healthcare, and the fascinating social science of the cost of hospital services.
All right, I'm delighted today to have Dr. Morgane Mouslim and Dr. Morgan Henderson in the studio to discuss some of their fantastic research through the Hilltop Institute. Thanks so much to both of you for being here. (MM: Thanks for having us. MH: Thanks very much, Dr. Anson). Great. So I want to jump right in to think a little bit about some of the research that you've recently been working on. This research has recently dealt with the issue of pricing for healthcare services at hospitals. And you know, I know, I'm not the only one who maybe has had some experience with these prices. You know I think back obviously, to the delivery of my daughter, which resulted in a very large bill that, you know, we had to pay. But you know, I don't think a lot of people have thought very much about the social science of these prices, you know, where they actually come from. So I wanted to just ask you, first of all, what in your experience are some of the biggest determinants of hospital pricing?
So you've started with like, the million dollar question here. It's a really good question. And like you mentioned, your daughter's birth, this is a subject that people really connect with, because if you've had the occasion to have been in the hospital, or have a loved one be in the hospital, and then you start getting the bills, plural often, it can really be like, Wow, where Where are these coming from? What on earth is driving these prices? And so the short answer is that there is no short answer to what are the biggest determinants of hospital pricing. So as a bit of a landscape, up until very recently, the only data that was really available to study anything related to what the actual prices are that are being paid to hospitals was claims. And theese are basically receipts. These are administrative datasets that were not intended to be used in research. These are, these are big datasets that are kept by insurance companies, essentially, to record kind of the money that insurance companies are sending to providers. And so it has been really difficult up until recently to study the prices that are being paid to hospitals for services because of this data limitation. This was the only data source in town and it was not particularly well suited to study this question. And we can add to that the fact that hospital pricing is really, really complicated. Hospitals provide tnes of thousands of services ranging from room and board in the ICU to that little aspirin pill and everything in between. So tens of thousands. Hospitals can contract with dozens, if not hundreds of separate plans. And there can be a separate contracting structure for every single thing. To find, meaning, there can be a separate price point for every, for that aspirin pill, there could potentially be 200 different price. One for every different insurance company that the hospital contracts with. And so wrapping our heads around this as social scientists is a wonderful challenge, but it is a huge challenge. And the research so far has shown that the factor that seems to matter, and I won't say matter most because we don't really know what matter matters most. But the fact that it seems to matter is market power. Because the way that these prices are set, it's, it's like a two party negotiation between hospital and insurance company. And if a hospital has marketing, has market power, for example, if they're the only hospital in town, or if they have a super good reputation, they can kind of charge higher prices. Whereas if the insurer has the market power, like if they're very, very big, big, powerful insurer, they can set lower prices. And so that that market power difference, that's what a lot of researchers think is is one of the big factors.
Wow. So Dr. Henderson, what I'm taking away from your really interesting discussion is that this is not quite like going to the restaurant to order a hamburger, right? Because it's not just you know, there's not one menu, right that everybody sees, right? There's, these are tailored essentially, to the kinds of insurance that people have, and a variety of other factors, and so this is a far more complicated scenario might otherwise be.
Exactly and I do try to think of a good metaphor, and it would, the one that I currently have, which is not perfect, it's it's like, if everyone, if people go to a restaurant, if everyone has a different menu, but the waiter orders for you, not even looking at the prices when you're ordering that food, and you're not really deciding what's gonna be ordered.
Yeah, that sounds like maybe not my first choice in terms of the dining experience. I'll be I'll be honest.
And I want to pass it to Dr. Mouslim if she had anything to add.
Absolutely.
Yeah, one thing I wanted to add is, so part of our research is actually beginning to look at things that are associated with higher or lower prices for things. And so of course, we can't say we don't know for sure, we can't say what actually determines the highest prices. But some of the early patterns that were observed is, for example, hospital ownership type. So there's for profit hospitals, nonprofit hospitals. Those are two broad categories. And so far we've seen and of course, there's going to need to be further research but a tendency for for profit hospitals to charge higher prices than the nonprofit ones. But again, this is, as Dr. Henderson mentioned, we are just starting to get this data and research. Research coming in.
Incredible. So the speaking of this data, right, I want to hear a little bit more about what's so new, what's so different about this data collection that you're able to, to accomplish in this study. So you know, you were talking a little bit about how data previously was mostly collected by insurance companies. And I could imagine that that's probably very difficult for independent researchers to get a hold of in general. So how did you get this data? And how is it advancing our understanding of the phenomenon?
It's a great question. So the data is actually public. So in January 2021, this regulation passed, and it's from the Centers for Medicare and Medicaid, I always get this wrong - CMS is shorthand for this. And all hospitals in the US, well, virtually all hospitals in the US have to publicly post their charges. So that's the sticker price for all items and services, but also their negotiated rates with every single insurance plan, and also discounted cash prices. So people who don't have insurance, what do they pay? As well as minimum rates and maximum rates. And so this is all public. The hospitals have to post it on their website. Theoretically, patients could download these files and look at these prices. I mean, in reality, it's way more complicated than that. These files come in a variety of formats. Hospitals can or cannot be compliant. So that's, that's what really changes. Since data became publicly available. As, and before, it was really a black box.
Wow. So these are provided at the level of the hospital, is that what you're saying? So every individual hospital posts these, I guess, somewhere for you to access.
ideally. So we found they mostly posted on their website. So if you google your local hospital name, and then price transparency, you'll usually land on a page that has the file that you want. And I also let Dr. Henderson talk about this because he loves this data just as much as me and he's, I know he's dying to say something.
It sounds very exciting, I will say but it also sounds a little daunting given that it's individually located at these different hospitals.
Yeah. No, that's exactly it, and thanks, Dr. Mouslim. So this dates back actually to the Affordable Care Act and like a very small 53 word little Section of the Affordable Care Act, which passed in 2010 and and it has been, it kind of had been in debated and debated and debated ever since. And then boom, rolled out, as Dr. Mouslim said January 1, of 2021. And so this requires the hospitals post these machine readable files. So they're usually spreadsheets, but they don't have to be they can be in TXT files or JSON files. And so it's it's kind of a data nerds sort of both dream and nightmare at the same time. The CMS did not put out any standards for, for example, such mundane matters as, for example, what the column names should be called. And so you know, they said, Hey, you gotta you got to include these data elements. But they didn't say, hey, you need to call this data element, this variable name and have like, specify what variable type it should be. So it's totally decentralized. Dr. Mouslim and my research has documented, and other researchers have documented, varying degrees of compliance. We wrote a piece for Health Affairs Forefront back in March 2021 where, you know, we just wanted to pull some data since we knew this regulation was was about to come. And we wanted to just pull some datasets and maybe just look at them and do a study on, hey, look at these interesting prices. And we started looking for the datasets, and we couldn't find them. And so there was a real, like, slow walk of compliance on this regulation. But yeah, it's supposed to apply to about 6000 hospitals across the country. It's totally decentralized. There is no centralized repository, official government data hub. It's hospital by hospital. And it's the laborious task of Google, like download, open it up on your machine, and use some sort of statistical program to be able to combine the files.
Wow. And so at this juncture, how many hospitals data have you managed to compile?
So we, we on other other organizations, and companies have sprung up to do the heavy lifting, thank goodness. So we yeah, we download files a lot. We're always playing with and downloading files, but we we are not trying to systematically download them. I mean, if, okay, there's about 6000 hospitals out there, there's probably 50% ish compliance. So we're talking 3000 datasets. A person could download these, it would take a few months, but a person could and our new project will be downloading some of these datasets. But yeah, on hand, probably have 100, or something's kind of in our files just randomly.
Yeah, well, still, I mean, 100 of datasets of this type are already a very impressive data collection process. Dr. Henderson, you just mentioned the sort of next steps for this project. And so recently, you received an NSF build and brought in grant to study this subject. Obviously, cause for great fanfare. Huge congratulations on that note. And obviously, as you're beginning to work on this, this grant project, I wanted to just to know a little bit about what the next steps for the, for the study are and how you plan to expand upon the work that you've already done.
Yeah, thanks very much for the question. So we are super happy that we got this NSF grant. It is an NSF Build and Broaden grant. And so it's a, it's a three year project, that will be collecting a lot of this hospital price transparency data, but but like a targeted subset. And so we, this project will be collecting the hospital pricing data sets on either side of Medicaid expansion borders. So Medicaid is a public insurance program jointly funded and administered by the federal and state governments. And as part of the Affordable Care Act, states could choose to expand their eligibility for Medicaid or not. And so to date, 12 states have not expanded their income eligibility thresholds for Medicaid. And there's been a lot of research showing that not expanding kind of has negative impacts for access to care and health consequences. And so, but there's one phenomenon that is still being debated. And this is whether hospitals shift costs from public payers to private payers. And so what this means is that, remember, I mentioned that a hospital can contract with dozens of different insurance companies. So this could be United Healthcare, Aetna, Cigna, Kaiser, but then also, they have contracts with Medicaid, managed care organizations typically. And so historically, Medicaid and Medicaid managed care organizations, they reimburse at a quite a low rate for services. So they, a Medicaid program, might pay $100 for an x ray for a hospital, and the hospital then might charge a private payer $500 for that same service just for the person who's covered by the private payer. And so there's a question of, do hospitals do this kind of strategically as a response to the low Medicaid reimbursements? And so this research is going to be collecting a bunch of these like new hospital pricing datasets, adding value to the research ecosystem by cleaning them up, documenting them, like stacking them all together, posting them on the Hilltop website, promoting them to outreach to other researchers saying, hey, here's this cool new data source, and then also doing a couple of studies to try to get at, does it look like they're this kind of cost, cost shifting happening systematically, in Medicaid, non expansion states versus expansion states?
Wow, what I really love about this project, is it's I think, perfect as a sort of emblematic example of Retrieving the Social Sciences, right, is that this is something that is at the intersection of public policy, that's bringing in economic theories, right about how you know, firms behave. But it's also deeply political, right, as a political scientist, I can really appreciate the notion that these you know, Medicaid expansions are, are determined in large part by sort of the political forces of various states. So I mean, you've got so much richness here to this project, in terms of both sort of theory and empirics. Uhm, Dr. Mouslim, can you tell us a little bit more about what's what's next?
Yeah. And so one of the parts of the project that's really exciting for us, is as you know, UMBC is a minority serving institution. And so in economics as a field that has had struggles with diversity, both gender diversity and racial ethnic diversity. So as part of this grant, we will actually be training undergraduate researchers at UMBC in economics, providing them with mentorship, they'll be helping us with this project, and hopefully giving them a good experience of economics and widening the pipeline into the field of economics. We will also be working with other minority serving institutions within the University of Maryland System. So making this data available, we talked about how difficult it is to get this data, so creating a database and sharing it with other researchers and hopefully creating a network for these MSIs to work together and more research economists at minority serving institutions. So that's a very exciting part of the grant as well.
Build and Broaden, right. That's the theme of this sort of NSF section. And what a fantastic opportunity for the students to be able to get this hands-on experience working with data. Obviously real, real data that's messy and not without its potential difficulties, but also extremely rich and rewarding in terms of its, its, what it promises in terms of research output. So that's really fantastic. Congratulations again, on this grant, I think it's going to be a huge resource both for our students and for the research community at large. Speaking of the research community at large, obviously, you're two researchers that are working within the context of the Hilltop Institute. And I know that some of our listeners are well and familiar with this Institute, but maybe some others are not as well versed in sort of the variety of different research organizations that are operating on UMBC's campus. So if you wouldn't mind, Drs. Henderson and Mouslim, just telling us a little bit about the Hilltop Institute more broadly. So maybe how does this project fit in to the Hilltop Institute's broader goals, and what else is sort of on tap, in terms of this, this research institute's output?
Yeah, great, great question. And this is where I wish our executive director, director Cynthia Woodcock was on the line. She had a prior commitment. But she would love to have taken this question, but she authorized me to do give it my best shot. Hilltop has been in existence since about 1994 or 1995 on the UMBC campus, and it came about actually to help the Maryland Department of Health roll out its Medicaid Managed Care Program. And so since then, we have been doing a lot of work for the Maryland Department of Health, the Medicaid program over the years. We help with rate setting, we help with evaluation and analyses. We do ad hoc requests for them and longer term projects as well. We've worked for a lot of different state agencies all around the state that I had never heard of prior to joining Hilltop, but that actually play very important roles in the health policy ecosystem. And we are a nonpartisan, nonprofit research institute, and we have about 40 to 50 researchers and various employees on staff and we have gone to a kind of a hybrid remote and on campus location, but we're usually in the third floor of Sondheim. And so, Go Retrievers! And we're always trying to students, we're always trying to find GRAs and student research assistants. So you should check us out at hilltop.umbc.edu. We do so many different cool projects and it's just a great place to work. Where, where hospital price transparency fits into Hilltop -that's a great question. And I don't want to say it doesn't fit in, but Maryland is a unique state vis a vis hospital prices because we are (IA: interesting) yeah, we are an "all payer state" quote unquote, where thanks to regulations and legislation that has dated back to the 1970s in Maryland. At hospitals in Maryland, every payer pays the same amount for a particular item or services. So that X ray that I mentioned a while back where maybe Medicaid pays $100 bucks, and the commercial insurer pays $500 bucks. That would not be the case. In Maryland, every payer commercial, Medicaid, Medicare, they would pay some some amount $300, something like that. And so we don't see these large disparities, these large variances in hospital pricing in Maryland. It's not really on anyone's radar, that the this like massive kind of confusion and chaos surrounding hospital prices in Maryland because of the all payer model, but that's, so Hilltop hasn't really done too much on hospital pricing in the past, although we do we do have a research portfolio around hospital community benefit, which Cynthia Woodcock is kind of the leading expert on. And so this actually, though, we think this gives us a good vantage point, because we can kind of be our all payer state where these files are nice and boring, every payer pays the same amount. And this gives us kind of a nice objective platform to kind of really take in and view the dynamics going on in other states. I'm happy to pass it over Dr. Mouslim if she wants to add anything.
I mean, that was a great overview of the Hilltop Institute.
Wow, that's really awesome to think about how the Hilltop Institute has begun its sort of existence in the 90s with this very expressed purpose of providing this sort of service and has now broadened, built and broadened, I guess you could say, right,into this, this institute that's performing research that's going to be of benefit to the entire country. So it's really, really incredible stuff that you all are working on, and I'm so glad that you're here to tell us a bit about it. Before we let you go, what I'd like to do is just ask for you to give us some words of advice for students who are maybe hoping to go pro in the social sciences like you one day. And you know, this question, I think comes with a little bit of a twist, because often, you know, when we're practicing the social sciences, and we're interviewing guests on the podcast, we're often you know, talking to people who are in faculty positions, but obviously this, you know, vantage point from the Hilltop Institute is a little bit different, right, because research goes far beyond just the academic setting in departments to nonprofits, industry setting, and to very special places like Hilltop. So from your vantage point, right, what are some pieces of advice that you might be able to give students who are interested in making a career out of research?
Yeah, that's a great question. And I will say, the number one advice I have is choose something that you're passionate about. Research projects take years. This NSF grant is a three year grant, and you want something that's going to be interesting to you and that you're going to be interested in one year from now, two years from now, three years from now. Uhm also don't be afraid to explore. I did not start out in the social sciences. I started in the biomedical sciences, and finding the time to really reflect and figure out what I wanted was very, very helpful. Also, from a more practical point of view, computer skills are very helpful nowadays, a programming language or two, it doesn't have to be that many. But SAS data, R, Python, there are many, many out there. It doesn't really matter which one, but learning one, very helpful really does help in the research world, in the non research world. Dr. Henderson?
So I will opportunistically put in a final plug for our NSF grant here. Any students, undergraduates at UMBC who might be listening. Go to the Hilltop website, go to jobs. There's a section at the bottom for students. Click on that section. There should be a button you can click on a form. Upload your resume, CV, excuse me, resume, cover letter, and a writing sample. Address it to the Buildi and Broaden Search Committee. And we will see it and uh, and this is this could be a great way to just get started down the professional researcher route.
Rarely on the podcast do we have such direct advice for someone. Give them you know exactly that sort of first step into into professional research career. And yeah, definitely we'll be dropping a link to that application in the show notes. So any students who are listening will be able to click on that directly and it'll take them right to the Hilltop page. But really great advice from from both of you. And I'm really excited to think that students might be now considering the possibilities in terms of research, not just within the social sciences, but even beyond in terms of their potential futures. So yeah, Dr. Henderson. Dr. Mouslim, thank you so much for coming on the podcast for just a few minutes to talk to us about this exciting project. And really all best to you as you continue to work on this for the upcoming three years. We can't wait to have you back on in a little while to see how things are going and hopefully to talk about all the exciting publications that you've produced out of the grant.
Now it's time for Campus Connections, a part of the podcast where we connect today's featured content to the work of others at UMBC. Today, our production assistant, Alex Andrews, is back with another great connection. What do you got for us this time, Alex?
Thanks, Dr. Anson. This week on Campus Connections we'll be taking a look at a research article called "Expanding Medicaid Coverage for Community Based Long Term Services and Supports: Lessons from Maryland's Community First Choice Program." This article was published in June of 2018 by several authors from Johns Hopkins, as well as two authors from our very own Hilltop Institute. Cynthia Woodcock, the Executive Director of the Hilltop Institute and Adjunct Professor working in the Erickson School of Aging Studies here at UMBC, as well as Ian Stockwell, an Associate Professor in UMBC's Information Systems department. His work in information systems is tailored to healthcare operations and healthcare systems. In this article, they assess the benefits and concerns of the Community First Choice Medicaid State Plan. This plan provides long term service and support in both home and community settings. Expanding CFC coverage for these settings in Maryland is not only financially feasible, but it also supports a more equitable approach to personal care services. That's all for this edition of Campus Connections. Back to you, Dr. Anson.
Thanks again for that great recap, Alex. We really can't wait to hear from you again next time. And I hope that you'll join us next time as well for more from the diverse and engaging world of social science research at UMBC. Until then, as always, keep questioning.
Retrieving the Social Sciences is a production of the UMBC Center for Social Science Scholarship. Our director is Dr. Christine Mallinson, our associate director is Dr. Felipe Filomeno, and our production intern is Alex Andrews. Our theme music was composed and recorded by D'Juan Moreland. Find out more about CS3 at socialscience.umbc.edu and make sure to follow us on Twitter, Facebook, Instagram, and YouTube, where you can find full video recordings of recent CS3 events. Until next time, keep questioning.
