Disparities in physician payments are a long-standing problem in healthcare with real impact on local physician practices. A cardiology group paid 20 to 30 percent less than its peers in a nearby metro area for the same procedures experiences that gap firsthand when it can’t recruit another physician. An OB/GYN practice that receives markedly lower commercial reimbursement for obstetric care than similar practices across town might have to limit Medicaid panels or stop offering high-risk services. An anesthesiology group that is persistently underpaid by plans might have to stretch its clinicians across more sites just to cover its fixed costs.
These sorts of price disparities, especially those occurring between practices in a close geographical distance, create an unstable healthcare market, and they are a key cause of the burgeoning healthcare costs we see today. Price transparency data can begin to reduce these disparities.
What payment disparity means at the practice level
Most people understand, in general terms, that commercial rates vary. But few appreciate what varying commercial rates really mean at the practice level. When a group’s financial viability hinges on a handful of contracts and codes, just knowing that its commercial rates might vary from those of nearby groups isn’t enough. Practices need to know: Are we being paid less than our peers for specific services, in this specific market, with this specific payer? And by how much? Without that clarity, payment disparities remain a source of quiet frustration and, in the long run, create significant business risk that can jeopardize a practice’s ability to offer certain services.
To tackle payment disparities, practices need granular, practice-relevant price data that answer questions such as the following:
- For our top 20 services, how do our contracted rates compare with those of other practices in our market?
- Are certain payers consistently below market, or are specific codes the issue?
- Are we being paid differently for the same services when we deliver them in different settings (such as office, ambulatory surgical centers, and hospital outpatient)?
- How do our commercial rates line up against Medicare or Medicaid benchmarks for our specialty?
Extracting insights specific to specialty practices
Even though commercial payment rates data became publicly available under the federal Transparency in Coverage (TiC) rule, getting clear insight from the massive raw TiC files is challenging. There are many price transparency tools available today, but few are built around the realities of a particular physician specialty. For a specialty practice, that creates a few hurdles for using the data effectively:
- The data are too broad and not deep enough
A generic tool may technically contain the rates for all codes, but it isn’t optimized around any specialty’s most important services, modifiers, and care pathways. Busy clinicians and practice administrators don’t have time to sift through everything to find the few insights that matter. - They have limited connection to specialty-specific questions
An ophthalmology practice wants to understand reimbursement for cataract surgery and intravitreal injections across payers, an oncology group cares about site-of-care differences for infusion services, and an OB/GYN practice needs to track obstetric bundles and gynecologic procedures. General tools rarely map cleanly to these specialty-specific questions. - There are access and cost barriers for smaller practices
Individual practices, especially smaller or rural ones, may not be able to purchase or implement enterprise-grade tools on their own, even if those tools contain relevant data.
Here, physician practices encounter a frustrating problem: The data they need to address payment disparity exists, and innovative tools exist, but they don’t yet line up neatly with what most specialty practices actually need.
That’s where medical societies can come in. For the societies that embrace the opportunity, the benefits of lining up these data and tools can drive value for members in a new and powerful way.
At the specialty level, societies and associations can use price transparency data for education, research, and advocacy on behalf of their membership. Insights derived from these data allow societies to:
- Measure the magnitude of variation in their specialty. A targeted analysis of a few procedures, payers, or markets can reveal where the largest spreads occur.
- Understand the drivers behind the disparities. Are the disparities primarily geographic? Do they vary by site of service or payer type? Combining price transparency data with publicly available benchmarks—such as Medicare or Medicaid rates—helps clarify commercial differences and patterns.
- Use the findings to advance the organization’s mission. Evidence of payment disparities can inform advocacy campaigns or shape continuing education for members on market trends and negotiation tactics.
At the practice level, medical societies can deliver even deeper benefits because of their keen understanding of members’ clinical realities and revenue mix. They also have powerful insight into which CPT/HCPCS codes, episodes, or service bundles matter most in their specialty. That makes societies the ideal conduit for transforming generic price transparency data into specialty-specific tools that practices can actually use. With their broad reach across various types of practice groups, medical societies can connect members with the curated and contextualized data and accompanying insight that would be cost prohibitive for a member to access on its own.
The right data solutions partner can help members address payment disparities
Societies don’t need to become data engineering shops that download, parse, and analyze hundreds of thousands of large machine-readable files from payer sites. Data solutions partners bridge the gap between raw price transparency data and practical insight by offering comprehensive support. A true partner will provide and maintain analytic-ready data that undergoes continuous validation to ensure accuracy and reliability, eliminating the need for practices and societies to manage complex data processing. Custom analytic tools designed around the unique market dynamics of a specialty or even an individual practice ensure that insights are relevant and precise. Their consultation services should leverage deep expertise in healthcare markets and policy contexts to offer insight into competitive and governmental landscapes. The right partner should deliver the following services:
- Price transparency infrastructure: Scalable pipelines to ingest, validate, and normalize TiC data across commercial plans
- Specialty-aware analytics: The ability to filter and structure data around the codes, services, and geographies that matter to a particular specialty, including site-of-service nuances and policy context
- Practice-level tools designed for real decisions: Dashboards and reports that let practices answer the questions that matter most to them, such as how their rates compare with local medians for their top CPT codes, which payers or codes are furthest below market, and what it would take to sustain their services in a lower-paying region
- Collaboration with society leaders: Co-design of metrics, visualizations, and use cases so the tool feels “native” to the specialty—not like a generic product with a new label
When societies pair their clinical and member knowledge with a partner’s data and technology capabilities, they can deliver specialty-specific pricing tools that help members see and address payment disparities where they exist—in day-to-day practice decisions.
With more than 50 years of experience in data analysis and healthcare policy, Mathematica is a trusted data solutions partner for the healthcare industry. Our healthcare data experts and purpose-built price transparency solutions can transform raw price transparency data into structured, action-ready insights.
Mathematica is already partnering with medical societies to build exactly this kind of bridge. To learn more, book a discovery call with us today.
