Journal of General Internal Medicine

, Volume 32, Issue 4, pp 434–448 | Cite as

A Randomized Trial of Displaying Paid Price Information on Imaging Study and Procedure Ordering Rates

  • Alyna T. Chien
  • Lisa Soleymani Lehmann
  • Laura A. Hatfield
  • Kate E. Koplan
  • Carter R. Petty
  • Anna D. Sinaiko
  • Meredith B. Rosenthal
  • Thomas D. Sequist
Original Research



Prior studies have demonstrated how price transparency lowers the test-ordering rates of trainees in hospitals, and physician-targeted price transparency efforts have been viewed as a promising cost-controlling strategy.


To examine the effect of displaying paid-price information on test-ordering rates for common imaging studies and procedures within an accountable care organization (ACO).


Block randomized controlled trial for 1 year.


A total of 1205 fully licensed clinicians (728 primary care, 477 specialists).


Starting January 2014, clinicians in the Control arm received no price display; those in the intervention arms received Single or Paired Internal/External Median Prices in the test-ordering screen of their electronic health record. Internal prices were the amounts paid by insurers for the ACO’s services; external paid prices were the amounts paid by insurers for the same services when delivered by unaffiliated providers.

Main Measures

Ordering rates (orders per 100 face-to-face encounters with adult patients): overall, designated to be completed internally within the ACO, considered “inappropriate” (e.g., MRI for simple headache), and thought to be “appropriate” (e.g., screening colonoscopy).

Key Results

We found no significant difference in overall ordering rates across the Control, Single Median Price, or Paired Internal/External Median Prices study arms. For every 100 encounters, clinicians in the Control arm ordered 15.0 (SD 31.1) tests, those in the Single Median Price arm ordered 15.0 (SD 16.2) tests, and those in the Paired Prices arms ordered 15.7 (SD 20.5) tests (one-way ANOVA p-value 0.88). There was no difference in ordering rates for tests designated to be completed internally or considered to be inappropriate or appropriate.


Displaying paid-price information did not alter how frequently primary care and specialist clinicians ordered imaging studies and procedures within an ACO. Those with a particular interest in removing waste from the health care system may want to consider a variety of contextual factors that can affect physician-targeted price transparency.


randomized trials electronic health record health services research 



Accountable care organization


Electronic health record


Price Education Initiative


Computed tomography


Magnetic resonance imaging




  1. 1.
    Bentley TG, Effros RM, Palar K, Keeler EB. Waste in the US health care system: a conceptual framework. Milbank Q. 2008;86(4):629–659. doi:10.1111/j.1468-0009.2008.00537.x.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Boyd C, Darer J, Boult C, Fried L. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA. 2005;294(6). Accessed 21 Oct 2016.
  3. 3.
    Rathod RH, Farias M, Friedman KG, Graham D, Lock JE. A novel approach to gathering and acting on relevant clinical information: SCAMPs. 2012;5(4):343–353. doi:10.1111/j.1747-0803.2010.00438.x.A.
  4. 4.
    Crosson F. Change the microenvironment. Delivery system reform essential to control costs. Mod Healthc. 2009;27(39):20–21.Google Scholar
  5. 5.
    Cohen DI, Jones P, Littenberg B, Neuhauser D. Does cost information availability reduce physician test usage?: a randomized clinical trial with unexpected findings. Med Care. 1982;20(3):286–292. doi:10.2307/3764297.CrossRefPubMedGoogle Scholar
  6. 6.
    Tierney WM, Miller ME, McDonald CJ. The effect on test ordering of informing physicians of the charges for outpatient diagnostic tests. N Engl J Med. 1990;322(21):1499–1504. doi:10.1056/nejm199005243222105.CrossRefPubMedGoogle Scholar
  7. 7.
    Bates DW, Kuperman GJ, Jha A, et al. Does the computerized display of charges affect inpatient ancillary test utilization? Arch Intern Med. 1997;157(21):2501–2508.CrossRefPubMedGoogle Scholar
  8. 8.
    Durand DJ, Feldman LS, Lewin JS, Brotman DJ. Provider cost transparency alone has no impact on inpatient imaging utilization. J Am Coll Radiol. 2013;10(2):108–113. doi:10.1016/j.jacr.2012.06.020.CrossRefPubMedGoogle Scholar
  9. 9.
    Everett GD, deBlois CS, Chang PF, Holets T. Effect of cost education, cost audits, and faculty chart review on the use of laboratory services. Arch Intern Med. 1983;143(5):942–944. doi:10.1001/archinte.1983.00350050100019.CrossRefPubMedGoogle Scholar
  10. 10.
    Pugh JA, Frazier LM, DeLong E, Wallace AG, Ellenbogen P, Linfors E. Effect of daily charge feedback on inpatient charges and physician knowledge and behavior. Arch Intern Med. 1989;149(2):426–429.CrossRefPubMedGoogle Scholar
  11. 11.
    Hampers L, Cha S, Gutglass D. The effect of price information on test-ordering behavior and patient outcomes in a pediatric emergency department. Pediatrics. 1999. Accessed 21 Oct 2016.
  12. 12.
    Marton KI, Tul V, Sox HC. Modifying test-ordering behavior in the outpatient medical clinic. A controlled trial of two educational interventions. Arch Intern Med. 1985;145(5):816–821. doi:10.1001/archinte.1985.00360050060009.CrossRefPubMedGoogle Scholar
  13. 13.
    Gama R, Nightingale P, Broughton PM, et al. Modifying the request behaviour of clinicians. J Clin Pathol. 1992;45(3):248–249. Accessed 21 Oct 2016.
  14. 14.
    Sachdeva R, Jefferson L, Coss-Bu J, et al. Effects of availability of patient-related charges on practice patterns and cost containment in the pediatric intensive care unit. Crit Care Med. 1996;24(3):501–506. Accessed 21 Oct 2016.
  15. 15.
    Schroeder S, Kenders K, Cooper J, Piemme T. Use of laboratory tests and pharmaceuticals: variation among physicians and effect of cost audit on subsequent use. JAMA. 1973;225(8):969–973. Accessed 21 Oct 2016.
  16. 16.
    Feldman LS, Shihab HM, Thiemann D, et al. Impact of providing fee data on laboratory test ordering: a controlled clinical trial. JAMA Intern Med. 2013;173(10):903–908. doi:10.1001/jamainternmed.2013.232.CrossRefPubMedGoogle Scholar
  17. 17.
    Berwick D, Coltin K. Feedback reduces test use in a health maintenance organization. JAMA. 1986;255(11):1450–1454. Accessed 21 Oct 2016.
  18. 18.
    Horn DM, Koplan KE, Senese MD, Orav EJ, Sequist TD. The impact of cost displays on primary care physician laboratory test ordering. J Gen Intern Med. 2014;29(5):708–714. doi:10.1007/s11606-013-2672-1.CrossRefPubMedGoogle Scholar
  19. 19.
    Fang DZ, Sran G, Gessner D, et al. Cost and turn-around time display decreases inpatient ordering of reference laboratory tests: a time series. BMJ Qual Saf. 2014;23(12):994–1000. doi:10.1136/bmjqs-2014-003053.CrossRefPubMedGoogle Scholar
  20. 20.
    Tierney W, Miller M, Overhage J, Mcdonald C. Physician inpatient order writing on microcomputer workstations—effects on resource utilization. JAMA. 1993;269(3):379–383. doi:10.1001/jama.269.3.379.CrossRefPubMedGoogle Scholar
  21. 21.
    Sinaiko AD, Rosenthal MB. Increased price transparency in health care—challenges and potential effects—NEJM. N Engl J Med. 2011:891–894. doi:10.1056/NEJMp1100041.
  22. 22.
    Shortell SM, Wu FM, Lewis VA, Colla CH, Fisher ES. A taxonomy of accountable care organizations for policy and practice. Health Serv Res. 2014;49(6):1883–1899. doi:10.1111/1475-6773.12234.PubMedPubMedCentralGoogle Scholar
  23. 23.
    Song Z, Safran D, Landon B, Landrum M. The “Alternative Quality Contract” in Massachusetts, based on a global budget, lowered medical spending and improved quality. Health Aff. 2012. Accessed 21 Oct 2016.
  24. 24.
    Sequist T, Schneider E. Quality monitoring of physicians: linking patients’ experiences of care to clinical quality and outcomes. JGIM. 2008:1784–1790. doi:10.1007/s11606-008-0760-4.
  25. 25.
    Sequist T. Physician performance and racial disparities in diabetes mellitus care. Arch Intern Med. 2008;168(11):1145–1151. Accessed 21 Oct 2016.
  26. 26.
    Sequist T, Adams A. Effect of quality improvement on racial disparities in diabetes care. Arch Intern Med. 2006;166:675–681. Accessed 21 Oct 2016.
  27. 27.
    Schiavoni KH, Lehmann LS, Guan W, Rosenthal M, Sequist TD, Chien AT. How primary care physicians integrate price information into clinical decision-making. J Gen Intern Med. 2016. doi:10.1007/s11606-016-3805-0.PubMedGoogle Scholar
  28. 28.
    Isaac T, Rosenthal MB, Colla CH, et al. Specificity of Overuse Measurement Using Structured Data from Electronic Health Records: A Chart Review Analysis. (In Progress).Google Scholar
  29. 29.
    Rosenberg A, Agiro A, Gottlieb M, et al. Early trends among seven recommendations from the choosing wisely campaign. JAMA Intern Med. 2015;19801(12):1. doi:10.1001/jamainternmed.2015.5441.Google Scholar
  30. 30.
    Consumer Reports. Choosing Wisely campaign brochures. Accessed 21 Oct 2016.
  31. 31.
    (NQMC) NQMC. Colorectal cancer screening: percentage of patients 50 to 75 years of age who had appropriate screening for colorectal cancer.
  32. 32.
    Agency for Healthcare Research and Quality. Chronic Condition Indicator (CCI) for ICD-9-CM. Accessed 21 Oct 2016.
  33. 33.
    Allan GM, Lexchin J. Physician awareness of diagnostic and nondrug therapeutic costs: a systematic review. Int J Technol Assess Health Care. 2008;24(2):158–165. doi:10.1017/s0266462308080227.CrossRefPubMedGoogle Scholar
  34. 34.
    Torgerson DJ. Contamination in trials: is cluster randomisation the answer? BMJ. 2001;322(7282):355–357.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Jones SS, Rudin RS, Perry T, Shekelle PG. Health information technology: an updated systematic review with a focus on meaningful use. Ann Intern Med. 2014;160(1):48–54. doi:10.7326/M13-1531.CrossRefPubMedGoogle Scholar
  36. 36.
    Whaley C, Schneider Chafen J, Pinkard S, et al. Association between availability of health service prices and payments for these services. JAMA. 2014;312(16):1670–1676. doi:10.1001/jama.2014.13373.CrossRefPubMedGoogle Scholar
  37. 37.
    Ginsburg S, Bernabeo E, Holmboe E. Doing what might be “Wrong”. Acad Med. 2014;89(4):664–670. doi:10.1097/ACM.0000000000000163.CrossRefPubMedGoogle Scholar
  38. 38.
    Sabbatini AK, Tilburt JC, Campbell EG, Sheeler RD, Egginton JS, Goold SD. Controlling health costs: physician responses to patient expectations for medical care. J Gen Intern Med. 2014;29(9):1234–1241. doi:10.1007/s11606-014-2898-6.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Reuben DB, Cassel CK. Physician stewardship of health care in an era of finite resources. JAMA. 2011;306(4):430–431. doi:10.1001/jama.2011.999.CrossRefPubMedGoogle Scholar
  40. 40.
    Chien AT, Rosenthal MB. Waste not, want not: promoting efficient use of health care. Ann Intern Med. 2013;158(1):67–68.CrossRefPubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 2016

Authors and Affiliations

  • Alyna T. Chien
    • 1
    • 2
  • Lisa Soleymani Lehmann
    • 1
    • 3
    • 4
    • 5
  • Laura A. Hatfield
    • 6
  • Kate E. Koplan
    • 7
  • Carter R. Petty
    • 8
  • Anna D. Sinaiko
    • 3
  • Meredith B. Rosenthal
    • 3
  • Thomas D. Sequist
    • 4
    • 5
    • 9
  1. 1.Harvard Medical SchoolBostonUSA
  2. 2.Department of Medicine, Division of General PediatricsBoston Children’s HospitalBostonUSA
  3. 3.Department of Health Policy and ManagementHarvard T.H. Chan School of Public HealthBostonUSA
  4. 4.Division of General Internal Medicine and Primary CareBrigham and Women’s HospitalBostonUSA
  5. 5.National Center for Ethics in Health CareVeterans Health AdministrationWashingtonUSA
  6. 6.Department of Health Care PolicyHarvard Medical SchoolBostonUSA
  7. 7.Kaiser Permanente of GeorgiaAtlantaUSA
  8. 8.Clinical Research CenterBoston Children’s HospitalBostonUSA
  9. 9.Partners Healthcare SystemBostonUSA

Personalised recommendations