Reference Pricing for Healthcare Services

Problem definition: The traditional payment system between an insurer and providers does not incentivize providers to limit their prices, nor patients to choose less expensive providers, hence contributing to high insurer expenditures. Reference pricing has been proposed as a way to better align incentives and control the rising costs of healthcare. In this payment system, the insurer determines the maximum amount that can be reimbursed for a procedure (reference price). If a patient selects a provider charging more than the reference price, the patient is responsible for the entire portion above it. Our goal is to understand how reference pricing performs relative to more traditional payment systems. Academic/practical relevance: Our results can help healthcare leaders understand when reference pricing has the potential to be a successful alternative payment mechanism, what its impact on the different stakeholders is, and how to best design it. Methodology: We propose a game-theoretical model to analyze the reference pricing payment scheme. Our model incorporates an insurer that chooses the reference price, multiple competing price-setting providers, and heterogeneous patients who select a provider based on a multinomial logit choice model. Results: We find that the highest-priced providers reduce their prices under reference pricing. Moreover, reference pricing often outperforms the fixed and the variable payment systems both in terms of expected patient utility and insurer cost but incurs a loss in the highest-priced providers’ profit. Furthermore, we show that in general the insurer utility is often higher under reference pricing unless the insurer is a public nonprofit insurer that weighs the providers’ utility as much as its own cost. Managerial implications: Overall, our findings indicate that reference pricing constitutes a promising payment system for “shoppable” healthcare services as long as the insurer does not act similar to a public nonprofit insurer.