Hawaii’s hospitals must post online the prices of procedures and services, such as cataract surgery or a mammogram, to comply with new federal price transparency requirements that went into effect in 2021. The rules are designed to allow consumers to shop and compare prices at different hospitals and estimate the cost of services to help shield them from getting hit with surprise bills, as well as bring competition to the marketplace.

But whether hospitals in Hawaii are fully complying with the new rules is a subject of dispute, and a review of hospital websites shows that how navigable the pricing information is for consumers is largely up to the hospital.

A report released in August by PatientRightsAdvocate.org, which advocates for health care price transparency, concluded that a year and a half after the law went into effect, none of the 10 hospitals in Hawaii that it evaluated were fully compliant. The hospitals included in the report are Adventist Health Castle, Kaiser Permanente Moanalua Medical Center, Kapiolani Medical Center for Women & Children, Kohala Hospital, Kua­kini Medical Center, Kula Hospital, Lanai Community Hospital, Maui Memorial Medical Center, The Queen’s Medical Center and Wahiawa General Hospital.

Nationally, PRA says that just 16% of the hospitals were compliant, a figure that PRA Chair Cynthia Fisher called alarming.

PRA is pushing the Centers for Medicare & Medicaid Services to increase fines against hospitals for failing to follow the rules, which can amount to up to $2 million per hospital annually.

But Hawaii’s hospitals say that they are in compliance and that PRA has invoked criteria not supported by the Centers for Medicare and Medicaid Services, which is in charge of implementing and enforcing the transparency law.

“This group that sent out the report that says all 10 Hawaii hospitals are failing, that is not true at all,” said Hilton Raethel, president and CEO of the Healthcare Association of Hawaii, which lobbies on behalf of Hawaii’s hospitals.

“Our government body is CMS, not this particular organization.”

Hawaii’s hospitals appear to have met the two major requirements of the rules. They’ve posted comprehensive lists of negotiated prices for all items and services — cumbersome spreadsheets that are nearly impossible for a consumer to make sense of when it comes to discerning what they will end up paying out of pocket. But the data can be scrutinized by policymakers, patient advocacy groups and other hospitals to discern price differences for the same procedure across hospitals, which sometimes are vast.

Hawaii’s hospitals also have complied with the second requirement of posting the prices of at least 300 “shoppable services,” common procedures or services that can be scheduled in advance.

But hospital pricing is extraordinarily complex, and PRA penalized Hawaii’s hospitals largely for not identifying specific plans for all commercial payers. The report also does seem to have errors. For instance, Kaiser Permanente Moanalua Medical Center was given failing grades in all 11 categories PRA identified, even though Kaiser was able to point to the lists of services and their prices on its website.

Kaiser said in a statement that it appears PRA didn’t account for its unique, integrated model of care, which includes a health plan, its hospitals and medical groups all under one umbrella.

“Kaiser Permanente does not negotiate rates for other insurers to use our hospital services and does not have negotiated rates with other payers,” Kaiser said. “Since there is only one Kaiser Permanente Plan rate, there is no negotiated minimum or negotiated maximum to include.”

How navigable prices are for consumers largely comes down to how hospitals display the information on their website. For example, Maui Health, which says it is in compliance with the pricing transparency requirements, posts its 300 “shoppable services” for Maui Memorial Medical Center on its website as a downloadable spreadsheet. But for a patient, trying to discern from the voluminous data what they will end up paying out of pocket is nearly impossible. A Maui Health spokesperson said that the public can call its Patient Access Services at 808-243-3051 if they need help.

Other hospitals, including Adventist Health Castle in Kailua and those owned by Hawaii Pacific Health, use a patient estimator tool that makes getting an estimate on a procedure based on one’s insurance coverage easy.

For example, if you plan to have a Cesarean section at Kapiolani Medical Center for Women & Children in Honolulu, it will likely cost you about $2,428 if you have a Hawaii Medical Service Association PPO individual, platinum plan, according to Hawaii Pacific Health’s Patient Estimator Tool.

Hospitals also are required to provide information on discounted prices if someone is paying out of pocket. If you are uninsured and have appendicitis, it will likely cost about $34,892 to have an appendectomy at Adventist Health Castle. But the hospital provides a 58% self-pay discount, bringing the price down to $14,654, according to the hospital’s patient price estimator.

Hospitals caution that those prices are just estimates, and a lot can change if there are complications and unforeseen health needs.

“It is complex, and it is very hard for an individual to understand the complexity of their health care — dealing with copays, deductibles, what’s covered, what’s not covered,” Raethel said. “It is very complex, and these transparency rules by CMS were designed to reduce some of that complexity and provide clarity for individuals. Now, do we have full clarity? No. Is it a work in progress? Yes.”