Hospital price markup patterns and outcomes after major surgery: A retrospective observational study of the National Inpatient Sample 2016–2019

INTRODUCTION: Substantial variation in hospital price markups has raised concerns regarding value and equity in inpatient care. Markup levels may capture organizational pricing strategies and local market dynamics; however, in contemporary all-payer national cohorts spanning multiple high-risk major operations, their relationship with risk-adjusted perioperative quality and safety outcomes, discharge disposition, and resource utilization remains poorly defined. METHODS: Using the National Inpatient Sample (2016-2019), adults (aged ≥18 years) undergoing coronary artery bypass grafting, abdominal aortic aneurysm repair, pneumonectomy, or major gastrointestinal surgery were identified. Hospitals were categorized into low-markup hospital, moderate-markup hospital, and high-markup hospital categories. Outcomes included postoperative complications, length of stay, in-hospital mortality, non-home discharge, and total costs. RESULTS: Among 600,828 patients (coronary artery bypass grafting: 26.0%; abdominal aortic aneurysm repair: 13.2%; pneumonectomy: 8.2%; major gastrointestinal: 52.0%), 23.3% (n = 139,991) were treated at low-markup hospitals, 37.2% (n = 223,468) at moderate-markup hospitals, and 39.5% (n = 237,369) at high-markup hospitals. A total of 4,764 hospitals were included; high-markup hospitals were more often medium or large in size (high-markup hospitals: 65.2%; moderate-markup hospitals: 63.2%; low-markup hospitals: 53.7%), urban (high-markup hospitals: 86.2%; moderate-markup hospitals: 76.9%; low-markup hospitals: 54.9%), and for-profit (high-markup hospitals: 36.0%; moderate-markup hospitals: 12.1%; low-markup hospitals: 5.1%) (all P < .001). Major surgery at high-markup hospitals was associated with higher odds of in-hospital morbidity (adjusted odds ratio, 1.07 [1.05-1.08]), non-home discharge (adjusted odds ratio, 1.07 [1.06-1.09]), and 50.3% higher index hospitalization costs compared with low-markup hospitals. Surgery at moderate-markup hospitals was linked with greater odds of complications (adjusted odds ratio, 1.03 [1.01-1.05]), in-hospital mortality (adjusted odds ratio, 1.07 [1.03-1.12]), and 24.7% higher costs (24.2%-25.3%). CONCLUSION: Higher hospital markups were predominantly observed among for-profit institutions. High-markup hospitals demonstrated higher rates of complications, non-home discharge, longer hospital stays, and markedly higher costs. Greater price transparency and payment models that reward quality and value rather than charges are necessary to promote equitable and affordable care.