This study follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines (https://www.strobe-statement.org/). Institutional review board approval and informed consent were not required as the study did not involve human subject research. All data were reported in aggregates.

We conducted a nationwide, cross-sectional analysis of hospital pricing data for vasectomy procedures identified by the Current Procedural Terminology (CPT) code 55250. The healthcare pricing data was obtained on October 7, 2022, from Turquoise Health, a data service company which maintains a database sourcing publicly disclosed machine-readable files from 6700 US hospitals in compliance with the CMS final rule on hospital price transparency (https://turquoise.health/researchers). This CMS final rule requires hospitals to disclose payer-specific negotiated charges, de-identified minimum and maximum negotiated charges, and discounted cash price for at least 300 shoppable services. Out of the 300 shoppable services, 70 are CMS-specified and 230 are hospital-selected. Hospitals must include as many shoppable services as they provide and indicate when a CMS-specified service is not offered. While vasectomy is not one of the 70 CMS-specified list of shoppable services, it is included in the dataset collected by Turquoise as one of the possible hospital-selected shoppable services [6, 13].

To examine factors that may influence reporting behavior as suggested by previous literature, we identified Hospital Service Areas (HSA) using the Dartmouth Atlas Project, determined urban versus rural hospital designations using the 2010 US Census, and extracted Area Deprivation Index (ADI) at the county level from the Neighborhood Atlas database estimates from the 2016-2020 5-year American Communities Survey via the sociome package for R [7, 14, 15]. ADI is scaled to a mean of 100 and standard deviation of 20 with higher scores indicate higher levels of deprivation.

Prices for vasectomy were extracted from Turquoise based on reimbursement source – cash price, commercial price, Medicare price and Medicaid price. Cash price refers to the price paid by patients to hospitals in cash or cash equivalents, unilaterally determined by the hospital. Commercial price represents the amount negotiated between hospitals and the top five largest commercial insurers in the US (United Healthcare, Blue Cross Blue Shield, Aetna, Cigna, and Anthem). Medicare and Medicaid rates are set by the government to cover individuals over the age of 65 and those with low income, respectively. We used the median price for a given reimbursement source at a hospital.

In addition, we collected various hospital characteristics from Turquoise, such as hospital type, region, and compliance score that ranks completeness of information provided by hospitals to better understand factors potentially associated with higher reporting rate. Hospital size was approximated by the total number of beds and the total number of staff with a Doctor of Medicine degree across the hospital system. For urban or rural status, if the hospital location was within ‘urbanized area’ or ‘urban cluster’ based on 2010 Census, then it was considered an urban hospital, otherwise it was considered rural. We used the number of hospitals from Turquoise in each HSA as a proxy for competition level, categorized into “1,” “2–10,” or “11+,” and used ADI to investigate potential disparities in hospital reporting patterns. Finally, hospital ownership structures were categorized into for-profit (“proprietary,” “physician”), nonprofit (“nonprofit,” “government”), and “other/unknown” (“Tribal,” missing data).

We determined the percentage of hospitals within Turquoise that reported a price for vasectomy and then utilized descriptive statistics to compare hospital-level factors between hospitals that provided price data versus those that did not. We used Mann–Whitney U tests for continuous variables and chi-square tests for categorical variables. Significance level is set at a p < 0.05.

Prices by payer source and hospital ownership were plotted via box plots to show variability. Average prices by payer source and ownership were calculated on the log scale and transformed back to dollars. The 95% confidence intervals for average price were calculated via bootstrap resampling with 1000 replicates.

For our multivariable linear regression, we log transformed hospital prices for vasectomy before determining whether the following hospital factors are predictors of a higher cash or commercial price: 1) number of hospitals in the HSA, 2) urban/rural location designation, 3) number of beds (0–100, 101–500, 501–1000, 1001+), 4) ADI, and 5) hospital ownership. Estimated marginal means, transformed back to the dollar scale, were calculated from the fitted models, and used to further assess price as a function of hospital ownership, adjusting for the other factors. Separate analyses were conducted for each payer source. All data analyses were performed using R (version 4.1.2).