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%; lowmarkup 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.Highmarkup 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.