It’s your health….your choice….your money….

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Patients urged to ask about cost of health care

by Ken Alltucker – Apr.  7, 2012 11:16 PM
The Republic |

Most people have little idea what a doctor or lab will charge before they slip on a patient gown for an examination or roll up a shirtsleeve for a blood sample.

But as the cost of health care continues to spiral, that is changing. In what could be a major shift in how Americans choose medical care, consumers are being encouraged to ask questions about the price of medical treatments, especially those their insurance plans might not cover.

And health-insurance industry officials say people are going to have to become better educated about how much it costs to get routine tests or major surgery if they don’t want to end up paying even more for their health coverage.

Two factors are driving the push for employees with health insurance to become more savvy about what doctors, clinics and hospitals charge: the growing prevalence of high-deductible insurance plans offered by employers, and a huge price variation in medical procedures that insurance companies want to rein in.

High-deductible insurance plans offer cheaper monthly rates but require employees to spend anywhere from $1,000 to $10,000 before substantial insurance coverage kicks in. That means consumers are on the hook for a greater share of their medical expenses, and knowing what simple procedures like an MRI scan or lab test cost can help save hundreds of dollars a year. Learning what hospitals charge for expensive surgeries can end up saving a patient thousands.

With the cost of preventive screenings, like a colonoscopy, or major knee-replacement surgery varying by as much as 100 percent or more depending on where they are performed, the insurance industry sees a better-informed consumer as a way to cut health costs for itself, which ultimately are passed on to customers.

To encourage people to take greater responsibility for their health-care spending, health-insurance companies and the federal government are providing online tools to help educate consumers.

Websites allow people to search for the average cost of a CT scan or an MRI, while private insurance companies offer customers robust, Web-based information about health-care quality and costs charged by doctors and hospitals. Even those without health insurance can use websites to compare prices.

Some experts believe being more responsible for payments will force people to make more informed choices about where they get non-emergency health care. As these Web-based tools allow consumers to compare prices and shop for less-expensive options, such scrutiny could save billions of dollars in overall health spending.

Thomson Reuters reported in February that consumers could save $36 billion in health-care spending if they spent the median cost of all procedures within their market. But persuading consumers to consider health-care pricing is a challenge because it marks a dramatic change for many patients and their families. People simply aren’t accustomed to asking about cost before visiting their doctor, lab or pharmacy.

“The first challenge is helping people understand there is this kind of (price) variation in the market,” said Bobbi Coluni, senior director of consumer innovations for Thomson Reuters, which provides information services to health care and other industries.

For people used to having their insurance cover their health costs, seeing the wide difference in pricing might come as a surprise.

For example, the final tab for a colonoscopy at a metro Phoenix hospital can be between $9,330 and $12,003, according to an analysis of metro Phoenix billing records provided by UnitedHealthcare, Arizona’s second-largest private health insurer. But the cost of the same procedure at an outpatient medical office would be between $1,075 and $3,076.

Experts say the price disparity among hospitals and outpatient clinics shows the potential savings for savvy consumers who choose less-expensive options.

US Airways pilot Steven Doss knows that firsthand after shopping around for the best price on drugs and lab tests.

“The savings, if you can achieve them, can be staggering,” Doss said.

Consumers’ burden

Doss is an example of the changing nature of health-care coverage and the shift toward a more educated consumer.

After switching to a high-deductible health plan that is being offered by more employers, he took time to learn about the costs of medical procedures and was willing to shop around.

High-deductible plans require consumers to pay more out-of-pocket for health care in exchange for lower monthly insurance premiums. They appeal to healthy consumers who can cut monthly costs, and to companies because they are typically less expensive than benefits-rich insurance offered through preferred-provider or health-maintenance organizations.

But they require a person to spend a certain amount on their treatment costs — the deductible — before insurance coverage kicks in. These plans typically fully cover preventive care, such as a physical, or wellness exam, but they shift some of the burden of costs for other medical expenses, including lab tests and drug costs, onto the consumer until they reach the deductible amount.

Deductibles can range from $1,000 to $10,000, and some plans pick up only 80 percent of medical costs after the deductible is reached, another reason consumers need to to know how much procedures cost.

A study by Kaiser Family Foundation found that 27 percent of all U.S. workers had an insurance deductible of $1,000 or more in 2010.

A survey of large employers by consulting firm Mercer shows the typical Arizona employee paid $39 a month for a high-deductible plan compared with $93 for a PPO plan. These plans often are accompanied with a health savings account that allows consumers to save money tax-free and roll over a balance from year to year to help defray the cost of procedures.

Five years ago, high-deductible plans were rare, with just 3 percent of employees in large corporations enrolling in such plans. But enrollment has swelled, with about 13 percent of U.S. employees, and 14 percent of Arizona employees, of large companies preferring such plans last year. That figure will likely increase in coming years, according to Mercer.

High-deductible plans are even more common at small businesses, with many employers making it the only health-care option for employees, other research shows.

With such plans gaining popularity, insurance companies are bolstering their technology tools to help consumers evaluate health-care pricing more easily.

“As consumers continue to move into plans that require them to take more financial responsibility, we need to put a tool in their hands that is easy to navigate,” said Victoria Bogatyrenko, vice president of product development for UnitedHealthcare.

The company has made price information available to its customers for the past five years, but the insurer plans to unveil a more robust site next month that offers both medical pricing and ways to measure the quality of health care provided by doctors and hospitals in comparison to cost.

Cigna, another major health-insurance provider, unveiled a new website in February that allows consumers to search costs for 200 common medical procedures and evaluate quality of service of hospitals and doctors.

Cigna says its customers can estimate prices for specialists, doctors and hospitals based on their own insurance plan, including out-of-pocket costs based on their deductible or supplemental insurance plans. The website also lets customers estimate how much a doctor would charge based on performing the same procedure at different hospitals.

By providing a database to measure the quality of doctors and hospitals, Cigna representatives said the insurer wants to show consumers that higher costs for surgeries and examinations don’t necessarily correlate with better medical care.

The difference in health-care pricing often stems from contracts that hospitals and doctors negotiate with health insurers and medical-device makers. Larger hospital systems can negotiate more favorable reimbursement rates with insurance companies. The amount that hospitals charge has little to do with outcomes of surgery, so consumers should not assume that high prices guarantee quality care, experts say.

“One of the biggest misconceptions people have is they mistake higher prices with higher quality,” said Joe Mondy, a Cigna spokesman. “People are beginning to realize there is variation in quality and cost. You can’t depend on word of mouth to know what the best hospital is to be at.”

Prices vary

Data from UnitedHealthcare and Cigna reveal that prices charged for common, non-emergency medical procedures vary widely among metro Phoenix hospitals and outpatient surgical centers.

UnitedHealthcare’s cost-estimator tool shows that metro Phoenix residents can expect to pay a range of $33,493 to $40,933 for knee-replacement surgery. The estimate includes all fees associated with the procedure, including doctors’ and hospital fees, imaging, anesthesia and medical equipment.

And when all of the bills are tallied, an Arizona resident can expect to spend anywhere from $9,643 to $11,539 for a Caesarean-section birth depending on the facility and physician, according to UnitedHealthcare.

The prices of colonoscopies have perhaps the most dramatic swing in price. If patients get a colonoscopy at a hospital, they can expect to pay nearly four times more than they would pay at an outpatient surgery center.

Because insurers typically cover only 80 percent of medical expenses, even for preferred-provider plans, consumers who do their homework and choose lower-cost options can see big savings. For example, a patient with an insurance plan that covers 80 percent of costs after reaching a $5,000 deductible could save $2,489 by choosing the least-expensive knee surgery instead of the most-expensive one.

The variation does not surprise experts who track health-care pricing trends.

Joel Brill, medical director of Fair Health, a non-profit consumer website that provides medical-pricing information, said that clinics and surgery centers have a limited scope and repeatedly do similar procedures, while hospitals need to absorb such extra costs as providing care to the uninsured and staffing medical specialists around the clock.

While the Fair Health database does not include a range of prices for procedures, it allows consumers to look up an average price for those with health insurance and an “out-of-network” price for the uninsured or people seeking health care from a health provider not part of their insurer’s network.

Officials at Fair Health, set up in 2009 after a New York state investigation into insurer payment practices, say that the drive toward public reporting of health-care pricing could reduce or eliminate the wide price discrepancies among different providers.

“The way we see it, we can change everything,” said Robin Gelburd, president of Fair Health. “We can contribute to greater rationality in the health-care system. Let consumers finally see the costs.”

Still, the move toward pricing transparency is not a perfect system.

A Government Accountability Office report issued last September found that accurate health-care pricing estimates were difficult to obtain, in part, because doctors and hospitals can’t always predict which treatments and tests are required for particular patients.

When GAO investigators randomly called 19 Colorado hospitals seeking quotes for knee-replacement surgery, they were told the procedure could range from $33,000 to $101,000 depending on factors such as the amount of time in the operating room to the type of anesthetic the patient may need.

Coluni, of Thomson Reuters, said it isn’t realistic to expect all consumers to use Web-based tools to compare cost and quality. But she sees a gradual shift that will impact what health providers charge.

“People are really surprised when they get their bills,” Coluni said. “The first challenge is helping people understand that unlike many things we buy, the cost of health care isn’t necessarily related to quality. It is driven more by the provider’s negotiated price.”

Shopping for care

Doss, the US Airways pilot, found out the hard way how confusing the pricing system is and how difficult it can be to find the cheapest provider. Doss traditionally carried a preferred-provider health-insurance plan that paid 80 percent of his medical costs, but because he is reasonably healthy, he switched this year to a high-deductible health-insurance plan through his employer, US Airways.

A recent physical examination showed that Doss has mildly elevated cholesterol. The physical and accompanying blood test were considered preventive care and were completely covered by his insurance plan. But he would have to pay for any follow-up blood tests with his own money.

Doss said that his medical provider, Mayo Clinic, charges $427 for a blood test to check cholesterol. So Doss called his insurer, Anthem Blue Cross Blue Shield, to find another “in-network” lab that would charge less. He had his blood drawn at LabCorps, which charged less than $86 for the test.

Turns out that Doss did not need to make any calls. Even though he called Anthem Blue Cross Blue Shield representatives seeking the lowest cost for a blood test, Doss said the insurer’s representative never explained that the insurer has negotiated a rate of less than $36 with all labs that are part of the insurer’s network, including Mayo Clinic.

Despite his own frustrating experience seeking out the best price for a blood test, Doss sees the possibility of an open market where consumers can one day take more responsibility for their own health-care spending.

“There could be a positive outcome,” Doss said. “We might find this becomes the new paradigm where patients take an active interest and shop for medical care the same way they shop for groceries or a new car.”

Skimping on care

While some consumers are taking more active roles in health-care shopping, others are finding that an unintended consequence of their high-deductible health plans has them skimping on health care because of concerns about high out-of-pocket costs.

Linda Bliss, 61, of Scottsdale, pays nearly $300 a month for a health-insurance policy that has a $5,500 deductible and can’t always afford even the less-expensive options.

“I have declined to do what doctors have told me to do,” said Bliss, citing costs of recommended medical tests.

Bliss, who is self-employed, said she evaluates the need for tests that her doctor tells her to undergo. When she feels she can’t afford to pay for a test or procedure, she looks for other options.

The American Journal of Managed Care published a study last year that found families enrolled in high-deductible insurance spent 14 percent less on health care than families with conventional health insurance. But those families also were more likely to skip critical preventive care, raising the question of whether short-term savings come with the potential of jeopardizing health.

Bliss has found some luck with community health screenings sponsored by hospitals or non-profits. She has attended heart-health and osteoporosis screenings sponsored by Scottsdale Healthcare. She also had a free kidney-function screening through the National Kidney Foundation.

“When you have a $5,500 deductible, you have to look for those things,” Bliss said. “I’m 61 and I’m just counting the days until I am on Medicare.”

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