Curbside Consult with Dr. Jayne 1/18/21

It’s finally time for price transparency, with hospitals now being required to disclose their contracted prices on their websites. I decided to see how difficult it would be to find out the potential pricing for my local hospital, and also to compare it to recent Explanation of Benefit (EOB) documents from a couple of friends and family members.

I first went to the hospital website. Of course there wasn’t any kind of notice about the availability of the new data, so had to guess where it might be filed. Clicking on “Billing and Financial Assistance” took me to a health system website, and after scrolling two full screens, I found an “Understanding Your Costs” header. Under that, I could select either a customized cost estimate or the “General Estimate Tool – Shoppable Services.” A description under that link noted: “Under 2020 pricing transparency guidelines from the federal government, this tool allows you to view your costs for the most frequently used hospital services.” I knew I was at the right place.

From there, I had to again select my hospital and agree to Terms and Conditions for the tool. Next, I had to select my insurance. My my plan was unfortunately not listed on the pick list, so the system instructed me to call to speak to a financial specialist. I backtracked and just selected Cigna since I have a general working knowledge of how their plans work.

I was next asked to select whether I was choosing an inpatient or outpatient procedure. Although the system defined these strictly as “staying overnight in the hospital” versus “not planning to stay overnight,” as a physician I know there are nuances to this. When I had my emergency gall bladder surgery, I spent the night on an inpatient unit, but my visit was billed as outpatient since I was admitted less than 23 hours. Patients aren’t going to know or understand this, nor should they be expected to do so.

After that, I was asked to choose a popular procedure. I’m not sure I would have chosen the word “popular” when building this user interface. Medical procedures are rarely popular, and perhaps “common” would be a better word.

Bouncing back and forth between the inpatient and outpatient lists, I quickly determined that the system wouldn’t let me match combinations that went with the EOB documents I had. These involved my outpatient gallbladder removal, an outpatient hysterectomy, and an outpatient hip replacement (for which this particular facility is renowned). Instead, I went with the colonoscopy, although my EOB was from an ambulatory surgery center rather than the hospital. From there, I had to input my insurance benefits, including deductible, how much I’ve met for the year, my out of pocket maximum, and whether I had met it. I also needed to know my co-pay and co-insurance for the procedure. Most patients aren’t going to have this at their fingertips.

The system told me I’d be responsible for $20 for my colonoscopy, which I know isn’t remotely accurate. I played around with the “my insurance benefits” screen and could make the numbers go up and down depending on what I put as a deductible. At no point did it tell me what the contracted charge was for the procedure, only an estimate of my patient responsibility. I went back and plugged in “uninsured” for my coverage and was able to get an estimate of costs for a diagnostic colonoscopy with biopsy, which ranged from $1,286 to $3,744, with a median of $1,575. There was no explanation whether the numbers being provided reflected only the facility fee or whether they included any other fees, such as pathology. Again, I wouldn’t expect patients to know that there are going to be multiple fees from multiple sources, so they are still likely in for some sticker shock.

Other things I learned: the system thinks a cardiac catheterization costs $141,636, which is grossly inaccurate. Based on the codes and descriptions displayed, I think they confused it with a cardiac valve replacement. Patients wouldn’t know that. The only chest x-ray on the list was a one-view, which isn’t typically done for outpatients. The hospital charge for that one view was four times what my urgent care charges for both the technical and professional components. The markup for a CT scan of the abdomen and pelvis was also four times higher. I guess those big fancy marble lobbies have to be paid for one way or another. The facility fee for a hospital outpatient clinic visit was $169 and that doesn’t even include seeing the physician. An emergency department visit ranges from $2,190 to $7,573, with a median of $3,310. That definitely underscores the benefit to patients who see us at the urgent care versus going to the hospital for urgent issues.

I ran through the various procedures at a couple of the other hospitals in the health system and found that even an as uninsured patient, I could receive some procedures for dramatically less by driving 20 miles, assuming the data was accurate. The $1,800 CT scan became $900 at the hospital that is in a somewhat economically depressed part of town. However, the mysterious cardiac cath/valve procedure jumped to $171,625 at that facility. The procedure jumped to $209,451 at the system’s flagship academic medical center hospital.

Although the push for price transparency was certainly a hot topic when it was initially proposed, it quickly became a battle between the patient advocacy factions and the hospital lobbyists. From my N=1 analysis, I’m not sure patients are any better off using the tool than using other available data or even a simple Google search. The data provided was too vague to be used for real decision making.

If I was really price shopping a major surgical procedure, I would want to call and talk with the system’s staff to see if they could put together a better estimate. One would also need to research all the ancillary costs, such as laboratory, anesthesia, in-procedure radiology, pathology, etc. Don’t get me wrong, this is a step in the right direction, but we just need to realize it’s a baby step.

Have you looked at price transparency for your institution or neighboring hospitals? What did you think? Leave a comment or email me.

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