June 25, 2014:
Because her family’s health insurance plan has a $10,000 deductible, Sue Haynie tries to watch what they spend on medical care and figure out what it will cost ahead of time.
But that’s easier said than done, she’s found.
There was the time her daughter needed to see a doctor about a lingering sore throat. Haynie wondered how she’d know the cost of any tests the doctor performed, so she asked her insurer, Aetna. Haynie said the representative suggested two options: Ask the doctor’s office to call Aetna and find out, or leave the appointment after finding out what tests the doctor recommends, price out the tests, and — if she decided they’re worth it — go back for another appointment to have the tests done.
Haynie chose the first option, so when her daughter went to the appointment, she asked the office staff to call Aetna. But Haynie said she was told they didn’t have time to do so, and that if Haynie wouldn’t pay the bill, her daughter could be pulled out of the visit.
“I was frustrated, my daughter was humiliated,” Haynie said — and they were no closer to finding out the price.
Haynie’s experience represents a challenge facing an increasing number of patients: Their insurance plans require them to pay a larger share of their medical bills. But finding out what their care will cost remains difficult, if not impossible.
“Anyone who’s trying to balance a family budget and has X amount of dollars to spend, how do you go and control something if you don’t know what the price is?” Haynie, of Norwalk, asked.
For years, experts have bemoaned the fact that the experience of buying health care is unlike any other shopping process. Patients with coverage have historically paid little if any of the cost of care, and have had little incentive to learn what kind of charges they racked up.
The rise of health plans with high deductibles — which require patients to pay a certain amount of money out-of-pocket before the insurance begins chipping in — has given more patients a reason to pay attention to costs.
But there’s a gap: finding out the costs.
“This information is very hard to come by,” said Lynn Quincy, associate director for health policy at Consumers Union. She noted that focus groups and other research have shown that people want the information.
“They feel very vulnerable in the health care marketplace,” particularly if they have to pay part of their costs out-of-pocket, Quincy said.
Timothy Jost, a law professor at the Washington and Lee University, is an expert in health care law and policy. His insurance plan now requires members to pay a portion of the cost of their care, but he doesn’t have any expert method for determining the price. So he asks providers what it will cost.
Sometimes, the answer is, “I have no idea.”
How to find prices
Why don’t you see a menu of prices when you walk into your doctor’s office?
In part, it’s because there’s no single price for any service. The doctor might get paid a different amount for each person in the waiting room. Medicare and Medicaid set their own payment rates, while each private insurer negotiates rates with health care providers.
So what’s a patient looking for price information to do?
Some experts say the most reliable source is the insurance company, since it negotiates payment rates with the provider. But getting the information from an insurer often requires knowing some key information, like what particular code will be used in billing. The prices — and billing codes — for tests like MRIs and CT scans vary based on several factors, including the part of the body being examined and whether contrast is used for the test.
Another factor that affects price: where the service takes place. Prices can vary widely depending on whether a procedure or test is performed in a hospital or freestanding surgical center, for example.
Some states have databases of medical claims known as all-payer claims databases, and some allow people to search for the cost of particular procedures. Connecticut is in the process of developing a database.
Quincy said some insurers are resistant to giving out price information, treating it as confidential. But some have developed online tools that members can use to look up prices for medical care — including Aetna, Haynie’s insurer.
Aetna’s Member Payment Estimator allows customers to search for what a particular medical service would cost if performed by different providers and shows out-of-pocket costs based on the members’ plan. There can be significant variations. Prices for an MRI with contrast in Hartford, for example, ranged from just over $700 to nearly $1,500, depending on the provider. Costs for an uncomplicated vaginal delivery in New Haven ranged from $3,600 to nearly $5,300.
The tool averages 140,000 hits per month, up 41 percent from the first five months of last year, said Charity Boutte, Aetna’s transparency project strategy manager. Members with high-deductible plans are twice as likely to use it as the company’s overall customer base.
The tool can affect patients’ decisions about where to get care. Boutte said research shows that members using the estimator have saved an average of $170 in out-of-pocket costs and $612 overall. Six out of 10 times, customers who use the tool pick a low or medium-cost provider. “They’re not going to the cheapest place all the time,” she said.
Move toward transparency in Massachusetts
In Massachusetts, a 2012 state law requires insurers to tell patients or health care providers who request it a quote for the cost of a health care service or procedure within two working days.
Later this year, insurance companies in Massachusetts will be required to have a website that members can use to obtain real-time estimates, said Alyssa Vangeli, senior health policy manager for the Massachusetts group Health Care For All.
Brian Rosman, the organization’s director of research, said the insurer websites he’s seen are encouraging. But he said it remains to be seen how important they will be in people’s health care decisions.
One study conducted last year found that while nearly all health plans offer a cost calculator, only 2 percent of members use them.
“It’s a new way of thinking about it,” Rosman said. “We’re not there yet for people to sort of think of health care as a shopping experience akin to buying a TV, because it’s really quite different.”
The limits of consumerism
And to Quincy, from Consumers Union, that’s an important distinction. There are limits to the effects price transparency can have on overall health care costs and changes in consumer behavior, she said.
That’s because the vast majority of health care isn’t the sort that people would shop around for. Instead, it’s either emergency care or services that are so expensive, insurance will pick up the majority of the costs.
Overall, only about 12 percent of health spending is paid out-of-pocket by consumers, Quincy noted, and the types of costs people are willing to shop around for represent a subset of that. A cancer patient whose oncologist recommends a $7,000 drug isn’t likely to argue for a cheaper drug, she noted.
Despite those caveats, Quincy said patients should have information about price as a matter of fairness. And having it makes them more confident consumers, she said.
A consumer or a patient?
Haynie is among those who feel vulnerable.
Her health plan covers many physician visits with a flat copay, but for tests and other services, her family could have to pay up to $10,000 before the plan begins contributing. And since doctors might order or perform tests, she’s nervous about seeing one. Her family is generally healthy, but she figures she sometimes waits too long to get care.
“You feel like you’re walking into a minefield,” she said of going to the doctor’s office. “You have no idea what you’re going to walk out there owing. It makes you very hesitant to go in there.”
Aetna spokeswoman Susan Millerick said she understands situations like the one Haynie’s daughter faced in the doctor’s office, when it might not be easy or convenient to leave an appointment to find price information. The company plans to have its cost estimator in a mobile app next year, which could make it easier to search for prices during a medical visit.
“I think we have to invite people to be consumers at every chance that they can, but when it feels like it’s a reach, it’s not just about the money, it’s about the whole decision process,” Millerick said.
The goal of Aetna’s transparency efforts is to make people aware of their ability to shop and compare prices, Millerick said.
“But we understand that there are times when people are really not health care consumers so much as they simply are patients,” she said.