How much for medical care?

Getting a clear answer on health care prices definitely isn’t easy

Betsy Q. Cliff / The Bulletin /

It’s easy to compare prices on a gallon of milk.

Assessing the cost of cars isn’t hard either.

Want to find out the price of a haircut, a massage or a shoe repair? That’s a cinch.

Now try asking about how much your primary care visit will cost, or a mammogram or a hospital stay.

In health care, prices are notoriously opaque. Whether for routine procedures or long bouts of treatment, it can be extremely difficult if not impossible to figure out the cost of care in advance. Calling hospitals or doctors can often result in very rough estimates or a directive to call an insurer.

Even if you do find out a price, it might not include major portions of the final cost, such as medication or doctors’ fees. Further complicating the issue, the price of a health care service may not tell people much about their own payments, which can be influenced by policy details including deductibles, co-pays and co-insurance.

When The Bulletin tried to find price information about the cost of various medical services in Central Oregon, we were out of luck most of the time.

In 30 separate calls, we were able to obtain enough information to reasonably estimate the price of a service just 43 percent of the time.

Those prices didn’t include what we would pay out of pocket if we had insurance or what could happen with more care, such as a needed X-ray or surgical complication. Even the savviest shopper, it seems, can be challenged to figure out what they will pay and what they will get for that price.

“If people have the option of choosing between two different providers or two services, if you don’t know which is cheaper, how do you make good price decisions?” said Teresa Miller, acting administrator of the state’s Insurance Division.

Miller compared the current situation to going into a grocery store and finding it devoid of prices. “If we don’t have any information on costs, you can’t have people making good decisions about their health care costs.”

Sticker shock

Despite the difficulties, many in health care say they want to help patients estimate costs and pay for services. Indeed, in our surveys, many of those who responded were eager to give estimates and suggest ways that someone could pay.

At Bend Memorial Clinic, a woman who talked to us about the price of a mammogram for someone who is uninsured mentioned a program through which a woman might get free screenings.

In St. Charles Bend’s emergency room, the person who answered the phone gave us rough estimates and also recommended going to an urgent care center where it might be cheaper. Multiple practices mentioned payment plans.

All of it is to help patients avoid the shock of opening big bills.

“One of the things that comes out in patient satisfaction surveys is people get really upset about the sticker shock,” said Mike Bragg, director of clinical performance measurement for Providence Health Plans. “I think it’s important to know ahead of time how much something costs so that they’re not shocked ~ so that it doesn’t leave a bad taste in their mouth about the health plan.”

Providence has an online tool that shows, on average, how much procedures cost and allows members to put in their policy details to estimate costs out of pocket. Price transparency, said Bragg, “is something we’re committed to doing better.”

Many providers say the issue is important from a business perspective.

“In this economy, people are starting to look at funds and what they can afford,” said Dana Jorgensen, who does billing for Advanced Specialty Care, a clinic in Bend. “If they end up with a huge bill, then they’re not going to come back and they are going to voice that in the community. We want them to have a known (price), not an unknown.”

Jorgensen said the clinic takes pains to be upfront with patients and to put those who can’t afford treatment on payment plans.

Marvin Lein, CEO of Bend Memorial Clinic, characterized price transparency as a customer-service issue. Lein said that in the case of higher-cost care, such as cancer care or surgeries, the clinic sits down with patients to estimate costs and figure out what insurance will cover.

“No one likes to be surprised with a bill they didn’t expect,” Lein said. “You and I don’t buy cars without knowing the price. Health care shouldn’t be any different, though it’s more complex.”

Diagnosis uncertain

Still, quoting an accurate price vexes many providers, as our survey found. That information is difficult to get for many services, Lein and others say, because of the inherent complexity of many health conditions and the way health care is paid for.

As an example, Lein said, in urgent care “an injured ankle is kind of a black box.” It could be something as simple as a bruised muscle or something as complex as a broken bone. With that range, it’s nearly impossible to give accurate pricing information.

“You don’t really know what the cost is going to be until you know the treatment,” said Lein. It could just need an exam, it could need an X-ray, or it could need more expensive imaging.

Indeed, in The Bulletin’s survey, we never got enough information to be able to clearly estimate cost for an ankle sprain in either urgent care centers or the St. Charles Bend ER.

We were more successful with procedures such as skin exams or mammograms, in which the service is better-defined. “When you call up and say it’s time for my annual mammogram,” said Lein, “we’re pretty sure that the straight series will be what you need and here’s the price.”

Sometimes patients need to provide obscure information to obtain costs. At St. Charles Bend and Redmond, the people in patient financial services said they did not give out prices without a CPT code, a list of codes that correspond to specific medical procedures and are often used for payment.

In our survey, we obtained the needed CPT code for an appendectomy from a doctor’s office, though it’s not something that can be readily accessed by patients. (When we asked about a colonoscopy, the employees were more forgiving; they asked for CPT codes but looked the procedure up when we said we didn’t have them.)

St. Charles Bend needs the CPT code to try to cut down on the ambiguity some of the more common terms for hospital services, said Karen Shepard, chief financial officer for Cascade Healthcare Community, the parent company of the hospital.

In other words, a heart surgery isn’t just a heart surgery; it can be many different types of procedures. For each type of procedure, Shepard said, “there’s a lot of different kinds and the CPT codes go down to a very detailed kind of service.”

Another issue that complicates pricing is that the cost is often shared between at least two parties, you and your insurer. Patients are often not paying the full price and may pay only a small fraction of the price of a service. That means that even if you know the price, you may not know exactly how much of that you will be responsible for.

“Most people are focused on what’s it going to cost me,” said Kevin Earls, legislative director for the Oregon Association of Hospitals and Health Systems.

Even if prices are uniform, then, the amounts people will pay vary greatly depending on what coverage they have or if they have coverage.

Starting somewhere

Currently, consumers can go one of several Web sites that estimate the average cost of procedures. Beginning next summer, state officials say they hope that estimating costs gets easier due to a new law.

The law, set to go into effect in July, requires insurers to set up Web site that will allow beneficiaries to plug in information about the procedures they need, their providers and their plans, and get a detailed estimate of how much it will cost them individually.

The systems will tailor information for each individual, said Bragg at Providence Health Plans, so that instead of averages, as their Web site currently gives, users will be able to get an estimate tailored to their personal situations.

Miller acknowledges that full transparency will always be difficult, but she said that shouldn’t keep people from trying. “You could throw up your hands and say it’s too complex and there’s too many pieces,” she said. “You may not know everything you’re going to need (for care), but you’ve got to start somewhere.”

How we did it

To try to assess the difficulty of finding price information, The Bulletin did a survey of hospitals, doctors’ offices and outpatient clinics in Central Oregon. We called offices and asked about the prices of various services, once for an uninsured patient and once for an insured patient, specifically someone with Providence Health Plans.

In all cases, we did not identify ourselves as reporters during the initial calls because our interest was in learning what a typical consumer would experience. After the survey, we called all businesses again to inform them of the survey and to ask for comment.

When asked for identification, we always gave real names and told those who asked that we were from The Bulletin and doing a survey. Out of 32 different inquiries, two people asked why we were calling.

One company, Mountain Medical Immediate Care, initially gave price information, though when we called back to let them know our intent to publish prices, declined to participate in the survey, citing the complexity of its pricing.

We found that we were able to obtain enough information to reasonably estimate a price for a medical service less than half the time, in 43 percent of inquiries.

Though some price information was given more often than that, information was sometimes too vague to be useful or did not include major pieces of a cost puzzle, such as a physician’s fee or the cost of anesthesia.

Often, it was easier to get information for the uninsured patient than the insured. With the uninsured patient, the success rate was 47 percent versus 33 percent for the patient with insurance.

Insurers negotiate a lower price for services than the provider would otherwise charge. Sometimes these discounted prices were given, other times we were told there would be a discount but that the amount was not known until the time of service.

— Betsy Q. Cliff, The Bulletin

How you could get cost information

Cost information is extremely hard to get and sometimes impossible. Nevertheless, there are a few things to try:

• Call the doctor’s office. Sometimes, as our survey found, they will have the answer quickly.

• Call your insurer. If you are using an in-network provider, the insurer will likely be able to tell you the cost and your portion of responsibility.

• Use the Web. The Oregon Association of Hospitals and Health Systems has a Web site to estimate hospital costs (www.orpricepoint.org) as does Oregon Health Policy and Research, a state office (www.oregon.gov/OHPPR/RSCH/comparehospitalcosts.shtml). Providence Health Plans has a Web site available to the public that lists costs for common outpatient procedures (www.providence.org/healthplans/members/cost-quality).