Quest to compare medical expenses can be challenging

Brenda Moore kept notes. First call, Feb. 22. Last call, April 5. Six weeks of calling physicians, hospitals and insurers.

Retired in Solon after 31 years as a nurse practitioner with University of Iowa Hospitals and Clinics, she was experienced - considered herself an expert - at helping others find care they could afford.

“That's why I hung in there,” Moore, 58, said.

A veteran of two colonoscopies, she never dreamed getting cost estimates for a third would take so long.

The price can be anything but transparent for Iowans trying to identify costs in advance of health care procedures ranging from childbirth and mammograms to knee replacement and colonoscopies, a Gazette investigation revealed.

Generations of physicians, focused since med school on providing the best care possible, may have no idea what to say to patients who want to know how much treatment will cost. Legislation mandating price transparency among all health care providers and insurers died in Congress last year. Meanwhile, medical professionals and insurers do not agree where price transparency should begin.

Not here, the reimbursement director of a Cedar Rapids eye clinic told The Gazette.

“Every time you call a physician's office for questions regarding your insurance coverage or estimates of costs, it increases the overhead of the physician's office,” Dawn Waller said. “We have to have someone answer the phone, triage the call, take the appropriate action and follow up.”

“I agree that patients need to be informed about their health care costs, but it needs to start with the patient and insurance company.”

Compare hospital costs for various medical procedures with the Iowa Hospital Association's cost comparison tool.

Some physicians' offices quote the price of the treatment they provide, but also tell patients to check elsewhere to find the overall cost, which might include radiology, pathology, anesthesia and hospital stays. Patients told The Gazette of being advised to check with insurance companies, hospitals, websites and human resources departments.

No matter whom consumers ask, the most common answer probably is, “It depends.”

“There are some 3,000 different procedures that are possible with a hospital, all of which have variations to them,” said Tim Charles, CEO of Mercy Medical Center in Cedar Rapids.

“While we tend to want to distill this all down to a highly predictable, factory-like environment, it's not always possible to do that,” Charles said. “It's very, very complex.”

Dr. Tom Evans, president of the Iowa Healthcare Collaborative, said health care reform and cost transparency encompass “a very complicated answer” that some providers are unable to explain and some consumers are unwilling to follow to the end.

As a result, while the quality of health care in Iowa never may have been better, the consumer experience in estimating costs can be exasperating.

What might have been

Estimating medical costs might have been easier if the Transparency in All Health Care Pricing Act had passed Congress last year.

“The piece of legislation I put forward, I can summarize it in one sentence,” said Dr. Steve Kagen, former owner of a group of Midwestern allergy clinics and a former Democratic congressman from Appleton, Wis.

"Any and all individuals or business entities, including hospitals, physicians, nurses, pharmacies, pharmaceutical manufacturers, dentists and insurance entities that offer health care-related items, products, services, or procedures to the public shall publicly disclose, on a continuous basis, all prices for those products, services and procedures in an open and conspicuous manner ...”

He paused for emphasis and a gulp of air.

“ ... including on the Internet, and including all wholesale, retail, subsidized, discounted or other such prices accepted as payment in full.”

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Kagen understands better than most the difference between sticker price and payment in full in the relationships between patients, providers and insurers.

At a time when consumers might have settled for a small advance in price transparency, Kagen pushed for a law that would have revealed the differences between price quotes and discounts down to the last cent.

“That would create a real marketplace,” he said in an interview. “Anything before the discounts is just an asking price.”

Hope for consumers

Even without the Kagen bill as law, consumers could shop someday for health care like they shop for cars, major appliances and home remodelers. When is not certain, but momentum in that direction is building. For it to happen, though, experts say consumers must accept greater responsibility for their health, diminish their roles as insured spectators and take advantage of transparency.

Writing during spring in the New England Journal of Medicine, Meredith Rosenthal and Anna Sinaiko of the Harvard School of Public Health examined factors that influence likelihood. Consumers “are generally ignorant” of price differences for the same procedures at different hospitals, they wrote. “Publishing price information could both narrow the range and lower the level of prices ...”

On the other hand and thanks to insurance, most patients pay little of the cost of their medical care. Because of that, their incentive to choose a lower-cost provider is dramatically weakened, the authors said. Patients also may be unwilling to go against a clinician's advice in the interest of saving a few dollars.

Finally, they pointed out, the price information consumers would find most useful - the personalized price an enrollee in a Blue Cross Blue Shield plan would pay at a particular hospital for a knee replacement, for example - is difficult to find.

During tests of the Wellmark Blue Cross Blue Shield online cost-estimator tool, three Gazette employees who are Wellmark members were unable to price knee replacements or colonoscopies in any specific hospitals nor could the tool be used to compare hospital charges for any procedure.

Confusion, frustration

Cost confusion lingers for countless reasons, including medical profession traditions and the complexity and controversy of reform - simultaneously cheered, condemned and legally challenged. Meanwhile, long explanations about cost estimates test consumer patience.

Evans, a former president of the Iowa Medical Society who practiced family medicine for 13 years, sees frustration boiling. “When patients say, ‘How much will this cost me?' they (physicians) may not know,” Evans said. As a result, consumers feel “health care won't give us a straight answer.”

Dixie Ann Scott, 67, a “retired grandma” in Cedar Rapids, agrees.

"I have found it very difficult to have a doctor, hospital or insurance company pinpoint the exact costs of different procedures,” she said in response to a Gazette solicitation for reader experiences.

“The doctor fudges and says to contact my insurance company. The insurance company (doesn't) want to give out information if the hospital costs are going to be different. The hospital gives you the routine that it depends on what your insurance company covers and what your co-payments are, etc., etc.

“Are you getting the picture here?

“I am done trying to get any info from the medical field. I have come to one conclusion. They all lie.”

Message disconnect

Evans and other Iowa medical leaders say they are eager to explain why pricing is a moving target and hope Iowans hear them out. They promise more accessible and precise cost information is coming.

Distanced from his medical practice, Evans' role as founder in 2005 and leader of Iowa's clearinghouse for medical professionals provides him with a broad perspective. Transparency is a cornerstone of the collaborative's mission.

He does not criticize physicians and hospital administrators who don't get it. He understands their baggage - a long tradition of care-centric, one-way, doctor-knows-best communications.

“Historically, the consumer was responsible for nothing other than showing up when the doctor said to and ‘do what I say and take your prescriptions.' We used to measure patient compliancy,” he said in an interview.

“In health care, historically, we have not been focused on costs. You come in broken and we fix you. That was our previous paradigm.”

In the new paradigm, physicians are to abandon the past despite uncertainties about the future. The pace of change is accelerating, which makes communication vital.

And that, Evans said, is where things have broken down.

Health care providers speak their own language and are “like at a second-grade level in communicating what they do” to the public, he said.

No single answer

There also is the exasperating absence of a single, straightforward answer to the fundamental, how-much-will-my-procedure-cost question.

Almost anyone in medicine knows why “it depends.” The difference between the wear and tear on your knee vs. the next patient's knee is a variable, one of hundreds.

“Say two people are scheduled to have a colonoscopy,” St. Luke's Hospital spokeswoman Laura Rainey said. “One of these patients is healthy with no underlying medical conditions. The other individual has diabetes. Both patients will pay the same base price for a colonoscopy, but there are a few more things medically that will need to be done to care for the patient with diabetes and that in turn drives up the cost for that patient's care.

“Add into that scenario that during the colonoscopy the surgeon removes two precancerous polyps and that also increases the original base price estimate. Some aspects of care cannot be predicted.”

Although 9,518 knee replacements were performed in Iowa hospitals last year, “doctors do it different ways,” Evans said. “Every patient is different. Different tests are required. Different techniques are used. There's variability, depending on how they treat you and how they were trained ... We need to reduce the variability.”

Price the variables

If variability makes up everything, why not give consumers cost estimates for the variables? “Personalized, episode-level costs would be more meaningful to patients,” Harvard's Rosenthal and Sinaiko wrote in March.

As recently as April, Mercy Medical Center boasted of having had a price transparency policy since 2007 and of offering patients a chance to compare costs for common procedures. However, an online cost-comparison feature it offered was a minimum of 17 unmapped clicks away from Mercy's home page, and on another website. Price ranges listed for common procedures were broad.

When those disconnects were pointed out to Charles, Mercy's CEO accepted the remarks as constructive criticism and took action.

Within weeks, Mercy's home page added a prominent “Pricing Quick Link.” One click enabled future patients to find the transparency policy. The policy page linked to the Iowa Hospital Association's website, where consumers can compare prices for every Iowa hospital.

Coincidentally, the association's site also underwent a significant spring makeover. Years of one-size-fits-all-patients' price ranges were replaced by categories of variables - four in the case of a knee replacement, 14 for a colonoscopy.

When all of the 1,726 non-trauma knee replacements performed at the four Cedar Rapids and Iowa City hospitals in 2010 are compared, consumers learn:

• Mercy Iowa City performed the most knee replacements of minor or moderate severity but the fewest of major or extreme severity.
• St. Luke's was the least expensive area hospital for a knee replacement of any level of severity.
• St. Luke's patients also experienced the shortest hospital stays in all categories of severity.
• Mercy Iowa City was the most expensive area hospital for knee replacements of minor or moderate severity; UI Hospitals was the most expensive for replacements of major or extreme severity.
• At an average of $39,746, a knee replacement of minor severity cost $5,106 more at UI Hospitals than the statewide average for all Iowa hospitals.
• A knee replacement of moderate severity cost $8,736 more at UI Hospitals than the statewide average.
• A knee replacement of major severity cost $17,450 more at UI Hospitals than the statewide average.
• A knee replacement of extreme severity cost, on average, $120,607 at UI Hospitals, $69,967 at St. Luke's and $85,965 statewide.

Brenda's revelation

If Brenda Moore, the retired nurse practitioner, had visited Mercy Medical Center's website home page during her six-week search for comparative prices for a colonoscopy, she would have seen no references to its transparency policy, pricing or cost comparisons. Similarly, the home page for St. Luke's offered no instructions for finding its price transparency policy or cost estimates.

UI Hospitals' website offered no mention of pricing transparency or cost comparisons and did not link to the Iowa Hospital Association comparison tool. Mercy Iowa City's home page did not mention pricing, transparency or cost comparisons but linked in just two clicks to the association's comparison tool.

Now, all but UI Hospitals link to the association's cost-estimator.

Moore recently visited Mercy Medical Center's updated site and clicked to the price comparisons. “I was shocked,” she said. “In five or 10 minutes you can pull up all that information. I thought, ‘I spent six weeks trying to get this!'”

Given her career and cost-comparison experience, Moore pointed out that physician, lab and other fees still had to be identified and added for an accurate estimate of out-of-pocket expenses.

Overall though, a few small clicks by Moore represented one more step forward in Iowans' journey toward health care cost transparency.