The long, confusing journey to find the actual cost of a medical procedure
Bob Sanders, New Hampshire Business Review
Blood in my urine.
That’s what I saw on Sept. 15 while inside the portable toilet in Warner at a rest stop some 65 miles into my 77-mile ride to raise money for the Concord Hospital Trust to help cancer patients.
It was not the first time my urine was red on a long bicycle ride, but this time I would not panic. This time, I would not walk blindly into the Concord Hospital emergency room for no good reason and exit with a bill that I was still paying off.
This time, I would know what the heck I was getting into and how much it would cost me.
It took a month to find out that, in order to save thousands of dollars, I had to put off a medical procedure until next year, thus risking landing in an emergency room, which could cost the health system more than I was trying to save myself.
But that’s the trade-off patients now have to make in the new world of high-deductible health insurance.
High deductibles used to be the exception. Now they are the norm, particularly in New Hampshire, where high-deductible plans are held by the highest percentage of policyholders in the country.
Nationwide, the total amount of deductibles paid by employees tripled from 2008 to 2017. The average individual deductible doubled to $1,500 in that time and the number of those with plans including deductibles rose from 60 to 81 percent, according to a 2018 Kaiser Institute study.
In New Hampshire, 69.3 percent of employees had high-deductible plans (more than the $1,300 individual threshold used for health savings account eligibility) in 2017, according to data from the University of Minnesota’s State Health Access Data Assistance Center. It was the highest percentage in the country.
The state also has the highest average family deductible ($4,381) and the second-highest individual deductible ($2,303), just $2 below Maine. In 2016 New Hampshire was ranked first in the average individual deductible as well.
(The prevalence of small businesses here might be a contributing factor: The smaller the company, the chances are the larger deductible an employee has to pay.)
The good thing about high deductibles is that they force the consumer to care about cost. But it also has a negative side as well.
During her presentation at NH Business Review’s Oct. 10 Healthcare Confronting Disparities event in Concord, Dr. Joanne Conroy, CEO and president of the Dartmouth-Hitchcock health system, said that people with high-deductible plans “aren’t getting the care they need. They are coming to the emergency for acute care that could have been cared for early on.”
Indeed, a study by the American Diabetes Association indicated that while large deductibles do save medical costs, they also resulted in lower-income patients going to the emergency room.
My individual deductible is $5,000. Even after my employer chips in $2,500 via a health reimbursement account, I have a high-deductible plan.
I found this out the hard way in 2016, that time on a 100-mile ride to benefit the Concord Hospital Trust. Back then, when I saw my bloody urine, I cut the ride short, went into urgent care at the Hitchcock Clinic. I was sent to the emergency room.
A doctor, who said I was slightly dehydrated, wanted to hook me to an intravenous bag. Way too costly, I said. I just drank a lot of water and was given a CAT scan with negative results because it wasn’t done correctly. When my urologist redid the scan, he found that stones in my bladder knocked about during the long ride, causing the bleeding. He sucked them out though the urethra, laser-blasting those too big to fit. I had no idea how much that cost, nor did I care, since I had already blown though my deductible in the ER.
This time, I figured they could just do it again. Sure enough, my urologist eventually confirmed, I had a “ton” of bladder stones again, and I should have them removed again, or they could block up the urethra, resulting in extreme pain and another ER trip.
But, he added, this is a recurring problem because my enlarged prostate prevents me from totally emptying out my bladder. The solution? Drill a pathway though the prostate.
The procedure — known as transurethral resection of the prostate (TURP) — would require an overnight stay in Concord Hospital (which owned the urology practice), though it would be less than 24 hours, so it would qualify as day surgery.
He had no idea, nor much concern, about how much this would cost me.
I tentatively signed up for the procedure, scheduled in two weeks, the Friday before Columbus Day. Then, armed with procedure codes, I proceeded to do my homework.
First, I called the cost information number on the urologist’s pre-op literature. I got a message inviting me to leave a voicemail with my procedure number and other information to get a cost estimate in 48 hours.
While waiting I called Anthem, my insurer, which confirmed that I had hardly touched my deductible, so I was on the hook for almost $2,500 after my employer reimbursement. Anthem told me the surgeon’s negotiated fee: $1,949 for the TURP and $812 for the bladder removal. But didn’t tell me the combined fee, nor the cost of the hospital and anesthesiologist because they vary so much.
The anesthesiology cost depended on the method, which — the urologist’s office told me — would only be revealed at the hospital before I was rolled into the operating room.
Concord Hospital (which called back more than four working days later after repeated messages) could only give me its “sticker price” — $28,000 to $41,500 — not the negotiated price with Anthem.
Anthem couldn’t tell me what that was either, but I was told that, since it would probably blow through my deductible anyway, what difference would it make?
It was only after I contacted Concord Hospital later on as a reporter that the hospital told me the negotiated price, including surgery but not anesthesia, was between $19,000 and $26,000 but “as a general practice we don’t disclose that,” said Tom Antinerella, director of patient access, explaining that contracts with the insurers were “proprietary” and besides, “it’s kind of a moot point, because if it’s more than your deductible it’s irrelevant.”
But I was still trying to make a decision, so I went on the state Insurance Department’s transparency website, nhhealthcost.nh.gov, which gives the negotiated rate on over 100 common procedures, including 22 surgical ones, but not mine.
Then I called Vitals SmartShopper, a company that works with my employer and Anthem and actually sends you a check if you go to the cheaper provider. However, my procedures were not included in our contract, so they couldn’t give me any cost figures.
Anthem later told me as a reporter that SmartShopper would have helped me with another operation — kidney stone removal — which has a different procedure code. The public information office also referred me as a journalist (but not when I called as a patient) to check out a tab section of Anthem’s website, called “Estimate Your Cost,” which allows you to compare the cost of a number of procedures, like kidney stone removal, but not bladder stone removal or TURP, so it wouldn’t have done me any good in any case.
Ambulatory surgical center
Time was ticking by. I called back the Center for Concord Urology practice and asked how urgent it was for me to get the bladder stones removed right away. Not very, I was told. So I canceled the procedure and continued my search.
I vaguely remembered during an employee health meeting that it would be much cheaper if I went to an ambulatory surgical center. My urologist did say the procedure required an overnight stay at the hospital, and Anthem didn’t suggest it, but I figured I’d give it a try. After numerous phone calls, I learned Manchester Urology Associates performs these procedures at Elliot Health System’s ambulatory surgical center, Elliot at River’s Edge in Manchester.
Manchester Urology said its negotiated fee was $3,800. The River’s Edge’s sticker price was $3,650 for the bladder removal and $9,105 for the TURP. Amoskeag Anesthesia’s sticker price was $1,500, negotiated down to $1,300, based on the average number of hours the procedure takes.
But all this was irrelevant after I called Anthem, which told me that all I would have to fork over was a $250 co-pay. That would cover the doctor, the facility, the anesthesiologist and even some lab work.
But as a new patient, I wouldn’t get to see anyone in Manchester Urology until early next year.
So betting to save $2,250 that my bladder stones will stay put for another three months, I set up the appointment. If I lose the bet, and wind up in the ER, I’ll only pay the same amount if I scheduled it at Concord Hospital. But the insurer would pay a lot more in dollars, and I could pay a lot more in terms of my health. Wish me and the health system luck.
It turns out I missed one important resource when trying to determine medical cost: MyMedicalShopper, started by Mark Galvin, a Portsmouth entrepreneur. I had even done a story about the company the year after it started up in 2014.
MyMedicalShopper has since gone national. Galvin has even been invited to the White House twice to talk about how price transparency can save the healthcare system, and Medicare in particular, billions of dollars.
It started up in 2013 when Galvin finally got a CD-ROM of actual claims data from the state. That data has since been updated every three months and augmented by the company’s customers, both businesses and individuals.
Like the state and Anthem sites, the data revealed a vast disparity of prices for some common procedures. Anthem, for instance, pays one provider $22 for an x-ray and another $327, with payments ranging from $335 to $4,221 for an MRI of the lower joint.
But MyMedicalShopper has information for a lot more procedures, including mine. Bladder stone removal prices range from $388 (at River’s Edge) to $6,112. And TURP costs range from $1,565 to $8,424. (The combined high estimates are actually $4,000 lower than the price provided by Concord Hospital, underscoring that the results were either off the mark, or not up to date, or that the hospital’s estimate was too high.)
But if MyMedicalShopper gets its data from the New Hampshire Comprehensive Health Information System — a result of a law mandating such transparency — why doesn’t the system website include the hundreds of other procedures included on MyMedicalShopper?
Most likely it’s “due to the relatively low frequency of the services in the commercially insured population and/or a high amount of variation among patients receiving the services,” explained Tyler Brannen, director of health economics at the NH Insurance Department, thus the state could not vouch for its accuracy.
But Galvin blames it on restrictions that the carriers put on use of the data. Brannen, however, said there are no restrictions on which procedures would be included on the database.
According to Galvin, however, carriers may say they want the transparency that will send consumers to low-cost providers, “but they really don’t. Carriers want to keep it a secret.”
He said that’s because of a rule that, in most circumstances, limits an insurer’s surplus to 20 percent of medical losses. The greater the medical losses, the greater their profit, argued Galvin.
When asked to respond to this, Anthem issued the following statement:
“Consumers rely on Anthem Blue Cross and Blue Shield to provide broad access to affordable, quality healthcare services. Prices for the same service can vary greatly from provider to provider, even those in the same area, which is why we work with consumers by providing them information and tools so they can be better informed about selecting the right care provider based on quality and possible out-of-pocket costs.”
The tools listed were the Estimate Your Cost website, the SmartShopper program, live customer support and benefit design. The first three tools failed to inform me of the cheaper alternative that was available under the latter. I had to come up with the information myself.
In some ways, this story has a happy ending. I was eventually able to get a rough idea of the negotiated costs and was — albeit with some delay and risk — able to find a cheaper alternative. But is this evidence of price transparency? Or is it an example of how difficult it can be to find out the cost of your very own healthcare?