If you were in the market for a new TV, you might search online or through printed ads for the best deal.
Maybe the federal government had such a process in mind when the Centers for Medicare and Medicaid Services mandated that the nation’s hospitals publish their charges online, effective Jan. 1.
But figuring out how much a procedure costs and which health care facility offers the least-expensive service is not the same as shopping for electronics. Stores don’t list the charge of each component of a big-screen TV separately, describe the pieces in language that’s foreign to consumers or accept different payments from buyers—which is the case with health care expenses and insurance companies.
Plus, what a hospital charges for a procedure, aspirin or stitch isn’t equal to the cost of care, according to local officials. Medicare, Medicaid and private insurers pay a predetermined rate for a “service,” be it a knee replacement or the birth of a baby. That negotiated rate is not the total of a thousand line-by-line items.
And individuals, even those without insurance, wouldn’t be expected to pay the charge that’s listed on the hospital website.
So what’s the purpose of the lists, other than to perpetuate more confusion?
“It’s a good first step,” said Lisa Henry, marketing director at Mary Washington Healthcare. “It’s a level of accountability and transparency that has not existed in this field before.”
But the lists, called chargemasters and published in spreadsheet form, are far from being user-friendly or even helpful.
“We’re just not there yet,” she added. “We’re not to the point where it’s a meaningful tool for the customer.”
‘THIS IS CHALLENGING’
Henry found herself “going down a rabbit hole” as she tried to explain some of the complicated aspects of health care costs and billing. She was discussing the difference between charges listed on the hospital’s website and a person’s out-of-pocket expenses.
Those costs can differ for the same procedure, not just from one consumer and insurance company to another, but also between packages offered by the same insurer. The cost also depends on how much of the deductible has been met.
“You can see how this is challenging,” Henry said.
She sat down last week with Kathleen Bourgault, vice president of revenue cycle management, and Sarah Ogle, director of payor relations, to discuss the published lists of hospital charges and how consumers can use them.
All three work for Mary Washington Healthcare, which owns Mary Washington Hospital, Stafford Hospital and more than 40 health care facilities in the region. Spotsylvania Regional Medical Center was asked for the same session, but couldn’t accommodate the request. Marketing Director Jael Cooper did respond to a number of questions from The Free Lance–Star.
From their explanations, it’s clear that one size does not fit all.
It isn’t possible to do a simple search in the published lists and find one line item that includes all costs associated with, say, a knee replacement—one of the 10 most common hospital procedures.
“Looking at that one item doesn’t mean that’s your cost,” Ogle said, because the line-item doesn’t include other supplies and medicines used during the procedure. Nor does it include physician fees. Doctors typically operate their own businesses and do their own billing.
And, how those items are listed differ from one facility to the next, making comparisons even more difficult.
“Hospitals have completely different codes, and there’s no standardization, no guidebook that says this is how it should be listed,” Bourgault said.
The list of charges can be downloaded from a hospital’s website. It’s typically found under the “Patients & Visitors” heading, then under financial information.
There are 5,742 items on Mary Washington Healthcare’s list, and 25,242 on Spotsylvania Regional’s.
The items range from the medicines amoxicillin to zolpidem, from sutures and screws to treatments and procedures.
Line items for the latter are harder to decipher. Someone who needs an x-ray of the tailbone won’t find the service listed in that language. Instead, the line reads: “RADEX SACRUM & COCCYX. MINIMUM TWO VIEWS.”
Consumers can do basic comparisons of tablets and pills to see how hospital prices compare with the local drugstore. A good example is Lisinopril, a popular drug for high blood pressure. It’s available at many pharmacies and discount stories for $10 for a three-month supply.
One 20-milligram dose is listed for $26.09 on Spotsylvania Regional’s site. It’s listed on Mary Washington’s site five times, with charges ranging from 3 cents to 10 cents. Seeing the same item on the chargemasters, with different prices, isn’t unusual, either.
But just because a hospital’s charge is dramatically higher than the price at a local pharmacy doesn’t mean the patient’s overall cost will be impacted, Ogle said.
Medicare, Medicaid and private insurers don’t look at individual line items,but consider the whole claim—”every single thing that happened to you” during the hospitalization, Ogle said.
Then, the payors, who have already determined a rate for that specific service, pay the hospital that amount. The payor looks at the individual’s insurance, and on a consumer’s explanation of benefits, determines what the individual will pay.
Consider this bill, shared with The Free Lance–Star. A 70-year-old retired employee from the Spotsylvania County school system recently had an endoscopy, a procedure in which a scope is put down a patient’s throat to determine what’s going on inside.
The total amount billed by the hospital was $11,642.68. She has Medicare and a supplemental insurance, and the total paid by her plan was $666.82.
Her financial responsibility was $118.82.
There’s no place on the chargemasters where she could have plugged in the details of her procedure and her insurance to determine what her actual out-of-pocket expense would be.
But, hopefully, there will be in the months or years to come, Mary Washington Healthcare officials said. They believe the federal government wants the data online so it can develop a tool that will allow consumers to find out, before a surgery, what the procedure will cost.
Until that level of searching is available, simply comparing random hospital charges can be misleading.
“You get to come to your own conclusions based on what’s there [on the list] and that can be dangerous,” Ogle said. “The assumption you make may not be correct.”
CALL FOR QUOTES
Mary Washington Healthcare and Spotsylvania Regional Medical Center encourage patients to call, before procedures, to get cost estimates. Patients are always reminded that estimates are based on typical cases, not complications.
This year, Mary Washington hopes to unveil on its website a price-estimation tool that consumers can use to get a customized estimate based on their individual plans.
Until it’s up and running, patients are encouraged to call 540/741-6675 for estimates of procedures for Mary Washington Hospital or Stafford Hospital.
Spotsylvania Regional patients can get the same information at 800/849-0829.
HCA Virginia, which owns the Spotsylvania hospital, has been providing price estimates for more than a decade.
“We believe it’s important for patients to be able to make informed choices about their health care and understand their financial obligations,” Cooper said.