“Much has been written about the relationship between high medical expenses and the likelihood of filing for bankruptcy, but the relationship between receiving a cancer diagnosis and filing for bankruptcy is less well understood.
“We estimated the incidence and relative risk of bankruptcy for people age twenty-one or older diagnosed with cancer compared to people the same age without cancer by conducting a retrospective cohort analysis that used a variety of medical, personal, legal, and bankruptcy sources covering the Western District of Washington State in US Bankruptcy Court for the period 1995–2009.
“We found that cancer patients were 2.65 times more likely to go bankrupt than people without cancer. Younger cancer patients had 2–5 times higher rates of bankruptcy than cancer patients age sixty-five or older, which indicates that Medicare and Social Security may mitigate bankruptcy risk for the older group.
“The findings suggest that employers and governments may have a policy role to play in creating programs and incentives that could help people cover expenses in the first year following a cancer diagnosis.” — Scott Ramsey, David Blough, Anne Kirchhoff, Karma Kreizenbeck, Catherine Fedorenko, Kyle Snell, Polly Newcomb, William Hollingworth and Karen Overstreet, via Washington State Cancer Patients Found To Be At Greater Risk For Bankruptcy Than People Without A Cancer Diagnosis, Health Affairs, May 21, 2013.
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“Much has been written about the relationship between high medical expenses and the likelihood of filing for bankruptcy, but the relationship between receiving a cancer diagnosis and filing for bankruptcy is less well understood.
The most common imaging test for breast cancer detection is the mammogram, but it’s not the only one.
A mammogram is an X-ray photo of the breasts. Just as you can see the shadow of your hand on a sunny day, breast tissue creates a shadow on the X-ray. Just as you can make complicated shadows by turning your hand or overlapping both hands, so can tissue from different parts of the breast overlap in the projections to make the x-ray hard to interpret. Taking two pictures from different angles eliminates some of the problems. Some cancers may not be visible on the mammogram. This is called a “false negative”. Normal tissue may look suspicious on an X-ray, but turn out not to be cancer. The rate of such false alarms (false positives) is so high that about 95% of women who have an abnormal
screening mammogram result do not have cancer.
The image can be collected on film (film mammography) or using a digital detector (digital mammography). Digital seems a little more sensitive in women with dense breasts (see below) before menopause. Film may be slightly more sensitive in older women with non-dense breasts (details here).
A “screening mammogram” is a routine mammogram done when a woman has no symptoms. A “diagnostic mammogram” is done for a reason other than screening, such as a previous abnormal screening mammogram, symptoms or signs noticed by the woman or her physician, history of breast cancer or biopsy-proven benign disease, or certain other factors. Even though the test is the same, price and insurance coverage rules may differ between screening and diagnostic mammograms.
Breasts differ in the amount of denser tissue (glands, connective tissue) they contain. Some women are said to have “high breast density” or “dense breasts,” because their breasts have more glandular and connective tissue. This shows up as more shadows on the mammogram.
With dense breasts, both the risk of missing a cancer (false negative) and the risk of an abnormal result in the absence of cancer are higher. For both these reasons, physicians may recommend other studies. Additional studies may also be recommended for women with higher than average risk of breast cancer based on family history, genetic testing, etc.
For all X-rays, there are occasions when the film/recording is not technically good enough. The technicians taking the X-ray should prevent this. When it happens anyway, it seems fair that it’s the provider’s cost. A more common reason to do a second mammogram is that some abnormality was seen on the first one. Taking images with a slightly different angle helps decide between “normal” and the need to do yet further tests. This second mammogram can be called “diagnostic” and billed separately. For Medicare, the screening mammogram is free, but co-pay applies to the diagnostic test.
Not sure it’s covered? The experts at the National Women’s Law Center write: “Health plans are required to cover, without copayments, the preventive services recommended by the United States Preventive Services Task Force (USPSTF), including annual mammograms for women age 40 and over.” There are subtleties, though; here’s a fact sheet. The American Cancer Society also has this page of resources for breast cancer screening, including a state-by-state list of laws on what’s covered.
In our crowdsourcing survey with the Brian Lehrer show on WNYC, we heard from a number of women who had similar experiences: They had a mammogram, left the facility, and were called back for a second mammogram because “after we read it we decided we need another view” or “something looked funny.” This practice of calling a woman back for a second mammogram, and then charging it at full price, caused worry and unhappiness. We also heard from a number of women who had experienced this – and chose to find a provider who would read their mammogram on the spot and give them the “all clear.”
Magnetic Resonance Imaging (MRI) of the breast uses differences in magnetic properties of different tissue to form a picture. Multiple images based on magnetic properties of tissue are combined using a computer to generate images. A breast MRI is not used for screening under normal circumstances, but may be indicated in high-risk individuals, as a follow-up of an abnormal mammogram or when mammograms are not that informative such as dense breasts.
A breast sonogram (ultrasound) uses sound waves from a hand-held wand to make a picture of the breast. This gives more information about any abnormality seen in a mammogram, or adds to the picture when mammograms give insufficient information.
O.K., so what does this all cost? Medical practices set their list prices based on normal business concerns such as staff costs, facilities costs, etc. Medicare reimbursement rates (what the government pays for Medicare recipients) are the closest thing to a fixed or benchmark price in this marketplace. They have long been thought to constitute the low end of reimbursement rates from all payers (government, private insurers, military insurers like Tricare, Medicaid and others). Increasingly, though, we are hearing of private insurers that undercut the Medicare rates.
The Medicare reimbursement rate varies with location, because different locations have different costs. A procedure reimbursed at $861 in some New York suburbs may be reimbursed at $828 in Manhattan, $675 in most of New York State and at $647 in Kansas. You can find the rates in your area in the search box on every page of our site. Most of your reports in our mammography survey come from the New York City area, which is more expensive than the national average.
National average Medicare reimbursements in 2012 to freestanding imaging facilities (all for two breasts including interpretation by the radiologist) were approximately:
Screening Film Mammomography (77057): $81
Screening Digital Mammography (G0202): $140
Diagnostic Film Mammography (77056): $112
Digital Diagnostic mammography (G0204): $169
Breast Sonogram (76645): $99
Breast MRI (77059): $717
How can you use these numbers? First, you can look at the relative rates. Likely, these will be reflected in the price. Expect an MRI to cost seven times as much as a sonogram. Insurance companies negotiate a price with their member practices. Usually, this price will be above the Medicare reimbursement and below the list price. Sometimes, it is based on Medicare rate plus some factor, for instance 20%. These rates are not public, but when you’ve had an insurance-covered test, your insurance statement will contain the info.
If you are planning to negotiate a price, look at the Medicare reimbursement rates as a floor and the listed price as a ceiling.
Want further information? Here are some resources:
Recommendations on early detection from the American Cancer Society
Early detection via mammograms from cancer.gov
The Mayo Clinic on breast MRI’s
Women and their insurance companies are paying wildly varying prices for mammograms, and doctors and clinics are charging wildly varying prices, we found in our crowdsourcing project with the Brian Lehrer show on WNYC.
We asked people to send in prices of routine mammograms for this project, letting us know what they were charged, what they paid and what their insurers paid. We knew that there would be some variation in what people considered a routine mammogram, and some variation in the price — but we never expected the range to run from $0 to $2,786.95.
First things first: thanks to the nearly 400 of you who shared your bills. We learned a lot, and we are honored that you joined in with us.
So, how much does a mammogram cost?
Well, your data shows a fairly substantial number of payments by insurers around the Medicare
rate for a screening mammogram, around $170. (More graphics soon). There is a substantial number of charges by providers, and payments by individuals paying cash, around $350-$550.
Another answer to the question: Here at clearhealthcosts.com, we do pricing surveys for cash or self-pay prices for common procedures. What we have found here in the New York area is a range from $50 to $607 for a mammogram if you ask in advance and pay cash; here’s our price list for New York and here’s one for Los Angeles. (Other cities coming soon.)
You told us you had heard $180 and $540 from the same provider.
You told us things like this: A charge of $1,195.90 and a payment of $1,195.90 at a big New York teaching hospital, “Insurance paid in full, employer pays 100% of routine mammograms. Received separate bill from radiology for $175, plan discount $123.02, plan paid $51.98.”
At the same hospital, a bill of $1,105.42 and a payment of $884.34, with this comment: ”The cost of a mammogram has increased enormously in the past 2 years. From the same facility in 2010 it was $175. It took almost a year for [insurer] to pay. In the meantime [provider] turned the billed over to a collection agency so I paid the 884.34. I have not as yet been reimbursed though I have tried, with calls to [provider] customer service and letters to them.”
At another big New York teaching hospital, you told us charged prices ranged from $505 to $719 (One higher charge, $972, was identified as a diagnostic mammogram). The payments from insurers ranged from $129.35 to $698.
A comment: “I went for a mammogram in Feb as that was the final month of my insurance with this particular carrier. They paid for my mammogram, according to the statement I received, $21, (which I was shocked at). Months later the hospital started billing me $719 and when I inquired why, they said my insurance company claimed I was only enrolled through Jan and they retracted the payment. I’m still fighting this but when I called the hospital and said, ‘Look I know the insurance only paid you $21, let’s negotiate a deal so that I don’t have to waste time fighting this’. The reply, ‘Ok, we’ll give you 10% off”. Me ‘Uh, No.’ ”
Wait, aren’t mammograms supposed to be free under the Affordable Care Act? Yes, and the law is coming into effect. But (sigh) it’s complicated, so we did a completely separate blog post about that. You can find it here.
Here are a few of the things you told us:
- There’s a great deal of confusion about what’s routine and what should be covered by insurance. Some of this seems completely innocent and accidental, but some seems to be annoying, costly for the woman involved and downright upsetting. Is there a charge for reading a mammogram? Is a mammogram of any value without a reading? Is there a charge for receiving a mammogram from a provider? Can it possibly be right that a mammogram is not read fully on the first pass, so the woman needs to come back for a second one, that second one no longer covered by insurance?
- Hospitals generally charge more than self-standing radiology practices.
- The figures we received often were clearly a routine screening mammogram, but just as often they were something different — a diagnostic mammogram, for someone who has signs of cancer, or a family history, or something similar, and therefore the mammogram is no longer a routine screening but a search for cancer. Because the routine, screening one is generally less expensive and less comprehensive than the diagnostic one, the price results are a bit apples to oranges to kiwis to bananas.
- Even knowing those differences, the prices varied widely. Further, the price that’s charged is often completely disassociated from what’s paid. In general, insurers reimburse a fraction of the charged price.
- People are upset about their health-care bills and looking for some clarity.
What does the rest of the marketplace look like?
If you just project this over the entire health-care marketplace, you get an idea of the chaos in pricing, which a well-known academic called “chaos behind a veil of secrecy.”
At clearhealthcosts.com, we are a partner to the Brian Lehrer show and thus we don’t have access to your email addresses under the WNYC terms of service. We wanted a second opinion on what we were seeing, so we showed a limited data set to several people, including Dave deBronkart, a cancer patient and advocate for transformation of the health-care marketplace, and he said he was blown away. He’s the guy who issued an RFP for treatment of his skin cancer, and who price-shopped a CT scan checkup for kidney cancer.
What he said about this information: There were some suggestions of ”vermin” picking patients’ pockets, and many “Mother Teresas” giving good care and thoroughly inspiring healing.
He added in an email:
“So pleased to see a number of people defining what they want and what they’ll put up with. Imagine what they’ll achieve when they have good information!
“Ultimate takeaway: Consumers evidently do use the info they have, within the constraints we put on them.
“Recommendation: it should be REQUIRED that every provider have a posted price list. Required. And every explanation of benefits should be required to list the medical code for every charge.”
As we analyzed the numbers on the share form, we learned a few things:
- We needed to make a better form, to clarify what’s routine screening and what’s diagnostic. We learned a lot about how to do that, and next time we’ll do better. And yes, we’re doing more of this. Count on it.
- Because this went through our partner WNYC and their terms of service do not allow them to pass on emails, we can’t thank you, our contributors, directly any way other than here and on WNYC. So, thank you. You are awesome.
- Because our questionnaire was slightly ambiguous, we drew some conclusions from the data you shared that we thought were unassailable. Other things – if we felt that we were guessing — we just left as they were. We made some charts and things that we’ll share with you over the next few days.
- The cost of a mammogram (what it costs to provide it); the price (what’s charged); and the payment from the insurer or the government are not related in any consistent way that we could divine — yet we’re still analyzing the data.
What you told us about what you saw
A number of people are negotiating prices with providers, asking for a cash or self-pay rate. Negotiation of this nature is possible in advance, but harder after.
One wrote: “Let me explain. I haven’t actually had the mammogram yet, but since I can’t afford the insurance premiums (over $1100 a month, individual plan, 3rd worst plan) I asked what it would cost me for a mammogram. The answer – $180 if I could pay it all that day, $540 if I wanted a payment plan. The amount of $180 appeared to be what they would collect from the insurance company if one was involved. This was for a digital mammo.”
Another wrote: “I have a very high deductible policy. I always say I don’t have insurance as I never meet the deductible. This facility has new digital equipment. I pay $100 for the mammogram and a similar amount for the radiologist to read it. I have done this for the past 10 years. I am lucky enough to be very healthy but I have had an occasional expense. All have been out of pocket, paid by credit card and are far less than I would have paid using an insurance policy. I view insurance as catastrophic coverage only. Truly much cheaper for the individual. …
“If we all took an interest in the total charges, fees would fall.”
A lot of people find bills impenetrable.
“I had to call hospital billing just now to get the price of the routine mammogram, because on my bill it was lumped together with the cost of other procedures I had done that day. I was also told there is no price list of procedures per se (even for routine mammogram).”
People are paying different rates depending on their insurance plans: i) where the insurance pays the negotiated amount and the insured pays nothing; ii) where the insurance pays the negotiated amount and the insured pays the rest. When you have high-deductible insurance, do you pay “covered amount” or “sticker price” out of pocket? It seems to vary a lot; this is an area we hope to explore more thoroughly, with the rise in high-deductible plans.
A bit about our methodologies
We talked a lot about naming providers. We decided to give props to providers by name if they were nonprofits and clearly a resource that women should know about (see our resources page, coming up, and our current “useful links“). What we list on the clearhealthcosts.com web site — our surveys of cash or self-pay prices in cities in the New York area and California, and, soon, Texas — have names, address and phone numbers of providers attached to them, so people can go directly to a provider knowing what that provider charges for a cash or self-pay person.
But with the WNYC survey data, we felt that naming a provider or payer for what looked like bad behavior was not part of our mission. (Our lawyers agreed.) We are not medical professionals; who’s to say if they didn’t read her exam properly the first time and called her back just to gouge her? Though we are really annoyed at the place that imposed a $50 charge for receiving a mammogram. And the hospitals that sent bills to collection when they were under discussion, or failed to explain what they were billing for.
We know enough about the system to know that there’s no one guilty party: incentives are misaligned, and so all the players are at odds. Providers say they have to charge inflated prices to win payments they can stomach. Payers say providers always inflate prices in an unjustified fashion. Government says it’s not able set prices or to regulate all transactions between for-profit entities that are doing business with each other. Drug companies say they don’t get enough money to cover research and development, and at the same time seek to put as many people as possible on their drug instead of a competitor’s. Device makers, pretty much the same thing.
Health care is a $2.7 trillion annual industry, and it eats up about 18 percent of our GDP. And yet the industry is opaque: no one knows what things cost in health care, because the price that’s charged by the provider is often not what’s paid — providers tend to charge a high “notional” price, and payers (insurance companies, or the government) tend to pay a lower rate, either one that’s fixed by law (Medicare, Medicaid) or by contract (private insurers). Who pays the high sticker price? The uninsured, and the uninformed.
There’s a growing interest in health-care prices. Health insurance is expensive and a lot of people are uninsured, or out of network or out of pocket for other reasons. (We heard a lot from people who swear by their provider and are certain they want to pay extra for what they regard as better quality testing.)
So rather than point fingers by naming providers and accusing them of misbehaving, we are going to say: It’s time for transparency. The system is broken.
* * * * * * *
Also in this series:
1. Where’s my free mammogram? (Already posted)
2. There are weird unexplained charges all over my bill. Can you help me understand this?
3. We don’t offer medical advice, but we wanted to tell you about the guidelines, what’s baseline etc.? Fred Lindberg is a doctor, and he’s going to offer some thoughts.
4. Women’s health resources. No one should ever have to go without a mammogram or other women’s health issues. Reproductive health belongs to us. Here are some resources, and some thoughts about women’s health.
5. Reader comments. We can’t wait to get to this. This is a big concentrated swallow of your thoughts and opinions. Dear listeners-readers, we love your voices. Hear them and see them here.
6. The takeaway: If a simple thing like a mammogram is this messy, then what does the rest of the health-care marketplace look like? We have some thoughts about how to be a patient, and a consumer, and — well, truly — a person in this marketplace.
* * * * * * *
Caption for graphic: Credit Frederik Lindberg
In the survey of mammogram costs, you gave us 325 responses. Some were exact duplicates, probably due to saving twice, so we removed the duplicates. There were two responses that clearly stated that the price was for both mammogram and ultrasound exam/sonogram, so we took them out for this analysis. In some cases, amount charged and negotiated price were in the comment section only, so we transferred those numbers to the correct fields. We then for this analysis looked at only responses that have a non-zero amount both for “Price” (the amount the provider charged/asked for) and “Payment” (the amount the provider was paid by the insurance, the customer, or both). This left us with 214 responses.
To show the information, we sorted the responses by price and for each report plotted both the price (blue dot) and the payment (red dot). You can see from the blue dots that the price ranges from about $100 to over $2,200, with most prices being $800 or less. You can see that payment (red dot) usually is quite a bit lower than price, although in some cases the are the same (red dot on the blue line). It looks like many payments are between $100-200 and most were below $600.
In the inset graph, we grouped Price and Payment separately into $100 ranges, $0-100, $100-$200, etc showing the distribution of the reports for Price (blue columns) and Payment (red columns). The middle of the range is shown on the bottom axis, for instance $250 for the $200-$300 range. You can again see that most prices were below $800. Many payments were at the Medicare reimbursement rate of $100-$200 and most payments were $600 or less.
This is not a scientific study of prices, just reports from interested persons. The questionnaire was quite complicated, to say nothing of the insurance forms, so there are likely some reporting errors. We also believe that several reports were for tests and services more complicated than a screening mammogram, which may explain some of the high price and payment points. Still, mammogram prices are very variable and most mammograms are paid for at a rate far below the listed price. It’s worth to ask about the price and to negotiate, especially when you pay yourself or go out of network!
So where’s my free mammogram? The Affordable Care Act mandates free mammograms for everyone, right?
Well, actually, it’s more complicated than that.
Some mammograms are covered completely, by either the company or by the insurer. Yet a lot of people are paying themselves, for various reasons, as we learned somewhat to our surprise during our project with the Brian Lehrer show on WNYC crowdsourcing the price of mammograms. (We will be posting about the results of our survey over the next week or so.)
The experts at the National Women’s Law Center write: “Health plans are required to cover, without copayments, the preventive services recommended by the United States Preventive Services Task Force (USPSTF), including annual mammograms for women age 40 and over. This provision took effect in September 2010. … ‘Grandfathered’ plans — those that existed before the Affordable Care Act was
passed — are exempt from this requirement, but plans will lose their grandfathered status if they significantly cut benefits, increase out-of-pocket spending, or change insurance carriers.” Here’s a fact sheet. The American Cancer Society also has this page of resources for breast cancer screening, including a state-by-state list of laws.
The picture we got of people assuming their mammograms were covered, and finding that they aren’t, raised questions: Many might have been under “grandfathered” plans, while others might be paying when they don’t need to. Some of the mammograms our contributors shared about took place over the past year or so, as the Affordable Care Act has gradually been coming into effect. We don’t know all the circumstances of everybody’s plan, so we can’t say definitively that everybody who paid shouldn’t have.
Also the costs varied widely (more later, and here’s a big shoutout of thanks to everyone who shared info: You. Are. Awesome.)
So do you think you are being charged when you shouldn’t be? What should you do? This article by the (NWLC) is a good guide — it refers specifically to contraceptives, but you could use similar wording for mammogram coverage.
For many people who shared their information, their mammograms were fully covered.
“My provider does not accept insurance, however, my insurance plan covers 100% of annual mammogram cost for women over 40.”
“I’m a self-employed Texan where health insurance is ridiculous: I’m stuck with an independent PPO policy with a $11,500 deductible. However I paid $0 because it was covered, I think because of Obamacare. Yay Obama!”
For many people, it was not covered at all, or only partially covered.
Here’s one, a charge of $380 and a negotiated rate of $170.37: ”According to my Statement of Benefits, my insurance company did not pay any of this — I had to pay all of the negotiated price out of my pocket ([insurer] put it toward my deductible). I thought that routine mammos were supposed to be covered 100% under the ACA…”
“Because I have to meet my deductible, none of the cost was covered.”
“My insurance would pay but I rarely meet the deductible and she’s not in network.”
Meanwhile, we heard a lot from women who chose to pay for their mammograms themselves because they trust their out-of-network providers. More about that in another post.
We heard from people who got a routine mammogram, and then were told after they left that they needed to come back and get an ultrasound, or even to get another mammogram. (Our friend who wrote a mini-three-part-series about this, here, here and here, is one such person.)
“I had a second mammogram on Apr 20, 13 as they needed to re-evaluate certain areas. The charges were $408 and member plan rate was $205.49.All was covered by the insurance I didn’t pay anything for the additional one. Couple of years ago, we had another insurance company and they had me pay the member rate fully as they didn’t accept the additional imaging!! this year I was lucky!”
“The radiologists at this clinic do not look at the mammogram until after the appointment. This year something was not clear so I had to return to have part of the mammogram redone. This redo cost me $366 out of pocket because it was no longer the routine annual screening (which is covered without a deductible). Will find a radiologist who will look at the results while I am still in the office for the next time around.” Charged: $623. Paid: 416.14.
Compared to this: “my first visit was 380.00 less 15% (uninsured discount)= 323.00/I had to go back for additional views 2 weeks later & that was: …same place, 519.00 (317.00 x-ray & 202.00 ultrasound), uninsured discount: 15% (77.85) to = 441.15. Very pleased to contribute my information!”
Not everybody thinks this is an innocent mistake. Casey Quinlan, a media strategist and author of “Cancer for Christmas” and herself a breast cancer survivor, wrote in an email:
“My advice to any woman scheduling a mammogram: work ONLY with facilities who read the scans during your appointment. Why this isn’t SOP everywhere isn’t clear to me, other than they didn’t get the memo about patient-centered medicine. What is clear is that women can wind up paying for a second scan, days later, if there’s something the radiologist wants another/better/clearer look at. That could indeed be a revenue-generating move on the part of some imaging centers.
“I’ve only worked with imaging facilities where the scans are read immediately, and have been lucky enough to find two locally (Richmond VA) where I get to see the films, too. The downside is that I was able to diagnose my own cancer, simultaneously with my doctor, back in ’07 – but that was most definitely a win! The cost for my diagnostic bilateral – in the latest technology: 3D – at my center in Richmond VA is $250. I self-pay, since I’m uninsured, and this is the top mammography center in my area. That’s another win, in my book.”
Once the mammogram is considered a diagnostic mammogram — when the radiologist is perhaps looking for evidence of cancer, a woman has a symptom, has had a history of potential problems, or is having a re-do of a routine mammogram, quite often the patient no longer falls under preventive services, and thus the procedure may not be covered.
There are also state-by-state variations. For example, Connecticut covers ultrasounds if recommended under certain circumstances. Rhode Island “requires individual and group insurers to provide coverage for 2 screening mammograms per year for women who have been treated for breast cancer within the past 5 years or who are at high risk for developing cancer due to genetic predisposition, have a high-risk lesion from a prior biopsy or atypical ductal hyperplasia),” the ACS Web site says, adding that in Wyoming, “the health plan is responsible only up to $250 for all cancer screenings.”
Screening is routine, the standard test, but a diagnostic procedure is on a more heightened alert. The script might go “we think there could be something here, so pay close attention.” The charge is higher. Sometimes also women were charged for both a mammogram and a sonogram, and received no insurance payment or only partial payment.
This was a typical comment: “Provider does not accept insurance reimbursement. Insurance (United Healthcare/Oxford) allows a maximum reimbursement of $222.75, but since we had not met our $9,000 out of network deductible, I received no reimbursement.”
“I pay the provider directly ($850.) This is for a mammogram AND a sonogram.
The insurance company covers $294 of this fee with a reimbursement check.”
If you’re uninsured and qualify for low-income services, here are some options. (we’ll add a separate, longer version of this in a couple of days).
“The Avon foundation offers FREE cancer screening for women with no insurance. They are associated with Columbia Presbyterian Hospital. Women can get their standard mammograms and Pap smears and I believe they also offer free prostate exams for men. I used me for my first 3 mammograms in NYC and when I had a lump and needed a sonogram and biopsy I was not changed for that either. It’s an incredible service for the low income uninsured.”
Women’s Outreach Network: “Free – if you have insurance they will bill them, but you won’t ever see a bill. It’s a mobil mammogram unit that parks in different places around the city. 631-581-4171 Let’s hope they still exist.”
And two other suggestions: People who are uninsured increasingly are negotiating prices for procedures before having them, paying cash. This is true not just for mammograms, but for other procedures as well. Here’s our list of mammogram prices in the New York area. You can find similar lists for other cities; just search.
And, to close, two of our favorite stories from the women who contributed their price information.
Here’s one: “Called to find out the cost since I don’t currently have health insurance. Was quoted $194. I can afford this and won’t have to wait until I do in fact have coverage.”
And this: “I was given a quote of $1,200 minimum for a mammogram at [provider No. 1]. [Provider No. 2] would not even put me on the schedule if I was paying out of pocket (“only Medicaid and Medicare). So for less half the price of a mammogram at [Provider No. 1], I bought a plane ticket to Kansas, rented a car, and had my mammogram on the same brand-new equipment they use at [Provider No. 1]. Ridiculous.”
We get excited about price information over here at Clearhealthcosts.com, and we like to share our wonky excitement with you.
Here’s a site where Medicare’s prices for drugs covered under Part B of Medicare are collected. The current data set is from April 2013. Chemotherapy drugs, vaccines, steroids, antibiotics, vitamins, painkillers and the like. These are drugs given in a hospital or clinic, often by injection; common prescriptions are not here.
We generally regard Medicare pricing as something of a fixed or benchmark price in this marketplace, and since medication prices are so hard to find we are pointing this out as a resource.
If you are searching in Excel, you may have to fiddle a while to get it to search properly. I got it to work by searching under “Workbook,” but its functions seemed inconsistent.
Our friend who was ordered to get a second mammogram, which was not covered by insurance, wrote to us again (if you missed it, here’s her first post.)
The day of my second mammogram coincided with news of Angelina Jolie’s double mastectomy. I was convinced I had breast cancer.
I had been told that I needed a second mammogram with very little explanation other than I knew I had to pay cash for it because my “testing budget” had been expended under my insurance plan, and because the doctor wanted to see “another view.”
When my turn came, the clerk sent me to radiology. When I got there, the clerk asked for my insurance card, and I reminded her I was paying for the test myself. She said she knew nothing about that, then directed me back to the waiting room I had started in.
The time of my scheduled appointment was near. I had a business appointment, and I was willing to write a check to get my test taken.
The patient representative appeared and ushered me to a room. She said she was the one who gave me
the estimated self-pay cost of about $365 for the second test. If I recalled, she said, first my application would have to be rejected by the insurance company before I could pay out of pocket.
I did not recall. I only recall that when it was suggested the hospital might be able to nudge the insurance company into paying, no one returned my call.
I did not want to deal with getting a whopping bill for the second test. I had already knew my insurance company would reject it. Couldn’t we just cut to the chase and avoid me having to negotiate later to a self-pay rate?
No. The best I could get was the direct phone numbers of the patient representative and the billing supervisor and their pledge that they would remember me and this conversation.
I had the option to walk out, and take my breasts elsewhere. I finally decided to stay because I wanted the test done — it had already been three months and I felt as if a time bomb was ticking.
The technician was patient and told me she was paying off a colonoscopy at $10 per month because her medical insurance had such a high deductible. “If you are ever in a position where you get a medical bill you cannot pay, just pay off a set amount every month and they can’t hurt your credit rating.”
She checked with the hospital administrator to confirm this was in fact the case.
Because of the situation, the technologist took my x-rays immediately to the radiologist to review just to make sure no third test would be requested — that would also not be covered by health insurance
The technician came downstairs to tell me all was good. I was told I needed a second mammogram because I have “young breasts” and the radiologist wanted to see them from a different angle. The density of tissue and lack of a benchmark test made her want to be absolutely certain.
I exhaled and said a little prayer of gratitude. I need to get myself mentally fit for the paperwork to come.
An ad for surgery on the side of a bus is guaranteed to get my attention. So this ad for “custom knee replacement” at the Raritan Bay Medical Center was definitely of interest.
I called the hospital to ask what that means, and what it would cost. The customization comes, according to Maryann Finney, assistant director of nursing for the surgical services, when a patient has an MRI
before surgery and the MRI is then sent to the implant maker, which customizes an implant based on the MRI results.
Would a price quote be available before surgery? Yes, she said, keeping in mind that implant costs vary.
“You’d have to make sure you have already gone to a physician,” she said. ”You can call us and tell us who your physician is, see what he will use as an implant and we would incorporate that into the price.”
If you wanted to shop around, you could use the interactive map on Medicare pricing made by The New York Times from the Medicare charge and payment data made public recently by the Department of Health and Human Services. The numbers include what hospitals charged Medicare and what Medicare paid them for 100 frequent diagnoses. “Major joint replacement” is one of the cases.
About the buses: they are New Jersey transit buses, according to Lynette King-Davis, vice president of marketing at the hospital, an independent nonprofit hospital with two locations, one in Perth Amboy and one in Old Bridge, licensed for 501 beds.
While prices for knee replacements are not listed on the hospital’s web site, they do have the answer to another frequently asked question: how much does gastric bypass surgery cost? At Raritan Bay, gastric band surgery costs $11,400; gastric bypass surgery $19,400; and gastric sleeve surgery $15,100,
“Please note that the prices below are ‘Bundled’ prices, which means that the prices quoted on this page are prices of the procedures quoted below, which includes hospital stay, anesthesiology and physician/surgeon fees. Any other fees associated with the procedures, including labs and radiology are not included. If you have any questions about the procedures and prices below, please call us at 732.324.5098.”
And also on Google, I see that knee replacements are being advertised quite a bit– a search brought up results from a large number of providers, including the Hospital for Special Surgery in New York.
A friend writes:
“Shoveling our voluminous heavy snow wreaked my lower back to new lows and, during an annual physical exam, my doc showed me a sample lumbar support (called back brace in the medical equipment world) that a rep left him.
“It was quantitatively better than what I’d previously purchased at Home Depot. I contacted the rep, whose
company has him a) on salary and b) making house calls (kudos on both counts).
“He came over and I tried several models. In the professional medical world these devices are also used post-surgically and are available in quite built-up form. In that form the Medicare-encodable item bills at $800; for self-pay or cash customers it’s $400.
“The stripped-down belt, which provides 80% of the support, bills at $400 for Medicare; for self-pay or cash customers, it’s $175-200. I found and obtained the item for $75 on Amazon, a price point offered by multiple vendors.”
A related question: How much does an Aircast cost? Not long ago another friend got a stress fracture from running. The orthopedist who diagnosed it put him in an Aircast. Since he was on a high-deductible plan and had not yet met his deductible, he was responsible for buying the Aircast, which was billed at $500.
Looking at the Aircast and the bill, he had the idea that such an item should be less expensive. He went to Amazon, and found it for $90. He went back to the doctor and explained that he thought the bill must be in error.
The doctor explained that the price was right, and that the markup was needed to cover overhead. My friend still wasn’t satisfied.
The doctor said, “How much do you think you should pay?”
My friend answered, “$90.” And that’s what he wrote a check for.
Everybody wants to be transparent these days.
A new pricing tool came across my radar today, this one from AthenaHealth, the medical services company that has expanded into electronic medical records, doctor practice management, patient communications and so on.
One of their biggest services has to do with practice management, and that, of course, includes on of our favorite topics, billing.
An AthenaHealth tech guy just wrote a blog piece rolling out a tool called “CodeView,” which lets us peek at some of Athena’s pricing information, that info that is usually kept under lock and key. This new tool shows average prices, along with Medicare and
Medicaid reimbursement rates, for a few key procedures and items. The data’s national; if you give up some personal information, you can see regional info (I didn’t).
“Actual commercial contracted rates are some of the best kept secrets in health care, and while we guard individual provider data with our lives, our massive database allows us to compare and benchmark contracted rates across 40,000 providers, in all 50 states,” writes the analytics chief at Athena, Iyue Sung. “We can access medical billing rates for commercial payers, Medicare and Medicaid, and have done so: the result can be explored in a new app we’ve developed called CodeView.
“CodeView displays the maximum, minimum and average dollar amounts that insurers pay providers. Why does this matter? Because having access to accurate price information is essential to decrease cost. Furthermore, as any free marketer knows, having visibility to the differences in prices is key (we won’t get into the issue of private vs. single-payer systems). Those differences, the gaps, are what CodeView really attempts to highlight.”
The most interesting thing in the blog post: “It is generally understood that commercial payers have a much wider variation in contracted medical billing rates than Medicare for a given procedure. What surprised us a bit with this data is that some providers are actually paid less by commercial insurers than by Medicare, for the same procedures.”
We appreciate and applaud all transparency plays — including healthcarebluebook.com, fairhealthconsumer.org (both services with large amounts of data that have a small consumer-facing tool and a big practice selling more detailed information to businesses) and CastLightHealth (available only through your employer).
Those three, and others, keep the really important information — how much will I pay to this particular provider? — in the dark. So they’re a kind of transparency, but really more on the order of transparency for a few.
So for whom is CodeView useful? A consumer/patient wanting to price a procedure or item? Or a physician practice, wanting to know what are the limits of pricing? Hint: “Select your specialty” is the prompt.
And so, CodeView. Also transparency, of a sort. For a few.
“The study found that among women and newborns with employer-provided commercial health insurance, average total charges for care with vaginal and cesarean births were $32,093 and $51,125, respectively. Average total Commercial insurer payments for all maternal and newborn care with vaginal and cesarean childbirths were $18,329 and $27,866, respectively. In Medicaid, average total maternal and newborn care charges for care with vaginal and cesarean births were $29,800 and $50,373, respectively. Medicaid payments for all maternal and newborn care involving vaginal and cesarean childbirths were $9,131 and $13,590, respectively. Both Commercial and Medicaid payers paid approximately 50% more for cesarean than vaginal births. For both types of birth, Commercial payers paid approximately 100% more than Medicaid. ” — Maureen P. Corry, Medscape, The Cost of Having a Baby in the United States: Executive Summary. Truven Health Analytics recently issued a major new report,The Cost of Having a Baby in the United States; with permission from Truven, Medscape is reproducing several items from the report.