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. When is a mammogram not a mammogram?
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!