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.

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.) Between insurance? You’ll learn a lot.

So, about my quest to find out the price of a second mammogram, because my insurance covers only $600 in testing in a   year, and I’ve expended my budget . …

I did not deliberately buy insurance that leaves me exposed.

When I was laid off last summer, I elected to take the expensive COBRA group coverage at  $1,094 per month. I didn’t want to shop for coverage that could leave gaps.

My employer was an entrepreneurial company insuring fewer than 10 people. It was Blue Cross/Blue Shield Horizon comprehensive, and  had a $2,500 deductible on certain categories of treatment. When I was an employee, the premium was fully covered.

I’d have been able to get two mammograms covered and not need to think about it.

Four months into my COBRA plan, which I was expecting to last the entire 18 months, through the end of

2013, I was advised that what was left of my employer’s company was dissolving completely and I should start shopping for my own plan.

I turned to an online insurance shopping marketplace. This was probably a mistake because it created a barrier between me and the insurance company, but I only realized that after the fact.

I applied for a major insurer’s EPO Plus plan, and thus began a series of  failed communications. I didn’t want to discontinue my COBRA until I got confirmation that the new policy had accepted my daughter and me, and at what rate.

My daughter has a history of sports injuries and I am youthful, but 55, the magic age at which all sorts of things can start to go wrong.

I was told I would not get accepted by the new policy until the old one was canceled. There could not be any overlap in coverage, even if I paid for both policies.

I had some misgivings, but instructed my employer to suspend my COBRA on Dec. 1, 2012. Through the first week of December I crossed my fingers that I had some kind of coverage, because no confirmation came.

After badgering the online insurance shopping marketplace by phone and by email, I finally got confirmation we were enrolled and at what price, which was the same amount quoted on the  website of $744.55 per month.

But I was cautioned not to cancel my existing insurance until I had received the full written prospectus for the new policy. WTF?!

Then came the wait. It took two months and several phone calls to receive the written policy terms. That’s when I saw in big letters. THIS POLICY HAS NO MAJOR MEDICAL and NO CHEMOTHERAPY.

Mind you, I wasn’t setting out to get cancer, but the idea that chemotherapy coverage was non-existent made me a little bit crazy. It got worse. I called again to learn that in fact I didn’t have the exact right description of coverage and I had coverage if I were to be hospitalized but yes, I had no chemotherapy. At this point, I wasn’t sure what coverage I had, but asked to upgrade my policy to make sure that if I ever got cancer I would be able to get treated by SOMEONE!

“You have to wait for the open enrollment period in November,” I was told because I didn’t request an upgrade within the first month of coverage. “But it took two months for the documents to arrive,” I blurted. “Why is that?” they asked me.

“HOW WOULD I KNOW?  YOU ARE THE ONES WHO SEND THE DOCUMENTS!!!”

I had expected to have a new full-time job by now with group health insurance. It’s true I have friends who have gone without health insurance for years. Everything is relative.

I’ve scheduled the second mammogram at the same place where I received the first one. They quoted me a self-pay price of about $365. but said that is not guaranteed.

Just breathe.

“Roughly 80 percent of health care costs are driven by just 19 percent of the population – encouraging healthy people to cut back on health care simply misses the majority of costs. … ”

Pretty cool: here’s a web site, AuntBertha.com, that catalogs government, business and charity aid programs and makes them searchable by subject and by location.

“We collect all federal, state, county, city, neighborhood, and charity program information and put it in one place. If it’s based on need, then we collect it. It’s pretty simple, really. Using information we learn about programs, and what we learn from the user, we intelligently match people with services that are designed specifically for their situation.”

Founded in Austin in 2010, the site’s search engine will help you find, for example, drug companies’  payment programs for low-income patients. Or food aid for people struggling to put food on the table.

Health, transit? Housing, legal help, education? Aunt Bertha’s got an answer for you.

And by the way, it uses Google Translate to offer versions of the page in French, Russian, German and a host of other languages, including Albanian and Esperanto.

People trying to save money on birth-control pills and other medications may look at online pharmacies — or at buying overseas (or across the border).

Online pharmacies — to use, or not to use?

We thought online pharmacies might be an important player. But most of the women we spoke with about buying birth-control pills were unenthusiastic about online offers. Many sites offer drugs cheap — really, really cheap. For some, no prescription is needed.  That worried us, not just for birth-control pills but for other medications as well. There is a whole slew of web sites selling cheap drugs, and some look really sketchy.

The National Association of Board of Pharmacy gives the stamp of approval (known as VIPPS, or

verified Internet pharmacy practice sites) to online drug sellers that meet its standards. It keeps a running list of VIPPS, which could be useful if you are in the market.

The approved sites listed here are all U.S. sites.

There tend to be two kinds: one supported by insurance companies for their insured population (Aetna, Cigna, Caremark) and another group — rxdirect.com, kmart.com, drugstore.com.

“It is technically illegal for individuals to order drugs online from other countries,” according to Roger Bate, an American Enterprise Institute fellow who wrote an article about this topic in the Op-Ed section of The New York Times. “And yet no sooner does the F.D.A. shut down one dubious online pharmacy than another pops up. According to the National Association of Boards of Pharmacy, only 3 percent of the 9,600 online pharmacies it has reviewed complied with industry standards.”

Savings can be significant, but, as Bate points out, the safeguards are limited. Then again, safeguards in the United States are limited too — just recall the Vioxx scandal, or the compounding pharmacy scandal that killed and maimed pain sufferers whose doctors gave them supposedly soothing shots of steroids that turned out to be tainted.

We are hearing a lot about people with creative overseas solutions also.

A friend writes: “A lot of people I know — including myself when I was using them — get their pills across the border in cities such as Tijuana and Juarez (yes, Juarez. People still go there to socialize and buy things like medicine). A month of pills in Mexico costs $4 or $5 US dollars. You can also put together your own ‘Plan B’ dose using Mexican b/c pills (which are made by multi-national companies, the same ones as in the US). Birth control in Mexico is sold without prescription. Anytime you talk about the wild fluctuations in birth control pill prices, you should be comparing them to what they cost in Mexico, and it also helps to recognize that many Americans who live near Mexico, or travel there frequently, economize by getting their medication just a few feet from the US.”

She also told us that she goes across the border to buy antibiotics and other common medications.

When we last wrote about buying birth-control pills overseas, we talked to women who were buying birth-control pills in Bangkok, Thailand; Cape Town, South Africa; and Ankara, Turkey, quite often when they were on vacation, visiting family or the like. One woman told us she has a friend who travels frequently to Hong Kong and brings back supplies.

Meanwhile, there’s a debate going on about whether birth-control pills should be available over the counter. Here’s an opinion piece by Libby Rosenthal from The New York Times about that.

And, in reproductive pharmaceutical news from all over, we note that Pfizer is now selling Viagra, its erectile dysfunction drug, via its Web site, apparently in a move to make it easier for men to buy it (and also save them the embarrassment of going to the pharmacy for this medication). The New York Times article about this development noted that Pfizer could be losing millions to black-market pharmacies selling counterfeit Viagra online.

***

Charges are not the same as payments.

This morning’s news brought a big helping of Medicare charge information: the release of a dataset of charges to the government’s Medicare program by hospitals across the U.S., as described in this article from The New York Times.

What’s charged by hospitals, of course, is seldom what’s paid by either Medicare or individual insurance companies.

The wide variation in charges made the biggest headlines today. But what did Medicare actually pay? The payments also vary widely, something we have reported on before.

We have a map based on slightly dated Medicare payment information, for about 70 different diagnoses in hospitals across the U.S. Take a look at the map here. It’s based on 2011 data.

As our map’s FAQ says: “Medicare pays  well below market price, so this would not necessarily be the cost that you would get walking in the door. That said, these numbers carry some correlation to market prices. Insurance companies and providers often use Medicare prices as a negotiating point.” We’ll be updating our map with the new figures.

The release of data today by HHS is a good step in the right direction. But it’s only part of the transparency picture. Hospital charges are sort of like the MSRP, an aspirational price. Those charges are applied to uninsured people, and that’s a huge problem: the people who are asked to pay those high prices, often, are those who are least able to afford them.

There’s another big important collection of information that we’d like to see: charges and payments for routine procedures, for the non-Medicare population. What does an MRI cost? We’ve found it could be from $400 to $3,500; here’s one of our pricing spreadsheets. A common prescription? From $9 to $63; here’s our partnership with the Brian Lehrer show on WNYC radio to bring to light the prices of common things like birth control and mammograms.

It’s hard to get the charge information from providers, but much harder to get the payment information from insurers. Insurance companies, you see, may not want Provider A to know she is getting $400 for an MRI, while Provider B is getting $2,300. (True story.) So getting the payment information from private payers is at least as important as getting the government payment information.

Another downside of the data release today: Most people don’t “shop” for the diagnoses that are posted in this data set: “Extracranial procedures w/o CC/MCC,” for example, means any extracranial procedure (?!) without complications or comorbidities, or without major complications or comorbidities. Many of us don’t need such treatment, and when we do, we tend to arrive in an ambulance and not with a shopping list. Plus, the data sets are delivered by diagnosis, not by isolated item or procedure (MRI, 1/2 hour in the operating room, for example). Here’s the data, on the Medicare site. Enjoy!

What the data released today includes:  ”Data being released for the first time by the government on Wednesday shows that hospitals charge Medicare wildly differing amounts — sometimes 10 to 20 times what Medicare typically reimburses — for the same procedure, raising questions about how hospitals determine prices and why they differ so widely,” The Times writes.