Summary: “Prices for many common medical procedures are higher in areas where physicians are concentrated into larger practice groups, according to a new study,” Michelle Andrews writes in Kaiser Health News. “The October Health Affairs study examined the average county prices paid by preferred provider insurance organizations in 2010. It focused on 15 high-volume, high-cost medical procedures across a variety of specialties, including vasectomy, laparoscopic appendectomy, colonoscopy with lesion removal, nasal septum repair, cataract removal and knee replacement. The prices studied reflected the negotiated prices between the PPOs and the physician groups, including payments made by both the plan and the patient. The average price ranged from $2,301 for a total knee replacement to $576 for a vasectomy. … In 12 of the 15 procedures, prices were 8 to 26 percent higher in counties with the highest average physician concentration compared to counties with the lowest average concentration, the study found. The three procedures where there was no significant relationship between physician competition and price were intensity-modulated radiation therapy, shoulder arthroscopy and kidney stone fragmentation. Although larger practices may have the resources to provide benefits to patients through better care coordination or access to new technologies, among other things, these practices’ greater market power may enable them to charge higher prices than smaller practices, the study authors said.” Michelle Andrews, Medical Prices Higher In Areas Where Large Doctor Groups Dominate, Study Finds,” Kaiser Health News. The original study in Health Affairs is here.
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Summary: She got a foot MRI, for cash, at $450, and considers it a bargain. The story involves a young woman I know who needed an MRI to diagnose a complicated foot injury. Two X-rays about five days apart showed that it wasn’t broken, but it was swollen and painful (the foot in question had been run over by a car). So the doctor recommended an MRI just to be sure — there are a lot of bones in your foot, and if one is broken it’s better to know and fix it. A friend who’s an orthopedist also concurred that an MRI or CT scan was recommended, so the young woman decided it was not one of those unnecessary MRI experiences we hear about — that MRI’s are overused and often superfluous.
What happened next was interesting. She’s insured in one state, and the accident took place in another state, where she goes to school. (I am not naming her because she asked me not to, and that seemed fair.)
At the emergency room (in the state where the accident took place), they recommended a follow-up within a week. A weekend intervened, so she followed up in five days, at which point an orthopedist (in the state where she’s insured) did the second X-ray and recommended the MRI.
The doctor wanted the MRI done immediately, and she needed to return to school. The insurance company said they’d need to pre-authorize an MRI, and that would take several days, most parties predicted. Also, they didn’t promise to pay: they just said they’d need to pre-authorize. So she could seek to pre-authorize, return to school, and then return to an MRI clinic in the doctor’s neighborhood, so he could see the MRI and results immediately — rather than wait for them to be delivered to him, with whatever delays might attend. Also complicating matters: the insurance point, since she’s insured in one state (where the doctor practices) and the accident took place in another state (where she goes to school). Her policy doesn’t cover her across state lines, except in an emergency — so it covered the emergency room, but not follow-up care.
What to do?
Phone calls were made to two self-standing radiology clinics. One said they charge $600 in cash. The other said they routinely charge $900, but cash patients paying at the time of service pay $450.
We have heard of people getting an MRI for $350, or for $6,200. We have also heard of people who were charged $2,800 and change for an MRI, while the insurance company paid $400 or so and the individual paid $1,900. Here’s a blog post about our California survey results, for example.
The decision was made: seeking pre-authorization would delay any treatment beyond the date recommended by most orthopedists for follow-up by a fracture. Waiting on the phone and urging pre-authorization to take place is a time-consuming thing. Requiring her to return to school and then travel back to the doctor’s neighborhood would be expensive and time-consuming.
The upshot? She got a $450 MRI for cash. And it kind of looks like a bargain.
Summary: “I must admit that I chose to be uninsured,” C. wrote to me. “My work does not provide health insurance and I looked into nystateofhealth.ny.gov during the fall of 2014, excited to have real health care options. I am 33 years old, and could comfortably afford an insurance that was $160 per month. I punched in my info and looked at my options. Nothing was lower than $240. And I knew from my boyfriend that the quality of these low ball ‘bronze’ options was pretty pathetic — waiting lists for appointments, long waits once there, poor visit quality — and he paid $120 per month for his.”
(Editor’s note: I am posting this essay from a friend’s daughter using only her initial, C., to preserve her anonymity. I also removed the name of a radiology practice she used because there’s not a good way to reconstruct her experience and validate it for my readers. At the bottom is a list of resources with explanation that I sent to C., which had been sent to me by my friend Casey Quinlan, a communicator and patient advocate and the author of “Cancer for Christmas,” about her breast cancer experiences.)
Summary: “Specialists in infectious disease are protesting a gigantic overnight increase in the price of a 62-year-old drug that is the standard of care for treating a life-threatening parasitic infection,” writes Andrew Pollack in The New York Times. “The drug, called Daraprim, was acquired in August by Turing Pharmaceuticals, a start-up run by a former hedge fund manager. Turing immediately raised the price to $750 a tablet from $13.50, bringing the annual cost of treatment for some patients to hundreds of thousands of dollars. ‘What is it that they are doing differently that has led to this dramatic increase?’ said Dr. Judith Aberg, the chief of the division of infectious diseases at the Icahn School of Medicine at Mount Sinai. She said the price increase could force hospitals to use ‘alternative therapies that may not have the same efficacy.’ Turing’s price increase is not an isolated example. While most of the attention on pharmaceutical prices has been on new drugs for diseases like cancer, hepatitis C and high cholesterol, there is also growing concern about huge price increases on older drugs, some of them generic, that have long been mainstays of treatment.” Andrew Pollack, “A Huge Overnight Increase in a Drug’s Price Raises Protests,” The New York Times.
Summary: “Offering women money, paid time off, or other incentives to undergo mammography screening is ‘ethically troubling,’ contends the author of a viewpoint published in the September 8 issue of JAMA. A better idea is to offer women incentives for using evidence-based decision aids, irrespective of their ultimate decision for or against screening, says Harald Schmidt, PhD, from the Department of Medical Ethics and Health Policy and the Center for Health Incentives and Behavioral Economics at the University of Pennsylvania Perelman School of Medicine in Philadelphia. Patient health incentives are increasingly common and can help prompt health behaviors that ultimately lead to a longer and better life, Dr. Schmidt noted in an interview with Medscape Medical News. Take quitting smoking or losing weight. ‘If you achieve what the incentive provider asks for, you only gain health. But with breast cancer screening, you might get a false-positive diagnosis and receive treatment that you don’t actually need,’ he explained. ‘The decision to undergo breast cancer screening is really very complex, yet the idea has been ingrained that screening will detect all cases of breast cancer and they will detect them early and save lives,’ he noted.” –Megan Brooks, “Cash for Mammograms Is ‘Ethically Troubling,'” Medscape Medical News.
Summary: “As options for cancer patients become increasingly complicated, and expensive, the most influential source for U.S. oncology treatment guidelines will for the first time offer a tool to assess the costs versus benefits of available therapies,” Deena Beasley writes for Reuters. The National Comprehensive Cancer Network (NCCN) says its new tool will provide a clearer picture of the relative value of medication options, particularly in cases where a very expensive therapy does little to improve survival. Doctors developing the measures expect them to shift demand away from less effective treatments, influencing the prices drugmakers are able to charge. They say they are responding to the needs of patients who are having to pay much more for their own care, with higher health insurance premiums, co-payments and deductibles, and want to know the value of their treatments. The NCCN, an alliance of 26 cancer centers, envisions the new tool as a supplement to its widely followed guidelines for oncology care, which set out protocols for treating a range of cancers based on diagnosis, disease stage and other factors, such as age.” Deena Beasley, “New tool will compare costs versus benefits of cancer treatments,” Reuters.
Summary: In our project crowdsourcing healthcare prices in partnership with MedPage Today, we were asking primarily for cash or self-pay prices — but one of the most interesting shares we got was from a provider who wanted to tell us reimbursement rates. This post appeared originally in MedPage Today, where I wrote it as part of our pricing transparency partnership with MedPage Today. Re-posted with permission.
Summary: “Quality measures are good, right? We all want our doctors and hospitals to follow best practices and be held to them,” writes Joanne Kenen, health editor at Politico, on the Association of Health Care Journalists blog. “It’s not so simple. Put aside for the moment whether the measure is accurate – we don’t always know or agree on what the best thing is in health care (Exhibit A: mammograms). There’s another quality problem. There too many quality measures. Oodles and oodles of quality measures. I first came to appreciate this a few months ago when I was doing some preparatory conference calls before moderating a panel with hospital and health system executives. They came from a variety of organizations – big, small, urban and rural. But all had some kind of accountable care organization or ACO-like value-over-volume arrangement. All were serious about trying to navigate a changing health care landscape. All took part in Medicare and Medicare Advantage and Medicaid (most had Medicaid managed plans). And, of course, they dealt with multiple private insurers. … Each of these payers had their own quality measures – some overlapping and some mutually exclusive. I’m not talking about 10 or 20 or 30 measures. They were dealing with 100, 110, 140 or more. They could not possibly meet those standards – or even measure and report their performance in so many sliced and diced ways. I remember wondering – but not getting a clear answer at the time – about how much money and work hours are being spent quantifying quality when the goal was, in part, to use quality to guide us toward a more efficient health care system.” Joanne Kenen, health editor at Politico, Look at how health quality measures have become a jungle,” Association of Health Care Journalists.
Summary: Our MedPageToday post has brought us a lot of interesting visitors. Providers, payers, government officials, individuals, academic institutions — they’re all here. Also: Epic, AthenaHealth and others. Here’s a sampling from today. A lot of our visitors are apparently on their own devices, perhaps mobile, and therefore the analytics program (it’s called Clicky) can’t tell us where they are, only who their carrier is, while for others on a company or hospital system, we learn where they’re from.
Summary: “I live in metro NY and received a bill for $2200 (approx) for a mammo/Ultrasound, of which approximately $767 was covered by insurance. I was balance billed $1,712,” the email said. “I am a 42 y.o. female physician with a family history of ovarian cancer, and I am covered by Blue Cross/Blue Shield. I was frankly horrified by the costs.” Of course we were interested: our research shows that a mammogram price can range from free (preventive, under the Affordable Care Act) up to $2,786.95. So … how much does a mammogram cost? Click for more details, or …