Summary: We often tell people who are looking for health care prices to ask “How much will that cost? How much will that cost me?” But not all providers think that’s helpful — in fact, some think it’s “an exercise in futility.” We don’t fully agree, because sometimes you can know (“How much will an MRI of the lower back, CPT code 72148, cost?”) while sometimes you can’t (“I have a sore throat, how much will it cost?”) In the interest of improving communication, and representing the view from the provider’s office, we’re posting this, sent to us by Cecily Murray from Camino Ear, Nose and Throat in San Jose, Calif.
Hi Jeanne,
Saw an article on Yahoo Health in which you were quoted. Thought the article was great, except that it left out a factor that complicates things entirely for patients who are trying to get price quotes.
Doctors (especially specialists) and their office staff don’t know up front what it’s going to take to evaluate and treat a patient before they walk in the door. Calling before to find out how much it’s going to cost is largely an exercise in futility, unless you are, say, calling pediatricians for a quote on a 6 month old well child — that’s one code that you know before you walk in will cover everything that happens in the room. Of course, those are largely 100% covered under the ACA.
We will often get calls from patients asking us how much will a doctor’s visit cost. We will say we don’t know, because that depends on:
1. If the patient is new or established (different codes required);
2. What is wrong (we are an ENT clinic, so is it an ear, nose or throat issue);
3. Will the doctor need to use a special piece of equipment to diagnose what is going on (our scopes cost upwards of 100K for the light source, tower and camera — it is a separate code with a separate charge for a reason);
4. Which piece(s) of equipment will the doctor use (they all have separate codes and reimburse different amounts);
5. If it is an ear issue, will the doctor need the audiologist to evaluate first (our audiologists are PhD’s in audiology. They have hilariously sophisticated (and expensive mind you) equipment that can take a potential range of 45 different diagnoses and whittle it down to 2-3 on which the doctor can then focus). If I had a buck for every time a patient said “but I don’t need a “hearing test” – I’m just dizzy…” Yep, and you need an audiologist first;
6. How medically complicated is the patient and the patient’s problem; and
7. How long the doctor will spend with the patient (doctors don’t know beforehand — the appointment time is a estimate. If somebody came in with a sore throat and ends up with a potential cancer diagnosis, that appointment is gonna take longer than the 30 minutes on the schedule, and it should).
That’s before we get to what kind of insurance do you have, is there a co-pay or co-insurance, do you have a deductible, how much of it have you met, how much of your out of pocket maximum have you satisfied etc.
It’s not a runaround, it’s the truth
Patients see these responses as a massive run around, but it’s the truth — someone answering a phone call has no idea what is going to happen in the exam room before that patient gets there, nor does the doctor.
One of the fastest ways to make a patient unhappy is to tell them upfront one price and then discover later that the doctor needed a flexible scope instead of a rigid and now the code is different and the insurance company is allowing a different, higher amount. Or, a patient described it as a straightforward nose issue on the phone, but when they get in the room, they also have a hearing loss they want to talk about and vocal cord polyps, etc.
Same goes for surgeries — although it’s a little clearer as there’s usually a clear plan and set of objectives.
Sometimes, however, a doctor and a patient will have a plan for surgery and then when the patient is on the table a doctor will discover something new (and small) that needs to be taken care of, and the doctor has a professional obligation to handle it then, rather than closing up the patient, informing them after and then having to put the patient back on the table later.
Other times, given the nature of what is discovered, the doctor will have to close up, re-consent the patient, and do the other procedure at another time.
Buying milk or making dinner
I often hear health care transparency compared to grocery shopping. “Why can’t it be like buying milk? I know at this store, it costs $4.99 a gallon. Over there it’s $5.89”.
My reply is that it’s more like a patient asking how much it’s going to cost to make dinner, not buy milk. I don’t know how much it’s going to cost for you to make dinner. What are you having? Except, the patient isn’t the cook, the doctor is, and he won’t know until he’s in the kitchen turning the stove on.
I can’t tell you how much it’s going to cost at one store versus another, unless I know exactly what he’s making, how many ingredients you have at home, etc. and the patient can’t tell me what the doctor’s making either, no one can not 2 weeks before hand anyway.
We have had patients suggest that a doctor should tell a patient while they are sitting in a chair that the scope he is pulling out of the cabinet is going to cost $xx.xx and get the patient’s consent to the charge prior to using it. Ha! We have over 3,000 carriers in our database — half the time we don’t know in the back office what we are going to get paid, let alone the physician.
Our doctors would have to be running in and out of rooms, staff would be on hold for 45 minutes at a go, waiting for a customer service rep from an insurance company to pick up the phone to give them a quote and tell us whether a patient has satisfied their deductible. Patients would be furious to be kept waiting. Our doctors would go from seeing 25 patients a day to seeing 6.
Overall reimbursement rates
The best information a patient can have is what the overall reimbursement rates are like for a particular physician or group vs. another, which is why the contracted allowed amounts are so important. Being able to discern that one group’s average allowed amounts across the board are about 105% of Medicare vs. another group is 250% of Medicare is where patients will discover value.
We have that spread here in the Bay Area. Sending them out to try to get doctors offices to predict what’s going to happen in an exam room is setting them up for a lot of very unsatisfying conversations for them, and unpleasant ones for staff who are trying to be helpful.
I continue to totally support this effort and would be so happy to be a part of figuring out how to get information out in front of consumers/patients so that they can report the important numbers (I.e. allowed amounts) and be a part of the project. Let me know if you’ve had any thoughts on how to get doctors offices to enlist their patients to report.
Best,
Cecily Murray
Editor’s Note: Cecily Murray sent this to me and I asked her if I could run it as a blog post. I changed only a few punctuation marks. Ms. Murray works as office manager and also does patient advocacy and community outreach at Camino Ear, Nose and Throat Clinic in San Jose, Calif.
