I’ve updated this post on May 5, 2019.
In this post on more affordable medical care, I attempt to find out what a standard cataract surgery with a monofocal intraocular lens will cost for patients who have health insurance and for those who do not have health insurance.
As in all pricing for medical care and medical procedures, finding out the cost of a specific medical procedure (anything from office visits to medical care to endoscopy to surgery) is very difficult.
While Google knows about lots of other things, it doesn’t have much easily accessible useful data on medical pricing. The information is out there and well known to healthcare firms* (hospital systems, hospital system consultants, healthcare insurance brokers, medical practice consults and others) but is behind pay walls, I believe.
*See Resources (5) and (6) below.
So, several years ago I went to a site that was in Oklahoma that advertised affordable pricing for medical and surgical procedures (including GI endoscopy and general surgical procedures). I did not post on it so I can’t find the name.
Today, I Googled “affordable medical procedures” in Oklahoma and found a link to The Surgery Center of Oklahoma. They do post their prices for all their surgical procedures but they don’t seem very affordable to me.
And when I visited their website I found a link to their pricing disclaimer:
The list of procedures on this website is a partial list of procedures available in this pricing model. If the procedure you believe you require is not listed on this website, feel free to call our contact number to inquire about availability and pricing. The prices listed are not negotiable and are available only to those who pay the entire amount in advance. We are able to offer these prices due to the lack of expense in processing the claims and the absence of risk for non-payment. Alternative payment arrangements can be made with human resource departments or divisions of self-insured entities if necessary. Once again, if you are scheduled for surgery at our facility and insurance is to be filed by us, these prices listed on our website do not apply to you. [Emphasis Added]
I picked a procedure, cataract removal with implantation of a monofocal intraocular lens, to see what The Surgical Center Of Oklahoma would charge a person with out insurance and then what Medicare would pay a participating physician for the same procedure.
The Surgery Center’s price for cash pay cataract surgery (presumably including an intraocular lens) is $4,000. Here is a link to their complete cash pay price list [spoiler alert – these prices do not seem more affordable to me].
The Surgery Center’s high posted price for cataract may be due to the influence of “Most Favored Nation Clauses”* in their contracts with health insurers.
*See References (1) and (2) below for information on the “Most Favored Nation Clauses” and other causes of high health care prices.
Today the Indianapolis Star had an article, Indiana hospital costs exceed neighbors’ published April 28, 2019. I subscribe to the Star but there is not yet a link on the website. I found the article in today’s print edition.
It turns out that Indiana healthcare costs skew higher than many places in the nation.
Here are excerpts:
[One auto executive said] We have plants all over the country, and whenever we’re talking about opening a new one, do you know what I say? I say, ABI.
What’s ABI?
Anywhere but Indiana. On average we pay $2,200 for every worker’s emergency room visit in Indiana. In Michigan it’s $800. The difference there is the profit margin on one car.
About a year and a half ago the Employers’ Forum and Rand Corporation researcher Chapin White collaborated on a study using hospital costs shared by employers that showed on average Indiana that on average Indiana outpatient care prices were more than three times those of medicare*.
* See Resource (3) below.
The study provided a rare look at what hospitals charge employers who provide insurance to their employees. The study called the prices “shockingly high” but could not determine whether Indiana was an outlier.
The historic lack of transparency in hospital pricing, likely also contributed [to the high cost of health care in Indiana] [Gloria Sachdev] said. Until the 2017 study gleaned from data that the employers shared, there was no way of knowing just how much employers paid.
“It was like cracking the code,” she said
The above article is an example of how hard it is for even employers to find out how much the hospitals are charging their employees for different health care services.
And the article, Resource (3) should be carefully reviewed as it addresses the awful lack of health care price transparency. It suggests some initiatives that might have some (really rather limited) affect on slowing the rise of health care prices.
In order to research the price you will pay for a diagnostic test, or any medical procedure you first need to learn the CPT code for your test or service.
Current Procedural Terminology (CPT®)* is a procedural code set used for reporting medical, diagnostic, and surgical services performed by health care providers. The American Medical Association (AMA) holds the copyright to CPT and the AMA CPT Editorial Panel maintains the CPT code set.
*See How Does a Procedural Service Become a CPT Code? from ACOG for a more complete explanation of CPT codes.
Every year the American Medical Association publishes a new CPT book with the complete list of codes.
You’ll need access to one of the above books to find out the CPT code for your test or procedure. The CPT book can be purchased at the usual places online. Your library may have a copy. And your doctor’s office may let you use their copy.
May 5, 2019 Update:
So I recieved my Professional Edition CPT (current procedural terminology) from my book seller.
I looked up the CPT code in the Surgery/Eye and Ocular Adnexa section, p 407, codes 666892–666985*. The different codes are for different types of cataract extraction with intraocular lens implantation.
*The page number and associated code ranges will depend on which of the CPT editions you are using. There is a new edition every year.
I decided to use code 66983:
Intracapsular cataract extraction with insertion of intraocular lens prosthesis (1 stage procedure)
So once I had the CPT code I needed, I went to the cms.gov Overview web page:
This website is designed to provide information on services covered by the Medicare Physician Fee Schedule (MPFS). It provides more than 10,000 physician services, the associated relative value units, a fee schedule status indicator and various payment policy indicators needed for payment adjustment (i.e., payment of assistant at surgery, team surgery, bilateral surgery, etc.). The Medicare physician fee schedule pricing amounts are adjusted to reflect the variation in practice costs from area to area. A geographic practice cost index (GPCI) has been established for every Medicare payment locality for each of the three components of a procedure’s relative value unit (i.e., the RVUs for work, practice expense, and malpractice). The GPCIs are applied in the calculation of a fee schedule payment amount by multiplying the RVU for each component times the GPCI for that component.
The Physician Fee Schedule look-up website is designed to take you through the selection steps prior to the display of the information. The site allows you to:
- Search pricing amounts, various payment policy indicators, RVUs, and GPCIs by a single procedure code, a range and a list of procedure codes.
- Search for the national payment amount, a specific Medicare Administrative Contractor (MAC) or a specific MAC locality. Each page has associated Help/Hint available to complete your selections.
So then I clicked on Physician Fee Schedule Search on the above web page and was taken to the License for Use of Current Procedural Terminology, Fourth Edition (“CPT®”) page where you need to accept the license agreement to use the Physician Fee Schedule Search Tool.
When you click on Accept on the bottom of the above page, you are taken to the Physician Fee Schedule Search webpage.
And on that page is enter your CPT codes and the Modifiers you are interested in you will get a whole bunch prices.
And so I entered the information below:
And this is the information I received:
Full disclosure, May 5, 2019 as I write this, I have no idea what all the above numbers mean so I downloaded Help with Physician Fee Schedule Search (PDF, 141KB) I will be reviewing it and posting on it tomorrow.
Resources:
(1) Issue Brief: Most Favored Nation Clauses, June 19, 2015 from The Source on Healthcare Price and Competition – “A project of the UC Hastings College of Law.”
(2) Who’s Driving Healthcare Prices: A Look at Anticompetitive Conduct of Various Players in the Healthcare Market, April 9, 2015 from The Source on Healthcare Price and Competition – “A project of the UC Hastings College of Law.”
(3) Hospital Prices In Indiana: Finding From An Employer-Led Transparency Initiative [Full Text PDF] by Chapin White of The Rand Corporation, 2017.
(2) Google Search on “cash pay surgery centers”
The above search did not yield any useful pricing information. When “cash pay surgery centers” listed procedure prices, they were artificially high and bore no relation to the more realistic Medicare pricing.
(3) Physician Center of the Centers For Medicare and Medicaid Services
(4) Overview Of Medicare Physician Fee Schedule from the Centers For Medicare and Medicaid Services
(4) Hospital develops package prices to lure cash-paying patients February 02, 2019 by HARRIS MEYER from Modern Healthcare.
(5) The Marriage of Health and Money – and How to Make It Last [PDF] from About Optum.
(6) About Optum
We are a leading health services innovation company. Our aspiration is to improve experiences and outcomes for everyone we serve while reducing the total cost of care.
Transformational solutions
We are distinguished by our core capabilities that deliver transformational health solutions.
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OptumIQ – OptumIQ™ represents the unique combination of data, analytics and expertise that is infused into all our products and services.
We connect and serve across health care
Our long-standing relationships across the health care eco-system, enable us to forge connections,
simplify processes, drive more effectiveness and help lower costs.Providers -4 out of 5 of U.S. hospitals
Employers – 4 out of 5 of Fortune 100
Health plans ~3 out of 4 of organizations
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Government – 50 states and D.C. served through states and federal government services
Consumers – 126 million empowered consumers
