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It is doubtful that there is any informed individual in the US that would disagree that our health care delivery and financing system is broken. Due to the complexity of the system, there is no simple discussion of causes or solutions.
I have consistently complained about the lack of transparency in the system. The popularity of high deductible health plans coupled with a Health Savings Account (H.S.A) continues to put the patient in the untenable position of trying to be a good health care consumer without even fundamental tools to be able to make informed choices.
This last week, I spent no less than 4 hours on the phone between insurance company, physician offices and endoscopy/surgical centers to help a relative determine how to proceed for a colonoscopy. The individual is under age 50, the age at which the ACA (Affordable Care Act, aka Obamacare) requires that the plan cover the procedure at 100%.
His insurance policy has a $3000 deductible, so the first $3000 of covered expenses will come directly from his pocket. His insurance is a PPO plan through Anthem Blue Cross of CA. Regular readers may recall a column a few years ago when I addressed this issue. I can assure you it has not changed, but is almost worse.
This “procedure” is actually comprised of multiple transactions: physician basic fee plus possible additional charge to remove polyps, anesthesiologist fee, lab costs for evaluation of any polyps removed and finally that facility fee charged for the use of the facility in which the test is administered.
There may also be an “upcharge” of about $200 for propofol that will likely not be disclosed until you arrive at the facility. You are “sold” on the concept that your recovery will be quicker. Studies show that the recovery time difference is about 20 minutes.
The facility has the added benefit that you can “recover” in a chair in the same room as the procedure, rather than supine in a recovery bed. They can bring in another patient that much quicker and not have to take up valuable real estate with recovery beds.
As for the physician fee, Calls to multiple offices did not show much difference in the chargewhether it was cash or if they were to pay the Anthem negotiated rate. The charge was about $575.
The facility fee was another story. One center is connected to a hospital. Cash pay is about $795. Anthem allowed amount is in the $2400 range! The other facility cash price is about $550, but the Anthem allowed amount has yet to be determined. Billing offices won’t give price quotes until you have been scheduled. That certainly makes that “informed choice” a big challenge.
Finally, I contacted a local primary care physician who takes no insurance plans, but will do the procedure in his office including poly removal if needed for a flat fee of $1146, no facility charge.
Can the individual indicate he is a “cash pay” patient, pay the cash price then submit the bill to his insurance plan? If so, how will it be processed? According to the claims rep that I phoned, the lower amount would be allowed, then credited to the individual’s deductible. Two more important tips:
- Request a lab slip before the routine physical appointment. This allows the doctor to discuss lab results at the time of the visit, thus saving the time and the charge for an additional visit.
- Be sure to request that a copy of all test results are provided to you to build your own files. We do not have the type of integrated patient medical record systems available at bigger city systems. It is to your benefit to build and maintain your own file.
This individual has been healthy for a long time and has had no need to attempt to navigate our health care system. He was shocked at the fact that he would not have even known to ask these questions.
There are important lessons from this exercise. First, the system is extremely complex. Second, there is no transparency, so you must be aggressive in your effort to determine costs. Third, if you don’t make $800 hourly consider asking for conscious sedation (versed), rather than pay $200 to gain an additional 15 minutes in your day. Further, if you are like me and have low blood pressure issues, that makes it even more important to consider this alternative.
You may find it interesting that not much has changed in 7 years, other than the amounts, if your review this article: . (https://www.reuters.com/article/us-anesthesia-colonoscopy/is-expensive-anesthesia-for-colonoscopy-worth-it-idUSBRE96O0RW20130725).