The Need for Transparency in Medical Costs

My healthcare career began in 1991 at a small HMO that was quickly purchased by Blue Cross. Over the years, I witnessed the changes in offerings from traditional Commercial plans to HMOs, PPOs, EPOs, etc. Looking back over my 26 years in the industry, I see how complicated healthcare coverage has become. As we struggle to navigate a sea of complex coverage options, transparency in cost and billing is more elusive than ever.

The challenge I personally face in today’s marketplace is a common one. After becoming a freelance healthcare consultant, I turned to the Exchange to purchase coverage for my family. As healthy adults in our early fifties, it was an eye-opener! I was quoted almost $1,700 per month with a $5,000 annual deductible. In my opinion, that’s a mortgage payment, not health insurance! In looking for a more affordable option, I sought out an insurance broker. Our heads spun seeing all the “a la carte” options available. In the end, the best option for my family was catastrophic coverage which still left us exposed to penalties under the ACA. While it wasn’t ideal, this choice worked for us; but the coverage was bare-bones basic and determining what was covered and at what cost was and is extremely difficult.

This very basic coverage requires that you research and carefully choose your care. A few months ago, I found a physician and scheduled an appointment for a physical, fully aware that the appointment would not be covered by my current plan. As a healthcare professional, I knew that the plan included a fee schedule that dictated the maximum I would be charged. I arrived at the doctor’s office and was told that I would need to pay out of pocket for the appointment as my coverage only included mammograms, pap smears, and colonoscopies. I was assured that the cost wouldn’t be too bad and that I could pay on the way out. After my appointment, I paid the calculated estimate of $300.

About a month later, I got THE BILL. I was appalled to find that the office visit was more than twice what I paid upfront and some of the charges were ridiculous. My flu shot was $58 with a $61 charge for the administration of that shot, the tetanus shot was $72 with another administration charge of $30. I immediately called but couldn’t get to an educated biller. I made it very clear that I understood the business and asked for the manager. I eventually got some of these charges removed or reduced, but my appointment still cost nearly double what I was quoted! What’s most troubling about this is that I know the healthcare business, so I knew these charges were inaccurate and had the ability to fight it, but there are many out there that have no clue if they’re being billed correctly or how to dispute erroneous charges. This lack of transparency has created an environment where many feel taken advantage of and are helpless in the face of skyrocketing healthcare costs.

The healthcare system is broken, but I’m still hopeful because the lack of transparency is being addressed in small ways thanks to emerging technology. Since our plan doesn’t include prescription coverage, the broker directed us to an app called GoodRx. I enter the name of a drug and it gives me the cost at pharmacies in my area like CVS, Walgreens, Walmart, your local supermarket, and even the smaller shops. This type of transparency empowers consumers by allowing for price comparison shopping. Another example is SaveOnMedical, which is a new company that lets users shop prices on radiology services and medical tests in their area. Some consumers have seen savings of up to 70% on these services. SaveOnMedical also gives drug prices at pharmacies and will soon be offering surgical and lab prices as well.

While this is a great start to increasing transparency in the marketplace, how can we, the consumer, build on this? Whose responsibility is it to keep innovating? Should we rely on 3rd party companies to create these solutions or should it be a collaboration between payer, provider, and technology firms? Imagine if there was a tool where I could have gone online to check the price of my physical before I went to the doctor! How is this not available to consumers yet? I firmly believe this is a challenge that cannot be overcome without the full buy in of patients, insurers, and providers. While the 21st Century Cures Act may have paved the way for innovation, we as healthcare professionals, patients and consumers must demand that transparency be a top priority moving forward.

MJ Wresneski

MJ Wresneski
HCIM Executive Adviser

About HCIM

Since 2000, HealthCare Information Management, Inc. (HCIM) has delivered expert consulting services and robotic automation tools for small to mid-sized healthcare payer and managed care organizations. Our concierge consulting services include everything from core claims system procurement to go live, including configuration, migration, upgrades, reporting, benefits and fee schedules, user training, and project resourcing. We also offer strategic consulting in the areas of value based payments, population health, medical management, medical loss analysis and recovery, care management, provider contract modeling, data analytics, and business process reengineering/analysis.