Shopping for the right medical tests and procedures at the right price isn’t easy—until now. Mark Galvin from MyMedicalShopper joins the Innovation Conversations with NFP podcast to talk about how a chance meeting he had with his doctor led to the creation of a better way to shop for medical procedures. Hear how Mark started in New Hampshire and expanded to all 50 states—and how putting information into the hands of health consumers really does make a difference.
https://mmsanalytics.com/wp-content/uploads/2019/06/MMS_Single_with_Slogan_600.png00Doug Hornerhttps://mmsanalytics.com/wp-content/uploads/2019/06/MMS_Single_with_Slogan_600.pngDoug Horner2020-07-23 14:41:322020-07-23 14:41:33Innovation Conversations with NFP Podcast
Does a real health-care market exist anywhere in the world? It certainly doesn’t in the U.S., where health-care providers don’t tell patients in advance about pricing, outcomes or alternatives. Consumers don’t know what they’re buying or how much it costs. And the costs are largely paid by insurance companies, which don’t spend their own money. With a health-care market this dysfunctional, little wonder the U.S. spends 18% of gross domestic product on health.
If the U.S. wants lower costs, better outcomes, faster innovation and universal access, it should look to the country that has the closest thing to a functioning health-care market: Singapore.
The city-state spends only 5% of GDP on medical care but has considerably better health outcomes than the U.S. Life expectancy in Singapore is 85.2 years, compared with 78.7 in the U.S. Singapore’s infant and maternal mortality rates are less than half the corresponding U.S. rates and rank among the lowest in the world.
What does Singapore do that’s so effective? A few things:
• Price transparency. All health-care providers in Singapore must post their prices and outcomes so buyers can judge the cost and quality.
• Health savings accounts. Singaporeans are required to fund HSAs through a system called MediSave and to purchase catastrophic health insurance. As a result, patients spend their own money on health care and get to pocket any savings.
• A limited but effective safety net. The MediFund program serves those who, after exhausting their health savings and government subsidies, still need help paying their bills.
The combination of transparency and financial incentives has led to price and quality competition so intense that health-care costs are 75% lower in Singapore than in the U.S. Scripps College economist Sean Flynn estimates a heart-valve replacement costs $12,500 in Singapore ($160,000 in the U.S.) and a knee replacement $13,000 ($40,000).
Singapore’s system of health-care finance shouldn’t seem foreign to Americans, nor should we doubt that it could work here. The U.S. has already seen that the combination of competition and price transparency can be successful: Witness the falling prices for Lasik and cosmetic surgery, which aren’t covered by insurance.
America also has HSAs—Congress authorized them in 2003—and one alternative model for U.S. health care would have employers and government provide everyone with a fully funded HSA. Consumers’ financial incentives would be aligned with keeping costs down, since this money would now be theirs—to spend on health care or to save for other purposes, such as retirement or giving to relatives.
U.S. transparency is improving, too. The Trump administration has put forward an executive order which would require insurers and providers to make price information available to beneficiaries, enrollees and participants in health-care plans. While this will take some time to implement, companies like MyMedicalShopper and Healthcare Bluebook have already “cracked the code,” finding secretly negotiated prices in the American market. People spending their own money can turn to them for the information they need to find value.
Key elements of the Singapore model can be implemented by U.S. employers right now without any additional legislation. Thanks to the Employee Retirement Income Security Act of 1974, employers have a fiduciary responsibility to know and justify the costs of health spending—just as they must for retirement funds. Erisa exempts health-insurance plans from various state- specific laws, allowing employers to adopt HSAs and self-insure. About 60% of U.S. covered workers are in self-funded plans subject to Erisa.
Rising prices and lackluster outcomes are already leading U.S. employers to drop large insurance networks. Instead, they’re contracting directly with providers via risk arrangements that hold providers accountable for fixed costs and guaranteed quality outcomes. Large employers can manage the financial risks of self-insurance, and smaller employers can purchase stop-loss insurance to cover large unanticipated expenses. Many employers who go to full self-insurance save 20% their first year and up to 40% by the fifth year with better outcomes and higher employee satisfaction.
Some employers with direct-contracting plans and their own on-site or shared near-site clinics, like Rosen Hotels and Resorts in Orlando, Fla., share some of the savings with their employees. As a result, Rosen has much higher employee satisfaction and retention rates than the best- known competing hotels.
Employers and employees can get better care and outcomes at a lower cost through direct contracting with centers of excellence—health systems and hospitals that offer exceptionally good or innovative care related to a particular expertise. Walmart, Lowe’s, and many other employers are using financial incentives to encourage their employees to undertake elective surgeries at centers of excellence like the Mayo and Cleveland clinics. Employers like these have found that when employees can get second opinions at these centers, a large share of the most expensive procedures aren’t medically necessary—including 50% of spine operations and 30% of hip and knee replacements. In these cases, less-expensive treatments yield superior results.
It has been well established by the RAND Health Insurance Experiment, the Dartmouth Atlas of Health Care and similar research that consumer involvement in price and treatment decisions results in savings and improved outcomes. New investments in digital health solutions are making market competition—facilitated by price and outcome transparency—increasingly achievable in America.
Let’s follow the path of Singapore, Rosen Hotels and Resorts, and Walmart by using markets and competition to make health care affordable for all while improving quality and innovation.
Mr. Shultz is a former U.S. secretary of state, labor and Treasury and a distinguished fellow at Stanford University’s Hoover Institution. Mr. Jorgensen is chairman of Cambridge Innovation Institute, World Congress and Validation Institute.
https://mmsanalytics.com/wp-content/uploads/2019/06/MMS_Single_with_Slogan_600.png00Doug Hornerhttps://mmsanalytics.com/wp-content/uploads/2019/06/MMS_Single_with_Slogan_600.pngDoug Horner2020-07-23 14:21:462020-07-23 14:29:26A Real Market in Medical Care? Singapore Shows the Way
There’s good news and bad news on the COVID-19 front. The good news is that state-by-state testing is up dramatically, with some states like New York (over 4.23 million tests in June); California (4.68 million tests); and Florida (2.2. million tests) leading the way.
The bad news? The days of the U.S. government promising “free COVID testing” are coming to an end.
While federal law requires health insurers to cover the costs of enrollees’ coronavirus tests, not everyone has health insurance, or at least the right health coverage, to guarantee full payment for COVID-19 testing.
COVID testing costs do vary, with “some insurers” reporting that those costs vary among states, labs, and providers—with charges ranging from as little as $23 to as much as $2,315,” according to AdvisoryBoard.
While insurance can help, the larger question is what happens going forward with COVID-19 testing costs.
Galvin’s firm MMS has taken a deep dive into costs associated with COVID-19 testing and treatment – and he doesn’t like what he’s seeing.
“Most states are underway with their reopening phases, but COVID-19 still remains a reality,” Galvin says. “Testing has ramped up alongside kit availability and testing costs are being promoted as ‘free’ in many locations. But are they truly coming in at no cost?”
MyMedicalShopper’s preliminary data analysis uncovered that charged amounts ranged from $51 to $351. “This is for both the official CDC and non-official CDC testing facilities,” Galvin says. “It appears the price differences for these COVID-19 tests are similar to the differences observed across thousands of types of routine medical care that MMS dedicates itself to shining a light on.”
According to Galvin, while the healthcare industry is taking steps to make this test available to all who need it, “the impact of coronavirus-related testing and treatment on future health insurance premiums is unknown, possibly costing billions to the industry and passed on to consumers.”
MMS has shown that, like most consumer health care pricing models, price transparency is a proven driver of cost reduction to the consumer.
Let’s see if the health care sector is paying attention, and is aiming to keep testing costs low for anxious Main Street Americans.
If you’re like me, and the numberssuggestyouare, you have a money habit so shameful that it revisits you in the darkest times. You’re trying to fall asleep but then you remember it and start running numbers in your head; or worse, you’re out with friends enjoying a beautiful afternoon and then a little voice appears in your ear, reminding you that you don’t get to have a beautiful afternoon. We hide these habits or one-off mistakes from our friends and even significant others, but it’s hardest to hide them from ourselves.
Here’s mine: I never pay my medical bills.
They live in a beige linen tote bag stuffed under my dresser next to the blue Ikea bags I use for laundry. I never even open the bills. Of course, I cough up my card for co-pays or prescriptions in person, and I’m a freelancer who pays for her own insurance via an automatic bill pay. But it’s everything in the middle, all the exams and cultures and procedures, that don’t get paid. And what’s worse? Nothing ever happens. It feels like my negligence is never punished.
The deeply weird thing is, I have the money to pay them off. Not all at once, but I could set up payment plans, or dip into savings. There is at least one four-figure bill from the time I got stitches after falling off a bike during the summer of 2015, but otherwise most bills are under $250. The other weird thing is that I’m pretty good at paying all my other bills. Rent, utilities, credit card, cell phone and insurance bills are all automatically deducted from my checking account. It’s the medical ones I can’t abide.
Why do I do this, and what are the consequences and how do I stop?
I could spend a few hours in a therapist’s office figuring that one out, but then I still would have to pay the bill off — so I asked the experts instead.
When I confessed my habit to Mark Galvin, who founded MyMedicalShopper, he laughed out loud over the phone. “Believe me, you’re not alone. That’s almost standard,” he said. “That’s why they try to collect everything from you in the office before you leave. Today, 50% of hospitals’ bad debt is from fully insured patients.” Galvin’s company allows customers to choose and compare medical services based on price.
Psychologist Brad Klontz helps clients with financial denial, which is what he says I’m dealing with. “Our stress goes up and avoidance goes up the less we feel we have the knowledge or confidence in our ability to cope with the problem,” he explained. In this case, I am not confident in my ability to navigate the world of health insurance — I always feel like I’m being taken advantage of. Which isn’t surprising, he said, because dealing with the American health care system is absolutely maddening.
“In every other market, you made a commitment. When you drove the car off the lot, or when you placed your order on Amazon, you knew what the cost was going to be,” Galvin said. “The basis for all contract law is you have to have two parties, and they have to have a meeting of the minds. You agree to something. In health care, that doesn’t happen. You might not even know what they’re going to do to you or charge you for.”
Every time I open my tiny urban mail slot and spot a medical bill, the envelope is housing some creepy surprise. Was that urinalysis $9, or $90, or $900? Am I meant to fight back?
I once received a bill for my “well-woman visit,” or the gynecological exam that women are encouraged to have annually. I was charged for each aspect of the exam, including the STD tests — even though I was pretty sure Obamacare resolved that well-woman visits were covered entirely by insurance. There was one final insult: my doctor charged $5 for the lubricant she used before she inserted tools inside me. Talk about a violation. I felt disgusted, angry, and worst of all, stupid.
My doctor charged $5 for the lubricant she used before she inserted tools inside me.
Klontz likens opening a medical bill to spinning a roulette wheel, but he has another metaphor for the experience. “The snakebite bias: If you stick your hand in a hole and get bitten by a snake, you are afraid to stick your hand in the hole again. One bill may have overwhelmed you, and you don’t want that experience again.” Who wants to feel stupid, poor, cheap and angry? Not me. So my solution? I don’t open them.
But surely there must be consequences. If I didn’t pay rent, I’d be evicted; if I didn’t make my car payments, the vehicle would be repossessed. Medical debt’s consequences are less tangible.
“It can trash your credit rating. You’re probably getting badgered with phone calls from collection agencies, or you don’t answer 800 numbers when you see them,” Galvin said. “You might get some collections activities in the mail. Eventually, there will be bad marks on your credit report.” While your credit score is important, it’s not top of mind for me right now, especially because I’m not currently trying to buy or rent a home. And on the rare occasion I’ve opened one of the envelopes from a debt collector, I noticed interest wasn’t being added to the original bill.
I worry, though, that my delinquency impacts the health care costs of others: that if I don’t pay, they raise the rates on everyone to make up for me and people like me.
“If you’re insured and you don’t pay, the loss is on the provider. It doesn’t impact your peers,” Galvin reassured me. “There is some claim that hospitals, specifically, raise the rates on those who pay to cover the costs of those who don’t. There’s some truth to that, but it’s way over-simplified by the hospitals.”
It seems that the person I’m most screwing over is myself. It’s my stress level at the sight of that overstuffed tote bag, and my financial future, that I have to deal with. So I do. A week ago, I poured a tall glass of water, cranked up the AC, and sat down with the tote bag and my debit card. After moving some money over from my savings account, I opened the envelopes one by one and paid, and paid, and paid. Most were under $100, and one was exactly $8.04. I could, indeed, afford to pay them off in an afternoon, for which I am extremely lucky. After about an hour of this, I realized that about 90% of the envelopes were different notices for the same few charges. I only had to pay off a few to fly through the entire pile.
I had been afraid to call the debt collectors — then they’d know I’m a real person — but the bored voices on the other end of the line didn’t reprimand me. They sounded bored. They do this all day.
And when I was done? I felt like I could lift a car. My ears started ringing like I had just bungee-jumped, or spoken to a crowd of thousands. I had conquered a fear, and fixed one overwhelming aspect of my finances in about an hour. Now I can return to just fearing illness itself, instead of the mail that follows.
https://mmsanalytics.com/wp-content/uploads/2019/06/MMS_Single_with_Slogan_600.png00Doug Hornerhttps://mmsanalytics.com/wp-content/uploads/2019/06/MMS_Single_with_Slogan_600.pngDoug Horner2020-06-25 20:43:262020-07-23 14:30:33Money Confession: I never pay my medical bills
PORTSMOUTH — When it comes the promise of free testing for COVID-19, free isn’t really free, according to Mark Galvin of MyMedicalShopper, an online health care price comparison tool.
Like other costs associated with the health care industry, he said, the cost of a procedure or a test or a drug or a vaccine is always ultimately paid by someone.
“There’s no out-of-pocket cost for the consumer, and they call that free; it’s not free,” said Galvin, president and CEO of MMS Analytics (https://mmsanalytics.com/), developer of MyMedicalShopper.com, an online price comparison tool of health care costs.
“They charge your insurance plan, which is paid for by your employer and paid by you as a percent of the premiums that you might cover in your payroll deductions,” he added.
Like other medical-related services that are often billed as free, such as a flu shot, the consumer doesn’t feel the charge come directly out of their pocket at the time, but the cost is borne through the health care insurance premiums they pay, according to Galvin.
And the ultimate cost of COVID-19 testing varies widely, based on the findings of MMS Analytics.
After analyzing test costs from testing facilities, MMS Analytics said it found charged amounts range from $51 to $351, while allowed amounts (the insurance-negotiated discounted amounts actually paid) range from $39 to $157.
“The industry has taken steps to limit the financial burden of COVID-19 testing and treatment on consumers, which is obviously a benefit to all patients who need care during this health crisis,” Galvin said. “Still, the impact of coronavirus-related testing and treatment on future health insurance premiums is only now beginning to take shape. It is the total cost of this care – not just the patient responsibility portion of it – that will drive the cost of our health insurance down the road.”
Just because we’re in the grips of a pandemic that’s created an urgency in health care for vast numbers of people, the pricing of that care is really no different from the vast difference in pricing for other types of health care, according to Evan Young, head of data analytics for MMS Analytics.
“While it’s still early in the collection and analysis process, our early findings on COVID-19 DNA/RNA identification tests expose yet another example of significant variation in medical care prices,” Young said.
“Based on our preliminary analyses, it appears that the price differences for these COVID-19 tests are similar to the differences we observe across thousands of other types of routine medical care,” he added. “Providing patients with accurate and timely information about cost and quality, as has always been the case, remains an essential step towards mitigating our collective exposure to unnecessary insurance costs over the long term.”
https://mmsanalytics.com/wp-content/uploads/2019/06/MMS_Single_with_Slogan_600.png00Doug Hornerhttps://mmsanalytics.com/wp-content/uploads/2019/06/MMS_Single_with_Slogan_600.pngDoug Horner2020-06-08 17:02:212020-07-10 18:43:49Free COVID testing is not really free, says health cost advocate
Health plans’ pricing structures have largely remained hidden behind labyrinth-like agreements with health systems.
Boston, February 11, 2020 –MyMedicalShopper’s products are designed to offer a simplified tool that presents various costs for medical procedures. This tool can be used by employees to search for and compare prices from a range of providers that offer a certain service. MyMedicalShopper’s solution is a healthcare comparison shopping tool that shows users price estimates based on actual prices paid using medical claims.
This Impact Brief highlights MMS’ key functionalities, its roadmap for the next two years, and Aite Group’s opinion and outlook on price transparency.
Clients of Aite Group’s Health Insurance service can download this 11-page Impact Brief. To learn more about the topic covered in this Impact Brief, please contact Aite at firstname.lastname@example.org.
https://mmsanalytics.com/wp-content/uploads/2019/06/MMS_Single_with_Slogan_600.png00Doug Hornerhttps://mmsanalytics.com/wp-content/uploads/2019/06/MMS_Single_with_Slogan_600.pngDoug Horner2020-02-13 16:59:432020-07-23 14:10:38MyMedicalShopper Recognized by Healthcare Industry Titan Aite Group
https://mmsanalytics.com/wp-content/uploads/2019/06/MMS_Single_with_Slogan_600.png00Christopherhttps://mmsanalytics.com/wp-content/uploads/2019/06/MMS_Single_with_Slogan_600.pngChristopher2019-02-10 18:11:002020-07-23 14:45:12A NH company’s medical shopping tool for transparency of costs
LITTLE ROCK, Ark. – In his State of the Union address Tuesday night, President Trump called for more affordable and transparent health care costs.
Arkansas is one step ahead of him.
“It’s a small step, but I think it’s an important first step toward unlocking the black box and having us all be able to understand how the health care system works and what it’s going to cost us both in the short term and the long term,” said Dr. Joe Thompson, the president and CEO of the Arkansas Center for Health Improvement (ACHI).
The federal government required hospitals to start posting their charges online Jan. 1.
“The information itself is not that useful for most consumers because what’s charged is usually not what’s paid,” Thomspson said.
The actual payment depends on a negotiation between the hospital and the insurance carrier, and also the design of the patient’s health plan.
Another website recently started to break down the average payment rates for different procedures in hospitals across the state.
“It will stimulate a conversation between the patient and their physician about what procedures are needed, how important they are and where to go to get the best procedure done,” Thompson said.
State lawmakers approved the Arkansas Health Care Transparency Initiative three years ago. Under the insurance commissioner’s authority, ACHI developed the state’s all-payer claims database. It tracks paid claims by insurance carriers.
“There has been anxiety about putting new, real information out on what health care costs, to actually shine the light inside the black box,” Thompson said. “Health insurance carriers are concerned, hospitals and providers are concerned.”
Hospitals in the area told KARK they plan to continue to “provide quality, compassionate care to all our patients in the most cost efficient manner possible.” They also said patients can call the hospital’s financial counselors for specific and personalized information.
To register for free to access the data on My Medical Shopper, click here.
“Users of our platform, which is accessible through our website as well as easy-to-use mobile applications, can find price estimates that reflect the insurance-negotiated discounts for thousands of medical tests and procedures before they seek care, rather than falling victim to surprise medical bills weeks or months after the care has already been received,” said Christopher Matrumalo, My Medical Shopper’s VP of Marketing. “We sought to work with ACHI because their Transparency Initiative’s stated goal is ‘to empower Arkansans to drive, deliver, and seek out value in the health system.’ We have found ACHI to be committed to this goal in practice, and we believe that our collaboration has introduced a powerful new dynamic to the healthcare marketplace in Arkansas.”
The website is the first of many that could make data like this available to Arkansas consumers. Thompson said other commercial entities and researchers have applied to gain access to the state’s all-payer claims database.
An advisory board reviews the applications to make sure there would be a benefit to Arkansans. The insurance commissioner ultimately approves the use, and ACHI provides the data to them.
According to the All-Payer Claims Database Council, 21 states have an existing database, 15 of them, including Arkansas, require submissions. Five other states are in the process of implementing one, and others are strongly considering it.
https://mmsanalytics.com/wp-content/uploads/2019/06/MMS_Single_with_Slogan_600.png00Christopherhttps://mmsanalytics.com/wp-content/uploads/2019/06/MMS_Single_with_Slogan_600.pngChristopher2019-02-06 18:22:542020-07-23 14:52:52Know Before You Go: Website posts prices of medical procedures in Arkansas
PORTSMOUTH — A Portsmouth business owner is hoping to drive down the price of outpatient medical procedures with his cost comparison tool.
Mark Galvin is president and CEO of MMS Analytics, the creator of MyMedicalShopper. He came up with the concept five years ago while he was at the helm of Whaleback Systems at Pease International Tradeport.
Galvin, who helped launch RAScom and Cedar Point Communications, calls himself a serial entrepreneur and said he began to get frustrated with the lack of transparency in costs for health care, both as an employer and consumer.
“What I found was, every time I started a company, as computers and servers were getting cheaper, the health benefits were getting more expensive — rapidly,” Galvin said.
When Galvin’s doctor told him he needed to go for a nuclear stress test, he shopped around and noticed a $5,400 savings if he chose a facility in Derry over one of the hospitals in Manchester. After Galvin told his doctor it was going to cost him at least $1,400 out of pocket to have the test performed, his doctor said he did not need to go ahead with the test because it was being ordered simply to set a target heart rate.
“This is the power of having the information available to you and your primary care physician,” Galvin said.
From there, Galvin set out to create a cost comparison tool for typical outpatient procedures. He used public information reported by medical facilities throughout the state to create MyMedicalShopper, which launched in New Hampshire in March 2015. Galvin was part of a group that started the New England Innovation Center in 2013, which helped 15 seed-stage companies get started, including MyMedicalShopper.
Recently, the tool became available nationwide.
MyMedicalShopper is purchased by employers for employees’ use. The data engine leverages more than 3.4 billion medical claims annually to power its platform.
Officials at the company say their analysis has determined the average U.S. employer can save at least 41 percent on their annual health care costs per year when employees have this information at their fingertips and choose to compare prices for procedures.
“It’s been hard because the industry does not want this information to be known. They consider it proprietary,” Galvin said.
Robert Cummings is CEO and founder of American Benefits Group in Northampton, Mass. The national benefits service and solution provider recently partnered with MyMedicalShopper to help employer clients and employees control health care spending.
Cummings said ABG provides flexible spending accounts, health savings accounts, health reimbursement arrangements and commuter benefits for 1,500 employers. He said as more and more employers move to high-deductible health plans, employees want to maximize how far their money goes, and a tool like MyMedicalShopper benefits both parties.
“We think it’s a very dynamic, cutting edge and disruptive solution,” Cummings said.
MyMedicalShopper’s employer dashboard provides chief executives, financial officers and human resources leaders direct visibility into their group’s claims experience and how much money they are saving.
Employees can use a MyMedicalShopper app from their cellphone and use their health insurance plan to compare prices for outpatient procedures before making a medical appointment or visiting a lab.
If employers purchase MyMedicalMetrics, they receive an analytics package that shows exactly how their employees are inadvertently driving up their own costs and overall claims for the group.
“The model is to incentivize the consumer to be engaged in how they’re making a decision on spending,” Cummings said.
Galvin said MMS expanded into other New England states in October 2017 and went national in September of last year.
The company has 14 full-time employees and two-part time contractors working in Portsmouth, and is hiring data analysts and engineers.
According to National Health Expenditure Accounts, U.S. health care spending grew 3.9 percent in 2017, reaching $3.5 trillion, or $10,739 per person.
Health spending accounted for 17.9 percent of the nation’s Gross Domestic Product in 2017, according to cms.gov.
https://mmsanalytics.com/wp-content/uploads/2019/06/MMS_Single_with_Slogan_600.png00Christopherhttps://mmsanalytics.com/wp-content/uploads/2019/06/MMS_Single_with_Slogan_600.pngChristopher2019-02-02 22:34:142020-07-23 17:44:36Portsmouth business offers medical cost-comparison tool
That’s what I saw on Sept. 15 while inside the portable toilet in Warner at a rest stop some 65 miles into my 77-mile ride to raise money for the Concord Hospital Trust to help cancer patients.
It was not the first time my urine was red on a long bicycle ride, but this time I would not panic. This time, I would not walk blindly into the Concord Hospital emergency room for no good reason and exit with a bill that I was still paying off.
This time, I would know what the heck I was getting into and how much it would cost me.
It took a month to find out that, in order to save thousands of dollars, I had to put off a medical procedure until next year, thus risking landing in an emergency room, which could cost the health system more than I was trying to save myself.
But that’s the trade-off patients now have to make in the new world of high-deductible health insurance.
High deductibles used to be the exception. Now they are the norm, particularly in New Hampshire, where high-deductible plans are held by the highest percentage of policyholders in the country.
Nationwide, the total amount of deductibles paid by employees tripled from 2008 to 2017. The average individual deductible doubled to $1,500 in that time and the number of those with plans including deductibles rose from 60 to 81 percent, according to a 2018 Kaiser Institute study.
In New Hampshire, 69.3 percent of employees had high-deductible plans (more than the $1,300 individual threshold used for health savings account eligibility) in 2017, according to data from the University of Minnesota’s State Health Access Data Assistance Center. It was the highest percentage in the country.
The state also has the highest average family deductible ($4,381) and the second-highest individual deductible ($2,303), just $2 below Maine. In 2016 New Hampshire was ranked first in the average individual deductible as well.
(The prevalence of small businesses here might be a contributing factor: The smaller the company, the chances are the larger deductible an employee has to pay.)
The good thing about high deductibles is that they force the consumer to care about cost. But it also has a negative side as well.
During her presentation at NH Business Review’s Oct. 10 Healthcare Confronting Disparities event in Concord, Dr. Joanne Conroy, CEO and president of the Dartmouth-Hitchcock health system, said that people with high-deductible plans “aren’t getting the care they need. They are coming to the emergency for acute care that could have been cared for early on.”
Indeed, a study by the American Diabetes Association indicated that while large deductibles do save medical costs, they also resulted in lower-income patients going to the emergency room.
My individual deductible is $5,000. Even after my employer chips in $2,500 via a health reimbursement account, I have a high-deductible plan.
I found this out the hard way in 2016, that time on a 100-mile ride to benefit the Concord Hospital Trust. Back then, when I saw my bloody urine, I cut the ride short, went into urgent care at the Hitchcock Clinic. I was sent to the emergency room.
A doctor, who said I was slightly dehydrated, wanted to hook me to an intravenous bag. Way too costly, I said. I just drank a lot of water and was given a CAT scan with negative results because it wasn’t done correctly. When my urologist redid the scan, he found that stones in my bladder knocked about during the long ride, causing the bleeding. He sucked them out though the urethra, laser-blasting those too big to fit. I had no idea how much that cost, nor did I care, since I had already blown though my deductible in the ER.
This time, I figured they could just do it again. Sure enough, my urologist eventually confirmed, I had a “ton” of bladder stones again, and I should have them removed again, or they could block up the urethra, resulting in extreme pain and another ER trip.
But, he added, this is a recurring problem because my enlarged prostate prevents me from totally emptying out my bladder. The solution? Drill a pathway though the prostate.
The procedure — known as transurethral resection of the prostate (TURP) — would require an overnight stay in Concord Hospital (which owned the urology practice), though it would be less than 24 hours, so it would qualify as day surgery.
He had no idea, nor much concern, about how much this would cost me.
I tentatively signed up for the procedure, scheduled in two weeks, the Friday before Columbus Day. Then, armed with procedure codes, I proceeded to do my homework.
First, I called the cost information number on the urologist’s pre-op literature. I got a message inviting me to leave a voicemail with my procedure number and other information to get a cost estimate in 48 hours.
While waiting I called Anthem, my insurer, which confirmed that I had hardly touched my deductible, so I was on the hook for almost $2,500 after my employer reimbursement. Anthem told me the surgeon’s negotiated fee: $1,949 for the TURP and $812 for the bladder removal. But didn’t tell me the combined fee, nor the cost of the hospital and anesthesiologist because they vary so much.
The anesthesiology cost depended on the method, which — the urologist’s office told me — would only be revealed at the hospital before I was rolled into the operating room.
Concord Hospital (which called back more than four working days later after repeated messages) could only give me its “sticker price” — $28,000 to $41,500 — not the negotiated price with Anthem.
Anthem couldn’t tell me what that was either, but I was told that, since it would probably blow through my deductible anyway, what difference would it make?
It was only after I contacted Concord Hospital later on as a reporter that the hospital told me the negotiated price, including surgery but not anesthesia, was between $19,000 and $26,000 but “as a general practice we don’t disclose that,” said Tom Antinerella, director of patient access, explaining that contracts with the insurers were “proprietary” and besides, “it’s kind of a moot point, because if it’s more than your deductible it’s irrelevant.”
But I was still trying to make a decision, so I went on the state Insurance Department’s transparency website, nhhealthcost.nh.gov, which gives the negotiated rate on over 100 common procedures, including 22 surgical ones, but not mine.
Then I called Vitals SmartShopper, a company that works with my employer and Anthem and actually sends you a check if you go to the cheaper provider. However, my procedures were not included in our contract, so they couldn’t give me any cost figures.
Anthem later told me as a reporter that SmartShopper would have helped me with another operation — kidney stone removal — which has a different procedure code. The public information office also referred me as a journalist (but not when I called as a patient) to check out a tab section of Anthem’s website, called “Estimate Your Cost,” which allows you to compare the cost of a number of procedures, like kidney stone removal, but not bladder stone removal or TURP, so it wouldn’t have done me any good in any case.
Ambulatory surgical center
Time was ticking by. I called back the Center for Concord Urology practice and asked how urgent it was for me to get the bladder stones removed right away. Not very, I was told. So I canceled the procedure and continued my search.
I vaguely remembered during an employee health meeting that it would be much cheaper if I went to an ambulatory surgical center. My urologist did say the procedure required an overnight stay at the hospital, and Anthem didn’t suggest it, but I figured I’d give it a try. After numerous phone calls, I learned Manchester Urology Associates performs these procedures at Elliot Health System’s ambulatory surgical center, Elliot at River’s Edge in Manchester.
Manchester Urology said its negotiated fee was $3,800. The River’s Edge’s sticker price was $3,650 for the bladder removal and $9,105 for the TURP. Amoskeag Anesthesia’s sticker price was $1,500, negotiated down to $1,300, based on the average number of hours the procedure takes.
But all this was irrelevant after I called Anthem, which told me that all I would have to fork over was a $250 co-pay. That would cover the doctor, the facility, the anesthesiologist and even some lab work.
But as a new patient, I wouldn’t get to see anyone in Manchester Urology until early next year.
So betting to save $2,250 that my bladder stones will stay put for another three months, I set up the appointment. If I lose the bet, and wind up in the ER, I’ll only pay the same amount if I scheduled it at Concord Hospital. But the insurer would pay a lot more in dollars, and I could pay a lot more in terms of my health. Wish me and the health system luck.
It turns out I missed one important resource when trying to determine medical cost: MyMedicalShopper, started by Mark Galvin, a Portsmouth entrepreneur. I had even done a story about the company the year after it started up in 2014.
MyMedicalShopper has since gone national. Galvin has even been invited to the White House twice to talk about how price transparency can save the healthcare system, and Medicare in particular, billions of dollars.
It started up in 2013 when Galvin finally got a CD-ROM of actual claims data from the state. That data has since been updated every three months and augmented by the company’s customers, both businesses and individuals.
Like the state and Anthem sites, the data revealed a vast disparity of prices for some common procedures. Anthem, for instance, pays one provider $22 for an x-ray and another $327, with payments ranging from $335 to $4,221 for an MRI of the lower joint.
But MyMedicalShopper has information for a lot more procedures, including mine. Bladder stone removal prices range from $388 (at River’s Edge) to $6,112. And TURP costs range from $1,565 to $8,424. (The combined high estimates are actually $4,000 lower than the price provided by Concord Hospital, underscoring that the results were either off the mark, or not up to date, or that the hospital’s estimate was too high.)
But if MyMedicalShopper gets its data from the New Hampshire Comprehensive Health Information System — a result of a law mandating such transparency — why doesn’t the system website include the hundreds of other procedures included on MyMedicalShopper?
Most likely it’s “due to the relatively low frequency of the services in the commercially insured population and/or a high amount of variation among patients receiving the services,” explained Tyler Brannen, director of health economics at the NH Insurance Department, thus the state could not vouch for its accuracy.
But Galvin blames it on restrictions that the carriers put on use of the data. Brannen, however, said there are no restrictions on which procedures would be included on the database.
According to Galvin, however, carriers may say they want the transparency that will send consumers to low-cost providers, “but they really don’t. Carriers want to keep it a secret.”
He said that’s because of a rule that, in most circumstances, limits an insurer’s surplus to 20 percent of medical losses. The greater the medical losses, the greater their profit, argued Galvin.
When asked to respond to this, Anthem issued the following statement:
“Consumers rely on Anthem Blue Cross and Blue Shield to provide broad access to affordable, quality healthcare services. Prices for the same service can vary greatly from provider to provider, even those in the same area, which is why we work with consumers by providing them information and tools so they can be better informed about selecting the right care provider based on quality and possible out-of-pocket costs.”
The tools listed were the Estimate Your Cost website, the SmartShopper program, live customer support and benefit design. The first three tools failed to inform me of the cheaper alternative that was available under the latter. I had to come up with the information myself.
In some ways, this story has a happy ending. I was eventually able to get a rough idea of the negotiated costs and was — albeit with some delay and risk — able to find a cheaper alternative. But is this evidence of price transparency? Or is it an example of how difficult it can be to find out the cost of your very own healthcare?
https://mmsanalytics.com/wp-content/uploads/2019/06/MMS_Single_with_Slogan_600.png00Christopherhttps://mmsanalytics.com/wp-content/uploads/2019/06/MMS_Single_with_Slogan_600.pngChristopher2018-11-09 19:35:192020-07-23 17:46:45A tale of healthcare transparency