The Joplin Globe, Joplin, MO


June 18, 2012

Insurer’s effort at price transparency raises hospitals’ concerns

ST. LOUIS — The purpose of United Healthcare’s new online medical cost estimator seems simple enough: to provide data its plan participants can use to comparison-shop for medical care.

Both consumers and the insurer, after all, could save lots of money by exploiting often hidden and inexplicable price differences among medical providers.

A patient seeking an MRI in the St. Louis area, for instance, would pay $367 at St. Louis University Hospital or $467 at Metro Imaging - or about four times that much, $1,563, at either SSM DePaul Health Center or SSM St. Joseph Health Center, according to United Healthcare’s online estimator.

Some hospitals, which generally negotiate multiple secret pricing schedules with various insurers, aren’t exactly embracing all this transparency. The largest provider in the St. Louis area - BJC HealthCare - declined to participate in the cost estimator. SSM Healthcare voiced surprise earlier this month that its claims data was included in the system. Both systems contend the data may not be accurate and could actually confuse patients.

Some health systems have also resisted attempts by United Healthcare and other insurers to post information on physicians’ adherence to national quality standards.

The dustup sheds light on much larger issues of pricing transparency and its relationship to controlling health costs - by empowering consumers who bear an ever-greater share of the financial burden.

Patients often lament that they often don’t know the true cost of a medical procedure until all the bills and statements from their physician, hospital and insurer arrive in the mail. And employers, facing sharp spikes in health benefit costs, are increasingly pushing more of those costs onto workers through higher co-payments and high-deductible plans. If patients assume greater responsibility for their own health care, the theory goes, they will spend less and demand more transparency and lower costs.

“There’s a huge amount of variability between the price of one option and another,” said Steve Walli, chief executive of United Healthcare of Missouri and central/southern Illinois. “And as you may have heard, the variation in medical cost is often hard to explain.”

Frank Ingari, president of Maryland Heights, Mo.-based Essence Healthcare Inc., called the use of insurer’s cost estimators a step in the right direction.

“In the long run, it’s inevitable that we’re going to get price transparency. This is the only market in the world where neither the provider nor the consumer knows what things cost,” Ingari said. “On the other hand, it’s not hard to understand the hospital perspective, because a price is not a price. . It’s not their fault that the price varies depending on the payer’s (health plan) and the ultimate payer - whether it’s government or a corporation.”

Dubbed “myHealthcare Cost Estimator,” United Healthcare’s website calculator provides individual patients with pricing estimates of their health care costs, based on the insurer’s contracted rates with hospitals and other providers. The cost estimates are personalized to reflect an individual’s health plan benefits, real-time account balance to pay toward expenses, and what will be owed out-of-pocket. The calculator is available only to United Healthcare customers who log in to a password-protected site.

From a consumer’s perspective, it helps enable patients to compare prices for lab tests, radiology tests, and office visits. The database has cost data for about 240,000 physicians and hospitals nationwide. Individuals can identify health providers who offer particular treatments near the ZIP code selected, and also determine how many such procedures a physician or hospital has done.

“The tool is really in response to consumer and employer demand,” Walli said. “They want better information to make better decisions for themselves and their families.”

Asked about BJC’s non-participation in the online tool, Walli said: “They have asked that they not be included in this tool, and we have honored that request.”

BJC operates Barnes-Jewish Hospital and a dozen other hospitals in Missouri and Illinois.

“We’re continuing to talk with United Healthcare and other managed care companies about these tools,” said June Fowler, a BJC spokeswoman. “Some of these cost estimators are not necessarily accurate.”

“Sometimes patients are left even more confused,” she said. “So we think it’s in the best interest of the patient to call and find out what their out-of-pocket expense is most likely to be.”

Fowler said that BJC does provide written estimates of medical costs to patients. “You can make that request,” she said.

Samuel Steinberg, an independent hospital consultant based in Florida, acknowledged that the move toward health transparency is in its infancy.

“The data is not absolutely accurate, but refusing to participate is usually the wrong sign,” he said. “Some hospitals are really committed to being transparent and willing to publish their prices. You can bet your last dollar that the ones that don’t publish are the outliers, and their rates are probably higher.”

United Healthcare’s Walli said the area’s other major health systems, including Mercy Health and SSM Health Care, have chosen to participate in the cost estimator.

But a spokeswoman for SSM Health Care voiced doubts about the online tool.

“We actually didn’t agree to participate, because we couldn’t ensure the accuracy of the data. They wouldn’t allow us to verify it,” said SSM spokeswoman Kristen Johnson. “I think they’ve gone ahead and used their claims data” to generate price estimates.

Insurers including United Healthcare have also tried to rank health providers on quality measures. Walli said that health systems in the St. Louis area have blocked attempts by insurers to publish “quality metric data” that profiles physicians using national quality and cost efficiency standards.

“In this particular community, the pushback has been great,” Walli said.

Just as with price data, provider reluctance to publicizing quality ratings may signal that the provider simply doesn’t rate well, Steinberg said.

“Anybody whose quality metrics are good is going to be happy to see them in public,” he said. “Anyone who’s reluctant probably doesn’t have good quality metrics.”

Fowler said that BJC is open to participating in a physician rating system with United Healthcare, as long as the ratings are based on national, evidence-based quality measures.

SSM’s Johnson said that the health system has declined to participate in United Healthcare’s physician ranking system because the insurer has not made its methodology for ranking doctors clear.

According to United Healthcare, its new tool provides estimates based on available fee schedules and actual contracted rates with health providers. If that information is not available, estimates are based on previous claims with the care provider.

The online tool is designed to create “care paths” that anticipate the steps and costs throughout a course of treatment, from an initial doctor’s visit to tests, surgery, physical therapy and any other follow-up care.

It also presents alternate treatment options to educate patients on their choices and to encourage them to have informed conversations with their physician.

“We’re not trying to sell one product over another. Were trying to help consumers with information,” Walli said. “Health care procedures are far more complicated than price alone.”


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