• Retail clinic: $110
• Physician office: $166
• Urgent care center: $156
• Emergency department: $570

Source: RAND Corp.

• Retail clinic: Allergies, strep throat, flu vaccinations, ear or sinus infections
• Urgent care center: Sprains, flu, minor cuts, headaches-migraine/tension
• Emergency department: Chest pains, trouble breathing, deep cuts, life-threatening symptoms

Source: Aetna

An article in today’s CBS Moneywatch.com reviews diagnostics tests, their costs, purpose, concerns and if then test is worth getting.   If you are considering getting a non-emergency MRI, mammogram, CT scan, or nuclear scan, be sure to read this article.  If you want to learn more about prices for these diagnostic tests, you can search the Outofpocket.com directory to find true prices for these services.

From MRIs to Mammograms: Which Tests Do You Really Need?

Chalk it up as one more symptom of our broken health-care system: Americans waste more than $250 billion per year on unnecessary medical tests and treatments, according to a Thomson Reuters health-care analytics report. Often, doctors order expensive, high-tech tests to rule out unlikely possibilities, reassure worried patients, or as a CYA strategy against a possible lawsuit. An American Journal of Preventive Medicine study found that in 43 percent of cases where healthy people went in for routine checkups, doctors ordered an X-ray, electrocardiogram, or urinalysis. So how can you be sure you’re not wasting your money on medical tests you don’t really need?

Unnecessary medical tests don’t just take money out of your pocket. They can expose you to radiation, cause mental stress, and kill a day or more. Not to mention their cumulative effect: ever-climbing insurance premiums.

MoneyWatch wanted to find out whether five commonly prescribed tests are worth getting: mammograms, CT scans, PSA prostate screening tests, nuclear heart scans and MRIs for lower back pain. So we talked to experts in preventative and family medicine and pored through the latest research about the risks and benefits of these tests, which can cost up to $2,000 or more a pop. What we found may surprise you.

Of course decisions about medical care are intensely personal, and everyone’s circumstances are slightly different. If there’s a key takeaway it’s this: Medical tests are not analogous to checking your car’s tire pressure. Sure there may be benefits, but there can also be negative consequences. Be sure to educate yourself on the downside.

CT Scan

• Purpose: Non-invasive and painless, doctors use them to get detailed images of everything from cancerous tumors to signs of heart disease to bone injuries. You lie on an exam table that slides in and out of a machine. More than 70 million CT scans are done annually; 23 times the number in 1980, according to the Radiological Society of North America.
• Cost: Varies widely; average price is $1,150 for a brain CT scan, $1,800 for a chest CT scan and $2,175 for an abdominal CT Scan
• Concerns: Researchers are increasingly fearful that the scans’ radiation could lead to increased cancer risk and say that safer tests such as an ultrasound can sometimes do the job. Then, there’s the danger of medical error. Last August, 206 patients at Cedars-Sinai Medical Center in Los Angeles accidentally received eight times the normal amount of radiation during their CT scans. “A single CT scan for an isolated problem I’m not so concerned about. It’s when patients keep coming back for repeated exams that cumulative radiation starts to add up,” says Dr. Aaron Sodickson, assistant professor of radiology at Harvard Medical School.
• Worth getting? If your doctor orders a non-emergency CT scan and you’ve already had at least one previously, “ask your doctor if there are alternative tests that can be done,” says Greg Morrison, chief operating officer of the American Society of Radiologic Technologists. If you will undergo the test, first ensure that the facility is accredited by the American College of Radiology and that technicians follow the ALARA (As Low as Reasonably Achievable) protocol, so you’ll receive the lowest possible dose of radiation.

PSA Prostate Cancer Test

• Purpose: Doctors encourage men to get this simple blood lab test every year to help them avoid the second leading cause of death among U.S. males. But the PSA, or prostate specific antigen test, may do more harm than good.
• Cost: About $45; up to $1,500 if the test leads to a biopsy
• Concerns: The American Cancer Society does not support routine testing for prostate cancer, because of the risk of over diagnosis and overtreatment. Studies recently published in the New England Journal of Medicine found that PSA screening does find more prostate cancer, but the early detection does not translate into lives saved. For every man whose life is saved by early detection of prostate cancer, 48 others will undergo unnecessary treatment with possible side effects including impotence and incontinence.
• Worth getting? Discuss your options with your doctor. Some men opt for regular PSA screenings, but not to have surgery or radiation therapy unless an aggressive cancer is detected.

Nuclear Heart Scan

• Purpose: Doctors usually order these two- to four-hour tests after patients have had unexplained chest pain or pain brought on by exercise. The scans are designed to help detect narrowing of the arteries, damaged heart muscle, or to evaluate how well your heart is pumping blood. After a radioactive ‘tracer’ is injected into your veins, you take a stress test, walking on a treadmill or riding a stationary bike at increasing speeds. Then photographs are taken, showing your heart after strenuous exercise.
• Cost: About $2,000
• Concerns: Although this type of imaging can be useful for diagnosing heart disease, it’s overused. A pilot study of 3,035 scans for the American College of Cardiology (funded by insurers and cardiology groups) found that about 18 percent of the nuclear heart scans were done unnecessarily; another 16 percent were ambiguous.
• Worth getting? Ask your doctor whether an alternative test is available, such as a stress echocardiogram, which does not involve exposure to radiation and costs about $1,000. Discuss the amount of radiation you’ve been exposed to in the past to determine whether you may want to avoid future radiation, when possible.

Lower-Back MRI

• Purpose: A spinal magnetic resonance imaging (MRI) test can find changes in the spine and other tissues, infections, herniated discs, and tumors without using radiation. You typically lie on a moveable table that slides into a tube surrounded by a magnet. Newer standing, or open, MRI machines are also available.
• Cost: About $2,000
• Concerns: MRIs can show every bump and lump, which may lead to procedures causing more harm than good. The Health Affairs journal found that the increasing availability of MRI is linked to an increase in surgery for lower back pain even though symptoms for most back pain sufferers often resolve themselves without invasive surgery. The researchers theorized that doctors ordering the MRIs have a tendency to find something to blame in the resulting images.
• Worth getting? Experts say that if you have lower back pain, wait at least a month before submitting to an MRI. “The main reason you’d have an MRI of your lower back is if you’re going to have surgery,” says Dr. Daniel Merenstein, Assistant Professor and Director of Research in Family Medicine at Georgetown University Medical Center. “But for routine low back pain, surgery has not been shown to be any better than Motrin or other non-steroidal anti-inflammatory drugs or acupuncture.”

Mammogram

• Purpose: The 10-minute X-ray procedure can be done for breast-cancer screening purposes in the absence of symptoms or for diagnosis purposes after a doctor detects a change in a woman’s breast.
• Cost: About $125
• Concerns: For years, women were advised to have routine screening mammograms every year or two starting at age 40. Last fall, the U.S. Preventative Services Task Force recommended less routine screening, concerned that mammograms on women in their 40s yield a high number of false positives. For women without risk factors, such as a history of breast cancer among close relatives, the panel now recommends biennial screenings starting at 50 and until age 74.
• Worth getting? Although the panel advises women in their 40s without significant risk factors to discuss the usefulness of a mammogram with their doctors, leading breast cancer experts, including American Cancer Society and Susan G. Komen for the Cure, still strongly recommend women get screening mammograms beginning in their 40s. “The American Cancer Society acknowledges the limitations of mammography [but] overwhelmingly believe[s] the benefits of screening women 40 to 49 outweigh its limitations,” Dr. Otis Brawley, chief medical officer of the American Cancer Society said, in a statement. “We believe the evidence does show there is survival benefit for women who get screening in their 40s, although we acknowledge that benefit is not great,” says Susan Brown, director of health education for Susan G. Komen for the Cure. So until the medical community reaches a consensus, it seems best to get the mammogram.

Here is what I learned. This type of information is called a FORMAL PRICING REQUEST and consumers (health plan members) must obtain specific information from the provider and follow the outlined procedures below. Contact your provider’s office and find out:

1. Provider’s NPI #
2. The specific diagnosis code(s) for the procedures that will be provided (ICD-9)
3. The specific CPT code(s) for the services that will be provided
4. The amount the provider charges for these services
5. The location (place) of service. This could be lab, outpatient facility, office, hospital)

After the member has all this information from the provider, the member should contact the health plan’s benefits/claims department and be ready to answer all these questions. Within 48-72 hours after the request is made, the insurer will provide the member with a letter identifying the member’s out-of-pocket costs for the services. As a convenience, the insurance plan has offered to read the letter over the phone, rather than mail it out to the member. Contact the Benefits/claims department.

Happy New Year!

Here’s what I learned:  the two most blatant culprits of the overcharges were due to Secret Prices and Coding Errors/use of an Internal Coding System…I’m sure that’s no surprise for OutOfPocket Blog readers.

A little background

It was suggested that I go to the Emergency Room by my doctor who had prescribed a course of oral antibiotics for an infection. I then came down with a stomach virus and was unable to keep down the medication.  My infection progressed, so my doctor instructed me to go to the ER for IV antibiotics.  I went, received excellent care, stabilized within six hours, went home and had a full recovery.

Then I received my first billing statement.  Those antibiotics and basic blood tests cost $7,051.  Then my PPO policy negotiated it down to $3,525, with no explanation.  These prices seemed so arbitrary to me, I just wanted to know they were fair and reasonable, as determined by industry standards. 

By working with a patient advocate at Southwest Bill Review, I learned that up to 90% of all hospital bills are coded incorrectly.  My patient advocate told me that there is supposed to be transparency in the billing system – and that there are definitive coding guidelines that apply to each hospital.  However, this hospital administers their own coding system – making it impossible to determine exactly what is being charged.    I learned that this is very common.

I then developed a 10-step-process to hospital negotiation. My hope is that this information will help people navigate through the current medical billing system.

The 10-step-process can be found at my blog, Hospital Overcharges 101. Also be sure to check out the Youtube video of my experience.

Free Medical Cost Savings Tips For All

I can be followed on Twitter at: MedOvercharg101 and the Facebook Fan Page, Medical Overcharges 101 – when the 140 characters on Twitter just isn’t enough. 

--By Lynn Jordan

Lynn Jordan is an award winning freelance producer and writer having worked in the television and live event production industries.  This is her first time with the hospital billing system and her hope is that what she has learned will help other people confront their medical bills.

With so much discussion on how we need to reduce health care costs, this article written by Dr. Bernadine Healy in the U.S. News and World Report, sheds some light on this issue as Dr. Healy discuses the secrecy of health care prices. 

When the price of a colonoscopy ranges from $450 to $10,000, there's room for plenty of savings.
By Bernadine Healy, M.D.

As President Obama said again in his recent address to Congress, an imperative for health reform is containing runaway health costs. But the elephant in the room that is a real driver of costs is something few people are talking about: the variable and hush-hush pricing of medical goods and services, set by the government or negotiated by insurers and largely kept secret from the patients ultimately responsible for their bills.

Look at a colonoscopy: When paid by Medicare, the fee is roughly $450. Insurance companies secretly negotiate a maze of different prices, generally two to five times that. But as the trade group America's Health Insurance Plans recently reported, patients who have to pay their own bill because they are uninsured, are seeking care outside of their insurer's network, or their insurer has denied their claim, can face retail charges as shameless as $10,000. And how can it be that Medicare pays $40,000, prix fixe, for the same heart operation, by the same doctor, at the same hospital, that costs patients paying privately $80,000 to $120,000?
Consumers' ignorance of what services truly cost blurs the connection between their rising insurance premiums and prices, setting the stage for those prices to soar ever higher. Little wonder that the country's total health costs—for public programs like Medicare and Medicaid, private insurance, and out-of-pocket payments—are twice those of other developed countries. Making prices transparent so they can be compared and giving patients the means to shop for insurers that will get them the best deals would put downward pressure on prices and bring sustainable cost savings.

Instead, Americans are led to think that what's mainly to blame for out-of-control costs is their own voracious overconsumption. So cutting down on the quantity of medical services used by the sick and reallocating dollars for wellness and prevention sound like definite cost savers. But that ignores a few facts. Compared with people in other developed countries, Americans see doctors less often and take fewer medications. They also spend the same or fewer number of days in hospitals, and they already lead the world in expenditures per capita on prevention and public health. Yes, more high-tech care may be given to the sick in this country, and yes, that contributes to higher costs. But whether it's low- or high-tech care, what is achingly obvious is that total costs are a function of prices. Ours are the highest.

As a classic 2003 report in the journal Health Affairs put it simply: "It's the Prices, Stupid." In their detailed analysis of health spending in 30 developed countries, leading health economists including Gerard Anderson of Johns Hopkins Bloomberg School of Public Health and Uwe Reinhardt of Princeton University determined that the greater cost of care in the United States was due to much higher prices for virtually all of its medical goods and services.

Our senior citizens must have read that study a few years back when they boarded buses to Canada to buy prescription drugs for half the prices they would pay here. Who stopped their burgeoning tea party? The federal government, citing safety concerns, with heavy pressure from the pharmaceutical interests intent on protecting the higher prices Americans are effectively forced to pay.

We are just beginning to see snippets of such comparative price information become more public in other medical areas, prompted no doubt by the growing out-of-pocket payments besetting insured patients. Just last month, a report initiated by Gov. Tim Pawlenty provided price and quality information on 100 medical services from centers throughout Minnesota. Prices were all over the map. The average for colonoscopies ranged from $325 to $1,354. The price of a simple blood count varied from $13 to $85. The wide variation for these and the other prices disclosed suggests lots of room for competition and cost savings. Another area where scrutiny is needed to understand skyrocketing outpatient bills is that of wildly varying and increasingly common "facility fees." A cardiac stress test, for example, can vary by thousands of dollars depending on the size of this tacked-on fee—a charge for the use of a room needed for less than an hour.

To turn these surprising revelations into useful information that can guide and reward patients for getting the best value for their healthcare dollar, prices have to be widely accessible and easily compared before care is rendered. One way to do this might be to expand the concept of the proposed health insurance exchange, which currently would be restricted to the uninsured. Allow for public and private exchanges, and make them open to all individuals who want to purchase insurance anywhere in the country at the best price. And make exchanges vehicles for price transparency, where consumers could get access to comparative and customary pricing information and then hold insurers' feet to the fire by selecting the company with the best available prices at the places they want to go.

The power of making medical prices transparent to the public has not been lost on the political establishment. Indeed, Sens. Charles Grassley and Arlen Specter have pushed legislation to require price disclosures in the private sector, where secrecy clauses between hospitals and manufacturers have been shown to double or triple the cost of medical devices for some patients. Meanwhile, it may surprise the public to know that the government has gone to great lengths to keep the rock-bottom prices it demands quiet, including entering into contracts with industry that make the prices Medicare and Medicaid pay for prescription drugs, say, inviolable trade secrets.

Why? Congress, as laid out in a 2007 letter from the Congressional Budget Office, recognizes that such disclosures would enable private insurers and their customers to be more insistent about getting similar pricing deals, making their own small discounts, and the government's large ones, converge toward an average. While this would lower costs for people with private insurance, it would make government prices—and costs—a bit higher. Disclosure has still not happened.

But if health reform is supposed to reduce costs, disclosing prices and enabling and incentivizing individuals to seek out the best value to serve their needs is a way to do that as a first step—and before making efforts to restrict or redirect care. I'd estimate a good 10 percent of total costs could be taken out of the system quickly, to the benefit of those in both private and public plans.

--Bernadine Healy, M.D.

Every day people make purchasing decisions based on firsthand knowledge of price, quality and service.   We do this all the time. You might not realize this, but consumers apply this behavior every time they purchase groceries, books, automobiles, and electronics and even when they book travel reservations.  Consumers can make informed purchasing decisions because they have access to meaningful tools and data that enable them to comparison shop and find the best value.

In the health care industry, consumers should be able to easily navigate through treatment and provider options, so they can research the appropriate quality and price information for needed services.  If we engage consumers in the health care decision making process, people will act more responsible.  I also believe our health care system should include programs that encourage accountability for providers, patients (consumers) and health plans.

The good news is health insurers are making progress in this direction.  Some of the larger health plans are finally accepting the fact that their members should be treated like customers and they are working to provide their members with meaningful tools because they realize this is “good customer service.”  What’s very interesting is that empowering their members to act more like customers benefits all the stake holders. 

Over the past month, I have reviewed price transparency tools offered my some of the major health insurers including Aetna, Anthem Blue Cross Blue Shield, Cigna, Humana, Regence and United Healthcare.  The tools are designed for members of the health plans and attempt to deliver some price and quality transparency, to help members make informed choices.  It’s definitely a step in the right direction but there is a lot of room for improvement.    We are all pioneers in this area and as the transparency tools evolve, consumers can expect to see some innovative, decision-making tools to help them make informed choices – before visiting a provider. 

The ongoing health care debate has caused some heated emotions, disagreements, great discussions on very important issues, and plenty of misinformation. Unfortunately, the most important issue of all has gotten lost in all the noise. 

We all need to remember that the real crisis is what’s already happening.  Today, the average price for health insurance premiums is $13,000 a year.  If we do nothing about reforming our health care system, this amount will double over the next decade to $25,000 and many more Americans will be forced to join the uninsured.  This is a real crisis.

Many of the discussions about health care reform focus on the 47 million uninsured Americans who do not have health insurance.  But remember, health care reform is just as important to the majority of Americans who already have health insurance.  Doing nothing results in a crisis that we cannot afford. 

Here are the facts:

• Rising health care costs are crushing American companies – particularly small businesses
• In 1960 U.S. firms spent 1.2% of their payroll on health insurance.  In 2006, they spent almost 10%.
• Health care costs put U.S. firms at a disadvantage to foreign companies and health care costs destroy U.S. jobs
• Escalating health care cost have been passed on to the middle class in the form of higher prices for products/services and flat wages.  Money that would have gone to raises has instead been spent on health care premiums that have doubled over the past 9 years.
• Small businesses pay 18% more per worker for health care than large firms for the same benefits.  They pay more because they have a smaller risk pool and have to absorb higher broker fees and administrative costs per worker.
• Businesses that offer employees health insurance:
  • Only 49% of firms with 3-9 employees offered health plans in 2008
  • 78% of firms with 10-24 employees offered health plan in 2008
  • 99% of firms with 200+ employees offered health plans in 2008
• This year health care expenditures are expected to account for about 18% of the GDP. Without reform, that number is projected to rise to 28% in 2030, and to 34% in 2040.

We all need to make sure that health care reform gets started this year.

The health care industry can learn something from the advertising industry.  The key to successful interactive campaigns is to delight and engage consumers so they want to participate.  This same rule applies to reforming the health care system.   We need to engage and delight consumers to get them to participate. 

Regence, a not-for-profit health insurer in the Northwest/Intermountain Region, has been a leader in transforming our health care system.  They have created an engaging, interactive presentation to kick off their launch of WhatsTheRealCost.org.  It’s a delightful presentation on transforming our health care system.  Also, be sure to check out the Regence award winning one-minute video, WhatsTheRealCost.org.

Imagine a reformed health care system where costs are clear, information is simply stated, procedures are openly and honestly evaluated.  Where participants share knowledge and information.  Where technology drives value.  Where all particpatants are informed, engaged and rewarded for smart choices and health behavior.   

This is how we need to reform our health care system.

Outofpocket.com is not a political blog, but it’s practically impossible these days to read any newspaper, listen to the news or turn on the radio without hearing about health care reform.  As informed consumers, it’s important to understand the complicated issues surrounding health care reform since it will affect everyone.  The more you understand the problems in our current system, the main points of disagreement, the proposals being presented, the industries that will lose/gain from an overhaul and what impact this will have on your own situation – the more you can make a difference.

In today’s Wall Street Journal, Janet Adamy, Health Care Reporter, wrote an outstanding article that explains the health care reform challenge by answering ten questions:

1.       What is the problem with health care?  Is it as bad as they say?

2.       Can Democrats and Republican agree on anything?

3.       What are the main points of disagreement?

4.       What would a public plan look like?

5.       Why is the total price of the overhaul so expensive, especially considering that it is designed to bring down costs?

6.       What are the most likely ways to pay for the overhaul?

7.       Which industries are most likely to lose, and which to gain, from any overhaul?

8.       I already have insurance through my employer – what happens to me?

9.       Politicians have tried for decades to push universal health insurance.  Why did they always fail before?  Why would this time be any different?

10.    What happens if the effort once again fails?

Ten Questions on the Health-Care Overhaul

The Effort to Change the System Enjoys More Support Than Past Attempts, but the Complications Are as Acute as Ever

By  JANET ADAMY

 It is crunch time for health care. Lawmakers who are trying to fundamentally remake one-sixth of the U.S. economy say this might be the most complicated legislation they have undertaken.

Here are some basics that everyone can grasp -- and probably ought to, because the health bill, if it passes, will affect almost everyone.

1. What is the problem with health care, anyway? Is it as bad as they say?

The problem, as advocates for change see it, boils down to two big areas: high costs and lack of coverage. For some households and employers, the cost of care already is out of reach, and many more will struggle to afford it if costs keep escalating. Medicare is eating up a bigger share of government spending, and a growing number of bankruptcies and home foreclosures are linked to medical expenses.

Even though the U.S. spends $2 trillion a year for health care, some 46 million people don't have health coverage. To be sure, that oft-cited number from the Census Bureau is somewhat misleading because it includes illegal immigrants, healthy young adults who don't think they need insurance and poor people who are eligible for Medicaid.

Still, as the recession wears on, the number of uninsured appears to be rising. One study, by the left-leaning Center for American Progress Action Fund, found that as many as 14,000 people are losing their health insurance every day because of job cuts. Families who have insurance pay an additional $1,000 a year in premiums to effectively subsidize all the people who receive care but don't pay for it, according to a separate study by the liberal group Families USA and actuarial consultancy Milliman Inc.

2. Can Democrats and Republicans agree on anything?

Actually, yes. There is broad support for changing the way hospitals and doctors are paid so that they are compensated for the quality of care they provide, not the quantity of procedures they do. Democrats and Republicans also back the idea of creating online marketplaces where consumers and small businesses can comparison-shop for plans.

Both parties want to bar insurance companies from denying coverage to people who are already sick. The insurers are willing to make that concession, as long as lawmakers also require most people to carry insurance, since that would force young, healthy people into the insurance system.

It amounts to a twin mandate -- one on insurers to sell policies, and another on Americans to buy them. Although there are pockets of Republican opposition to the latter idea, both have enough bipartisan support to pass. These steps alone would represent big changes to the status quo.

3. Where are the main points of disagreement?

The sharpest divide between the two parties: Whether to create a government-run insurance plan (otherwise known as a "public plan") that would go up against private plans in online marketplaces. President Barack Obama says a public plan will keep private insurers honest. Republicans say it would give the government too much control over health care.

The other main battle, which doesn't break down as easily along party lines, is how to pay for a plan expected to cost at least $1 trillion over a decade. Many lawmakers think it makes sense to impose a tax on employer-provided health-care benefits, a perk that currently is tax-free.

Then they looked at the poll numbers. Many voters hate the idea of paying taxes on something that right now costs nothing. So Democrats have instead proposed raising taxes on the rich.

Congress also remains divided over whether to make employers (except really small ones) provide insurance. House Democrats propose that if companies don't offer insurance, they should contribute as much as 8% of their payroll spending toward helping workers buy insurance on their own. Republicans argue that companies will make up for it by cutting jobs and lowering wages.

4. What would a public plan look like?

The country already has a huge public plan -- Medicare, which covers the elderly and some other groups. It generally pays doctors and hospitals less than private insurers. Liberal Democrats would like to replicate it in the new marketplaces. They want the government directly to set premiums and services under the plan, perhaps with basic and premium options.

That isn't going to fly in this Congress, despite Democratic control of both chambers. Republicans are more opposed to having a government plan than Democrats are bent on having it. Conservatives figure the government would quickly drive private insurers out of business by undercutting them on price.

Two other scenarios have emerged as compromises. One is to hold off on creating the plan and instead impose heavy regulations on insurance companies aimed at making coverage accessible and affordable. If that doesn't work, then the government insurance plan would kick in after several years. The other idea is to create a batch of regional nonprofit insurance cooperatives to compete with private insurers. But many liberals consider that a far stretch from the original idea, since the government wouldn't run those plans.

One point that gets overlooked in the debate is that most people probably wouldn't even be eligible for the public plan. Only individuals without affordable employer-provided insurance and businesses that aren't big enough to buy reasonably priced plans on their own would qualify.

5. Why is the total price of the overhaul so expensive, especially considering that it is designed to bring down costs?

The cost mostly comes from giving people subsidies to buy insurance, and from expanding Medicaid, the federal-state insurance program for the poor, to cover more low-income Americans.

The theory is that once more Americans carry insurance, the entire health system will spend less money caring for them. Those people will have more access to care that prevents them from getting sick in the first place, and they would rely less on costly forms of treatment such as visiting the emergency room. But it could be years before that really reduces health costs, if it ever does.

President Obama often talks about more fundamental fixes for high costs, like paying for quality and blocking doctors from boosting their income with unnecessary tests. But Congress has limited power to change that.

6. What are the most likely ways to pay for the overhaul?

The White House has proposed about $950 billion in savings over 10 years to pay for the plan that include things like lower reimbursements to hospitals that treat Medicare patients.

The wealthy are a natural target. One proposal is limiting itemized tax deductions for families who earn more than $250,000 annually, a campaign idea of the president. House Democrats want to impose a surtax on wealthy individuals. Less likely are new taxes on soda and sugary drinks, which many lawmakers see as politically unpopular.

7. Which industries are most likely to lose, and which to gain, from any overhaul?

Perhaps no industry stands to gain more from the changes than health insurers, who would get tens of millions of new customers because Americans would be required by law to carry health insurance. Pharmaceutical companies would sell more prescription drugs because more people would have coverage for drugs and access to doctors who prescribe them. Hospitals and doctors wouldn't have to provide as much free care as they do now.

But each of those groups also could take hits, particularly the health insurers if some kind of public option drives down their profit margins. The big losers would be retailers, restaurants and other businesses with low-income workers who provide little or no health insurance, since they would be forced to start paying for it.

Businesses that are too small to afford health insurance but not tiny enough to fall below the proposed $250,000 annual payroll cutoff that exempts them from providing coverage also could get squeezed by the legislation.

8. I already have insurance through my job - what happens to me?

Not too much at first. A handful of tax-free perks for the insured could get axed. For instance, lawmakers want to end the practice of allowing people to put money into so-called flexible spending accounts, which allow them to pay for everything from cosmetic dental work to surgery with tax-free dollars.

Longer term, a lot could change. For instance, your employer could drop coverage, preferring to pay the penalty for doing so and deflecting employees to Uncle Sam's plan. Cost-cutting efforts in other parts of the system could eventually affect employer-provided plans as well.

9. Politicians have tried for decades to push universal health insurance. Why did they always fail before? Why would this time be any different?

These efforts stretch back to the 1930s, when President Franklin Roosevelt proposed creating a compulsory health-insurance system for all Americans, run by the states. Doctors, worried it would hurt their pay, helped kill the measure, buoyed by opposition from business and labor groups. Other major health overhaul attempts, most notably President Bill Clinton's 1993-94 effort, died because powerful interest groups feared their members would either earn less or have to pay more under the new system.

What is different now is that major health and other interest groups are on board with the idea. Many insurers, hospitals, doctors and drug companies agree that the system is so flawed it isn't sustainable, and they see a bill as a chance to push through improvements like adopting electronic health records, broadening the use of data to show which treatments work best and reducing the threat of malpractice lawsuits. Employers see it as a chance to curb the sharply rising price of covering their workers. Almost no one is arguing that the system is fine the way it is. Mr. Obama's high popularity, coupled with wide Democratic margins in Congress, also grease the wheels for passing a bill.

10. What happens if the effort once again fails?

Lawmakers would likely scale back their plans and try to at least pass a measure that partially expands insurance coverage or helps stall the increase in health costs. But so many parts of the legislation are intertwined that they will be less effective, and perhaps impossible to achieve, if done piecemeal. Lawmakers might be reluctant to take up the controversial legislation ahead of congressional elections next year. So it would probably be several years before lawmakers tried again.

As an accomplished triathlete, I have been honored to be involved in helping coach women train and prepare for their first triathlon. The women I train are in their 20s through 60s, and after an 8-week training program, everyone successfully completed the TrekWomen’s triathlon this past Sunday in Wisconsin. It’s a truly rewarding experience for me to see all these women reach their goal of finishing their first triathlon. Everyone established their individual fitness goals, whether it was is to exercise on a daily basis, to increase their level of fitness, to eat healthier in order to perform better, to feel better, get fit and to lose weight. After finishing their first triathlon, many of the participants now have “triathlon fever” and plan to do another triathlon next year to improve their time.

What's remarkable is that these women are actively participating in wellness, improving their health and the quality of their lives. As these women continue to maintain healthy lives, down the road, I am certain that health care expenses will be lower for these women due to their focus on wellness and improving their health.

Congrats to all the women athletes and I look forward to training with next year’s team!

Ten Ways Consumer Driven Health Care is a Proven Success

By Greg Scandlen

A revolution is underway in American health care, but you won’t read about it newspapers or see it on TV.

The revolution involves a growing number of Americans who are reclaiming their right to buy health care goods and services that they decide are beneficial. They are shrugging off the heavy hand of regulation by Washington politicians, insurance companies, pharmaceutical firms, hospitals, medical organizations, federal agencies, and giant employers, all of whom are fighting over who gets what of the trillions of dollars Americans spend each year on health care.

This is a Consumer Driven Health Care Revolution.

The revolution got underway six years ago, when consumers were able to redirect some of the health care money they earned into new deposits such as health savings accounts, health reimbursement arrangements, flexible spending accounts, and insurance policies with low premiums and high deductibles.

Empowered by control over their own money, consumers increasingly demanded the information needed to make good decisions about their health care. Once they possessed both the money and information, consumers forced changes in the delivery of services to make health care more efficient, more accountable, more convenient, and certainly more affordable.

Instead of paying an insurance company for maximum coverage they were unlikely to use, increasing numbers of consumers decided to buy less-expensive insurance for expensive services and products while banking the monetary difference to pay for services only when they needed them. Employers liked the revolution, too, because it left them more money with which to raise wages or fund a savings account.

Recent studies find that consumer driven health care plans are being used by 20 percent of the privately insured population.1 This is an astonishing rate of growth for an approach that began just six years ago.

But these insurance plans are only the beginning. The important thing is what happens after consumers have more control. Already, consumer driven plans are having a profound effect on the health care system.

The growing use of generic drugs, retail clinics, medical tourism, concierge medicine, physician owned specialty hospitals, and the reduction in the use of hospital emergency rooms may all be attributed to the growth of consumer driven health care.

Even the current recession is highlighting a new era of consumerism in health care. Health care spending usually grows in times of recession because workers who fear losing their jobs—and their insurance coverage—try to maximize their use of services before they get laid off. But during this recession, consumers are deciding how best to spend their own money, and are choosing to preserve their funds instead of spending them on unnecessary health care services. As a result, spending on prescription drugs dropped by 2 percent in the year ended Sept. 30, 2008, physician office visits are down 1.5 percent, and hospital admissions are down by 2 percent.

The Consumer Driven Health Care Revolution has only just begun, and here’s why it will grow:

1. Consumer Driven Care dramatically reduces premiums
2. Consumer Driven Care reduces the rate of increase from year to year
3. Consumers can use the savings to fund their accounts
4. The money consumers put in the account is triply tax advantaged, saving even more
5. Consumer Driven Care is good for the sick as well as the healthy
6. Consumer Driven Care is good for the poor as well as the wealthy
7. Consumers may choose their own provider and their preferred service
8. People with Consumer Driven Plans change their behavior to get more value out of the system and become better informed about their treatments and costs
9. Consumer Driven Care is taking over the insurance market
10. People with Consumer Driven Care are increasingly satisfied with their coverage

Click here to read the complete article

Greg Scandlen is the director of Consumers for Health Care Choices, a project of The Heartland Institute. He may be contacted at gscandlen@heartland.org.

 My current auto insurance policy offers me discounts on my premium for: 

-       Save driver (accident free)    

-       Multi-car policy                     

-       Good grades for teenage drivers in the household

-       Anti-theft device installed in vehicle(s)

-       Air bags installed in vehicle(s)

What if health insurance policies started offering premium discounts for behaviors like:

-       Taking a health risk assessment

-       Exercising on a daily basis

-       Eating healthy

-       Reducing weight

-       Stop smoking

-       Lowering blood pressure

-       Lowering cholesterol

-       Monitoring and follow-up on chronic diseases 

As more consumers take personal responsibility for their own health, these kinds of tactics will become more common. 

I recently received recognition from Wellsphere that the OutofPocket.com blog has been designated as a Health Maven! I joined forces with an amazing group of health care bloggers on Wellsphere to participate in a community of writers that share expert advice on a variety of health care topics. Wellsphere’s mission is to help millions of people live healthier, happier lives by connecting them with the knowledge, people and tools they need to manage and improve their health.

If you haven't visited Wellsphere.com yet, you should definitely check it out.

Recently in the Wall Street Journal, Steven Burd, the CEO of Safeway Inc., and founder of the Coalition to Advance Healthcare Reform, wrote an article on reducing health-care costs.  Mr. Burd discusses how market-based solutions can reduce the national health-care bill by 40% and the key to achieving these savings is health-care plans that reward healthy behavior.    While comprehensive health-care reform is extremely complicated and needs to address a number of critical issues, personal responsibility and financial incentives are the path to a healthier America.  This is a proven fact. The Safeway team calculates that if the nation adopted their approach in 2005, the nation’s direct health-care bill would be $550 billion less than it is today.

Financial incentives certainly help modify behavior.  Rewards like reduced premiums, rebates, discounts, gift cards, free health club memberships, bonuses, certainly help influence employees healthy behavior.   And the greatest rewards of all --ones that provides you with “feeling terrific, looking terrific” and “living healthier” are priceless.

Radiology tests like MRI and CT scans have become key tools for physicians to help diagnose and monitor disease. It's no surprise that diagnostic imaging has become one of the fastest growing segments of healthcare, consuming billions of dollars per year. In fact we will spend over $20 billion in 2009 just on MRI scans alone.

Many consumers are increasingly forced to burden the costs of these high-tech medical tests through high deductible plans, often paying hundreds of dollars out of pocket for a scan. And uninsured consumers are faced with costs that can easily run into the thousands of dollars. For example, a Lumbar Spine MRI scan performed at a hospital can cost an uninsured consumer $3,000.

Healthcare is still mired in complex and opaque pricing strategies that make it difficult, if not impossible, for uninsured consumers to discover the real costs of Radiology tests and receive the same prices that health insurance companies enjoy. Fortunately there are technology companies, like RemakeHealth, that are building online resources to help healthcare consumers.

RemakeHealth recently launched its Radiology shopping website which lets consumers look up prices for nearly any outpatient Radiology test, find a local certified imaging center and purchase the test with a credit card. Radiology tests featured include X-rays, MRI scans, CT scans, Ultrasounds and more. All the imaging center providers on the website are certified by the American College of Radiology and staffed by American Board of Radiology certified Radiologists.

RemakeHealth acts like a travel agent and has negotiated prices for uninsured consumers in advance. When consumers purchase a test they receive concierge like services which include a personal phone call to set up the appointment and answer any questions about the test.

RemakeHealth is also working to eliminate confusing healthcare pricing schemes. For example a Brain MRI usually has 3 different prices: without dye, with dye, with and without dye. They have simplified this by offering one price and not charging extra for dye injections. Consumers are also often unaware of large price variations that occur between facilities in the same town. RemakeHealth has addressed this by creating one price for each type of test in each of their local service areas.

The company was founded by Dr. Ravi Sohal, who is a Radiologist, and its cofounders are from the Radiology industry as well. The founders have dedicated themselves to helping uninsured consumers make informed decisions by building healthcare shopping tools similar to the ones we all enjoy when looking to buy nearly everything else online.  They have always been amazed that you can shop for an airline ticket and hotel room but not for an X-ray and MRI scan, until now.

Every so often you run across a touching story about people who really make a difference in improving the lives of others.  This is one of them.

Dentistry From The Heart (DFTH) is a dental program that provides free dental care to those who need it.   Since 2005, this non-profit organization has provided free dental services at more than 50 locations across 29 states. Founded in Tampa, Florida in 2001, Dentistry From The Heart started as Dr. VincentMonticciolo’s way of giving back to his community and providing aid to the growing number of Americans without dental insurance. Over the past eight years, more than 4,000 patients from across the state have traveled to attend Dr. Monticciolo’s DFTH events to receive a free filling, extraction, or cleaning.

After realizing the potential impact DFTH could make across the country, Dr. Monticciolo registered DFTH as a national non-profit organization and created all the tools needed for dental practices to host DFTH events in their community.

“With the number of Americans living without dental insurance on the rise, my desire is for more dentists to look to Dentistry From The Heart as a way to directly impact lives and provide invaluable services to their community,” said Dr. Vincent Monticciolo.

Since 2005, Dr. Monticciolo has enlisted more than 60 dental practices across the United States to host their own events. With their help, Dentistry From The Heart has now served more than 10,000 people and given away more than $2.5 million in free dental work. Dentistry From The Heart is a registered non-profit organization that provides free dental work for people who need it. Dr. Vincent Monticciolo founded the organization as a means to give back to the community and address the growing number of people without dental insurance. In the past eight years, Dentistry From The Heart events have contributed more than $2.5 million in free dentistry and helped more than 10,000 patients across the country.

In the Personal Journal section of today’s print version of the Wall Street Journal, Aetna has a full-page ad.  The headline of this ad, “How Aetna can even help you keep your wallet healthy,” caught my attention because the ad promotes a few tips on how consumers can keep health care costs down including:

·         Use generic prescriptions rather than brand-name

·         Use mail order service to fill prescriptions

·         Preventative care to keep yourself healthy

·         Stay in network when selecting providers (hospitals, doctors)

I have a tip for the health insurer --  why not keep health care costs down by eliminating expensive advertising!  I wonder how much this full-page ad cost Aetna.   With the rise in health care costs, including insurance premiums, cost of service, and administrative fees, I find it disconcerting that health insurers spent so much money on this ad.  If I had my choice, I would prefer my health insurer save me money and reduce my monthly premiums, rather than spend extravagant amounts of money on unnecessary advertising. No offense Aetna, but with health care costs spiraling out of control, consumers are more interested in reducing their out-of-pocket costs.   I’m not sure this ad keeps my wallet healthy.

Happy New Year!  Spending wisely for health care services is definitely a priority in 2009 and with a little knowledge; you can easily save hundreds –even thousands of dollars.   To get you started, here are some excellent tips on how you can save money on routine health care services. 

Affordable Medical Care Services

Federally-funded by the Health Resources and Services Administration (HRSA), there are thousands of health centers around the U.S. that provide low-cost health care to people based on financial need. You pay what you can afford, based on your income. For more information visit www.findahealthcenter.hrsa.gov, or you can call (888) 275-4772.

Hill-Burton facilities: There are around 200 Hill-Burton health care facilities around the country that offer free or reduced-cost health care for people that cannot afford to pay for services.  To locate a facility or to see if you qualify, visit www.hrsa.gov/hillburton or call 800-638-0742.

Free clinics: These are privately funded, non-profit, community-based clinics that typically provide care for common illnesses and injuries to those in need, at little or no cost. There are around 1,000 free clinics nationwide. To locate one in your area, call your local hospital or visit www.freemedicalcamps.com for more information.

Indian Health Service (IHS): A government agency within the Department of Health and Human Service, IHS provides free medical care to American Indians and Alaska Natives in 35 states. Visit www.ihs.gov for more information.

Remote Area Medical: A non-profit, charitable organization that provides free health, dental and eye care to uninsured or underinsured people in remote areas of Tennessee, Kentucky and Virginia but may be expanding to other states in the future. Visit www.ramusa.org or call (865) 579-1530.

Making Sense Out of Existing Data

Did you know that health care price data exists today --it's just not available to the public. I am passionate about bringing consumerism to health care, and dedicated to promoting price transparency.  My goal is to make sense of the existing price data to help consumers make informed choices. 

For CONSUMERS

• Hunting down true out-of-pocket expenses for health care services – in advance, can be frustrating.  Unless you are an experienced data minter, this type of hunting can be intimidating and time-consuming.  If you are uninsured, under-insured, looking for an out-of-network provider, or have a high-deductible health plan, you are probably trying to make cost-effective choices before purchasing health care services.  And you are probably interested in knowing your true out of pocket cost for the services BEFORE you visit the provider.    That’s just being a good consumer.  You need useful and relevant tools to help you make good choices.

For INSURERS

• You are the keeper of all the claims data for your members.  You know exactly the negotiated (contracted) price for every provider, for every service, for every different insurance plan you offer.  You also know how much of a member’s deductible has been met.  You have databases of prices paid for every service for every member and could make life a lot easier for your members and possibly change health care if you agreed to share this data to make it publically available.  Yet you insist on keeping this data a secret. 

For OUTOFPOCKET.COM

• I am inviting consumers to post/share prices they paid in the directory.   Everyone wants to look up prices, but very few are willing to take a minute to post/share their prices.  We could wait years for legislation to pass, insurers to agree to make prices public, or we could do something today.  Consumers are invited (and encouraged!) to collaborate and share prices they paid on OutofPocket.com.  If enough consumers participate and share prices, consumers collectively will create a very powerful directory of true out-of-pocket prices.

For PROVIDERS

• You have an opportunity to transform health care as we know it today.  You can help promote transparency by publishing your prices for services.   Why not let consumers know up front what your services will cost them?  OutofPocket.com invites you to include your prices/services in the directory - free of charge.  This not only promotes your practice, but also helps consumers understand what they will be required to pay for services at your facility.

Imagine how easy it would be to comparison shop for health care services if relevant data was available. If consumers had access to true healthcare price data, comparison shopping for health care services could be a lot like your experience shopping for a book on Amazon.com, booking a vacation on Travelocity.com or purchasing an item on eBay.com. 

Tell a friend about OutofPocket.com and be sure to add prices you paid for health care services to this directory.   Not only will you be sharing data, but you will be contributing to a powerful directory of prices that will help promote more affordable health care services.

Doctor Review Websites

The November 28 edition of Slate.com included an interesting article by Dr. Kent Sepkowitz.  His article sheds some light on all the doctor rating websites available today.  Dr. Sepkowitz spent many hours reviewing doctor rating tools, including free sites and sites that require subscriptions or fees to obtain this information.  His conclusion:  the online doctor rating tools are very lean, content-free and lack any useful information. 

Last month I posted a blog about finding the best value (understanding the quality side of health care in addition to finding the best cost) and listed 25 different websites that offer doctor ratings.  I neglected to mention that I never use these doctor rating sites because they are not useful.   They lack meaningful data.  All of them.  Instead, I ask my doctors, family, friends, and community for their personal recommendations.  Then I go online and start to research the doctor’s certifications in more detail using many websites, tools and blogs to read other patient’s comments and experiences.  Since this is user generated content, you need to be able to read between the lines.  Sometimes people just have a bad day and they should skip writing reviews online until they have 24 hours to think about what they want to write and their mood stabilizes.

Price Transparency Tools

I am dedicated to promoting price transparency in health care.  This is what I do and that’s why I launched OutofPocket.com almost two years ago.  If I can help consumers make more informed and cost-effective choices before visiting a provider, then I have accomplished my mission.   When consumers start making more informed choices, become active participants in their own health care and demand greater transparency  --- good things result including lower costs, more innovation, more choices and improved access to medical care.
 
OutofPocket.com is not the only price transparency tool available.  Dozens of others are out there and I research all the new tools to evaluate their usefulness so I can talk about these tools in my next presentation.  Unfortunately, the price transparency tools seem to have the same disease as the doctor rating tools.  Each has some amount of data, but not enough to be meaningful and comprehensive.  Wouldn’t it be interesting if these tools collaborated and consolidated their data to produce a robust tool where shopping for routine health care servcies would be comparable to the experience of shopping for items using eBay or Amazon.com, where you can easily compare quality, prices and recommendations?

Here is the short list of 20 price transparency tools.  If you would like my comprehensive list and review of each tool, please send me a note and I’d be happy to forward this information to you.

Alijor
AMA CPT Lookup Tool
Carol
CostHelper
DoctorPricing
HealthcareBlueBook
HealthPricer
HospitalVictims
MainStreet Medica
MedcareCompare
MyHealthScore
MyMedical Costs
MyRegence
OutofPocket
PatientCare
RemakeHealth
Spectrum Health
UCompreHealthCare
USA Healthcare Costs
Vimo

Do you know how to find affordable lab tests?

Fortunately I have good health insurance.  Four years ago I signed up for a high-deductible health plan for my family in order to keep our premiums down.  My deductible is $5,200 and as a result, I am getting really good at shopping around for the best value, negotiating cash prices with providers, calling around to get prices and using available tools/resources to comparison shop/understand fair prices.  The more money I am able to save on finding affordable health care, the more money I have to spend on family vacations.  That’s enough incentive for me.

My health insurer has negotiated special deals (discounts) with providers in my network.   When I use these network providers, I am charged the discounted rate for services.  This carefully guarded rate is difficult to find out until after services are provided because health insurers keep negotiated prices a secret.  That’s why I encourage consumers to post/share rates they paid for actual services in OutofPocket.com directory, to share with other consumers.  If insurers and providers will not reveal these prices, consumers should!

I recently had a series of blood tests done that were required for my upcoming surgery.  I realized if I went to my doctors office to have these blood tests taken, my out-of-pocket costs would be much higher, so I selected a stand-alone lab testing facility that offers affordable lab tests.  I went online to find Quest Diagnostics and scheduled my appointment.  I just received my EOB and here’s what I discovered

Prices For My Lab Tests for Comprehensive Blood Test

Total Quest Labs billed to my insurance plan      $ 193.78

Total discounted by my insurance plan                 $ 143.78

Amount of my out-of-pocket for my lab tests         $   50.00

If I wasn’t careful, I could have easily ended up paying a lot more for my lab tests.  If I did not have insurance, I would have negotiated a cash discount with the lab when I scheduled the service, to make sure I get a fair price.  Because of my cost-effective choices, I saved about $144.

Here are some resources you can use to find affordable lab tests in your area.

www.PrivateMDLabs.com

www.MedLabUSA.com

www.DirectLabs.com

www.LabSafe.com

www.MyMedLab.com

www.QuestDiagnostics.com

Why would a consumer overpay for any health care service?  This happens all the time because consumers have no idea what they are being charged for a service, and they have no idea what the fair price is for this service.  Since our health care system doesn't provide consumers with meaningful tools like Amazon.com, Expedia.com or Travelocity.com to research and compare prices/services --consumers are basically on their own to determine the best value.

I just read about a consumer that paid $1900 for an MRI at Wake Forest Baptist Medical Center.  The consumer has BCBS health insurance so we are not talking about an inflated price for someone that is uninsured.  About six months ago I conducted research on "the quest for the true price for an MRI".  I ended up researching 50+ tools available to consumers to help determine the price of an MRI at many providers around the country.  The results:  an MRI (in this example for a knee) can cost a consumer anywhere from $600 (in Milwaukee at SmartChoice MRI) to $3500 (Dartmouth Hitchcock Medical Center in New Hampshire) - for the exact same diagnostic test. An MRI is an MRI is an MRI.  Isn't it?  So why the huge variance in price?  In fact, if you are charged more than $1000 for an MRI I would suggest you negotiate down the price, offer to pay cash at time of service and start negotiating with the price that Medicare reimburses providers for an MRI- which is $463.  You can download a copy of my research here.

To help you make the most of your health care dollars and find the best value for routine services like MRIs, x-rays, mammograms, vaccinations, office visits, lab tests, vision and dental services, I suggest you use OutofPocket.com to compare and share prices of health care services so you know what others are paying for similar type of services.  Information can be powerful.  

One excellent reason to purchase health insurance is so that you do not have to pay full price (list) for services.  When you have health insurance, you get the discounted (negotiated) price for services that the insurer has negotiated with the health care provider.  If you don’t have insurance, then you are on your own to negotiate a price with the health care provider – and you should definitely ask the provider for a discount. 

Insurers and health care providers consider t the “negotiated prices” proprietary information that they don’t want this price publicized.  These negotiated prices are what insured consumers are expected to pay for services, but they are kept a secret and it’s difficult, if not impossible, to find out what these prices are until after you have visited the provider. 

From what I have heard, Blue Cross Blue Shield negotiates the best discounts from provider list prices.  Where BCBS negotiates 60% off list, other insurers negotiate 40% off list.  Knowing this can help consumers make informed decisions when purchasing health insurance.

Office visit list price:  $100

BCBS negotiated price for office visit: $ 40

Other insurer negotiated price for visit:  $ 60

It’s also very interesting that a provider can have up to 100 different prices for the exact same service, one for each type of insurance they accept.  Most price differences have more to do with a doctor’s negotiation power than with the quality of care from the provider.  Wouldn’t it be nice to know up front what providers offer the best value?

Here’s an interesting approach to exposing “true” health care prices (the negotiated price providers really charge for their services).  As you well know, most providers and health plans are unwilling to share pricing information before services are delivered.  In a bold move, two innovative health care providers are collecting contracted prices for services from consumers - for a reward. In April 2008, Alliance Community Hospital in Ohio launched a program offering consumers $100 if they share their EOBs so the hospital can find out how much health insurers paid for health care services received at rival hospitals. They received a lot of participation and this program is still active today. Just recently, Wuesthoff Health System in Florida announced a new transparency initiative offering consumers $100 in gas cards if they share cost information on health care services from providers in the surrounding area. This is an attempt to provide consumers with meaningful information on the true cost of health care services.

Transparency brings good things for consumers like:

1. lower prices
2. more innovative services
3. expanded choices
4. better patient care

Wouldn't it be nice to see more providers sharing true price information with consumers?

Selecting the right doctor

Consumers can find out about a doctor's experience and a hospital's success rates, and even find information on what these services cost.  First, get to know your doctor.  Do some research to find out what other patients have to say about the doctor.  Personal recommendations carry a lot of weight and people trust what other consumers have to say.  Check if your doctor is board certified.  Search the American Board of Medical Specialties to find out.  Make sure your doctor has done this procedure before.  Use Vitals.com to find out how many times a doctor has performed certain procedures in a year, and look up historical data to determine if there are any sanctions or malpractice claims.  If you cannot find this information on public sources, call the doctor’s office and ask. You want a doctor that has lots of experience.  Know the price before you visit the provider.  If you have out-of-pocket expenses, it’s well worth your time to call your doctor and your insurer to determine the amount you are responsible for.

Selecting the right hospital

Hospitals provide a lot more performance data.  Just like doctors, hospitals get better with experience.  You can use Vimo.com to find out how many times a hospital has performed a procedure.   RevolutionHealth.com also provides similar information.  HealthGrades is an excellent source of quality ratings for hospitals. You can purchase a report from HealthGrades to obtain cost and quality information. 

I am pleased to announce the new release of OutofPocket.com, version 2.0.  Our new search engine enables consumers to look-up prices for health care services, and allows providers to list their prices/services in the directory - free of charge.  In addition, the search engine features expanded search technology and searches for health care price data across other public price transparency tools.

I welcome all your feedback and comments on this new release and I would appreciate if you could help us spread the word.  As you know, the more people that contribute and use this tool, the more powerful it will become for everyone.

Thank you for all that you do to help promote health care price transparency. 

NEW FEATURES IN OUTOFPOCKET.COM VERSION 2.0

(1) Enhanced search engine provides more relevant search results

(2) Easy for consumers to post/share their own visits and prices they paid for services

(3) Comprehensive search results - searches other websites that publish pricing and websites that offer price transparency tools

PRICE DATA COLLECTED FROM MULTIPLE SOURCES

·         Providers can submit price lists for their services

·         Consumers are invited to post/share prices they paid for actual visits, along with their personal recommendations on the provider

·         Claims Data from Businesses, Health Plans or TPAs

·         Government CMS Medicare payment data

·         Websites that publish prices for health care services including hospitals, diagnostic testing facilities, clinics and physician practices

·         Price Transparency Tools on public websites including health plan tools and state price transparency tools

BENEFITS for BUSINESSES

·         Load your claims data into OutofPocket.com to enable your employees to search for their true out-of-pocket costs for specific service

·         Employees can use OutofPocket.com to search for prices for specific services in your network plan

·         Encourage employees to collaborate and post prices they paid for health care services, to share these good deals with other employees

·         Eliminate providers that overcharge - Use OutofPocket.com to direct your employees to affordable, low-cost providers

·         Avoid providers with poor performance by encouraging employees to share recommendations on provider visits

BENEFITS for CONSUMERS

·         Look-up prices, comparison shop and find the best value for routine health care services in your neighborhood

·         Tool makes it easy for you to post/share prices you paid for actual services with other consumers

·         Share your recommendations on a specific provider with other consumers

BENEFITS for PROVIDERS

·         Add your true prices/services to the directory – free of charge

·         Consumers can easily find your services and link to your website

·         Include additional information about your practice, services

·         Search results links directly to your website

·         Provides additional exposure for your services

A recent article in the March issue of Consumer Reports identifies some contributing factors to the high cost of health care.  The article High Health Care Costs discusses some of the factors including:

1. Hospitals and doctors  - in our current health care system financial incentives are given for costly interventions rather than preventative care

2. Drug companies -  rise in prescription drug spending and large amounts of money being spent on pharmaceutical advertising (have you seen all the commercials?)

3. Insurance companies - increase in administrative and marketing costs contribute to inflated premiums

4. Politicians and government regulators - policies affect the bottom line

5. Lawyers- malpractice insurance premiums and defensive medicine (overuse of diagnostic tests)

6. Health care consumers - modifiable behaviors such as poor eating habits, lack of exercise, and smoking, all contribute to poor health

Here’s my recommendation.  Some of these factors consumers have no control over, but two of these factors consumers are definitely in the drivers seat.  First, healthy lifestyles result in healthy people. Make good choices.  Good health is priceless.  Second, consumers need to educate themselves.  Do your research to help you make informed choices about health care services.  Use tools like OutofPocket.com to look up prices, find the best value and make the most out of your health care dollars.  If you shop for health care services the way you shop for electronics, automobiles, and clothing, you will save yourself thousands of dollars.

Are you paying too much for your health insurance?  Before you go out and replace your current health insurance plan, you really need to do your research to understand the different options that are available for you to choose from.  

Years ago, health insurance was almost always provided by your employer.  The only choice you had to make through your Human Resources Manager was whether to choose plan A, B, or C.  Today, more individuals are now purchasing health insurance on their own.  As the cost of health care continues to rise, many employers can no longer afford to provide their employees with health insurance.  Some businesses are even offering their employees more affordable options that are described with words like “consumer directed”, “high deductible”, and “HSAs”.  What exactly does all this mean to you?  If you have always had traditional first-dollar coverage employer-based health insurance, this could all be very confusing to you.  My advice to you -- before you go out and purchase health insurance on your own, you should get up to speed on some important issues that can save you thousands of dollars and avoid making painful mistakes selecting the wrong plan for you/your family.   Purchasing health insurance requires a level of knowledge that many of us are not comfortable with.  

I just read a book that does an excellent job informing consumers on how to save money on your health insurance.  This easy to read book, Get a Good Deal on Your Health Insurance without Getting Ripped Off, written by Jonathan Pletzke was recently published and is a must read if you are a consumer in the market for health insurance.   I highly recommend this book if you feel like you’re paying too much for your health insurance and want to understand your options.  For $16.45 at Amazon.com your return on investment (ROI) is substantial.  You can save yourself hundreds of dollars a month by becoming a well informed consumer and can avoid making the costly mistakes from purchasing the wrong type of health insurance plan for your family.   The book and accompanying website is available at www.BestHealthInsuranceBook.com. 

Happy Holidays,

Mona

Last week I attended the AHIP Business Forum that was held in Chicago on November 12-14.  The conference had outstanding speakers, and some very interesting ideas were being discussed concerning transparency. 

Pete Neupert, Corporate Vice President Health Solutions Group, Microsoft Corp. shared some practical comments about transparency during his keynote speech.  He described transparency as enhanced customer service.  He also suggested the healthcare industry should start using copies of data since the data is already being collected and the technology already exists.  Peter said data should be shared in a meaningful way.

Some of the challenges and chief concerns for transparency include:

·         Who will be the first mover to disclose this “secret” data

·         Who is accountable

·         Existing cultures within insurance companies are a huge barrier– guts to let go and share data

·         Existing complicated pricing structures (result of the system)

·         Are the motivations in the industry aligned

·         What is our capacity for change

·         Who will develop the standards

·         How will health plans use the information to make it available to members

One of the presentations at this conference was an interactive session, “Preparing for Transparency: What it Means to You” and included lively discussions on transparency.  The discussions included understanding the vision behind a transparent health care system, how transparency promotes competition in a consumer-driven world and practical approaches and tools for achieving transparency.

The session was presented by:

Mark Ganz, President and CEO, The Regence Group

Luis Machuca, President and CEO, Kryptiq Corporation

Guiding Principles for Transparency

1.       Focus on the consumer

2.       Cover members, providers and organizations

3.       Requires historic collaboration across the industry.  Understand the difference between competitive differentiation and common infrastructure

4.       Must be forward focused and relevant and valuable to the consumer

5.       Requires significant culture shift  (control à empowerment)

The closing keynote speaker was Regina Herzlinger, professor of business administration at Harvard Business School, senior fellow at the Manhattan Institute and author of “Who Killed Health Care?” Regina is a powerful speaker.  She fills the room with compelling research statistics, bold statements, and her humor.  Regina is an advocate of market-driven, consumer-oriented health reform.  Her powerful closing statement was, “….the governments micromanagement of the prices of insurers and providers should be avoided, not emulated.  Instead the government should help lower-income people, enforce transparency, prosecute fraud and abuse---but otherwise get out of the way.”  I had the honor of meeting her in person after the event and I mentioned OutofPocket.com to her.  She said my price transparency tool using consumer collaboration to expose true prices is a great idea!