The impenetrable mystery: What health care really costs

The impenetrable mystery: What health care really costs

May 21st, 2013 in Opinion Times

Jennifer Clark is a good comparison shopper and a bad gambler.

Clark and her husband took a risk when they opted out of group family insurance at work, and then she developed a kidney stone.

The sticker price for her emergency room visit, follow-up and lithotripsy to break up a kidney stone was just over $17,000 -- the price of a new compact car, or a down payment on a home, or the difference for some between solvency and bankruptcy.

Here's where the comparison shopping comes in: It showed this family, and all of us, what an impossible and ridiculous nightmare maze our health care system -- or lack thereof -- already is, from caregivers to hospitals to insurers.

Health care already is and was a mess long before the Affordable Health Care Act, which is set to begin in 2014 as a first effort to help straighten things out.

Clark, who lives in Fort Oglethorpe, first was charged $7,000 for her emergency room visit. Because she is a "self-payer" the hospital ultimately agreed to charge her $900. Her follow-up was $1,600. And the lithotripsy price -- which she shopped at hospitals in Chattanooga and within a two-hour drive -- ranged from $8,600 to about $4,300.

Clark, incredulous, asks exactly the right questions:

"How can there be that much of a difference? What does it actually cost?"

The answer is hard to find, as Chattanooga Times Free Press reporter Kate Harrison found in reporting a story Sunday on the "seemingly shape-shifting nature of costs and charges." Traditionally, the only real measure has been Medicare's set payment for each of hundreds of procedures.

Only uninsured patient who are not indigent are billed from the hospital's inflated retail price list, dubbed the "chargemaster." This is what hospitals charge before negotiating down payments with insurance companies or Medicare.

Now, as part of changes leading up to the implementation of the Affordable Care Act, Medicare/Medicaid norms have been released in a massive database online. The trick for consumers is to know how to use the information -- especially if they have insurance because each insurance company has contracted its own rates for each group. The insurance rates are private, at least for now.

That's actually part of the fly in the ointment.

Tennessee Hospital Association President Craig Becker says the real picture won't be clear until insurance companies put what they pay online.

Insurance companies say they no longer base their rates just on the chargemaster, but also on "diagnosis-related groups." And the insurance companies -- which make a profit, too -- carefully guard their mojo-algorithms from everyone: government, employers, workers and direct customers.

"Charges don't really mean anything," Becker said.

Most of us customers seem to already get that. And what's still more complicated and not addressed yet by any clear data is how insured customers get charged or don't get charged for the difference between what the hospitals and doctors bill and what insurance pays.

But it is illuminating that the database shows the disparate range in just hospital charges.

For all its public money concerns, and despite general attitudes that teaching hospitals cost more, Erlanger is the clear bargain -- if we can call any health care costs a bargain.

On six common surgeries, Erlanger and Memorial billings are lower than national average billings. Parkridge is on par or slightly above national average. SkyRidge Medical Center in Cleveland should change its name to Skyhigh, since it charges as much as twice the national average on at least two of the six surgeries the paper examined. Not enough information was available for a generalization on Hutcheson and Hamilton medical centers in North Georgia.

It's a given that life is complicated. But something as important as health care should not be impenetrable.

A longtime health care advocate with the Tennessee Justice Center, Gordon Bonnyman, put it best: "No other industry works like this, where the consumer doesn't know what the prices are, where they are incapable of understanding or controlling the aspects of the procedure they're paying for and the doctor is deciding for them; and where there is little to no accountability for the quality of the product."

This is what the Affordable Care Act is aimed at fixing. The new law -- dubbed Obamacare by the insurance-driven lobby propelling conservatives to hopelessly spend $55 million dollars in taxpayer money to try yet again to repeal it -- would shift the pay system to outcomes and quality care, not mojo.

It has gotten "precious little respect" from many Tennessee, says Bonnyman. Yet it has a huge potential to improve the system in ways consumers can't.

What might it be like to shop where the prices and goods are not hidden? Insurers and providers might not like it pulling back the curtain on costs, but customers just might.

Health care as we know it today is a ridiculous maze of smoke and mirrors charging one thing, accepting another from insurance companies and accepting something else from uninsured customers (people with no third party making a profit).

Though it is "free market" and not government run, health care really is the least transparent thing we pay for. Not even taxes are this hard to trace.

It is long past time to reinvent this wheel.