MEDARVA: "Price Transparency"

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Your out-of-pocket health care costs could be less if you understand how it works and how it can help you make smart decisions.

Eddie Edwards
Henrico Monthly
December 2014

My insurance plan won’t cover everything – and I can’t afford the difference. Are there options?

I want the best possible care – what choices do I have?

Questions like these are asked thousands of times every day. If you or a family member is facing surgery, you’ll want answers, but most people don’t know how to navigate the prodigious amount of information.

Picking a surgeon and deciding where to have your surgery are among the most important decisions you will make. It’s a lot more complicated than calling someone your cousin really likes or who practices around the corner. There are currently nearly 40,000 surgeons in the U.S., and more than 10,000 medical institutions where surgery is performed. How do you make the best decisions for yourself, your kids or your aging parents? How do you answer these questions? Does less money mean less quality?

This article explains the current landscape and offers full details on what will go into your decision. And, we’ve also included a brief list of suggestions on choosing a surgeon if you’re in this situation and want quick guidance.

Here’s why finding answers is such a challenge.

Medical pricing, particularly for surgery, is all over the place. For the time being, there is no official standard for how patients are given pricing information, so one group’s information may be hard to compare with another’s. For example, it may not be clear whether the anesthesiologist’s bill is included in the estimate or whether the provider routinely charges more than your insurer will pay. You might be required to stay overnight at additional cost. These issues make it even more important to understand the system and to work with physicians and facilities that make pricing policies completely transparent.

Pricing isn’t transparent yet, but it’s getting there.

Transparency means that you get pricing upfront and you understand what you are paying for. Nothing is left out, and everything is presented to you in a clear and understandable way. In October, Massachusetts became the first state to require health insurers to provide real-time pricing for procedures. So it may not be easy yet, but you want to find a surgeon and facility that clearly spell out your costs.

“Stony Point Surgery Center knows that helping the patient and the family prepare financially is just as important as preparing medically for any surgery,” says Bruce Kupper, president and CEO of the Richmond ambulatory surgery facility. “We are aggressively working to achieve transparency in pricing, and I’m proud to say that we were recently recognized for being one of the first ambulatory surgery centers in the country to provide [the] full cost for our 30 most often performed procedures. You’ll find them on our website (stonypointsc. com).”

Mr. Kupper adds, “We’re hoping that this will trigger patients to do some research, including asking their surgeons ahead of time about value-based, outpatient surgical centers. Ambulatory surgery centers have a greater efficiency because the entire enterprise is aimed solely toward ambulatory surgery,” Mr. Kupper notes. “This results in better value while maintaining quality for patients.”

Costs can vary significantly from one physician and hospital to another.

Hospitals and physicians often negotiate different rates for similar procedures with insurers, Medicare or Medicaid. This means that two hours use of a surgical suite might cost $1,200 in one hospital and $4,500 for the same procedure and the same surgeon in a different hospital. What’s more, these costs may or may not include fees to the anesthesia team, the costs of maintaining surgical instruments, etc. This is all information you need to know before you make any decisions and, for the time being, it’s your responsibility to ask.

An overnight stay will add significantly to the total bill. Experts recommend that if you can avoid an overnight stay using what is known as same-day or ambulatory surgery, you can save a lot of money. Research has shown that use of a free-standing surgical center (ambulatory surgery center or ASC) for same-day surgery is even less expensive, costing up to 75 percent less than the same in-hospital procedures.

There are sound reasons to choose an ASC.

Here are additional reasons why ambulatory surgical care can be a smart choice:

• The overall infection rate is much lower than in hospital-based surgery. One study (Annals of Surgery. 2011;253(2):365-370) showed that the overall rate of surgical site infections (skin or deeper infections at the repair site) for in-hospital surgery is about 5.4 percent. While this includes all kinds of surgery, similar infections are found to occur in far fewer than 1 percent (.1 percent) in free-standing ambulatory surgery centers.

• ASCs are typically designed for specific specialties. Staff is selected and trained in support of the surgical patient, anesthesia is considered part of the process and is billed as such, and there are no distractions from patient care.

• Ambulatory surgery centers are regulated like any other health care facility. They are licensed, certified by Medicare and the state and often choose to undergo voluntary accreditation by the Accreditation Association for Ambulatory Health Care or the Joint Commission. Comprehensive records must be maintained and emergency medical support – including immediate transport to a local hospital in the rare event it is needed – is available.

Full transparency is coming. For now, you may have to shop around.

To get the services that you can best afford, your surgeon should be willing to work with you to find the best medical and financial fit. Do your research, including comparing facilities’ costs and expenses. If you can’t find the information, that may mean that transparency is not a high priority for that institution.

This table will give you an idea of how surgical facility costs can vary in our region.

You may not get your first choice hospital or surgery center.

Understanding how physician’s practices work can shed light on why doctors want to admit patients to specific hospitals.

Most doctors are in private practice – either alone or with other physicians – and most are full or part owners of the practice. Since they are not employed by a hospital, private practitioners need to have admitting privileges to hospitalize patients; these privileges are granted based on the doctor’s background and experience. Most doctors will have privileges at several local hospitals, so you may have some choices.

Groups of surgeons sometimes form or affiliate with independent surgical centers for surgery not requiring an overnight hospital stay. These are usually free-standing facilities with their own staffing; an example of this is Stony Point Surgery Center in Richmond.

If you are set on going to a specific surgical facility and your surgeon cannot admit there, ask him or her to refer you to a surgeon with privileges at that facility. Courtesy privileges may be given in certain circumstances; your physician will know what needs to be done. As you can see, there are many variations in practice patterns and who can admit where – so ask!

Medical tourism or medical auctions may be an option for you.

While we traditionally think of medical tourism as traveling to another country to get treatment, it can also be brought down to a more local level. Suppose your research shows that you can get better information and transparency from a surgical facility or surgeon not in your immediate region. Deciding to travel to have your treatment could save you a lot of money in the long run.

You may also want to consider a medical auction, one of the more innovative solutions to the typically high expenses of medical and surgical care in the U.S. Companies such as allow patients to input their needs online for a nominal fee and then they provide pricing estimates from multiple providers. This is a national network so the care could be anywhere in the U.S. Here again, it’s important to do additional homework. While this is a valuable resource for potential cost-savings, the companies do not rate or make any assurances for quality.

For both of these options, you will need to factor in travel costs, housing, rehab issues and other expenses. Find out if there are local families that will pitch in and help with housing and transportation for nonlocal patients. Remember that medical care value is measured in quality, not in dollars, but there are some high-quality, cost-effective alternatives available to savvy consumers.

The final word in choosing the right surgeon and surgical facility.

First things first: While discussing surgeon options with your primary care physician, you should also take into consideration at what facilities the surgeons operate, and if your procedure can be performed at an ASC.

Your family physician should be your touchstone for all of your care. He or she should be able to help you pick the best specialists for your problem and you should feel that you can trust his or her judgment and advice. He or she should help you make the health care decisions to keep you and your family healthy.

Though the system is not perfect, this is an exciting time in the American medical environment. Competition, transparency and information availability are increasing daily and there is great hope that medicine will soon be affordable and accessible for all medical consumers.

Stony Point Surgery Center
Average in the Richmond area
Breast reduction
Cataract surgery
Ear tube placement

Choosing A Surgeon

• Check with your health insurer to get a list of approved surgeons and surgical facilities so that your care will be covered. You will want to see hospital affiliations, education, training and any other information that may be offered. Some companies have a list of especially highly-rated providers; if your company offers that information, be sure to find out how these surgeons were selected.

• Find out what your policy will pay for your surgery. Confirm that anesthesia and other costs are covered.

• Assume that a surgeon referred by your doctor will be board certified and medically competent. You cannot assume, however, that you will automatically have the same kind of relationship with the specialist that you have with your primary care physician – and that is just as important as the medical decision-making. Ask for a second opinion if you are not comfortable. You can ask your primary care doctor, the specialist or your insurance company for the names of other board-certified surgeons.

• Use the Internet wisely to cross-check whatever information you find. There are lots of resources available, but you need to know which are the most reliable and helpful. Many sites claim to rate doctors and hospitals. Keep in mind that these scores are based on consumer experiences. While some of the sites will measure things like waiting time, ability to get a timely appointment, time spent with the patient and other important criteria, note that the final ratings are often made up from just a handful of people and can be wildly inaccurate.

• Individual ratings are always personal. One individual’s rating can result in a poor rating for an excellent physician, especially if the number of raters is very small. Research has shown that when a lot of people highly recommend a physician, the chances of a new patient being happy with the doctor are higher.

• It’s also important to see if the rating sites are affiliated with a specific hospital or insurance group. While this is not necessarily bad – if you’ve done your homework – it may limit your choices. These sites will be as honest as they can, but they will naturally highlight their own physicians over those who are not part of their groups.

• Finally, and most important: The relationship between you and your surgeon is almost a sacred bond of trust and openness. This is a person you should trust to understand your health issues and needs.