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How the Cost of Health Care Creeps Up and Up
Trudy Lieberman | March 1, 2011
In a previous post, I talked about what happens when a radiology practice goes digital for mammography, even though there's scant evidence that more-expensive digital is better than cheaper film for detecting cancer in older women.' Yet the higher-priced procedure is winning out.' That's pretty much the norm for U.S. health care, for instance, when ThinPrep replaced the conventional method for doing Pap smears.' ' I used to pay $9 for the test; the one I had last summer cost $250.' Cardiac angiography is in wide use even though the Centers for Medicare and Medicaid Services had proposed paying for the procedure only for two types of patients. But that was before letters from doctors and General Electric flooded the agency. My mammograms now cost $400 instead of $250.
These are just a few examples showing why American health care is the most expensive on earth and why it's so hard to control costs, which in turn boost the high insurance premiums we scream about.' Gobs of money are to be made from new technology.' In the United States, it doesn't seem to matter that some new test or treatment doesn't produce significantly improved outcomes or results'which might have justified the increase in costs'the 'new' technology gets used.' There's currently no government agency, as there is in England, that evaluates new technology on cost and efficacy, and sometimes says 'no'it's not worth the public's money.'
But there's another part of the U.S. cost problem'the doctors who use the technology and pass the increased costs onto their patients as part of a game between them and insurance carriers.' ' My recent mammogram showed how the game is played, bringing up the mysterious Explanation of Benefits (EOB) forms once again.
Since the radiology practice was an out-of-network provider for my health plan, they wanted me to pay half of the $400 bill when I received my screening.' ' 'It's a shame you're not on Medicare,' the office receptionist said, 'because we don't take your insurance.'' A week or two later an EOB arrived from my carrier saying that the doctors had sent in a claim for $500, not $400.' The doctors tacked on an extra $100 for 'computer-aided detection' on top of the $400 for a digital screening mammogram.' Medicare says doctors can add this extra charge.' Maybe that's why the billing office workers mentioned Medicare.' They knew they could squeeze more out that way.
The insurer has improved its EOB since the last time I got one.' Now it lists every service and gives the CPT code instead of a general description of what was done like X-rays and lab tests.' ' This welcome transparency highlights another reason the practice may have added the extra $100 when it billed the insurer, but not me.' All these charges go into a great big database and become part of what's the customary and usual charges for various procedures'called UCRs for short.' Insurers use UCRs in their negotiations with doctors to determine what they will pay.' So some docs jack them up as high as they can.' Sometimes insurers pay based on what doctors claim are their usual and customary fees; sometimes they push back.' That's when patients get mad because they have to pay for what the insurance company doesn't.' Charges for care creep up.
The doctors took a chance that I had some level of out-of-network benefits, which I did.' The insurer calculated that the cost negotiated for digital mammograms was $350; it paid 80 percent of the $100 charge and the $400 charge for a total of $280.' My plan has no deductibles for mammography.' I am still waiting for my refund from my doctor.
Meanwhile, just like the wide range of 'enhanced' Tide laundry detergents on our grocery store shelves or the latest must-have Smartphone''new' often signals that the market has grabbed an opportunity to raise prices.' This marketplace ingenuity works well for soap and luxury items'but for mammography and many other medical procedures, the lure of increased payments trumps any real improvement in care or service.
More Blog Posts by Trudy Lieberman
Trudy Lieberman, a journalist for more than 40 years, is an adjunct associate professor of public health at Hunter College in New York City. She had a long career at Consumer Reports specializing in insurance, health care, health care financing and long-term care. She is a longtime contributor to the Columbia Journalism Review and blogs for its website, CJR.org, about media coverage of health care, Social Security and retirement. As a William Ziff Fellow at the Center for Advancing Health, she contributes regularly to the Prepared Patient Blog. Follow her on twitter @Trudy_Lieberman.
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