How much is that X-ray in the window?

I had extensive back surgery in 1972. One of the things I remember clearly about the experience was the bill. It arrived some weeks later, and seemed to be close to a ream of paper, since everything, and I mean everything down to the sutures, was itemized. I had a visceral sense about what things cost.

Fast forward to today. The Boston Globe recently reported that many consumers are opting to purchase high deductible health care coverage. I’m one of those many consumers.

I funded a health spending account to cover out-of-pocket medical costs, taking the deductible into account.

After some ambivalence and some minor symptoms, one of you persuaded me that it might be time to have some follow-up x-rays taken to document the current state, and help better diagnose any future issues – trend data always gives you more perspective than a single point in time picture.

Megan, my primary care practitioner’s PA, asked me where I wanted to have the x-rays taken. I opted for the most convenient location where I also thought the waiting time would be minimized.

It wasn’t until I was pulling into the Mt Auburn Hospital parking lot that it occurred to me that the cost might be different at the different locations. Even though I was fully aware that I would really have to pay for these pictures, it hadn’t occurred to me to ask how much they would cost. And Megan only offered that she might get the results faster from Mt Auburn. Hmmm. Hard to believe that I would discover a cost difference worth the time I’d spent so far, but now having made the decision to consciously buy x-rays, I wanted to do so intelligently relative to my policy and about-to-expire savings account.

I began my quest at the registration office. They had no idea what things cost – nothing in my file indicated the need to make a payment in advance – as far as they were concerned, this was covered by my policy. I was insistent that I was buying the x-rays and they suggested I ask about their cost at the radiology desk.

I surrendered to my fate, and headed to the basement, also noting that my enthusiastic (and inexperienced) PA had ordered lots of x-rays. I asked the person at the desk if a) I really needed all these x-rays and b) what they would cost. The head x-ray technician was summoned. The good news was that Maggie was a pro and reduced the 6 plus requests to a single scoliosis series. The bad news was that no one had the faintest idea about what things cost and suggested that I call my insurance company.

I called the insurance company. Maria reported that the hospital had up to 90 days to bill them for the service. They would then bill me for what I can only assume is 100% of the cost from the fine print of my policy. That’s when we would all know what the x-rays cost. When pressed on the likely charge, she confessed to having no idea and suggested that I contact the hospital billing office.

I called the hospital billing office and the first person told me that it would be impossible to tell me what it would cost. I asked her if she routinely ordered food at restaurants off a menu with no prices. (These are not the circles in which I travel, but I do remember having someone take me to one once. In this particular case, I think it was because guests and/or women shouldn’t concern themselves with the prices. However there are such places in the world where this is the logic: if you have to ask how much it costs, you can’t afford it. It’s a sign of having money to burn that you find out what things cost only after consuming them.) She thought this was a great question and transferred me to head billing manager, Rick. Rick spent a little time investigating and said that if I walked in off the street, the series I had would cost $250. HOWEVER, Tufts health plan has a GREAT deal with Mt Auburn Hospital. He couldn’t tell me what it was, but he doubted the bill from the hospital would be more than $200. Oh, and there will be another bill from the physician group that reads the x-rays – he had no idea what that costs, but gave me their number.

I called the reading service and got voicemail. I gave them full permission to talk to my voicemail with an estimate of their bill. No message yet.

My health spending account will only cover expenses incurred through next week. Then a new year begins. Any balance remaining is forfeited. Because of the timing, I have until July 31 to submit expenses for reimbursement. This is an anomaly of changing jobs – I could have ended up with about 8 weeks to submit expenses – over 30 days less than the maximum amount of time it might take for me to find out what the services really cost with the arrival of the bill from my insurance company. After all this, I’m still not sure how anyone can plan and make good economic decisions working under these well-intentioned but flawed structures.

High deductible plans and health spending accounts should be a great way to get everyone to stay healthy and save insurance for the catastrophic events and unavoidable illness we all would wish to avoid; it should help us all think twice about what things cost, relative to their likely value. Instead, I can only tell you my experience of living a fix that backfired.

Unfortunately, high deductible plans are most used by those who can easily absorb the risk and are relatively healthy, and those who can least afford the risk. This latter group is the cause for the biggest concern. What seems to be happening is that they are opting to avoid “routine” preventive health care, EVEN WHEN IT’S FULLY COVERED by their policy. Presumably this is because they can’t figure out what is covered and what’s not, and certainly can’t a afford to order from a menu without prices. The consequence is that the very disasters they are conscientiously insuring against may ultimately come to pass due to the behavior their policy is inspiring.

Given some of the symptoms I’ve had, Megan couldn’t believe that I didn’t have any neck pain. If only metaphorically, I certainly have a pain in my neck now.

And by the way – if I was looking for a community organizing campaign to launch, I think I’d seek to imitate our public health colleagues. I’ve been making different choices at Panera, Starbucks, etc as their menus display calorie content as prominently as the price. Wouldn’t it be interesting to see what would happen, if we all knew what things cost?

Note: After writing this I discovered that the “menu with prices” metaphor appears in:

“A Menu without Prices” (editorial), Alan M. Garber, MD, PhD Annals of Internal Medicine: June 17, 2008 vol. 148 no. 12 964-966

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