Medical bill transparency: Patients struggle to find info that would let them comparison shop for care
The federal government is requiring hospitals to make their pricing easily accessible but there is a lack of compliance.
Chapter 1 A physical and financial fight
Within one year Susan Rostkowski, 49, went from a cancer diagnosis in her right breast to learning she would be living with breast cancer spreading through her body for the rest of her life.
When she was diagnosed with stage 4, metastatic breast cancer she went through so many emotions. She wasn’t pleased with the way the doctor presented the information.
“First it was anger and then it was oh no, I’m going to die and within a week. My thoughts were, well, let me just start giving away my things. Let me go ahead. I’m not going to buy anything anymore, it’s just stuff. I’m just going to start purging and making things easier on my spouse for when I pass.”
Admittedly, she went down a very dark hole for a long time.
“When you have these serious chronic illnesses and it's not only cancer, it’s any chronic illness, anything that puts you in a hospital and puts you in recovery takes you away from work. And of course, the less you work, you have no salary,” Rostowski said. “When I have complications and I’m put in a coma and unexpected things happen, we still have our normal bills.”
The cost of health care continues to go up and navigating the system isn’t easy. For nearly a year and a half the federal government has required hospitals to make their pricing transparent before care but not all hospitals are compliant.
“Hospitals and insurance companies, as long as they keep patients and consumers in the dark they’re making so much money,”
PatientRightsAdvocate.org Founder and Chairman Cynthia Fisher said, “If you don’t know what the price is, hospitals can charge whatever they want.”
Chapter 2 The Study
The non-profit released findings in February, 2022, after surveying 1,000 hospitals, that showed “only 14.3 percent were complying with the transparency rule.” Out of 10 Ohio hospitals included in the report only two, MetroHealth Medical Center (Cleveland) and The Cleveland Clinic, are complying.
According to Centers for Medicare and Medicaid Services, which is part of the U.S. Department of Health and Human Services, “Starting January 1, 2021, each hospital operating in the United States will be required to provide clear, accessible pricing information online about the items and services they provide.”
It's supposed to happen in two ways including “a comprehensive machine-readable file with all items and services,” and “a display of shoppable services in a consumer-friendly format.”
Fisher said the data would give tech companies the ability to synthesize the data across hospitals.
“Imagine when we get all the data unleashed from these hospitals, we’re going to have shopping tools much like airlines do,” she said. “Like Expedia or Kayak or Google Flights did for airlines, consumers are soon going to be able to find what is [the cost of] an MRI and if I want to get one in 48 hours where can I get one and at what price.”
PatientRightsAdvocate.org’s study found “37.9 percent of hospitals surveyed posted a sufficient amount of negotiated rates, but over half were not compliant in other criteria of the rule, such as listing rates by each insurer and named plan.”
Hospitals can be fined significantly but so far that hasn’t happened. In a written statement, a CMS spokesperson told WTOL 11, as of May, 2022, after a ‘comprehensive review,’ 352 warning notices have been issued to hospitals who were out of compliance with Hospital Price Transparency regulations.” Of those, 169 hospitals have addressed the citations. “To date, each hospital that has come under compliance review has resolved its deficiencies or is in the process of doing so. Therefore, it has not been necessary for CMS to issue any penalties.”
Bowling Green State University Assistant Professor in the Department of Public and Allied Health, Jinha Lee said eventually patients will choose hospitals that are more open with information. It could also help level the field when it comes to care.
“This transparency is the first step to make things affordable and to make health care service more common to everybody,” he said.
With the help of PatientRightsAdvocate.org, WTOL 11 was able to use the cost of one of Rostkowski's procedures as an example.
The hospital charged $1,712 for the procedure. Her insurance paid $707.79 of that but the lowest discount cash price among a select group of hospitals in northwest Ohio was $211.50.
Fisher said price transparency is transformative. “We all need to care about prices in health care because coverage comes out of our paychecks and our wages and the only way we can bring down the cost of health insurance and get more money into our wages and earnings and to be able to protect our health by having financial certainty is to know the prices before we go,” she said.
“If you choose to be overcharged by a hospital for $3,500 for an MRI that is what then comes out of your premiums and the premiums come out of paychecks and wages because every employee shares in charges for their health benefits that otherwise would be take home pay.”
Chapter 3 Local Providers Respond
WTOL 11 reached out to McLaren St Luke's, Toledo Clinic, University of Toledo Medical Center, Mercy Health Toledo, ProMedica Toledo and Wood County Hospital for their responses to the Hospital Transparency Rule and compliance. Here’s what we received:
ProMedica-Toledo
In accordance with the hospital price transparency rule, ProMedica publishes standard charges for all items and services for payers and health plans and a standard charges list for the 300 most common services. ProMedica has received confirmation from the Centers for Medicare and Medicaid Services (CMS) that it is in compliance with the hospital pricing transparency rule.
In addition to the pricing information available on our website, ProMedica provides a hotline for patients who would like to understand their estimated out-of-pocket responsibility before a service is rendered. Patients are encouraged to use this free service so that they can be as informed as possible when making their health care decisions. The number for procedures that will be performed in a physician office or hospital outpatient department is (419) 824-7250, and patients will need to have their procedure code when calling.
As part of our not-for-profit mission, ProMedica offers a comprehensive and generous financial assistance program to help cover the costs of certain services. It is available to patients who qualify based on income/resources. If patients are concerned about how they will be able to pay for services, they are encouraged to call 844-373-0871 and request a financial assistance application.
Mercy Health-Toledo
Pricing information is readily available on mercy.com and meets the price transparency requirements as mandated by federal and state laws. Information is provided through a self-service price estimator tool to help patients understand their out-of-pocket medical costs based on insurance coverage. Detail files are also posted on mercy.com under patient resources in the “Pricing” section of our websites. The Centers for Medicare & Medicaid Services (CMS) requires hospitals to post their current standard charges for services on their websites.
Toledo Clinic
We would first like to convey that we are a multi-specialty physician group with hospital partners, versus the classic ‘health system’. The Toledo Clinic is probably the most aggressive in price publication and patient disclosures, most notably in terms of lab and imaging. We do have a cash price and standard fee schedule. We have not broken this down by insurance carrier. We are not a hospital but happy to disclose, compare, and contrast with consumers, employers, and government/commercial payers. We have taken i upon ourselves and have been providing this level of cost transparency for years.
McLaren St. Luke's
Health care consumers often seek information comparing hospital services and costs. While an individual’s costs will vary based on insurance and the level of health care services delivered, there are a number of resources that provide public pricing information to help educate consumers.
Here is where you can find pricing info on our website.
Wood County Hospital
Wood County Hospital does publish its prices on the Services Pricing section of our website.
Patients have access to both the full chargemaster data, as well as our online patient estimator. Patients may also reach out to our patient financial services staff to request information about the cost of care.
University of Toledo Medical Center
The University of Toledo Medical Center is committed to providing clear, accessible pricing information for all of the procedures and services we provide our patients, including both the cash price as well as our negotiated rates with health insurers.
Pricing information is available on the UTMC website at http://utmc.utoledo.edu/ut-medical-center/billing/chargemaster.html.
In addition to our chargemaster patients also can view the cash price and negotiated rates for some of most common procedures and tests in our list of shoppable services on our pricing website.
Chapter 4 Patient Advocate
Initially Rostkowski was more focused on care than dissecting her medical bills. “When you’re just trying to survive a surgery or even just survive day by day even just to get out of bed, I’m not going to look line item at a bill I’m getting,” she said. “I’m starting to focus more on it and seeing what I can do to help other people,”
She wants to be able to choose a hospital based on how it will benefit her financially and diagnostically.
“We are at the mercy of a system that we don’t understand,” Rostowski said. “Advocacy is the number one thing. It is so important to advocate for yourself.”
She’s been grateful for support from family, friends, other cancer survivors and organizations like The Victory Center, which helps cancer patients and their families in a variety of ways.
There is a GoFundMe set up for Rostkowski to help with expenses.
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