Medical costs are clearly unclear

A new federal rule designed to make the prices of hospital procedures and services more accessible to patients may be confounding an already complicated situation for health care consumers.

“We have been working with legislators for years trying to get transparency laws in place,” said Rick Rasmussen, CEO of Northwest Specialty Hospital in Post Falls. “But the new rule that started Jan. 1 is very confusing and not helpful, in my opinion, to patients and their families.”

The rule, proposed by the Centers for Medicare and Medicaid last spring and finalized in August, requires hospitals to publish a list of their standard charges via the internet.

But there’s a hitch.

The prices published by hospitals under the rule don’t reflect the actual costs to patients.

The purpose of the regulation is to give patients the ability to research options and make informed decisions on their care, Bonner General Health CEO Sheryl Rickard said.

While the information patients want most is the amount that they will actually be billed, this data will not reflect what a patient’s insurance pays or what their out-of-pocket costs will likely be based on their individual benefits, Rickard said.

It also doesn’t factor in whether those without insurance may be eligible for charity care or other cash discounts.

The way to get the quickest and most accurate estimate of care from the hospital is to call Bonner General’s Patient Financial Services Department.

“The CMS rule requires chargemaster pricing to be posted, but the chargemaster pricing is not what a patient pays,” Rasmussen said.

The chargemaster, or charge description master, is a list of items billable to a hospital patient or a patient’s health insurance provider. Chargemaster prices don’t take into account adjustments for contractual discounts, self-pay discounts and other negotiated adjustments, Rasmussen said.

“So I feel this rule does not give patients and their families all the information they need to effectively shop for high-value care,” he said.

Northwest Specialty Hospital’s price list can be found on northwestspecialtyhospital.com by clicking on “Resources” and selecting “Patient Pricing Information.” The page tells consumers that while Northwest Specialty is providing the information in compliance with federal regulations, health care billing is complex.

“It is extremely important for you, as the consumer, to understand that standard charges may not be a relevant starting point for estimating what costs you may incur during an episode of care,” the hospital’s website states. “… Everyone’s case is different based on that patient’s medical condition.”

The website also encourages consumers to contact the hospital directly for more information regarding their specific financial responsibilities, and provides a phone number.

A link named “NWSH Price Transparency” and found at the bottom of the webpage will open a spreadsheet listing services and prices.

The CMS rule requires hospitals to publish the price information in a “machine-readable format,” meaning the data can be automatically read and processed by a computer, and it must be updated annually or more frequently when appropriate.

Kootenai Health in Coeur d’Alene provides its pricing information similarly. It can be found on the hospital’s main website, kh.org, by clicking on “Patients and Visitors” and selecting “Price Estimates.” The “Pricing Estimates” page provides a phone number patients are encouraged to call for a personalized estimate.

A link named “Pricing for Common Procedures” can be found at the bottom of Kootenai Health’s “Pricing Estimates” page. That link takes visitors to the website to another page with links to lists separated by type of service. Each link states, “I have read the disclaimer and understand this is only an estimate.”

The disclaimer advises that information provided on Kootenai Health’s website is an average estimate of the charge for a medical service or procedure.

“Billed amounts can be higher or lower, based on the actual services provided, existing health conditions that may impact the procedure, and the patient’s specific insurance plan or coverage,” the website states. “Please note, this list does not include physician, anesthesiologist, radiologist, pathology charges, etc.”

Kim Anderson, spokeswoman for Kootenai Health, said the health care system always welcomes the opportunity to have a conversation with patients about the cost of their procedures or services.

“Our recommendation is for patients to call the number on the website and talk to a live person who will take a look at insurance coverage and the procedures or services needed and give them a quote,” Anderson said. She added that speaking to someone at the hospital is the best way for patients to get the most clear picture of the likely costs of health care at Kootenai Health.

Rasmussen said he believes the CMS rule should call for all hospitals to have transparency tools on their websites, along with people who can help each patient determine the prices for their health care procedures and services by starting with the chargemaster pricing and taking into account their health insurance coverage. That would give patients their true out-of-pocket costs, Rasmussen said, and not a price they will never pay.

“This rule is a step in the right direction, but we can’t stop until there are transparency tools that show bottom line costs to the patients and their families,” Rasmussen said.

Staff writer Caroline Lobsinger contributed to this story.