A law that took effect in January requires hospitals to post costs of medical procedures. Area hospital administrators say they are complying, but that complexities in pricing make it best to telephone them for the most accurate information.
Called the Affordable Care Act Price Transparency, the law is supposed to help consumers make better informed decisions about their health care. But there are many factors that go into pricing a service.
The hospital spreadsheet is lengthy and lined with medical descriptions and average charges for things like pneumonia, chest pain, diabetes, allergic reaction; and a second list includes charges for things like acetametaphine, splints, sutures and other things.
When it comes to HSHS St. Anthony's Memorial Hospital in Effingham and HSHS Good Shepherd in Shelbyville, the costs found on the hospitals' websites do not cover physician fees. However, they do include inpatient stay, nursing staff, pharmacy monitoring, case management for discharge, said Nikki Harper, vice president for Revenue Cycle with Hospital Sisters Health System.
According to the list at St. Anthony's, the cost of treatment for chronic obstructive pulmonary disease with complications could be $16,337. An amputation due to circulatory system disorder, except to upper limb and toe, is listed at $34,249. An anterior/posterior spinal fusion with no complications is priced at $143,407.
Similarly, at Good Shepherd, the cost of treatment for chronic obstructive pulmonary disease with complications could be $15,724. This list of services are not identical at different hospitals in availability and price.
Harper said at Good Shepherd is a Critical Access Hospital, based on the geography and cost to provide care. Sometimes, the charges there are sometimes less, but also not as plentiful, based on comparison of the two lists. Critical Access means that it is an eligible rural hospital by the Centers for Medicare and Medicaid Services or CMS.
She said by posting prices up to a year, it won't affect the quality of care a patient will be given.
“Price Transparency is our opportunity to provide patients with true cost information for services so there isn’t a surprise after care,” said Harper. “Price Transparency doesn’t affect the quality of clinical care; we already provide great quality at HSHS. This will allow us to provide better quality financial care for our patients by having solutions that provide estimates on procedures.”
Experts quoted in a Jan. 13 New York Times article said the new law falls short in educating patients.
“This policy is a tiny step forward, but falls far short of what’s needed,” Jeanne Pinder, founder and chief executive of Clear Health Costs, told the newspaper. “The posted prices are fanciful, inflated, difficult to decode and inconsistent, so it’s hard to see how an average person would find them useful.”
Harper said that at HSHS they find that patients still get the services after they get their estimated cost, although some might wait and delay an elective procedure say from January to April, after their tax return arrives.
“Costs are coming out very consistent with the estimates,” said Harper. "We also talk patients through payment options including financial assistance and payment plans. “We don't have examples where patients who needed a procedures didn't get them due to the estimate being high.”
All of the pricings for several HSHS facilities can be found at: http://www.hshs.org/aca-pricing-transparency . Next, look for the blue box with hospital name of choice.
Once the link to the hospital you want is found, select the link and it will open to an Excel listing of the hospital charges with descriptions and prices.
However, these are gross charges, not what every patient will pay, administrators explained.
“This list is confusing because it doesn’t factor in what a patient’s health insurance will cover for these services,” said Harper. “To get an estimate on what you’d pay out-of-pocket, you are welcome to call our business offices.”
• For HSHS St. Anthony’s Memorial Hospital (part of the HSHS Southern Illinois Division) – 877-636-2261
• For HSHS Good Shepherd Hospital (part of the HSHS Central Illinois Division) – 888-477-4221
The Effingham and Shelbyville lists encompass several hundred different disorders between the two hospitals and also hundreds of medical care supplies and medications, as well.
The Illinois HSHS hospitals, including HSHS St. Anthony’s Memorial Hospital in Effingham and HSHS Good Shepherd Hospital in Shelbyville, will be rolling out two solutions this spring and summer to assist patients with a true out-of-pocket estimate.
“One solution is a service called Simplee which is a web-based solution where a patient can enter their insurance information and get a price estimate for services,” said Harper. “Another solution is a service called Estimates where you can get estimates when you are logged into Epic MyChart. Today, you can get that information by calling our business offices.”
Both will provide the cost the patient will be billed after insurance pays.
While services at these two hospitals might vary as well as its prices, Harper said patients using the Shelbyville facility are commonly there for radiological procedures, while patients at the Effingham facility might be in for surgical and radiological procedures.
And even if two people enter the hospital with the same diagnoses, they shouldn't expect to pay the same price at the end. But, that's because one may have complications the other doesn't, or one may have a medical history that the other doesn't, said Harper.
All of this goes into factoring out the final cost of a hospital stay. On the hospital's website it will list a “DRG Description,” which stands for Diagnosis Related Group, but Harper said that means little to the average patient. Some include w CC and w MCC, which is “with complication or comorbidity,” or “with major complication or comorbidity,” which are assessed and determined by clinicians, she added.
“If two people enter the hospital with the same diagnoses, they may or may not have the same charges,” said Harper. “It depends on their past history, current health status and any comorbidities (complications) they may have.”
For example, if two patients enter with pneumonia, one being a 40-year-old with no other health history would be different than a 62-year-old entering the hospital who might also have other health conditions such as being diabetic, obese and with a family history of heart problems, she said.
When it comes to billing, the clinicians weigh the conditions the patient has including if one has multiple chronic conditions that warrant more monitoring, more pharmaceutical charges and more complex treatments, Harper said.
To accommodate the requirement, there were no new positions created, however many leaders and hospital colleagues had to be educated to interpret and understand the new law.
“In addition, HSHS seeks to make these types of laws more patient-friendly so we are investing time and money to provide potential solutions to make this easier for patients,” said Harper.
According to the New York Times article, after the administration proposed the price-disclosure requirement in April 2018, many hospitals warned of the shortcomings that are now becoming evident.
The administration says it is open to suggestions for 2020 and beyond.
The price-disclosure requirement, issued by the Department of Health and Human Services, grows out of one sentence in the Affordable Care Act: “Each hospital operating within the United States shall for each year establish (and update) and make public (in accordance with guidelines developed by the secretary) a list of the hospital’s standard charges for items and services provided by the hospital.”
Dawn Schabbing can be reached at email@example.com or by phone at 217-347-7151 ext. 138.