Pricing in medicine is a source of endless frustration for patients and healthcare providers, including radiologists. Medical expenses are the most common cause of personal bankruptcy in the U.S., so patients are right to be worried.1 “Financial toxicity” describes the devastating effects medical bills have on patients’ wellbeing, which may outweigh the benefits of receiving medical care. Non-adherence to treatment increases as a patient’s financial burden increases, leading to poor outcomes.2 In the last decade, a proliferation in high-deductible health plans has shifted more costs to patients. In theory, these high-deductible plans give people incentive to shop for the best deals on health services. In reality, however, people covered by high-deductible plans instead save money by avoiding medical care.
A major reason people have difficulty price shopping in healthcare is the opaque and obscure nature of healthcare billing. Few medical practices in the U.S. list service costs in a way that patients can understand. Hospital chargemasters are price lists available by federal law since 2019, but they bear little resemblance to what a patient will be charged, what their insurer will agree to cover, or the amount that the patient will ultimately be expected to pay. A lack of transparent pricing is related to the nation’s patchwork coverage by different insurance plans, which produce marked variability in the out-of-pocket amount that is left for patients to cover. Prices shift again when the issues of in- versus out-of-network status and tiered policies are considered.
Fortunately, medical practices employ experts who understand the specific benefits and services that patients are entitled to under their insurance policies. These benefits specialists help patients navigate the system and can offer payment plans or adjustments. However, patients are usually placed in contact with benefits specialists after being denied for services or receiving a bill that the patient considers unexpected or is unable to pay. More recently, some healthcare providers, including providers at our hospital, Children’s Hospital of Philadelphia, have moved benefits specialists to the front line, allowing patients to request an accurate estimate of out-of-pocket costs for the services that their physicians recommended, paving the way for a more positive patient experience.3 For example, patients in high-deductible plans and/or those requiring repeated advanced imaging might choose to time their appointments according to their plan’s coverage year. Moreover, access to this type of planning during an inpatient visit can help patients navigate the scheduling of outpatient services, allowing families to plan accordingly.
In our hospital setting, patients can reach benefits specialists in the cost-estimation center by requesting a quote by email, phone, or through the patient’s health portal. Alternatively, the services may be offered at the time of exam scheduling. In our hospital-based practice, the number of estimates provided has more than doubled in three years of service, reaching 1,737 for the most recent data year. Patients report that the cost-estimation service helps them plan for the upcoming expense, giving them more control over its impact on their budget. In some cases, patients chose our practice after appreciating the transparency of the process.
While helping patients plan their medical payments, our practice has also seen revenue losses for these exams decrease by threefold in the first year of service to sevenfold in the most recent data year. With experience, our estimates have become more accurate. Erring toward overestimation has led to the unusual situation of medical bills being smaller than expected. The cost-estimation service is especially valuable for patients and families on a fixed budget, who may find care more accessible when the out-of-pocket costs are clear and payment plans are arranged in advance.
As healthcare finance evolves to shift more burden to patients and healthcare costs continue to soar, doctors need to consider cost as an essential part of patient care.4 Proactively providing reasonable out-of-pocket cost estimates and scheduling services to maximize patients’ benefits coverage is a step in the right direction. Diagnostic radiology is well-positioned to provide these estimates; imaging exams rarely vary from the requested service, often resulting in predictable out-of-pocket costs. For practices struggling to recover from COVID-19-induced loss of outpatient volume, providing cost estimates up front may help us understand how economic distress contributes to low visit numbers.5 Out-of-pocket costs in healthcare shouldn’t be a mystery, and providing the answer benefits both patients and medical practices.