pricing variations in the consumer market for diagnostic...

Pricing Variations in the Consumer Market for Diagnostic Imaging Services /

Prepared by: Reginald D. Williams II, Amy Rousseau, and Jon Glaudemans, Avalere Health LLC

For: CareCore National

December 2005

Avalere Health LLC 1

Prices for healthcare services are frequently a mystery to even the most informed consumers. Increasingly, as insurance companies and HMOs continue their move away from fixed dollar co-payments to percentage co-payments, consumers’ and patients’ first glimpse into the cost of a service comes when they receive a bill in the mail from the healthcare provider or the insurance company. As more and more patients seek ways to “shop” for expensive healthcare services, they face a set of frustrating and bewildering barriers to obtaining accurate projections of their expected out-of-pocket expenses for a given service. Some of these are personal: many people are uncomfortable asking their physician or local hospital for a price list. Other barriers are more institutional: many insurance companies and physicians either refuse or are reluctant to disclose the prices for individual services. A recent analysis of prices among competing providers of high-cost diagnostic imaging services reveals significant variation among these providers, and suggests that consumers are likely to experience widespread differences in out-of-pocket costs, depending entirely on where they obtain the imaging service. Is the healthcare marketplace prepared to offer consumers the pricing information to make meaningful choices? In particular, can a would-be patient today effectively “shop” for high-cost medical services—such as magnetic resonance imaging (MRI) and computerized tomography (CT) scans—the way they would for another high-cost purchase?

There is broad consensus that would-be purchasers of high-cost healthcare services, including

diagnostic imaging, would be stymied today in their search for accessible, easy-to-understand

measures of quality, performance, and overall value.

Despite new price transparency efforts that have been launched by various managed care

organizations, information on the actual cost of healthcare services is not widely available to most

consumers. The absence of data is particularly troubling for individuals facing significant out-of-

pocket expenses for healthcare, either because they have an insurance plan that imposes

percentage co-payment requirements, or, increasingly, because they are enrolled in a so-called

“consumer-directed health plan,” where the consumer faces significant first-dollar exposure for

most healthcare services.

Consumer-Directed Health Plans on the Rise

Consumer-directed health plans (CDHPs) are based on the premise that consumers will actively

seek out and use information on quality and cost to make better healthcare decisions if they face

direct and personal financial consequences for their decisions. For members of CDHPs this

level of financial responsibility is significant. Consumers enrolled in CDHPs typically buy into

high-deductible health insurance products, coupled with individual accounts for health expenses.

These accounts are similar to 401Ks.


How real is the rise of CDHPs? The passage of the Medicare Prescription Drug Improvement

and Modernization Act of 2003 increased the momentum of the CDHP movement by introducing

tax-advantaged Health Savings Accounts (HSAs). A 2005 survey estimated that the number of

employers offering high-deductible CDHPs has increased from 5% in 2003 to 20% in 2005.1

Within the past year, the number of enrollees in CDHPs has doubled. According to America’s

Health Insurance Plans, in September 2004, only 438,000 consumers were in CDHPs. As of

March 2005, over one (1) million people were enrolled in these plans.2 With no easing of rising

healthcare costs in sight, and more consumers seeking to assert increased control over their own

healthcare, industry analysts have projected that CDHPs will cover 22 million lives in the

commercially insured market by 2008.3

In 2005, deductibles averaged $1,901 for single-person coverage and $4,070 for family coverage

in high-deductible health plans with an individual account. The maximum out-of-pocket liability

for cost sharing averaged $2,551 for single-person and $4,661 for family coverage. In CDHPs,

that couple high-deductible insurance coverage with HSAs, healthy individuals needing

expensive services, such as diagnostic imaging, are likely to incur the entire cost of those

services before reaching their maximum liability. For example, a healthy jogger who needs one

MRI for an injured knee could be exposed to an out-of-pocket cost of over a thousand dollars,

depending on the choice of providers. Against this possibility, what tools do consumers need to

make informed decisions?

Regardless of whether the patient is in a CDHP, or, alternatively, in a “percentage co-pay”

traditional plan, patients need help to navigate the healthcare system’s invisible pricing system.

CDHPs Meet Diagnostic Imaging / The Challenges of Shopping for High-Cost Medical Services

Diagnostic imaging modalities, such as MRI and CT, are widely available in the United States. As

these technologies improve and more indications are found for their use, diagnostic imaging will

play an increasingly important role in improving people’s health. The rise in utilization of

noninvasive diagnostic imaging procedures has proved to be a leading cost driver in overall U.S.

healthcare expenditures. The Blue Cross and Blue Shield Association estimated that about $70

billion was spent on diagnostic imaging in 2000.4 In Medicare alone, spending for imaging

1 Kaiser Family Foundation (KFF) and Health Research and Educational Trust (HRET). Employer Health Benefits, 2005 Annual Survey. Washington, DC: KFF. 2005. 2 America’s Health Insurance Plans, Center for Policy and Research. Number of HSA Plans Exceeded One Million in March 2005. Available at www.ahipresearch.org/pdfs/HSAExceedMillion050405_full.pdf. Last accessed September 14, 2005. 3 Henrickson, Katy. Employers Sound Off on CDHPs. Cambridge, MA: Forrester Research. May 12, 2005. 4 The Blue Cross Blue Shield Association (BCBSA). Medical Technology as a Driver of Healthcare Costs: Diagnostic Imaging. Chicago, IL: BCBSA. 2003. 5Claxton, Gabel, Gil, Pickreign, Whitmore, Finder, Rouhani, Hawkins, and Rowland. What High-Deductible Plans Look Like: Findings From A National Survey Of Employers, 2005. Health Affairs Web Exclusive released September 14, 2005.


services grew from $5.7 billion in 1999 to $9.3 billion in 2003—an increase of over 60 percent,

and one of the fastest-growing portions of the Medicare budget.5

The majority of patients who require diagnostic imaging services are currently shielded from the

full costs associated with them because they are enrolled in either traditional managed care or

indemnity plans. These plans limit patient liability to a modest deductible and percentage co-

payment arrangements, where the patient is required to pay 20-50% of the insurance companies’

negotiated rates. Traditional theories of insurance suggest that such patients have little incentive

to seek out cost-effective imaging providers.

Under both percentage co-payment plans and under CDHP plans, patients referred for high-cost

diagnostic imaging have a strong incentive to exercise prudent purchasing. However, to date,

they have typically lacked the information on cost to help them make an informed decision.

Consumers need accurate tools to access this information, and educational support to evaluate it.

What Would You Do? A Glance at Diagnostic Imaging in New Jersey A new analysis conducted by Avalere Health, using data provided by one of the nation’s leading

diagnostic imaging management companies, examines the dilemma facing an average patient in

New Jersey “shopping” for a provider of diagnostic imaging services. This detailed analysis

reviews the cost of imaging services performed at a variety of imaging facilities under contract to

two large managed care plans in 2005. These facilities offer a range of services including those

that involve two of the most costly and commonly used imaging modalities—CT and MRI.

Table 1 shows the top five imaging procedures (identified by CPT 5 Code) in New Jersey for each

of these two modalities—CT and MRI—and arrays the charge data (what the facilities would

typically charge a walk-in patient without access to insurance or insurance company-negotiated

rates). Throughout the paper, dollar amounts represent the sum of the technical (cost of the

machine) and professional (cost of the physician) components of an imaging service. As Table 1

shows, a walk-in patient’s out-of-pocket exposure can vary by as much as 950%. Clearly, with

these substantial differentials among the imaging providers’ charges, information on prices would

be useful data for the consumer.

6Miller, Mark. Medicare Payment Advisory Commission (MedPAC) Recommendations on Imaging Services: Testimony of Mark Miller,

Executive Director of MedPAC before the Subcommittee on Health Committee on Ways and Means U.S. House of Representatives. March 17, 2005.


Table 1. Provider Charges for Top 5 CT and MRI Procedures Across New Jersey

Provider Charge

CT CPT 5 Minimum Maximum Percent

Difference

Sinuses 70486 $600 $1,850 208%

Chesta 71260 $700 $3,200 357%

Pelvisa 72193 $700 $3,150 350%

Abdomen 74150 $250 $2,100 750%

Abdomena 74160 $300 $3,150 950%

MRI

Brain 70551 $1,000 $4,250 325%

Brainb 70553 $1,500 $4,750 217%

Back (Lumbar Spine) 72148 $1,000 $3,850 285%

Upper Extremity Joint 73221 $1,000 $2,750 175%

Lower Extremity Joint 73721 $1,000 $2,700 170%

Based on a sample of state-wide charge data from two health plans in New Jersey; data rounded to nearest $50 to avoid revealing competitively useful information. a With contrast, a substance used to enhance the quality of diagnostic imaging b Without contrast, followed by with contrast SOURCE: CareCore National

Despite these significant statewide charge variations, most healthcare is accessed locally.

Patients’ willingness to travel long distances for care—especially care that is relatively routine—is

limited. Thus, our analysis further examined the market from the patient’s perspective, and

focused on facilities in each of two separate counties, X and Y. We use counties as a proxy for

patients’ local communities. Table 2 presents the mean price variation in provider charges for the

top 5 CT and MRI procedures, in each of these two counties, and displayed in two groups: high-

and low-cost facilities, with the figures again, rounded to the nearest $50 increment.

The figures in Table 2 are charge levels—and typically represent the “retail” price faced by the

self-insured or uninsured patient. The higher-cost facilities tend to be hospitals (designated by an

“H” preceding their identifying number) and the lower-cost facilities tend to be free-standing

imaging centers (designated by “FS” preceding their identifying number).

Even within a county, there exist significant charge disparities among providers. Again, a

consumer facing significant out-of-pocket exposure under a high-copayment plan or a CDHP

would experience major variations in cost, even when limiting her search to providers within a

relatively tight geographic market.


Table 2. Provider Charges for the Top 5 CT and MRI Procedures in X County and Y County

X County High-Cost Facilities Low-Cost Facilities

CT CPT 5 H1 H2 H3 FS1 FS2 FS3

Head or Brain 70450 $1,800 $1,250 $350 $700 $750 $750

Sinuses 70486 $1,850 $1,250 $800 $700 $750 $750

Chest 71250 $2,150 $1,250 $500 $700 $750 $750

Chesta 71260 $2,400 $1,550 $900 $700 $800 $800

Pelvis 72192 $2,150 n/a $550 $700 $750 $750

MRI

Brain 70551 $4,250 $1,600 $850 $1,000 $1,200 $1,200

Brainb 70553 $4,350 $2,500 $1,650 $2,200 $1,700 $1,700

Back (Lumbar Spine) 72148 $3,850 $1,600 $850 $1,000 $1,200 $1,200

Upper Extremity Joint 73221 $2,750 $1,600 $1,300 $1,000 $1,200 $1,200

Lower Extremity Joint 73721 $2,350 $1,600 $1,300 $2,000 $1,200 $1,200

Y County High-Cost Facilities Low-Cost Facilities

CT CPT 5 H4 H5 FS4 FS5

Head or Brain 70450 $800 $1,550 $650 $700

Sinuses 70486 $1,500 $1,550 $650 $750

Chest 71250 $1,000 $1,950 $650 $900

Chesta 71260 $1,950 $3,200 $800 $1,050

Pelvis 72192 $1,550 $2,300 $650 $900

MRI

Brain 70551 $1,400 $2,700 $1,000 $1,100

Brainb 70553 $3,100 $4,750 $1,500 $1,650

Back (Lumbar Spine) 72148 $2,050 $2,700 $1,000 $1,100

Upper Extremity Joint 73221 $2,050 $2,700 $1,000 $1,100

Lower Extremity Joint 73721 $2,150 $2,700 $1,000 $1,100

Based on a sample of charge data from two health plans in X and Y counties in New Jersey; data rounded to nearest $50 to avoid revealing competitively useful information.

a With contrast, a substance used to enhance the quality of diagnostic imaging b Without contrast, followed by with contrast SOURCE: CareCore National


All insurance plans and most CDHPs offer their enrollees “access” to negotiated rates that are

often well below facilities’ charges. Recognizing that many consumers have access to the plan’s

negotiated rates, Table 3 arrays the median negotiated rates, rounded to the nearest $100

increment. Again, the variation is striking—and differences between providers in excess of 300%

are not uncommon.

Table 3. Negotiated Rates for Top 5 CT and MRI Procedures and by High-Cost and Low-Cost Providers in X County and Y County

X County High-Cost Facilities Low-Cost Facilities

CT CPT 5 H1 H2 H3 FS1 FS2 FS3

Head or Brain 70450 $1,200 $1,000 $300 $200 $100 $300

Sinuses 70486 $1,200 $900 $500 $300 $300 $300

Chest 71250 $2,200 $1,000 $400 $300 $300 $300

Chesta 71260 $1,600 $1,200 $700 $400 $400 $400

Pelvis 72192 $1,300 $1,000 $500 $300 $400 $300

MRI

Brain 70551 $1,900 $1,200 $600 $500 $600 $600

Brainb 70553 $2,000 $1,800 $1,300 $1,200 $1,400 $1,300

Back (Lumbar Spine) 72148 $1,800 $1,200 $700 $600 $700 $700

Upper Extremity Joint 73221 $1,500 $1,200 $1,100 $500 $600 $600

Lower Extremity Joint 73721 $1,400 $1,200 $1,000 $800 $600 $600

Y County High-Cost Facilities Low-Cost Facilities

CT CPT 5 H4 H5 FS4 FS5

Head or Brain 70450 $600 $1,200 $300 $200

Sinuses 70486 $900 $700 $300 $300

Chest 71250 $700 $500 $400 $300

Chesta 71260 $1,000 $1,100 $500 $400

Pelvis 72192 $800 $1,800 $400 $300

MRI

Brain 70551 $900 $1,100 $700 $600

Brainb 70553 $1,500 $3,800 $1,000 $900

Back (Lumbar Spine) 72148 $1,200 $1,500 $700 $600

Upper Extremity Joint 73221 $1,200 $1,100 $700 $500

Lower Extremity Joint 73721 $1,500 $2,200 $700 $600

Based on a sample of negotiated rates data from two health plans in X and Y counties in New Jersey; data rounded to nearest $100 to avoid revealing competitively useful information.

a With contrast, a substance used to enhance the quality of diagnostic imaging b Without contrast, followed by with contrast SOURCE: CareCore National


In both cases—charges and negotiated rates—there are significant variations between facilities,

suggesting that negotiation may reduce the absolute level of payment but not the variance in

payment rates. Consumers are, on average, better off using negotiated rates. But significant

disparities among providers offer little comfort to the uninformed consumer seeking “best value”

for their healthcare dollar.

Finally, to address the legitimate possibility that facilities with different prices may offer different

levels of quality, the analysis compared groups of “high-cost” and “low-cost” facilities that

happen to use the same radiologists to oversee and interpret the images. For each county, we

created facility “pairs,” where the only difference between the two facilities was site of service.

For each, given “pair,” the same radiology group performs the test and interprets the image. This

analysis eliminated a major possible source for pricing discrepancies: variation in the quality of

the physician. Table 4 displays these “paired” facilities.

Table 4. Variation in Charges Between Pairs of Facilities Using the Same Group of Radiologists

Radiologists in X County High Cost Facility Low Cost Facility

Group A CPT 5 # Charges # Charges Percent

Difference

CT-Head 70450 H1 $1,800 FS2&3 $750 140%

CT-Chest 71250 H1 $2,150 FS2&3 $750 187%

CT-Pelvis 72192 H1 $2,150 FS2&3 $750 187%

Group B

CT-Sinuses 70486 H3 $800 FS1 $700 14%

CT-Chesta 71260 H3 $900 FS1 $700 29%

MRI-Upper Extremity Joint 73221 H3 $1,300 FS1 $1,000 30%

Radiologists in Y County

Group C

CT-Head 70450 H5 $1,550 FS4 $650 139%

CT-Chest 71250 H5 $1,950 FS4 $650 200%

CT-Pelvis 72192 H5 $2,300 FS4 $650 254%

Group D

MRI-Braina 70551 H4 $3,100 FS5 $1,650 88%

MRI-Back 72148 H4 $2,050 FS5 $1,100 86%

MRI-Lower Extremity Joint 73721 H4 $2,150 FS5 $1,100 95%

Based on a sample of charge data from two health plans in X and Y counties in New Jersey; data rounded to nearest $50 to avoid revealing competitively useful information.

a With contrast, a substance used to enhance the quality of diagnostic imaging SOURCE: CareCore National


Again, the price variations are striking. Even when the same radiologist oversees a head CT

scan for a patient in X County, the out-of-pocket exposure for a walk-in patient visiting Hospital 1

(H1) is nearly 140% more than a similar patient’s exposure visiting either free-standing Facility 2

or 3 (FS2&3). Recall that such variation exists with negotiated rates as well, even if negotiated

rates tend to be lower than charges.

These results demonstrate how confusing it can be for patients to evaluate cost and quality

differentials for similar services. Yet, as more patients face higher co-payment levels, and as

CDHP enrollment rises, healthcare consumers will surely demand better information and tools to

assist them in making important healthcare decisions.


What’s Next? Employers, insurers, and the imaging industry can work together to help consumers make

empowered, data-based decisions in the marketplace. There is a real opportunity to develop

valuable tools that assist consumers and patients in choosing the appropriate providers of care.

Absent clear and accurate information on quality differences between providers, a useful first

step may to provide patients and consumers with accurate cost information. Insurance plans and

providers that choose to offer cost data to enrollees who need diagnostic imaging procedures will

help their members and patients make better decisions by increasing their ability to select cost-

effective, high-quality providers.

Providing enrollees with selected cost information will not guarantee a more efficient

market for diagnostic imaging procedures. A more comprehensive approach would

combine three essential services for a patient: an independent assessment of the

appropriateness of the recommended imaging procedure; assurance that the recommended or

chosen facility meets a rigorous set of quality and service metrics; and timely and accurate

information on the out-of-pocket prices across competing facilities.

Avalere Health LLC 1350 Connecticut Ave. NWSuite 900Washington, DC 20036

www.avalerehealth.net

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