The Secret’s Out

Worth A Look, Healthcare & Welfare, Frontier Centre

For consumers trying to budget their medical costs, one obstacle has been the extreme difficulty of getting advance price information for even the most routine procedures. Now, one major insurer is changing that by offering its members access to what they will pay — before they enter a doctor’s office.

On Sunday, Aetna began allowing its members in the Washington area and several other markets to access prices for “30 of the most widely accessed services” and care-quality information via the company’s member services site.

“Most consumers have no idea of the true cost of their health care,” said William Fried, Aetna’s medical director for the mid-Atlantic region. “And most consumers don’t know how to evaluate their health care. . . . It’s a resource to assist members in making informed health care decisions.”

The company expects pricing information will likely be most helpful to people who have health savings accounts (HSAs) tied to high-deductible insurance plans that place more of the burden for containing health costs on consumers, rather than their employers. The posted prices are the rates that care providers have agreed to accept as payment for services to Aetna members; prices for patients who are not Aetna members may be higher.

Health analysts generally applauded the move, saying that any step that makes more information available to consumers is a good one. But one expert noted that there are still relatively few HSA users — estimates place the number at four million nationwide, though that is expected to grow.

“This transparency helps some people but doesn’t help a lot of other people,” said Arthur Levin, director of the Center for Medical Consumers, a New York-based nonprofit organization. “Many people have no interest at all [in] what the arrangement is between the plan and the doctor. They really want to know, ‘What’s the arrangement between the plan and me?’ ” — particularly when a patient sees a provider who is out of network, he said.

The program is also not useful for the nation’s 45 million uninsured and those insured by non-Aetna plans, experts noted.

The service, begun a year ago in Cincinnati, allows the estimated one million Aetna members in the District, Maryland and Virginia to log on to the company’s Web site, pull up a provider’s name and view price and quality information. Another 1.3 million members in other parts of the country also gained access to the new service. The Washington-region debut, initially slated for Friday, was delayed until Sunday because of computer system problems.

Aetna members in those markets can view — from any computer with Internet access — how much specific services will cost them at their provider’s office.

For example, a listing for District internist Theresa A. Stone shows rates of $127.62 for a “new patient office visit for moderate problems,” $69.95 for an “established patient office visit for low to moderate problems” and $109.31 for an “established patient office visit for moderate to severe problems.” A “periodic comprehensive well visit for an established patient ages 40-64” is $141.78. At that same provider, a “test for blood in stool” is $3.43, an “incision and drainage of abscess, simple or single” is $125.22 and the “administration of [a] single immunization” is $25.13.

A search of the site yesterday suggests it may be worthwhile to compare prices. A listing for Horacio G. Schapiro, another District internist, includes lower rates than those listed for Stone’s office. Schapiro’s listing shows rates of $108 for a “new patient office visit for moderate problems,” $59 for an “established patient office visit for low to moderate problems” and $93 for an “established patient office visit for moderate to severe problems.” A “periodic comprehensive well visit for an established patient ages 40-64” is $120.

An advisory on the site reminds members that posted rates are the “maximum amount allowed by Aetna. Depending upon your particular plan, your actual out-of-pocket costs may be less (for example, co-pays, co-insurance and/or deductibles).”

Quality information is drawn from Aetna’s “Aexcel” network, described on the company’s web site as a “designation for specialist physicians . . . who have demonstrated effectiveness in the delivery of care based on a balance of measures of clinical quality and efficiency.” Quality ratings are available for providers who specialize in 12 areas: cardiology, gastroenterology, cardiothoracic surgery, general surgery, obstetrics and gynecology, neurology, neurosurgery, orthopedics, otolaryngology, plastic surgery, vascular surgery and urology.

The quality information is divided into three categories: clinical quality, volume and efficiency, according to the company. Clinical quality is based on 30-day hospital readmission rates, number of complications during hospital stays, use of recommended screenings such as Pap tests and breast cancer screening, and compliance with recognized treatments for certain patients such as prescribing beta blockers for those with a history of heart attacks and using ACE inhibitors in cases of chronic heart failure.

Volume is rated by determining whether the provider has seen at least 20 Aetna members in the past two years, a number the company chose because it is “important to have a minimal number of cases to have a reasonable sample” from which to gather ratings, Fried said.

The efficiency standard is a “measure of cost-efficiency of care compared to [the provider’s] peers,” Fried said. The rating is based on the total costs of tests, inpatient and outpatient care and medications — “anything that goes into the cost of care for a specific diagnosis,” he said.

“We look at the total claims experience in managing a patient for a specific condition and compare that,” Fried said. Those who more “efficiently” treat patients pass this measure.

A search of Aetna’s site yesterday showed that District cardiologist Elizabeth Ross passed all quality measures — indicated by a checkmark placed next to each of the three categories. But listings for some other providers included no quality or efficiency results.

Regardless of such ratings, Aetna’s Web site cautions, “there is no guarantee as to the quality of the service you receive from that doctor, or the outcome of any treatment by that doctor.” Instead, the site states, “the Aexcel designation is one of many factors that you may consider when making health care decisions.”

Even a doctor who failed to reach the quality standards would not necessarily be dropped from the insurer’s roster of providers, said Aetna’s Fried.

That was bothersome to Sidney Wolfe, director of the Health Research Group at Public Citizen, a District-based consumer advocacy group. “It pretty much says there’s little if anything a doctor can do that would keep them from being a participating provider,” he said. Aetna said it’s rare for a provider to be removed as a participating provider; situations that warrant removal typically involve patient safety, fraud, crime and loss of medical license or hospital privileges.

Wolfe also said the quality information could be expanded significantly to include other publicly available information, most notably from state medical boards. “I don’t want to sound like this isn’t a good start,” Wolfe said. “It just could be more. They’re providing just a fraction of the information that they could be providing.”