Last updated May 2022
New laws should help consumers find out what they’ll pay for healthcare services, but many available tools are still works in progress.
Because our researchers consistently find huge price differences from company to company for the exact same products and services, we constantly urge you to shop around. But with medical care, it’s nearly impossible to identify lower-cost providers that might save you money.
Medical costs should become more transparent due to new federal regulations and laws that provide hospital patients with price protections, and require facilities and private health insurance plans to disclose fees. (Since, after meeting their annual deductible, Medicare beneficiaries don’t pay additional medical costs, many of these new rules and protections don’t directly affect them.)
It’s about time. Since 2003, traditional health plans sponsored by large employers have shifted more of the cost-sharing burden to policyholders through higher deductibles and other coinsurance obligations. This may alleviate skyrocketing healthcare costs if patients seek out low-priced providers, but consumers have seldom been given any tools to do that shopping—or even a way to find out in advance what they’d get charged for their care.
Despite the new laws, healthcare price tools currently available to patients are still works in progress. Many we checked were clunky, glitchy, and not very useful. Still, some were promising, and the avalanche of medical service price data becoming available to consumers, analysts, and digital entrepreneurs is powerful info—meaning price-comparison tools should improve and greatly help consumers.
Elimination of Surprise Medical Bills for Emergency Care
On January 1, 2022, the No Surprises Act became law, providing critical protections for patients when they seek emergency medical care. For those covered by group and individual health insurance plans, the law eliminated the potential nightmare of thousands of dollars in unexpected medical bills from out-of-network providers.
Patients usually select providers that participate in their health insurers’ networks. That’s because those doctors, hospitals, and other in-network providers have typically agreed to charge lower rates to the insurance plan and its members, usually resulting in lower out-of-pocket costs for patients compared to out-of-network providers. After your copay, annual deductible, and other cost-sharing obligations are met, insurance pays the rest of the bill—but if you use an out-of-network provider that charges more than the plan is willing to pay, you’ll have to cough up the remaining balance.
It’s especially important that consumers are protected from huge fees when they use hospital emergency departments or urgent care facilities. In these situations, you can’t shop around to obtain price quotes from several ERs.
Before the No Surprises Act went into effect, many patients got hit with big bills, even after using emergency rooms at hospitals that participate in their insurers’ networks. The hospital might be in your plan, but its anesthesiologists, radiologists, pathologists, and other physicians may not be. As a result, consumers were often charged thousands more for care.
In these cases, payments made by patients’ insurers covered only part of the out-of-network providers’ tabs. Consumers had to pay the remaining balances, a practice called “balance billing.” According to the Centers for Medicare & Medicaid Services (CMS), these surprise charges can often be 10 times higher than the typical anticipated bill.
These surprise medical bills weren’t uncommon. From 2010 through 2016, almost 40 percent of emergency room visits at in-network hospitals produced out-of-network bills, according to a study published in Journal of the American Medical Association (JAMA) in 2019. Another study published in JAMA found that from 2012 to 2017, 20 percent of patients who had seven common surgeries by in-network surgeons at in-network facilities were billed by other out-of-network clinicians.
The No Surprises Act largely bans this type of balance billing. Most out-of-network providers can no longer charge more than stipulated under facilities’ in-network cost-sharing agreements. In addition to most emergency care, the Act covers nonemergency care in hospitals, hospital outpatient departments, and ambulatory surgery centers if they participate in your insurance plan’s network, plus air ambulances. (The Act does not cover bills from ground ambulance services.)
The law also gives uninsured patients the right to Good Faith Estimates (GFEs) of costs before they receive care.
Hospitals Are Now Required to Disclose Pricing
Starting on January 1, 2021, the CMS Hospital Price Transparency rule requires hospitals to provide consumer-friendly online price tools showing charges for at least 300 “shoppable” nonemergency services that can be scheduled in advance. Although hospitals could decide which of 230 services to include, the remaining 70 were specified by CMS and include procedures such as hip or knee joint replacement without complications, routine obstetric care for cesarean or vaginal delivery, and surgical removal of the prostate and surrounding lymph nodes with an endoscope. Hospitals were also required to post online computer-readable files listing their prices for all items, services, and service packages they offer.
Lawmakers hoped this would provide the public with easy-to-access price info for most common procedures. These tools might help rein in rising medical costs by empowering consumers and employers to compare costs between specific providers before receiving care and, in turn, put downward pressure on health care prices and encourage providers to compete on price and quality.
Because byzantine billing schemes have created myriad possible prices for the same item or service, the rule requires each hospital to disclose its “standard” gross charge (the hospital’s “list” price, which few if any insurers or patients pay); discounted cash price (what uninsured patients usually pay); payer-specific negotiated charges (prices various insurers have agreed to pay); and minimum and maximum negotiated charges (the lowest and highest negotiated rates).
But so far the rollout has been a mixed bag.
“We saw mass noncompliance,” said James Gelfand, executive vice president of public affairs for the ERISA Industry Committee (ERIC), which represents large employers on benefit issues.
Last year employers and other transparency advocates pushed CMS to impose higher penalties for noncompliance, and in November the Biden Administration raised the maximum annual penalty from about $110,000 to more than $1.2 million. Gelfand said that is pushing more hospitals toward compliance, but problems persist.
“The presentation of information is not standardized. Shoppers at some hospitals may have to look at an Excel spreadsheet with a series of numbers and procedure codes, and it’s not always clear what you’re looking at,” said Krutika Amin, associate director at the Kaiser Family Foundation (KFF).
Checkbook also found that cost estimates seldom include doctor fees—the rule doesn’t require them if they’re not employed by the hospital—but sometimes they do.
“The American Hospital Association [AHA] supports price transparency and believes patients deserve the best possible information about what they should expect to pay for a scheduled service,” said Ariel Levin, AHA’s director of coverage policy, without addressing our findings. “Hospitals and health systems are working to help patients access useful information about their costs, including through the use of price estimators and other tools.”
We have not yet done an extensive analysis of local hospitals’ consumer tools. But our test drives of several found considerable room for improvement.
For example, when we searched Boston Medical Center’s price estimator for its negotiated prices for a total knee replacement, we found its tool wanting. To start, it was available only as a downloadable Excel spreadsheet. The dropdowns used in that document to obtain prices worked only if you knew to click the “enable editing” button at the top of the window.
After that, the tool was straightforward. We entered our insurer (Blue Cross), PPO, and the Diagnostic-Related Group (DRG) code for hip or knee replacement surgery without complications. The spreadsheet instantly spit out an average total charge of $61,965 and indicated our insurer would pay the hospital $20,702, and that the price paid by those without insurance was $15,491.
However, a disclaimer warned that the insurer’s price was only for the hospital’s charges and did not include additional fees for services provided by doctors and other professionals who do the work. Costs also vary based on a patient’s individual circumstances, and the prices don’t show your out-of-pocket cost under your health plan. So you can’t bank on the prices shown, and the hospital advises that the best way to get a cost estimate is to email the hospital’s Patient Financial Services department and contact your health insurer.
Comparison price shopping several area hospitals would have required a similar search at each, including at lousy sites like the one for New England Baptist Hospital. After requesting costs for “major hip and knee joint replacement” and inputting our insurance info into its online tool, we got multiple error messages. We called the helpline during afternoon business hours and left a voicemail message. We then tried the website again, using another procedure option for “total knee replacement.” That worked and produced an out-of-pocket estimate of $440 to $660. But a link to “view estimate details” turned up a $550 out-of-pocket cost and the negotiated price ($21,664). Not only were the multiple out-of-pocket costs incorrect (the correct number is $900) and confusing, but it wasn’t clear why there were two different procedure names for the same service or which one we should have picked. Two days later, we got a call-back and a financial consultant estimated the hospital would charge our insurer $31,896 for the inpatient major hip and knee joint replacement and about $25,000 to $26,000 for the total knee replacement—excluding anesthesia and the surgeon fee—with a $900 out-of-pocket.
The CMS transparency rule also sought to provide employers and health insurance plans with info on real-world pricing.
“When a hospital has humongous list prices, it negotiates what looks like lower prices with the insurance companies. The insurers know the list price is nonsense, but they tell the employer and member that price is real and that they negotiated 50 to 60 percent off the list price,” Gelfand said.
The new rule should enable employers to compare what various insurance plans are paying for medical services to see which plans are paying a lot more than others for the same services.
“It’s not Joe Employee who will reduce healthcare prices by shopping at the point of purchase for medical services, it is giant companies that insure hundreds of thousands of employees who will do that on the front end of the insurance purchase,” said Gelfand.
Insurance Plans Soon Will Be Required to Offer Cost Estimators
The CMS Transparency in Coverage Rule requires that health insurers eventually make available to the public detailed pricing information for all covered in-network services and procedures. By July 1, 2022, computer-readable files must be available to consumers, researchers, and third-party app developers. By 2023, plans must have online tools that let policyholders see their personalized out-of-pocket costs and the underlying prices for 500 shoppable covered items and services. And by 2024, these web tools must expand to include all covered items and services.
According to America’s Health Insurance Plans (AHIP), a trade association, “77 percent of commercial health plans already make a cost calculator tool available to their policyholders, which checks most of the boxes required for the new rule.” According to Kelley Schultz, AHIP’s executive director of commercial policy, “One hundred million covered lives already have access to this information, and it’s important for consumers to know these tools are available and how to use them.”
We found some plans already have tools sharing useful price intel with their members. For example, we checked the tool offered by CareFirst, a Blue Cross and Blue Shield company that provides coverage to Checkbook staff, for “knee” and quickly found a section for total knee replacement surgery.
The website then produced a list of 17 in-network hospitals within a 25-mile radius of downtown Boston, ranked by default from lowest- to highest-cost, and an estimate of our maximum cost for each: $900 for the copay and remaining annual deductible.
When we checked on pricing for Brigham and Women’s Hospital, the tool gave us an estimated cost of a whopping $53,754 (but, again, our cost would remain $900, with the insurance company picking up the rest).
While looking at Brigham and Women’s profile, we got a popup window that requested, “Help us save on your knee replacement [and]…help control healthcare costs for everyone,” and pointed us to two hospitals where CareFirst could save more than $20,000. It reported that Beth Israel Deaconess Hospital in Milton would charge the plan only $33,262, and Lowell General Hospital would charge $33,669.
CareFirst’s tool also includes some quality measures. For example, it reported that all three of these hospitals have earned The Joint Commission’s Gold Seal of Approval, but that Lowell General has earned the insurer’s Blue Distinction Specialty Care recognition for excellence in delivering safe and effective treatment for knee and hip replacement.
So, overall, CareFirst’s tool gave us helpful information to maybe prefer Beth Israel Deaconess or Lowell General as a low-cost (from the insurer’s perspective), high-quality choice.
We also sat for a demonstration of the tool offered by Blue Cross and Blue Shield of Illinois, which has been providing information on costs to its members since 2010, when it launched a price-comparison website.
Its tool provided similar info to that of CareFirst, but it further encouraged cost-cutting by offering up to $750 as a reward when policyholders use low-cost providers.
“In any other industry, when you shop for value, you get that value,” said Rania Bollegar, senior director of product solutions at Health Care Service Corp., which operates the plans for Blue Cross and Blue Shield of Illinois, Montana, New Mexico, Oklahoma, and Texas. “But when you shop for healthcare, you may or may not realize a portion of the claim savings. We pay benefits exactly as structured, but then, separately, we reward policyholders who help us save.”
Creating a Path for Useful Price Comparison Tools
The wealth of price information liberated by new laws and regulations is spawning websites to analyze these data and provide price estimates. Several already promise to provide cost comparisons. But, like the hospitals’ websites and those offered by some insurance plans, we found these companies don’t yet provide consumers with much actionable info.
For example, we signed up for a HealthcarePriceTool.com subscription, for $9 a month. The site said it collects prices from insurance claims data and therefore obtains the actual costs that insurers and real patients were billed by each provider. The website claimed it aggregates the prices of more than a million doctors, hospitals, and other providers around the U.S., and presents the average price charged by each provider for each procedure.
When we searched the tool for knee replacement surgery, it produced a sortable list of 29 Boston area hospitals, with prices ranging from $18,270 (Mount Auburn Hospital) to $68,842 (Brigham and Women’s).
These prices represent only the average out-of-network fees paid by those without insurance and are of little practical use to the vast majority of consumers with private health insurance.
We also tried out another web tool offered by Turquoise Health, which said it gets prices from disclosures required by CMS.
Our search for knee replacement surgery turned up 29 providers within 25 miles of downtown Boston but only had Boston Medical Center’s negotiated rate ($11,969) for our insurer. The site reported our out-of-pocket cost there would be $900.
Turquoise also provided cash prices for 25 of the 29 hospitals, ranging from less than $7,300 to $53,733. And it listed four other facilities, but didn’t have cash prices or our insurers’ rates for them. Turquoise said it didn’t list information for 14 other hospitals because it couldn’t find their data or the hospital didn’t comply with CMS’ publication requirements.
Some states—including Massachusetts, Colorado, Maryland, New Hampshire, and Washington—are also offering consumers online healthcare cost estimate tools for common shoppable treatments.
Massachusetts’ CompareCare website reports the average costs for procedures in 10 categories of medical treatments, including physician’s office and emergency room visits, maternity services, behavioral healthcare, lab tests, radiology, colonoscopy, physical therapy, and eye exams, based on actual claims data that health insurers must provide to the government.
Unfortunately, we found CompareCare of little use. When we searched for cesarean childbirth within 20 miles of downtown Boston we got no result with 11 insurers, only one doctor’s price when we chose Blue Cross and Blue Shield of Massachusetts, and three doctors’ prices with Harvard Pilgrim Health Care.
Although we greatly appreciate Massachusetts’ effort, which includes provider quality indicators, and we look forward to further innovation from it, like so many other online healthcare cost tools its website is not quite there yet. The prices we got for a maternity “bundle,” ranging from $4,170 to $5,642, were the full cost of the procedure paid by the insurer and the patient, with no breakout for our out-of-pocket price. The prices represented only the doctor’s fee and didn’t include hospital charges—not much of a bundle or full-cost. And the 2017 price data is five years old.
Fortunately, we think existing tools will continue to improve especially as insurance plans comply with new rules, allowing healthcare advocates and others use newly available data to invent comparison tools. We’ll keep you posted as that happens.