HFMA's healthcare pricing guide for consumers falls short

In advance of its annual national institute that opened in Orlando on Monday, the Healthcare Financial Management Association has released an update of "Understanding Healthcare Prices: A Consumer Guide."

The 23-page guide is earnest, clear, straightforward and entirely well-meaning. However, it does not even come close to providing the assistance patients require in navigating their healthcare options and understanding how much it costs. Instead, it pretty much details the myriad obstacles that exist to obtaining clear prices for healthcare services.

For example, the guide suggests that patients obtain ICD, CPT or HCPCS codes as a key to understanding their bills. The HCPCS and ICD codes are fairly easy to obtain if patients are enrolled in Medicare, but if patients are enrolled in a commercial plan and need CPT codes, they have to pay for them, as the American Medical Association holds the copyright.

Moreover, as soon as the guide explains what the codes do, it disclaims that "in many instances, the exact code is not known until the procedure is performed. Because thousands of codes are in use, the codes may not be available at the time of your request. Your doctor or hospital may need to follow up with you to provide this information."

Isn't it too late at that point for the patient to do anything in advance regarding the services performed and what appears on their bill?

The guide also provides some very handy information for consumers about contacting their insurers for a price estimate. But again, the limitations are nearly as clear as the options. The guide notes that the price estimate may not include medications, medical devices, care at a rehabilitation facility, or specialty services such as anesthesiology or pathology. And while it does note that using a provider out of your health plan's network is likely to lead to much higher out-of-pocket costs, it does not mention surprise charges that may appear on a bill from out-of-network providers (or that hospitals in some states are fighting tooth-and-nail to keep those surprise charges in place), or that health plan provider directories can often be inaccurate.

The guide does suggest that patients insist that their physician or surgeon ensure that everyone else on the team are in-network providers. It makes no mention of doctors being overloaded and forgetful on matters such as these (after once asking the price of the brand name medication for my daughter and then requesting the generic, the pediatrician phoned the pharmacy downstairs just a few moments later--and ordered the brand name medicine).

The passage describing what happens when a patient receives a surprise bill or one that is higher than the estimate is also is as clear as it is telling. The first bit of advice--and the best offered--is to take a deep breath. "then, take the time to compare the specifics of the estimate with those on the bill. At that point, you'll be ready to call your doctor's office or the hospital's patient financial services department to get more information and find out what options are available to you. For best results, take a constructive, solution-oriented approach to the conversation and expect the other person to do the same."

Considering all the times I have either read of or written about patients who never resolve these disputes in their favor, being optimistic that a hospital with hundreds of millions or even billions in annual revenue (and paying dues to lobbies that are fighting to keep surprise bills in place) will see the error of its ways is a notch above wishful thinking.

The conclusion of the guide is also overly optimistic: "Doctors, hospitals, health plans,and consumer groups agree that it should be easier for consumers to get the healthcare price information they need. That's why these groups are working together to improve price transparency." Yes, except for all the times they do not, such as the continual inflation and dismissal of chargemaster prices, the fight to keep those surprise bills in place and many other acts of anti-transparency.

I like the HFMA guide, the rationale behind it and that it is being propelled by the best intentions of its publisher. But I fear there may be dozens of editions published before it will actually be a go-to guide for consumers to easily comprehend healthcare pricing. -- Ron (@FierceHealth)

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