Health Care Consumers’ Bill of Rights
1. You are a health care consumer – not just a patient.
2. You have the right to determine where you receive your health care.
3. You can choose to have your imaging performed at a hospital or at a freestanding imaging facility. Either entity will provide you with one free copy of your images on a disc for you to give to your doctor for review.
4. You can choose to have your blood work performed at a hospital or at a freestanding clinical laboratory. Freestanding clinical labs can interface with most Electronic Medical Record (EMR) systems.
Medical facilities with higher charges usually result in higher medical bills, even for those with health insurance. Your health insurance premium does not cover co-pays, co-insurances and high deductibles. Higher medical charges do not result in better medical care but they do guarantee you just what you don’t want - higher medical bills.
The Pratter Principle
Pratter believes that all health care provider costs should be made known before the time of purchase of health care services. If one goes to the grocery store, every single item in the grocery store has a known cost before you purchase it. If you go to the mall, every piece of clothing and food has a known cost before you purchase it. Similarly, by principle, Pratter believes that every bit of health care provided, ranging from a cholesterol level to a knee replacement has a known cost that should be made conveniently available to every health care consumer before undergoing such testing or medical care.
We do have a right to know health care costs. This is referred to as medical cost transparency. Health care providers, in general, have claimed that it is too complex to provide medical costs because they vary so much, especially for inpatient medical care (staying in the hospital) after a heart attack or emphysema exacerbation. Such responses ignore the obvious – most medical care received in a person’s lifetime is outside the hospital (i.e. outpatient)!
These outpatient costs are easy to report. There is a five digit medical code for each procedure whether it is a shoulder joint injection, a lumbar spine MRI or a brief follow up doctor visit. Each code is assigned a dollar figure. There is no “it depends” in this setting. Pratter has set its mission to make these straightforward costs known to you – the public. Gone will be the day you are referred to as a patient. You will now be referred to as a health care consumer. As a health care consumer, you have rights. Some of the rights you should know about are as outlined below.
Pratter Position Statements on Medical Cost Transparency
The Pratter team has heard all of the excuses as to why medical cost transparency is not possible. These excuses by some medical facilities are offered to protect their business profit model embedded in a veil of pricing secrecy. Our company’s website is living proof that not only is it possible but we have accomplished it. Pratter.us has the answers to make medical cost transparency a reality now!
First excuse: Medical cost transparency is too difficult to compare apples-to-apples because one medical institution’s heart failure and cancer patients are sicker than another medical institution’s patients with the same diagnoses. Therefore, pricing doesn’t reflect the sickness of the patient population.
Pratter.us response: 95% of medical care received in one’s lifetime is outpatient-based. This means that there are no hospitalizations. Outpatient medical care can and should be cost compared. A cholesterol level or MRI via the same medical equipment at different medical facilities should not have prices that vary across the country more than a new car – but they do. A simple outpatient procedure such as carpal tunnel surgery or a colonoscopy requires a fixed amount of time in similar medical settings and again can and should be cost compared. An unfortunate person diagnosed with cancer will quickly go through a $5,000 high deductible health insurance policy and thereby eliminate the need for medical shopping. For the majority of America looking to stay healthy, seek preventable care and treat small medical problems early, becoming a health care consumer is vital a household’s financial stability.
Second excuse: Medical facilities are not allowed to publish their medical costs because their negotiated contract rates for payment of medical services by an insurance company has a confidentiality clause.
Pratter.us response: The first half of this statement is false. The second half is true. Insurance companies do make the medical facilities that they deal with for a health care provider network sign a confidentiality clause in regard to reimbursement rates. Hospitals and surgery centers would have adverse financial and legal consequences thrust upon them if they published insurance company reimbursement rates. However, hospitals, surgery centers, imaging centers and lab centers are permitted, encouraged and should provide their medical charges for all services for their communities. According to Pratter.us, the fair market price for a medical test is the average reimbursement amount by the most common insurance carriers in the region.
For example, if a medical facility charged $2,000 for a lumbar spine MRI yet the average insurance reimbursement was $1,000 as payment in full for an individual with excellent health insurance coverage, $1,000 becomes the fair market value and a $1,000 price tag should be assigned to a lumbar spine MRI posted by that facility on Pratter.us to best serve its community. If $1,000 is considered as payment in full in this example, it should be considered as payment in full for all parties and not just insurance carriers. Individuals should not have to bear the burden of a $2,000 charge as punishment for not having an excellent insurance policy they cannot afford particularly when the medical facility’s business revenue and profit model is based off insurance company reimbursement rates.
Third excuse: It would take too long and too much effort to calculate and post medical prices online. In addition, we don’t have the medical cost and billing software expertise to do this.
Pratter.us response: Pratter.us is not asking medical providers to make public what they don’t already have in hand. All medical facilities and providers have a charge master, most often in an Excel spread sheet format. Each and every medical test has a unique five digit billing code that is standard in all 50 states. In terms of posting costs, Pratter.us has a secure portal with medical line item by line item test name with proper billing code adjacent to it. One medical biller or CFO can enter the medical test or procedure cost on each line. Cost search results would immediately be available.
Fourth excuse: Listing a medical cost for a procedure is not fair because it does not reflect the value of our service because we do it better and should be able to charge more than other medical facilities in our community.
Pratter.us response: Pratter.us is not meant to be all things to all people. Cost is a consideration in all other aspects of consumerism. Health care consumerism is here to stay as the cost burden has shifted to individuals bearing greater medical costs. If a person goes to buy a car, he or she is well aware of the good price for the desired vehicle via online searching. Quality assessment is based on other factors such as personal experience, word of mouth recommendation, review articles and consumer education by the car dealership. This process applies to all purchases and health care should be no exception.
Fifth excuse: Our medical facility has been able to charge more and get reimbursed more because we have more overhead. Therefore, if we post our medical prices online, we would lose market share.
Pratter.us response: Reduce your overhead or lose market share. Pratter.us’ mission is to provide actual medical costs to health care consumers and reward medical facilities with cost effective, quality medical care. Medical facilities that refuse to post their charges on Pratter.us have one thing to hide – high prices. We believe that the majority of medical care providers are able to tout their value based upon pricing and performance and we welcome all to our platform.
Medical Transparency Laws and Position Statements
Below are some laws and position statement further supporting your right to medical cost transparency as a health care consumer.
A. The Affordable Care Act. The Affordable Care Act, also referred to as Obamacare, requires hospitals to disclose its charges for medical services. The following is noted:
Standard Hospital Charges. Each hospital operating within the United States shall for each year establish (and update) and make public (in accordance with guidelines developed by the Health and Human Services Secretary) a list of the hospital’s standard charges for items and services provided by the hospital, including for diagnosis-related groups (DRGs) established under section 1886 (d) (4) of the Social Security Act.
There has been no national standard reporting method for medical costs made available to the public until Pratter. Pratter has a Hospital, Ambulatory Surgery Center, MRI Center, and Blood Work Center portal where it is easy and convenient for medical costs to be disclosed and displayed in a user friendly way. At the same time, compliance with federal and state law is achieved.
B. AHA Position
According to the American Hospital Association (AHA) website, “consumers deserve helpful information about the price of their hospital care, and the AHA is committed to providing it.” In fact, the AHA has a position statement on this topic noted as follows:
Hospitals are a critical component to the fabric and future of our communities. We agree that consumers need useful information when making health care-related decisions for themselves and their families. Providing understandable and useful information about health care costs is just one way America’s hospitals are working to improve the health of their communities.
The AHA and its members stand ready to work with policymakers on innovative ways to build on efforts already occurring at the state level, and share information that helps consumers make better choices about their health care. AHA Principles for Price Transparency. In 2006, the AHA Board of Trustees approved a policy regarding hospital pricing transparency. That policy calls for information to be presented in a way that:
- Is easy to access, understand and use;
- Creates common definitions and language describing hospital pricing information for consumers;
- Explains how and why the price of patient care can vary;
- Encourages patients to include price information as just one factor to consider when making decisions about hospitals and health plans; and
- Directs patients to more information about financial assistance with their hospital care.
Here at Pratter, we challenge the AHA to honor its position of medical cost transparency by actively encouraging its hospitals to post its charges for all 595 line items listed by medical procedure name and CPT code via our authenticated Pratter portal. These 595 procedures encompass well over 90% of all outpatient medical care performed in the United States. Pratter has already contacted AHA headquarters about its medical cost transparency mission.
C. State laws about medical cost transparency. 35 states require hospitals to report information on hospital charges or payment rates and make the data available to the public. There are many shortcomings with these legal requirements, including the following:
1. Many state laws do not require that the medical costs made public be formatted in an easy-to-understand way for the average health care consumer.
2. Those states with medical transparency laws that require the medical costs to be easy-to-understand do not enforce the “easy-to-understand” clause.
3. Hospitals in states that are required to submit their charge masters with their line item costs simply do not submit line item costs for all they do. The largest omission by far is a lack of reporting of all physician fees, whether it is surgical fees or office visit fees. Since hospital systems employ physicians, they obviously charge for their employed physicians’ services. They certainly do not donate them. Therefore, a line item listing of all of the employed physicians fees for all medical procedures needs to be made transparent as well.
4. There is no standard submission requirement in any state. Pratter is the first-to-market in the United States with standard medical cost formatting based on standard medical billing Current Procedural Terminology (CPT) coding. Pratter places medical charges into a user-friendly database for medical cost comparison purposes. This is where Pratter has become your advocate. Pratter is set up to facilitate any and all state and federal medical transparency laws. If you have laws such as these, simply require submission of all outpatient medical cost data to the Pratter portal at www.pratter.us. This makes the medical costs for a health care provider, such as a hospital or surgery center, both legally compliant and health care consumer friendly.
An example of a state with a medical transparency law, Massachusetts, is set forth below. The bottom line is that the hospital and/or insurance carrier has two days to provide cost information after a patient has requested it. Each hospital system in Massachusetts, like all other states, is welcome to upload their charge data to Pratter via our Hospital/Surgery Center/MRI/Lab Portal. This will make matters more convenient and timely for you, the health care consumer (otherwise, spend hours on the phone), as well as the hospital system. In addition, it will satisfy legal requirements.
Advance disclosure of allowed amount or charge for admission, procedure or service as per Massachusetts’ state law:
- 228(a): Prior to an admission, procedure or service and upon request by a patient or prospective patient, a health care provider shall, within 2 working days, disclose the allowed amount or charge of the admission, procedure or service, including the amount for any facility fees required; provided, however, that if a health care provider is unable to quote a specific amount in advance due to the health care provider’s inability to predict the specific treatment or diagnostic code, the health care provider shall disclose the estimated maximum allowed amount or charge for a proposed admission, procedure or service, including the amount for any facility fees required.
(b) If a patient or prospective patient is covered by a health plan, a health care provider who participates as a network provider shall, upon request of a patient or prospective patient, provide, based on the information available to the provider at the time of the request, sufficient information regarding the proposed admission, procedure or service for the patient or prospective patient to use the applicable toll-free telephone number and website of the health plan established to disclose out-of-pocket costs, under section 23 of chapter 176O. A health care provider may assist a patient or prospective patient in using the health plan’s toll-free number and website.
D. H.R. 1326: Health Care Price Transparency Promotion Act of 2013. Representative Michael C. Burgess of Texas introduced this bill on March 21st, 2013. It has not become law yet. In this legislation, all states would be required to disclose information on hospital charges, to make such information available to the public and to provide individuals with information about estimated out-of-pocket costs for health care services.
E. Summary. As you can see, there is a lot of momentum gaining toward medical cost transparency – and there has to be. Health care costs makes up about 20% of our nation’s economy. Health care insurance also makes upward of 20% of a middle class American family’s budget today and that is expect to double to an unfathomable 40% by 2020. For costs so great, you deserve to know what they are before the time of purchase just like you do for the other 80% of goods and services sold in our country!