The ambiguity of a hospital charge

It all started while out to dinner with a couple of my fellow Brigham/Massachusetts General Hospital OB/Gyn residents. We were discussing our favorite old TV shows and one fellow resident’s love of The Price Is Right with Bob Barker. After talking about the game show, a light bulb went off in my head and I thought, “Why can’t we play The Price is Right with hospital charges to our patients?”

With further discussion we realized that none of us knew the hospital charge, or the cost to our patients for routine workups we routinely order in our gynecology clinic. We really had no idea.

After asking around, I realized that I was not alone in my lack of knowledge, or the idea to play The Price is Right with hospital charges. A couple of years prior the Massachusetts General Hospital Internal Medicine residents had played a similar game with the goal to create awareness of the costs associated with routine workups.

There is very little data on how much residents (and attending) physicians know about the costs of what they prescribe, of what changes practice patterns. I had an upcoming conference for the gynecology residents and faculty around the Christmas Holiday and figured that this might be a good venue.

In first thinking about what costs to use, I consulted my esteemed colleague, Neel Shah. He directed me to use hospital charges which are standardized across patients and not specific to the insurance company or patient. I wanted to use Brigham and Women’s specific charges, with local comparisons. Because I wanted it to be pertinent to every day care, I decided to use case based scenarios with 3 of my clinic patients, a hybrid with Choose Your Own Adventure.

I started with our gynecology clinic practice manager (after she overheard me discussing where to find these numbers). She had some information on the visits to our gynecology clinic and hospital charges for the technical end for procedures. But, I soon realized that no one really knows how the hospital charge value is arrived upon, or if and how it changes year to year. And while she could tell me the charge for a RN intramuscular injection fee, she told me to contact the pharmacy for the drug charge. After asking around, I resorted to calling the individual labs/departments to find the appropriate costs. People were often willing to tell me as few people even ask. I called the pharmacy, hematology lab, microbiology lab, emergency room billing, hospital billing, the nurse practice manager for the family planning clinic who coordinates with the nurse in charge on labor and delivery, and a separate operating room billing manager. Because OR costs are determined in increments of 15 min, they are provider and case specific.

We choose a recent hysteroscopy that I had done with an attending who does many hysteroscopies on an average case, and she gave the line item hospital charge breakdown. The microbiology manger prefaced her costs with, “Do you have a pencil and are you sitting down, because you will be blown away!”

The ambiguity of the hospital charge was most apparent when discussing abortion. This is one of the few procedures that many insurances do not cover, so the hospital charge is paramount to self pay patients. The hospital based family planning clinic uses charges from 2004 that are currently being debated. It is unclear if there are separate anesthesia charges, or if they are included in the hospital charge. And because the quotes are outdated, it was difficult to tell what the hospital charge in 2011 is. There is also significant variance in performing the same procedure- dilation and evacuation (or curettage) in the hospital based clinic, the main operating room, in a procedure room on labor and delivery, or in an affiliated private outpatient facility. All of these charges affect our counseling and referral of self-pay patients, and the affordability of these procedures.

The game went over very well with participation and wild guessing from attendings and residents alike. I am not sure if and how practice patterns will or should change, but perhaps knowledge of the systemic charges will better inform our counseling of patients, and consideration of their resources. And, I did pause before obtaining an unneeded gonorrhea/chlamydia culture the day afterwards with my newfound knowledge.

Shilpa Iyer is an obstetrics-gynecology resident.

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