My Ultrasound: Three Tests, Three Pricetags

By Rachel Zimmerman

My doctor said I needed a pelvic ultrasound.

Fine, I said. Do you know how much it’ll cost?

No idea, she said. But you can ask.

Great, I said. I love comparison shopping (especially when I don’t have to pay).

To be honest, I never would have shopped around for an ultrasound if not for my colleague Martha Bebinger. She’s just launched the cool, forward-thinking, social networking site, Health Care Savvy, which will serve as a forum for patients to compare prices, brainstorm on how to get costs under control and generally vent.

So, motivated to become a savvier health care consumer, I set out on my journey.

1. Insurance

My family has Blue Cross Blue Shield of Massachusetts health insurance through MIT, where my husband works. So, the first thing I did was to call the referral office to find out what my options were for getting the ultrasound. (The details of why I needed the ultrasound aren’t necessary here, believe me. Suffice to say there were some questions about minor bleeding. But don’t worry, it turns out everything’s OK.)

I had three choices: Massachusetts General Hospital in Boston; Mount Auburn Hospital in Cambridge; and Diagnostic Ultrasound Associates in the Longwood area. I asked the nice referral lady what the costs were at each. Call billing, she said. At referrals, no one has the prices for services.

2. Billing

All of Billing seemed to be on vacation. At least that’s what I figured since I pressed all of the possible extensions available and got no human voice. So I went back to referrals and talked to someone else who told me, eagerly, my ultrasound wouldn’t cost a thing, no co-pay, nothing. “I don’t want to know what it costs me, I want to know what it costs,” I explained. Silence. I was told to call each medical facility separately for that.

3. Three Prices

I called each facility, and here are the prices I was quoted for a pelvic ultrasound:

–Mass. General: $2847 or $2563 (more on this later)
–Mt. Auburn: $971.96
–Diagnostic Ultrasound Associates: $516

All three quotes were for the imaging only and did not include professional services or other additional costs, I was told.

So, is it just me, or is a five-fold difference in price for the same procedure at three greater Boston facilities kind of shocking?

I called MGH back to make sure I heard right. Weirdly, on Wednesday, the ultrasound price was $2,847, but on Thursday it was $2,563. (Do I hear $2,000?) I called the hospital’s PR office for a comment on why it costs so much more. Here’s the statement they sent me from Sally Mason Boemer, Senior Vice President of Finance: “MGH typically benchmarks our gross charges with like institutions and find our charge levels to be consistent with other urban medical centers that have a significant amount of complex care, teaching and research missions, and a high uncompensated care burden.”

OK, I get that pricing isn’t simply about pricing. Hospitals have higher overhead than stand alone imaging clinics, for instance. And I understand that Partners HealthCare, the parent of MGH and the Brigham, needs to subsidize the very important, but often money-losing parts of its business (like Paul Farmer and the Division of Global Health Equality at the Brigham and providing psychiatric care and a round-the-clock burn unit, to name a few).

But still, from a patient perspective, the choice seems more straightforward: it’s the $2,500 ultrasound vs. the $500 one.

4. Not Like Buying A Car

The question I keep coming back to is this: Why is paying for health care so different than buying a car or paying for private school or getting a pedicure? Why is health care the only valuable item we purchase blindly, in effect, with absolutely no idea how much it costs?

Jeff Levin-Scherz, an assistant professor at Harvard Medical School and Harvard School of Public Health (and also a doctor, former health care executive and blogger) explains via email that “health care prices represent an intricate web of cross-subsidization and historical accident. Consumers rarely have access to prices – and even physicians often have little idea what patients will be billed. Consumers care more about prices now, as more have high deductible health plans. Many employers are also starting to consider reference pricing – where they will pay a set fee for a service, and patients will pay the difference if they go to a more expensive provider. ”

Robert W. Seifert, Principal Associate at the Center for Health Law and Economics at University of Massachusetts Medical School said the different prices I was quoted for my ultrasounds were “certainly eye-opening.”

But, he wrote, also by email, it will take more than just knowing what health care costs to change the system:

More transparency about what different facilities charge for the same service and more price-consciousness on the part of consumers (and their accountable care organizations, as we move away from fee-for-service and toward more global financing) will undoubtedly narrow this range. But it won’t do away with it completely, and not because the higher-priced facility necessarily delivers a higher quality service. It’s because a big hospital must build more costs into its ultrasound price – a piece of the costs of running the hospital, supporting its research mission and training new clinicians – than a business that does just ultrasounds.

The value of a provider’s brand and the provider’s market strength (and the market strength of the insurers with which it negotiates) also affect the price. So an easily accessible price list (a smart phone app?) gets us only so far. The rest is a community-wide discussion about what we should pay for, what is the most effective and efficient way to provide certain services, and how costs that ultimately benefit all of us (like research and medical education) should be covered.

5. Location, Location, Location

Clearly, all of this blithe ignorance (mine included) about pricing has huge implications. Pretty much everyone knows that Massachusetts is desperately trying to figure out how to control ever-rising health care costs. What we don’t seem to get, however, is that until patients know the actual cost of their care, they will remain disengaged from the debate, and it will be left to the politicians, hospitals, insurers and other entrenched interests to figure out how things will look in the future. And that’s why Martha’s HealthCare Savvy site, with its focus on patients and honest discussion, is a great first step.

In the end, since my ultrasound was totally covered by insurance, I kind of ignored the prices and went to Mt. Auburn. Why? Well, I gave birth to both my children there, so I’ve got a bit of nostalgia for the place, but the honest to God reason for my choice was…parking. With my Cambridge neighborhood sticker, I got a free spot right down the street.

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  • louise

    when I read stories like this, I can’t understand why Americans are so against socialised medicine. It seems to me that costs in the US are outrageously and artificially inflated. Country to country ranking also show that despite having the highest healthcare spending per capita, the health status of people in the US is below that of many other nations (including countries like Brazil).In Australia, a rountine ultrasound costs around $120 (and the exchange rate is pretty much on par so that would be around US$120). That is what it what the service costs regardless of whether you have private insurance or not. What you pay depends on whether you have insurance, or whether the service provider bulk bills. Over here the public system covers around 60-80% of the basic costs, and if you want better coverage (eg private room, dental, extras etc) you get private insurance. Everyone pays a medicare levy of 1.5% of their taxable income. When you see a GP or use a service you usually pay the fee, and then claim back a percentage of it through medicare. Some service providers will “bulk bill” which means they charge the govt directly for their services (ie they get the 60-80% directly from the govt, and you pay nothing). While it’s not a perfect system, the cost of care is affordable and kept competative because of the out of pocket payments, and everyone has some kind of coverage. In contrast the US system seems to be about delivering the best results for the insurance companies, but not for the public or the service provider. When the health system seems so inequitable, I can’t understand why all US citizens (and not just those that are poor or denied insurance coverage) are not demanding a better deal. access to healthcare, like education, law and justice, is a marker of development and civilised society.

  • http://www.facebook.com/people/Robert-Newman/1583246177 Robert Newman

    So, your insurance carrier paid $455 for nostalgia and free parking. Actually, I had a similar experience with an echocardiogram. It was scheduled to be done at a local county hospital but the 3-month waiting period was a non-starter. I started shopping for independent imaging labs and found one the would do the imaging and interpretation for $100 or so. Out of curiosity, I checked with the hospital on their pricing since I was going to have to pick up the deductible on my own. The hospital tab would have been $2,200 and my deductible 20% of that. This was a no-brainer given that the independent lab could schedule the test a week later rather than three months and the out-of-pocket difference about $340.

  • truly a sceptic

    Comparing prices is all fine and well if the patient has the time and energy to do so. The fact is, many (if not the majority) of the most expensive medical procedures take place under time-sensitive conditions — and/or when the patient is very ill. A person who is severely injured or very ill is not in the physical or mental shape required to figure out how best to save his or her healthcare provider money, never mind weigh the question of whether it’s worth going against his or her doctor’s recommendation for the sake of doing so. And where does all of this “saved” money go? To the insurers: their advertising departments and their shareholders. The idea that an ill person is supposed to spend his or her last gasp working on their behalf gives me a migraine. Oh! I guess I’d better spend a couple of hours looking at my blinding screen so I can be sure to ask my doctor to prescribe the cheapest medication.

  • gaucamayo

    I just enjoyed your story, Mrs. Zimmerman; and the complicated reasoning that went into your final decision.

  • Collie

    I agree!  The games need to stop with Pricing.    I know some clinics who bill the highest rate possible in hopes that they can recoup the full rate minus 30%.

    Let’s use a TENs unit for example.   The clinic may purchase a TENS from a manufacturer or distributor for 30 bucks, then try to bill the Insurance Company for $600.00 bucks and be very happy with getting $450.00.

    Now in all defense, that clinic has a lot of overhead to pay.  

    The point is, the billing game needs to be revised.

  • Collie

    As a medical device sales rep, I can tell you that the big problem in health care costs today is in OVERHEAD due to Insurance and Government Regulations.  Also the device companies try to bill at huge rates because of not getting many claims paid.

    The Ultrasound Device most likely cost your clinic or hospital around $30,000.00 and they have to recoup their costs plus pay salaries of many people who are behind the scenes.

    If Insurance did not exist, these devices would probally cost around $10,000.00 and the clinic could afford to just charge around $100.00 per test.

    It’s really crazy.

  • http://www.facebook.com/profile.php?id=1683140168 Kenneth M Fish

    Perhaps this article points out the obvious.  Some healthcare services should clearly taken out of the hight priced environment into a more efficient one.  Until then, we are doomed to the excessive charges pointed out in this article.

  • DavidS

     You are right that what really counts is the actual payment from the insurance company, rather than the quoted cost. I went through a similar experience to Rachel Zimmerman last year shopping for a colonoscopy, and chose an $800 option over several others in the range of $2,000 to $2,500. The hospitals that quoted over $2,000 would not tell me how much they really would get paid, which makes it very difficult to make a true comparison.

  • Mindy’sMom

    As all to often questioned here, I have one comment on quality of care.
    A close friend just left upstate NY where she was a Radiologist specializing in Nuclear Medicine and moved to VA.
    One of her comments to me about the hospital of 800+ paitents she is now working with in VA was the quality of the machines she was using.
    In NY, at a fairly small hospital she had new equipment, she moaned as she told me that what was she was now working with, was at least EIGHTEEN years old.

  • Mindy’sMom

    There are three reason, for some of the difference. 1– Insurance never pays what you see, it is always less—-they have contracts. The— second one, the smaller hospitals do not have the number of uninsured complicated cases. They do not have to be ready for every possibe need. 3 —Pirivate facilities are exactly that, they do not have walk in patients, that can not pay, either by insurance or their personal funds.

    I have to have my after cancer yearly colon exam, and asked my Doctor about the difference. Although either way I have the same (different Dr.) specialist, one is a private facility, and the other at one of the major teaching hospitals in Boston. The exam will be the same, the Doctor will be the same, but I am sure the charges to my Ins. will be different. What they actually pay is, is an unknown.

    I do know because having avery close friend that used to be an Exec. with Children’s hospital, that BC never paid anywhere near what was on a bill, they paid according to their contract

  • Pookie_bear83

    As a medical biller, I absolutely agree with you. The actual costs and the actual payment is all depend on the contract that the insurance company have negotiate with the providers. Let just say we have a contract with Blue cross and Cigna. Blc will pay up to $90 for a visit and Cigna will pay up to $150 a visit. If we charge $120 a visit, we will lost profit from Cigna, thus we will charge to its max, $270 a visit, whatever the left balance is, we write off or put as it “provider discount rate” or whatever it stated on your EOB.

  • Guest

    MGH quoted you a price that is their “retail” price, or their dream price – what they bill the uninsured.  What they didn’t tell you is the negotiated price – what they’ve agreed to accept from your insurer.  My guess is that the actual price that the insurer pays each of these facilities for the ultrasound is about the same.  

  • J R

    An amazing and informative article.  Keep up the great reporting.

  • LLB101

    The problem with picking lowest cost is the impossibility of comparing quality.  I had a mass of some kind growing in my hand.  The difference in quality between the MRI at one facility to another was huge, completely shocking and lead to a different diagnosis.  I would have never known except that the first facility misplaced my file and I got angry and went somewhere else.  Only then did I find out the huge difference in imaging quality.  How could we as consumers realistically compare the quality of less tangible care?  Comparing prices will be a mess without a way to truly compare quality and make sure we can compare meaningfully.

  • Iceland2us

    I think the best way to control health care costs is to have everyone pay a flat 1% copay…on anything.  Right now it’s almost impossible to get costs.  Most people don’t know that the insurance companies are billed MUCH lower discounted prices (negotiated) than those people who don’t have insurance (even in MA) or are otherwise paying out of pocket.

  • guest2

    i can relate to your story, i just had an ultrasound in the Fall. i had been following writing/stories on the health bill and understood that you are billed based on insurance, etc. I have insurance and my ultrasound was well below $500. however, i had additional tests and Aetna covers only 80% of everything. what i found most disconcerting about my experience was that when discussing the options (given the results of the ultrasound, that’s just the first step) i mentioned the insurance issue, that as a doctoral student 20% can be tough on limited funds and asked how much the next thing costs? the answer from my provider was: “i don’t know, i don’t have to pay for care bc i work here”.   

  • Ted

    while the author admits that she won’t have to pay for any of the ultrasounds the bigger point is that with insurance it really doesn’t matter what the price tag for these procedures are.  MGH could have said $900,000 and she could have gone there and her insurance would have paid the same amount as they would have to any of the other providers.

  • Rayenna53

    Wish I’d read this article before I got charged big bucks for mammogram and followups that I had to pay for. Pharmacies also don’t post prices in the United States. You have to call each one to comparison shop. In contrast, Canada pharmacies readily post prices online, just like any other commodity. Why the secrecy?

  • guest

    I would be careful about assuming that because all the ultrasounds would have been done to evaluate pelvic bleeding, that each site would have done the same thing, used the same equipment, or would have equal quality standards. Not necessarily that the higher-priced sites would have been better, but there are multiple choices each site has to make about what to do and how to do it. It could actually cost one site significantly more than another to do the “same” test. It might or might not be worth the difference in cost in your case. Unless you are a radiologist expert in ulrasound, you would not have a chance of even identifying the quality difference, let alone having an informed opinion on whether you needed the higher quality exam. Price is certainly an important consideration, but you would also like to know quality, and right now there is no way for you to do that.

  • Ljwhorselover

    Do you suppose that   if more folks chose the  lower costs options it might drive the cost at the  higher cost hospitals down? A  little competiton folks? But then the average perosn  neither knows or asks….possibly a large part of the problem.

  • Charley on the MTA

    More reporting like this, please. Terrific work. Rah rah.

  • Christine

    I’m insured by Cigna who sends out a claim that tells me both what they were billed and what they paid. It’s never less than shocking seeing what the actual costs of care is.

  • Carol Steinfeld

    As someone who was uninsured for many years, paying out of pocket for knee X-rays, doctor appointments, preventive testing, etc., I can assure you the price varies widely, as you see. The best prices are from direct providers. As a doctor said to me, “The 3 women working behind the desks you saw when you first came in? They are all processing insurance claims. If everyone wrote me a check [as I was], I wouldn’t need them.” I’ve also seen my gynecologist’s billing agent prepare to bill my insurer for $270 for an appointment for which she charges me $90 direct pay. Health insurance actually raises the price of health coverage for all of us. Let’s consider what I have now: a $5,000 deductible with $120 monthly payments for “catastrophic” coverage. This can create a competitive market for the small stuff—the mammograms, the PAPs, the sprained ankle, the diagnosis of shingles and common infections, etc.

    • Guest

      You point out that your doc billed the insurance company $270 for a visit that you pay $90 for directly and conclude that insurance raises the price of coverage.  But I’ll bet that despite the $270 bill, the insurer actually paid far less, probably $70 or so, for the visit.  Insurers almost always get better deals than self-pay patients because they have more negotiating clout than you do as an individual.  Charges and bills are nearly meaningless in health care.  The only things that really count are the actual costs and the actual payment.

  • Guest

    Curious what the actual charges on the bill were, as I am sure you know depending on what type of pelvic scan the price can vary widely…which makes me think you have apples and oranges between institutions

    • Rachel Zimmerman

      Hello Guest –

      I am curious about the actual charges on the bill as well! But when I called each facility, I was consistent in the way I framed the question: I said my PCP told me to get a pelvic ultrasound because I had some bleeding between periods. None of the facilities I spoke with asked any questions about the type or scope of the ultrasound, they just gave me the price quote.

      Rachel Zimmerman

    • The art of clinical practice

      Amen Guest. You have stated subtly what I would like to say more bluntly. 
      Writer: it sounds like you are having the U/S for reassurance and KYA. Get the cheapo test Please. Or better yet…
       
      Let us not do it. Did you insist on follow up follow up follow up?

      If you were my Mom and I seriously thought you had an issue:
      right to the Brigham. 

      Since we have lost faith and trust in clinicians and developed an ugly adversarial system, clinicians can’t tell you “you’re fine, a hypochondriac”. No we say “get the U/S”. Should you or your insurers choose the less academic U/S and they say you’re fine. Well then only, you only cost the HC system (US: You and ME) 1 Grand. Hope you don’t have uterine cancer. You and your clinician could have done a better job up front and saved $1000. That you saved the rest? Well sure hope you don’t have anything serious. But that would be between you and your radiologist of choice (and Technician, and quality of equipment). Why buy crap? 

      Serious risk: Get the really good U/S at the academic medical center.
      Baloney worried well: Don’t get the U/S.
      Give real Clinicians the time to spend with you to figure it out! That is how we save money!

  • Robyn

    Knowing prices only matters if consumers have a stake in them.  In part because of $10 parking and the cost of your time, you picked an option that cost MIT double, about $500 more than the Longwood option.  That’s a perfectly rational choice for you.   And it shows just how price sensitive consumers are when it’s their time and money.  What consumer would schlep over to Longwood for a diagnostic to save someone else money?  If you had to pay an extra $100 to stay at Mt. Auburn, would you have schlepped to Longwood?  We can’t solve our cost problems until consumers have a real stake in containing those costs.  

  • Philip Kousoubris

    This is a classic problem with all tests, particularly radiology services. I’m a radiologist and had to accomodate parents of a physician friend at my center – from an EU country, where the dad is chief of a hospital department – for a whole body PET scan. We had to charge them the same (multiple thousands of $) amount that we bill american insurers. They charged it on a VISA , and took the receipt back to their country for reimbursement. Lesson? Even I was mildly surprised at the actual charge, considering cost shifting inside the hospital, regional contracts, and the ~30% of the (total) bill that insurers ultimately pay…In a way, the system encourages adversarial pricing tactics, in the name of ‘good business’ practices. More transparency may be in order. This ain’t the used car business after all !

  • Josh Archambault

    Rachel your story hits the nail on the head for system wide cost control. Until consumers have an incentive to pick the lowest priced (yet still high quality care), patients don’t care where they go. That is why it is so sad that MA regulations have put a damper on consumer driven insurance products such as HSAs, with MLR rules, and capping deductibles. This would be a great area for you all to explore in the future.

  • http://wbur.argosit.es/about/rachel-zimmerman/ Rachel Zimmerman

    Thanks for the comment Robyn. To answer your question:

    Yes, if I had to pay $100 out of pocket to get my ultrasound at Mt. Auburn, I probably would have shlepped to the cheaper place in the Longwood area. But, as I said, with no personal financial stake, and three options, I chose the one with the easiest parking.

    Rachel Zimmerman