Cautionary tale for health care price shoppers

My family member paid steep price for seeking best deal

PRICE SHOPPING for health care services like laboratory tests and imaging has been touted as a promising mechanism to reduce spending and patient out-of-pocket expense. With increasing price transparency and significant variation in prices, the potential for savings is seemingly enormous – not just in paying less by increasing patient traffic to lower-cost providers, but using the competitive pressure to force down prices of the higher-priced providers as often occurs in “normal” markets. My family’s recent experience, however, illustrates just how unrealistic this strategy is when put in practice.

A family member who had been experiencing periodic abdominal pain was ordered an ultrasound after several visits with his primary care physician. As a health policy professional who is often called upon to help family and friends navigate the health care system, I suggested that he may be able to save some money by undergoing imaging at another facility instead of using his well-reputed, but expensive, hospital system in Boston associated with his primary care provider. I even volunteered to find such a facility for him using his insurance information.

Trouble began right away. The search tool on the insurer’s website malfunctioned for three days and would not display any facilities that offered abdominal ultrasounds. When the site returned, I was able to identify prices only after inputting a CPT code (something the average patient is unlikely to know), as neither the search word “ultrasound” or “abdominal ultrasound” produced the right procedure. (I later learned the correct procedure name in the database is “ultrasound (complete), abdomen”.) I found a hospital close to his home where he would save about $150 in deductible and sent the name along (though I’m unable to share the precise dollar amount as the price estimator tool on his insurer’s website appears to be malfunctioning again as I try to reproduce my search for this piece.)

Next, his primary care physician had trouble sending the imaging referral to the new hospital, and his repeated phone calls to the hospital trying to schedule the ultrasound were met with skeptical questions of “you are trying to do what?” — as it became apparent that arranging an imaging service for a patient in another hospital system was a logistical challenge that the radiology office had never dealt with before.

The ultrasound ultimately took place weeks after, but an even bigger hurdle appeared: getting the image sent back to his primary care physician. Whatever technical or institutional barriers were preventing the transmission weren’t clear – his doctor couldn’t get it at first, then he received it but lost it, he requested the image again but no one responded. On the other hand, bills for the ultrasound from the second hospital arrived promptly.

In the end, more than three months went by before his doctor received the ultrasound and determined that his gallbladder was filled with small gallstones and thick bile, requiring swift surgery. Meanwhile, his condition worsened through the long wait and landed him in the emergency room three times with severe gallbladder attacks before his scheduled surgery, including the last one involving an ambulance ride at 4 a.m. that finally resulted in an emergency operation.

While price transparency is an important tool that allows researchers, payers, and policymakers to understand health care cost drivers and make more informed purchase decisions, it is rarely practical for individual patient shopping.

A nationally representative survey of Americans found that while they support the idea of price shopping, few actually do due to the difficulty of finding price information and an unwillingness to disrupt existing relationships with their providers. My family’s painful and long drawn-out experience shows that even with the knowledge and proximity to an abundance of world class medical institutions, the infrastructure that facilitates price shopping – accessible price information, care coordination, and interoperability between systems – simply does not exist in some cases. And provider systems clearly have few incentives to facilitate it.

Yet, price transparency laws and regulations, including the federal hospital and insurer price transparency rules that went into effect in the summer of 2022, continue to be framed as ways to “empower and incentivize” consumers to be savvy shoppers. In our case, my savviness cost my loved one precious time, months of suffering, and thousands of dollars of medical bills to come that could have been avoided with more timely care.

Yue Huang is a health policy researcher living in Watertown.