You Want to Know How Much A Colonoscopy Costs?

I’m as confused as the next person about health care reform - but I know we need it; it’s completely bat-shit crazy the way it is now. In my heart of hearts, I think we should have a one-payer socialized system, and I'm disappointed that the “public option” may be dropped from the current attempt at health care reform.

You know that I had two colonoscopies done this summer. Both were done by the same gastroenterologist –but for some scheduling reason unclear to me, the first was done in the hospital, and the second was done in the doctor’s office. Mind you, it’s not a sole practitioner’s office, it’s a big clinic operation with a full scale suite for endoscopies and colonoscopies (and who knows what else). The insurance we have is the kind where you have to stay in-network, and then you pay a small co-pay. In an effort towards transparency, the insurance company sends an Explanation of Benefits out after any claims, showing what the doctor billed, and what insurance paid, and what the patient’s responsibility is.

I compiled the numbers for the two colonoscopies and I’m kind of flabbergasted.

#1 in the hospital

Charges billed by doctors and hospital	$9,142.84
Amount paid by insurance	$5,742.67
Co-pay due from me	$125.00

#2 in the doctor’s office

Charges billed by doctors and lab	$5,322.76
Amount paid by insurance	$2,922.63
Co-pay due from me	$30.00

The submitted charges for the procedure in the hospital were 72% higher than the charges for the scope in the doctor’s office. And the insurance company paid out 96% more for the hospital procedure. At the end of the day, my doctor got reimbursed just about the same amount – so why did he schedule one of the scopes into the hospital? It wasn't for convenience; the hospital is about a half mile from his office. Why isn’t the insurance company protesting? They had to pre-approve the procedure – why didn’t they require that the first scope be done in the office – which would have saved them nearly $3,000? Why did the insurance company pay a bigger percentage of the first scope (63%) and less for the second scope (55%)?

The thing that strikes me about all of this is the irrationality – there’s seemingly no rhyme or reason to either the pricing or the reimbursement. Why is the system so broken?

An article in the September Atlantic suggests that the way out of the mess is to put decision making back into the hands of the consumer – also known as the patients. I don't know that consumer driven health care is the answer, but if I’d known how much the colonoscopy was going to cost in the hospital as compared to in the office, I’d have chosen the office both times - even though the bulk of the cost wasn't coming (directly) out of my pocket. And I’d have saved myself nearly $100 on the co-pay in the process.

Again, I have no idea what the answer is, or how to achieve it, but there is a problem and it needs to be solved. Further, it seems clear that a solution lies in the systems in place in other first world countries. "Every wealthy country other than the United States guarantees essential care to all its citizens. There are, however, wide variations in the specifics, with three main approaches taken." That's a quote from Paul Krugman, in today's Times. Go read the whole piece. He ends thusly:

So we can do this. At this point, all that stands in the way of universal health care in America are the greed of the medical-industrial complex, the lies of the right-wing propaganda machine, and the gullibility of voters who believe those lies.

I don't know where this will end.