Federal health care data on Medicare provides a starting point to comparison shop; some in medical community stress that the numbers don't tell the full story.
WASHINGTON – When it comes to the price of visiting a doctor, location matters in Minnesota.
If you visit a family care physician for the first time up north in Warren, for example, the bill could run as low as $150. The average charge for the same initial visit at a suburban Minneapolis clinic? Possibly as high as $313.
Billing amounts also vary within cities and regions of the state, according to data released by the U.S. Department of Health and Human Services for the first time in 35 years. It shows what health care providers billed Medicare for services.
Although they are only for Medicare patients and just a portion of what is billed is actually paid, the billing records provide a glimpse of what top-line prices typically might be for all patients. And like sticker prices on cars, they offer a way to compare general rates.
That information is more critical than ever. With the growth of high-deductible health insurance plans, patients are paying more out of pocket, forcing them to shop around for the best deal.
A Gannett Washington Bureau analysis of the data for Minnesota found that there is indeed reason to comparison shop.
In Central Minnesota, the charge for an initial office visit by a Medicare patient to a family practitioner in 2012 ranged from an average of $125 each for a solo practitioner in Cold Spring to $263 for a pair of doctors at a HealthPartners clinic in St. Cloud.
The statewide average for such a visit was $200. Family practitioners at the Mayo Clinic — which accounted for 23,500 of the 150,000 Medicare average provider billing records released for Minnesota — charged $120 to $150.
Charges also varied among specialists around the state.
Cardiologists and thoracic surgeons submitted bills ranging from $1,200 to $3,900 to insert pacemakers and $5,800 to $10,900 to repair faulty heart valves. The single highest average physician charge was for total knee replacement surgery at a Mayo Clinic in Albert Lea, where bills for 21 such procedures averaged $11,900 each.
A starting point
The American Medical Association, which fought the release of the data for decades, argues the records do not provide enough details for people to make accurate determinations about health care providers.
"This information isn't going to necessarily allow them to determine 'Is my doctor good? Is my doctor not so good?' " AMA President Dr. Ardis Dee Hoven said. "There's no way for them to know how this relates to quality, how it relates to health outcomes and access and all sorts of issues. Raw data simply does not give the correct determination of value."
Hoven also noted that the accuracy of the data has not been verified with the doctors themselves. In a few cases, Gannett found mistakes in the records. For example, one doctor listed in Minnesota was actually working in another state. The data also does not include facility fees that hospital-based providers can tack on. That may make their billed rates appear artificially low.
But some industry groups say the records at least provide an important jumping-off point for asking more questions, such as why are charges high or low, and what's included in the price?
"The unfortunate thing is consumers don't even know where to start in asking the question," said Carolyn Pare, president and CEO of the Minnesota Health Action Group, a coalition of companies and others that buy insurance and want to reduce costs. "And now having this out in the public, to a certain degree, gets consumers asking the question."
Many factors affect the rates that providers set, from basic overhead expenses such as rent to the mix of patients a practice has, Minnesota health care providers say.
More Medicare or Medicaid patients might prompt a higher billing rate for other patients because federal insurance for poor and elderly people only covers a fraction of what providers say it costs to treat them. The average amount Medicare actually paid for the initial office visits in Minnesota was $65, according to the 2012 data.
At CentraCare Health, Chief Financial Officer Tom Feldhege said prices are determined in part by the resources needed to provide care at a given facility.
"These resources translate into costs, including professional fees (provider's time, expertise and training, malpractice insurance), patient care staff (nurses, other clinical staff, imaging, front desk, schedulers, etc.), staff behind the scenes (IT, billing, medical records, cleaning, quality, administration), equipment, furniture, facility costs and overhead (water, lights, electric, etc.)," he wrote in an email.
Keeping costs down
Some providers say they have deliberately tried to keep costs low by eliminating unnecessary tests, medications and other ancillary costs and focusing on managing care efficiently. At Mayo, spokesman Bryan L. Anderson said he's not surprised the Medicare billing records reflect comparatively low rates for Mayo providers.
"This data reflects the 'Mayo Model Of Community Care,' with an emphasis on a physician-led team to care for patients," Anderson said.
Dr. Christopher Wenner, the solo practitioner who charged the lowest amount in Central Minnesota — $125 on average for a moderately complex first-time visit — said he keeps his overhead as low as possible. For example, he has only one assistant at his Cold Spring office.
"It's nice to have a lot of administrators and a lot of people to do things," said Wenner, who worked at a multispecialty provider before opening his solo practice. "But medicine is so inflated with different levels of administrators and bureaucrats, and I'm very convinced that it contributes to the overall cost of medicine."
The provider with the highest average charge statewide for an office visit by a new patient, Allina Health's Sports and Orthopaedic Specialists in Edina, said the family practitioner who billed $313 each for initial visits, on average, has additional certification in sports medicine.
"The visits in question are sports injury or other types of orthopedic visits," Allina spokesman David Kanihan said. "It is therefore not appropriate to compare her to regular family practice doctors."
That doctor's average billed rate, however, was also higher than the average billed for sports medicine specialists in the state ($180), orthopedic surgeons ($215) and neurosurgeons ($220).
In the central part of the state, a spokesman for HealthPartners Central Minnesota Clinics said he could not explain the average $263 billed by two doctors at a clinic in St. Cloud.
"Without knowing more about an actual patient visit, we can't speculate further as to the type of care provided by our physician and the associated expense for that care," spokesman Adam R. Bauer said.
He also said that first-time office visits can include various levels of service in a wide array of settings, including retail clinics, urgent care clinics and home visits.
Pare of the Minnesota Health Action Group said the conversation about cost previously has been almost exclusively between insurers and providers. Getting more consumers involved now — because they have "skin in the game" with high-deductible plans — is an important step forward.
"We're trying to move from a totally opaque system to something that is a little brighter," she said. "And I think this information should be used to ask questions, not necessarily to say everything's bad, but to start asking questions and having an honest dialogue about how we're going to change."
At MN Community Measurement, a nonprofit dedicated to improving quality and value in health care, President Jim Chase said his organization has long known there are variations in pricing. MNCM posted data on clinics and hospitals in the state on mnhealthscores.org.
"You still need to look at your own plan's data to be able to see what you might pay or what your variation might be," he said. "But we were doing it mainly to raise awareness that cost matters, and the pricing in costs matters, because there's a lot of differences."