Thanks to a unique state law, millions of Massachusetts residents finally can get an answer to the question that has long befuddled consumers seeking medical care: How much will it cost me?
Many consumers may be unaware, but health insurers have been required since October to provide their members with cost estimates — within two working days —
And by next October, insurers will have to provide this information instantaneously. By January, hospitals and doctors will be required to provide their own cost estimates to patients.
“This is a really revolutionary law that hasn’t gotten a lot of attention yet,’’ said Barbara Anthony, undersecretary of the Office of Consumer Affairs and Business Regulation, which is overseeing insurer compliance. She said there is a learning curve for insurers and providers — who have never been required to disclose this level of detail about their prices before — and for patients who may have been shy about inquiring.
For patients, it “means being aggressive and not being afraid to speak up,’’ she said. “It’s a cultural shift.’’
Greater openness about the price and quality of medical care is a cornerstone of the state’s landmark health care cost control law passed in 2012. Backers believe transparency will lead to lower prices as providers compete with one another and consumers shop around. So far, health insurers, hospitals, and doctors have been slow to spread the word about the initiatives, fearing patients will inundate them with requests for estimates before they are fully ready.
Over the coming months, that should change.
By now, the dozen insurers who operate in Massachusetts should have a toll-free number available to members who want to receive a price estimate for a medical service. The estimate is considered binding. In other words, if a provider charges a consumer more than the estimate, or the estimated range, then the insurer must make up the difference. However, insurers don’t have to cover the cost of unanticipated medical care not included in the original estimate.
Since October, requests to the state’s three largest insurers have been modest. Blue Cross Blue Shield of Massachusetts has fielded only 74 inquiries, mostly for outpatient services; however half were regarding dental services, which the law does not include. Harvard Pilgrim Health Care has taken 120 calls, while Tufts Health Plan has received 40.
The three insurers said they have been able to provide estimates within 48 hours, and many times, within one day.
Currently, Blue Cross Blue Shield requires consumers to know the industry code that identifies a specific medical service. Providers use thousands of these codes to bill insurers for medical care. But both Anthony and Health Care for All, a consumer advocacy group based in Boston, said that is a burden for patients: Most would have no idea what the code is for their treatment and would have to ask their provider. Blue Cross Blue Shield said it is phasing out this requirement.
“Consumers are not going to use this unless it is easy to navigate and easy to use,’’ Anthony said.
Anthony’s office plans to issue guidelines for insurers as they implement the law. Deborah Devaux, a Blue Cross Blue Shield senior vice president, said that without the specific industry code, the insurer will provide a price range rather than an exact dollar amount.
Health Care for All is also urging regulators to make sure insurers and providers display the cost estimate service prominently on their websites.
Gail Figa, 59, of Hanover said she wished she had a cost estimate available to her before her annual physical last December. Her doctor recommended she get a shingles vaccination, which Blue Cross Blue Shield did not cover because she was not yet 60. The bill for the visit was $757, which she paid. Figa and her husband also have high-deductible plans — $2,000 each — which means they are responsible for a large portion of their medical bills.
“If I knew it was going to be $700, I would have waited until I was 60,’’ she said. Or, she could have gotten the vaccination for about $200 at a local drugstore.
Harvard Pilgrim plans to launch a website by the end of the month that will allow members to call up immediate estimates — far in advance of the October 2014 deadline — with comparisons for 1,000 outpatient procedures. It also will include prices for delivering a baby, an inpatient procedure that women shop around for in advance. The insurer will gradually add other inpatient procedures that patients tend to research ahead of time, such as hip replacement surgery.
Harvard Pilgrim will allow consumers to search by provider, procedure, or condition. For each provider, consumers will see the total cost of the service, how much their plan will pay, and how much the consumer is responsible for paying.
Tufts is developing a similar system, which the insurer expects to go live by March. “We are spending a lot of time making sure we build a good interface for members,’’ said Derek Abruzzese, vice president for product strategies. Blue Cross Blue Shield is also working on a site.
Anthony said that though the plans are making progress, her office will make sure they are complying with the law by employing “secret shoppers’’ to test the estimates, regularly meeting with insurers, and investigating consumer complaints.
Starting next month, the law expands to include providers — who must give cost estimates within two working days to patients and potential patients who request them.
Beth Israel Deaconess Medical Center has already provided more than 500 written estimates to patients since May in a pilot program that includes obstetrics, colorectal surgery, orthopedic surgery, and breast imaging. In many of these departments, the hospital is providing the estimates prior to service, regardless of whether the patient requests it.
But other hospitals are worried about the complexity of fielding requests from hundreds of patients, all with different insurance plans and benefits.
“Hospitals already work to try to provide information about what various procedures and services will cost, said Karen Granoff, senior director of managed care policy at the hospital association. “They do not have all the information at hand. How much does a patient have left on their deductible for example. Providers have to work with insurers to try to get this information.’’
She said she does not want to see patients “shunted back and forth between insurers and providers.’’
Dr. Ronald Dunlap, president of the Massachusetts Medical Society, said he is not optimistic that physicians will be prepared to provide cost estimates to patients for all procedures by Jan. 1. The organization will encourage legislators and regulators to relax the deadline.
Of course, even if doctors aren’t ready, patients can still turn to their insurers for information on the cost of doctors’ services.
“It’s going to open the curtain on health care prices,’’ Anthony said.