I’m going to give you fair warning that the language of this post might get a little strong.  I can’t promise that I’ll control my fingers because I’m just a little pissed.  Here’s the story.

In August Celeste hurt her shoulder.  It got to the point that she couldn’t raise her arm past shoulder level without experiencing severe pain, and she couldn’t sleep comfortably because whenever she moved she experienced sharp pain radiating from the shoulder.  Eventually she scheduled and appointment to see a doctor for an examination.  He checked her out and thought maybe she’d torn her rotator cuff, but since he couldn’t be sure he ordered an MRI, which she had done late in the evening on August 25th.  The MRI came back negative so the doctor suspects that the rotator cuff is strained and that the because the shoulder is a complex joint that depends on all the non-bone stuff (my technical term) to keep the bones in place.  His thinking is that the strain has caused the ball to be pulled back into the socket and it is "catching" when she tries to raise her arm.  The prescription?  Physical therapy.  So Celeste and I went to Comp Rehab for one session where we were taught all the exercises, and she’s been doing all the exercises at home and making pretty good progress.

Here’s where it gets good.  Our insurance company informed us that the MRI wasn’t medically necessary.  That means that we’re paying it 100% out of pocket, which we would anyway since we have a high deductible policy tied to a Health Savings Account (HSA), but now it won’t count towards our annual deductible.  Then we get the notice from Wake Forest University Baptist Medical Center that our bill for the 1/2 hour MRI is $1,900.  What the hell?!

So here’s what kills me about this.  First, the medical necessity thing.  If Celeste hadn’t had the MRI the doctor would probably have ended up doing surgery.  At a minimum she would have had to have seen the doctor several more times in order to gauge what was going on with the shoulder, figure out a course of treatment, etc.  Even then he would not have been sure of his diagnosis and if she didn’t recover rapidly she’d end up under the knife.  As it is the rehab is taking time and without knowing for sure what’s going on with the shoulder Celeste and the doctor probably would have looked at alternatives by this point.  In other words it would have been much less efficient and much more costly to treat than the MRI was.  We’re going to appeal the BCBS decision, but I don’t think it will do us any good.

Second, no one ever told us what the MRI would cost.  The doctor ordered it and we went. Now, part of the theory behind HSAs is that since we are responsible for paying the bills directly we’ll help keep costs low because if something is too expensive we’ll squawk or go to a competitor.  Well, it’s kind of hard to do when no one tells you what it will cost.  There’s no price transparency!  Also, no one told us what our options were, if any, for alternative places to have the MRI done.  I’m willing to take some responsibility here.  We probably should have asked ahead of time if there were other places to do the MRI, what the MRI would cost, etc.  Unfortunately we’re still conditioned by our lifetime of working within a health care system that traditionally kept the decisions in the hands of the doctors and insurers.

Still, even with me acknowledging that maybe we should have been more diligent consumers I want to know what other business out there provides a service without telling you the price up front?  I guess there’s auto repair shops, but often they don’t know what the problem with the car is until they look at it and then they usually call you to tell you what the financial damage will be before they start to work.  With an MRI they know up front what it costs them to administer the test so why not publish their pricing?  Could it be that they have different rates for different people?  If you’re uninsured it’s one rate, but if you’re insured it’s another?  Could it be that maybe there’d be a mass revolt if everyone knew that an MRI process that takes 1/2 hour costs more than most peoples’ monthly rent?

Compare this to our experience at the dentist.  They always check with us before doing a procedure, and the pricing is readily available.  They understand that we may not deem teeth whitening to be worth $75, so they make their recommendation, tell us the price and then let us decide.  In the end they may not sell that one procedure, but they keep us happy and thus keep all five of us in their chairs.

I can tell you right now that if there’s another instance where one of us needs something done medically we will be much more active shoppers.  I’m not saying we’ll necessarily move away from Wake Forest, but if there’s a better alternative out there we’re going to take it.  Of course pricing isn’t the only consideration, but it is one of them.  Trust is another, and if they can’t provide pricing up front then they’ll probably lose us because I can’t trust someone who won’t level with me about the terms of our relationship. 

To reiterate, I don’t know if Wake Forest provides pricing up front or not because we didn’t ask, but the fact that we do have to ask in the first place tells me that the health industry isn’t yet ready for the "free market" that is represented by health plans like our HSA.

Last point: is there any question that our health care system needs fixing when you consider that one simple MRI costs $1,900?  Yes it’s an expensive machine and yes you have to pay a technician to operate it and maintain it, but if you do the math you realize that this is way out of whack.  If they charge that rate to everyone, average two scans an hour for twelve hours a day and work 365 days a year they are grossing over $16.5 million per year for that machine’s use.  Even if you cut that back to one scan per hour that’s $8.3 million per year.  Let’s say a new machine costs $2 million and lasts 10 years, that means that the machine averages $200,000/year for acquisition.  Then let’s assume that it costs $2 million a year to maintain and operate it, a number I think is high, then you have $2.2 million annual cost.  That means that the profit on the operation of the machine can be comfortably guesstimated at a minimum of 300-400%.  Feel free to correct me if I’m wrong, but my gut says this is highway robbery.

Oh, and Wake Forest University Baptist Medical Center is a "nonprofit."