Patients have a right to information about charges, insurance payments and out-of-pocket costs for the most common types of care at hospitals and clinics under a new state law.
The health care transparency law, which also aims to raise awareness about the quality of care, moves Wisconsin a step closer to creating a consumer-driven environment some say could improve health care and reduce costs. It took effect Jan. 1.
Hospitals and clinics will be posting signs saying patients can request the data. Many people might find the information confusing: Making sense of it involves factoring in cost shifting, negotiated discounts, tiered co-pays and widely variable insurance plans. Also, fees for lab work, X-rays and other extras usually won't be included.
An example of the complexity: Meriter Hospital had a median charge of $42,377 for a hip replacement in a recent 12-month period. That was much higher than St. Mary's Hospital's charge of $26,608 and UW Hospital's charge of $32,821. But insurers typically paid Meriter only about $3,800 more than they paid the other hospitals, and it's possible a patient's out-of-pocket cost was no higher or even lower at Meriter.
Charges for pneumonia care were lowest at UW Hospital, but patients with that condition at Meriter and St. Mary's were older and stayed longer, contributing to their higher fees. And UW Hospital scored lowest among the three hospitals in quality of care for pneumonia — but was in the middle of the pack for quality of care for heart failure.
The data may be most useful to people with high-deductible insurance plans, no insurance or plans requiring patients to pay a percentage of medical bills. Still, other people will be able to learn more about health care costs.
"Any information is better than no information," said Chris Queram, chief executive officer of the Madison-based Wisconsin Collaborative for Healthcare Quality.
Rep. Jon Richards, D-Milwaukee, a co-sponsor of the bill creating the law, said, "We wanted people to have a clear sense of where they can get the best value for their health care dollar."
To learn about out-of-pocket costs, patients will need to contact their insurance companies, as before. But the law requires insurers to provides estimates, and it allows patients to get coding information for their care from hospitals and clinics to help insurers make estimates.
Many insurance companies have already made estimates available, but the law will force all to do so, said Phil Dougherty, senior vice president of the Wisconsin Association of Health Plans.
Some details of the law:
• Hospitals must release the median charge and estimated payments from private insurers and Medicare for the state's top 75 hospitalizations and top 75 outpatient procedures. Some of the information has been available for a few years at this Wisconsin Hospital Association website: www.wipricepoint.org.
• Beginning March 1, clinics with four or more doctors must release similar information for the top 25 reasons people go to the doctor. Other kinds of providers, from pharmacists and podiatrists to acupuncturists, are supposed to be added later.
• Hospitals and clinics that report data to quality organizations must let patients know how to obtain it.
The law won't create a consumer-driven health care environment overnight, but it will help patients assess their expenses if they want to, said Rachel Currans-Sheehan, outgoing executive assistant at the Wisconsin Department of Health Services.
"It's one more tool in their toolbox," she said. "But there still is work the consumer has to do."