Only one major hospital network and one free-standing hospital in Maine are in compliance with a new federal law that requires hospitals to publish detailed prices of medical procedures.

And the published data is on hospital websites that are difficult to navigate, confusing and, in some cases, require consumers to enter extensive insurance information to obtain cost estimates.

Nine months after the Jan. 1 compliance deadline, the MaineHealth network of nine hospitals and MaineGeneral Medical Center in Augusta have published charges for a range of services and procedures. The remaining 26 hospitals in Maine have not met the requirements of the law, but several say they will be posting the full database of price comparisons soon to come into compliance.

A national consumer advocacy group, patientrightsadvocate.org, estimated that less than 6 percent of hospitals had fully complied with the law by July.

But based on what has so far been published in Maine, prices for medical procedures vary widely.

Knee replacement surgery can cost $13,000, $55,000 or prices in between. Colonoscopy prices range from $1,000 to $2,000. The cost of the same medical procedure can vary widely depending on the hospital, insurance carrier and what plan the consumer chooses.

For instance, a colonoscopy at Maine Medical Center can cost about $1,000 to $2,000, depending on what insurance plan a patient has. And that’s not factoring in co-pays, deductibles and cost-sharing components that are part of the byzantine way that the United States pays for its health care.

Maine’s 36 hospitals are working to comply with the new federal law, but the state also publishes its own price transparency tool, the comparemaine.org tool that gives average prices by hospital for hundreds of medical procedures.

MaineHealth, the parent company of Maine Medical Center in Portland, seven other hospitals in the state and one in New Hampshire, including Mid Coast Hospital in Brunswick and Pen Bay Medical Center in Rockport, is publishing the detailed data required under federal law, but the website is difficult to navigate.

Others, such as Northern Light Health in Bangor and Central Maine Healthcare in Lewiston, have not yet complied with the new law, but do provide some of the prices and are working on standing up websites that will be in compliance.

“It’s definitely on every hospital’s work plan,” said Jeff Austin, vice president of the Maine Hospital Association. “Even the regulators understand it is complicated and there is a lot of data to upload. They’re not going to go from 0-60 immediately.”

The U.S. Centers for Medicare and Medicaid Services began sending out warning letters in May to hospitals that hadn’t complied, giving them 90 days to publish the data. Since then, CMS has indicated it would give hospitals at least an additional 90 days – totaling 180 days or about six months – to comply. If hospitals fail to comply they could eventually incur penalties from hundreds of dollars per day to thousands daily, depending on the size of the hospital.

Suzanne Spruce, spokeswoman for Northern Light Health, the parent company of Eastern Maine Medical Center in Bangor and Mercy Hospital in Portland, said they are working on “full compliance” in the next two months.

“We are diligently working to comply with price transparency requirements and have been adding information as it has been completed, including a recently added shoppable services price estimator tool for most of our (hospital system),” Spruce said. Central Maine Healthcare, the parent company of Central Maine Medical Center in Lewiston and MaineGeneral Medical Center in Augusta have similar “price estimator” tools as those used by Northern Light Health.

John Porter, spokesman for MaineHealth, acknowledged that its price transparency website is not user-friendly. The database can list several very similar procedures that cost different amounts. But he said there’s a financial helpline that patients can call to walk through the process.

The state website – comparemaine.org – is much easier to navigate, and it also can give prices based on a patient’s insurance company. But those prices are an average and not the actual sticker price that’s required in the federal law. The state website has been running since 2018.

Mitchell Stein, a Maine-based health policy advocate, said price transparency is an important step forward, but it doesn’t address the underlying problems with the way Americans pay for health care. Prices for the medical procedures are negotiated between insurance companies and health care networks.

“So much of health care is not shoppable,” Stein said. “How useful is this going to be for consumers? You are not stopping to check the database on the way to the ER or the urgent care. You are focused on getting care as soon as possible.”

A poll this summer conducted by the Kaiser Family Foundation, a national health policy think tank, found that 85 percent of patients do not shop for medical services.

But Ann Woloson, executive director of Maine’s Consumers for Affordable Health Care, said she’s encouraged by the new price transparency law, and it will be a boon to Maine patients once it’s fully implemented.

“Any step that provides pricing information to consumers is a good thing in general,” Woloson said. “It increases transparency, which is important. It could lead to improved competition and lower prices overall.”

Woloson said the information could be best used for planned procedures, such as colonoscopies, elective surgeries and imaging tests. The data can also be used for research and advocacy purposes.

“There is at times a real difference in what you pay, for instance, for a knee replacement,” Woloson said. “Depending on what coverage you have, the costs you see on the website could play a role on where you have a procedure done.”

Woloson said despite what’s published on public databases, patients should always double check with their insurance company to make sure what they are choosing is indeed the most affordable. A procedure that looks more affordable on the website may incur some unforeseen costs, such as if it’s out-of-network or how close the patient is to meeting an annual deductible.

At comparemaine.org, for example, the cost of a knee replacement varies from $13,237 at Central Maine Orthopedics in Auburn to $55,575 at Northern Light Maine Coast Hospital in Ellsworth, with most prices in the $30,000 to $40,000 range. Woloson said even the MaineHealth site, which has the actual sticker price, may be deceiving, because the customer may be choosing a plan on the website that is not the same as the plan that they have through their employer or through the Affordable Care Act marketplaces. So Woloson said it’s best to always call your insurance company after shopping for prices.

Heather Bouffard, director of marketing and communications for Community Health Options, a Lewiston-based insurance company, said that although the price transparency tools are helpful, “there are still details to work out.”

“The source data is quite complicated, and service definition inconsistencies among hospitals could lead to consumer confusion. The ease of use and the reliability of digital tools are paramount as people try to make sense of the data,” Bouffard said.

Austin, with the hospital association, said complying with the law is going to take time because of the large amount of data that has to be sorted and the complexity of making it available in a way that patients can search for it. But Austin said a companion regulation that will be implemented over the next few years will require insurance companies to make the same information available.

Patients will be able to search on their insurance company’s website, type in their plan and see how much they will pay for a medical procedure, but specific to their plan, such as deductibles, co-pays and cost-sharing.

“The one thing we can’t give you right now, but a lot of people want, is ‘OK, but what am I going to have to pay for this?'” Austin said.

Trevor Putnoky, membership and communications director for the Healthcare Purchaser Alliance of Maine, which represents employers in purchasing health care plans, said that the law is an important step toward creating a “functional market.”

“Transparency is a critically important component of a functional market, and traditionally health care has lacked insight into cost and quality, so this is a big step forward,” Putnoky said. “Where there is transparency in markets, unwarranted price variation diminishes, and numerous studies have shown that the price variation in health care has no correlation to quality or outcomes.”

But Putnoky also said that while the data is “critically important, it will only have an impact if it gets used, and there isn’t a lot of awareness of it right now.”

Putnoky said he doesn’t believe that the data will impact negotiations between employers purchasing health plans for their workers and insurance companies.

“Studies show that rates paid to hospitals vary significantly for individual procedures from (insurance) carrier to carrier, but in aggregate the carriers are all in the same ballpark when it comes to spending within a given network,” Putnoky said. “It would also be extremely difficult to tease out how price variation at the procedure level – especially when there’s only reporting on a subset of services – translates into total premium paid.”

There are other quirks as well. For instance, MaineHealth’s official cost for the uninsured is often higher than for people covered by insurance plans. But Porter said that the cost to the uninsured is not likely to be what people actually pay.

Porter said when an uninsured patient sees the high prices, it could spur them to get insurance. Now that Maine has expanded Medicaid, people living near or below the poverty line will either qualify for Medicaid or a very low-cost plan through the ACA.

“The price for an uninsured patient is meant to be the beginning of a conversation,” Porter said.

But Stein said that’s the major problem with the underpinnings of how health care is financed in the United States. Prices are almost “random.”

Stein said one reform that would make costs more predictable is to establish an independent “all-payer rate setting board” where prices for medical procedures would be the same throughout the state. Maryland is the only U.S. state that has set up a rate setting board.

“At that point, insurance companies would be competing with each other on a level playing field,” Stein said. “Currently, there seems to be not much rhyme or reason to how prices are related to one another.”


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