Sonoma Valley, other hospitals must post prices

Folks in the Sonoma Valley and across the country likely will have an easier time finding and comparing prices for hospital services under a new federal mandate that went into effect Jan. 1.

The new rule requires hospitals to publish online price lists for all the medical services they provide. The hospitals already had to release prices publicly under the Affordable Care Act, but under the new rule, the prices must be published online in a format that can be downloaded to computers.

Sonoma Valley Hospital has listed the charges for all 3,000 of its services on its website. The list can be found at svh.com/patients-visitors/billing-insurance-financial-assistance/cdm-drg-search/.

For purposes of comparison, the charges for the most common outpatient procedures at California hospitals can be found on a central location, the website of California’s Office of Statewide Health Planning and Development, at oshpd.ca.gov/data-and-reports/cost-transparency/hospital-chargemasters/2018-chargemasters/.

The federal mandate was issued in mid-December and went into effect Jan. 1. California hospitals were a bit ahead of the curve, because “for more than a decade, California hospitals under state law have been required to publicly file their prices annually,” said Jan Emerson-Shea, a spokeswoman for the California Hospital Association.

The list of prices is known as a “chargemaster” - a master list detailing the official rate charged by a hospital for individual procedures, services and goods.

Reactions to the new requirement have been mixed.

“It’s important to understand that when a consumer looks at this document, it’s not going to be particularly useful to what they are seeking. This list of prices is not what an individual person would pay,” Emerson-Shea said. “It’s a master list of prices a hospital would use to negotiate.”

Medicare and Medi-Cal do not pay based on the list; both entities pay a flat rate, Emerson-Shea said. The amount a person with insurance pays depends on their insurance coverage, not the chargemaster, she said.

“If you have an HMO, you typically have a flat out-of-pocket payment,” Emerson-Shea said, referring to health maintenance organizations such as Kaiser that have their own network of doctors, hospitals and other healthcare providers who have agreed to accept payment at a certain level for any services they provide.

“Someone who has a PPO might be responsible for 20 percent of the copayment,” Emerson-Shea said, referring to preferred provider organizations, which offer the freedom to receive care from any provider in or out of network.

Sonoma Valley Hospital’s charge for an emergency room visit on the moderate severity level is $1,326, according to the Office of Statewide Health Planning and Development website. The charge for such a visit at Queen of the Valley Hospital, about 16 miles away, is $2,518. Santa Rosa Memorial, about 20 miles away, listed its charge as $2,315 and Marin General’s charge is $2,310.

For an MRI of the brain without contrast followed by contrast, Sonoma Valley’s charge is $9,486, Queen of the Valley’s is $7,452, Santa Rosa Memorial’s is $2,338. Marin General did not list a charge.

For an abdominal CT scan with contrast, Sonoma Valley’s charge is $6,844, Queen of the Valley’s is $2,318, Santa Rosa Memorial’s is $1,875 and Marin General’s is $5,700.

The charge for a bilateral mammogram screening is $761 at Sonoma Valley, $273 at Queen of the Valley, $257 at Santa Rosa Memorial. The charge for Marin General was not listed.

“We post the prices but that’s not what we get paid,” said Kelly Mather, chief executive of Sonoma Valley Hospital. “We get paid what the insurers pay us.”

Sonoma Valley Hospital’s posted charges for a moderate severity emergency room visit are about $1,000 less than those of the other three hospitals.

With regard to the discrepancies in charges between the hospitals, “Basically that’s because of Kaiser. Over 60 percent of our community has chosen Kaiser. We set our prices for emergency services based on what Kaiser can pay us,” Mather said.

She was referring to the fact that Sonoma Valley Hospital’s emergency department provides services to Kaiser patients and then is reimbursed by Kaiser.

Mammograms are listed as more expensive at Sonoma Valley Hospital.

“We now do 3-D mammography. It’s a far better technology,” Mather said. “If we charge $700 for mammography, we probably get paid less than $200 by most insurers. Most insurers, almost all of them, probably pay 30 percent, sometimes 50 percent, but most of the time it’s probably 30 percent.”

The chief executive added that 80 percent of the hospital’s payments are from Medicare and Medi-Cal. “We do not get paid our charges by any means.” She said Marin General and Queen of the Valley are reimbursed more highly by Blue Cross for the same services.

The mandate to post prices online in a downloadable format came in a 2018 guidance from the Trump administration that builds on rules from the ACA. One of the notable elements of the mandate is that there is no penalty for failing to post.

“In order for patients to become consumers of healthcare they must have transparency in pricing and in outcomes, so that they can shop for quality and value. To this end, CMS has proposed requiring that hospitals become more transparent with their pricing,” Seema Verma, the administrator of the federal Centers for Medicare and Medicaid Services, said in a July 25 speech at the Commonwealth Club in San Francisco.

According to Emerson-Shea, the best way to get a sense of the cost of a given procedure is to ask the hospital.

“Call the hospital, tell them who your doctor is and what procedure you are having and your insurance. They will be able to look that up for you and give you a good faith estimate,” Emerson-Shea said.

Such estimates are only an approximation and can vary depending on what happens with the procedure, she said.

“People need to understand that on the front end the best a hospital can do is give an estimate, but they can do it based on what your insurance coverage is and what copayments you have,” Emerson-Shea said.

Reach Janis Mara at janismara@gmail.com.