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Reasonable Cost for Procedures: An Anonymous Survey of Healthcare Providers
David Shin1,2, Carson Cummings1, David Cheng1
1School of Medicine Loma Linda University, Loma Linda, California.
Insights
Healthcare providers perceive significant cost discrepancies for medical procedures across different payment systems. This study surveyed providers to determine reasonable costs, revealing a gap between their expectations and current reimbursement models.
Area of Science:
- Medical Economics
- Healthcare Policy
- Health Services Research
Background:
- Medical procedure costs in the U.S. vary significantly based on payment systems like Medicare, Medicaid, private insurance, and lien-based models.
- Discrepancies in costs can impact physician participation in public programs, patient access to care, and legal compensation determination.
Purpose of the Study:
- To survey healthcare providers to establish reasonable costs for specific medical procedures.
- To explore potential alignment between legal standards for compensation and actual healthcare costs.
Main Methods:
- An anonymous 8-question electronic survey was distributed to various medical specialists and advanced practice providers.
- The survey focused on three procedures: epidural injection, facet injection/medial branch block, and radiofrequency ablation.
- Participants categorized costs into five ranges and provided insights into discounts for cash and lien-based payments.
Main Results:
- The most common perceived cost range for all procedures was $1,000-$4,999.
- Neurosurgery providers reported significantly higher costs for epidural injections, facet injections/medial branch blocks, and radiofrequency ablations compared to other specialties.
- Physicians not accepting lien payments reported significantly lower cost values across all specialties and procedures.
Conclusions:
- The study reveals a notable discrepancy between physicians' perceived reasonable costs and existing reimbursement models, indicating a lack of standardized pricing.
- Medicare reimbursement rates for these procedures are below physician-perceived reasonable costs and significantly lower than lien-based case charges.
- Findings may aid in refining reimbursement models, ensuring consistency in legal proceedings, and improving patient and provider compensation and access.
Background:
The cost of medical procedures in the United States varies dramatically depending on the payment system, including Medicare, Medi-Cal (California's Medicaid program), private insurance, or lien-based payment models used in personal injury cases. Cost discrepancies can discourage physician participation in Medicare and Medi-Cal, potentially limit access to care for vulnerable patient populations, and complicate the determination of proper compensation in court.
Objectives:
To survey healthcare providers to determine reasonable costs for medical procedures, potentially aligning legal standards with healthcare costs.
Methods:
An anonymous, 8-question electronic survey was distributed through Survey Legend® between February and September 2023 to providers in orthopedic surgery, neurosurgery, anesthesiology, interventional radiology (IR), physical medicine and rehabilitation (PMR), pain management, and physician assistants (PAs) or nurse practitioners (NPs). Three procedures-epidural injection, facet injection/medial branch block, and radiofrequency ablation-were included, with participants selecting from 5 cost categories: < 1000- 5000- 10000- 20,000. Additional questions explored participant insight into discounts for cash and lien-based payments.
Results:
For all procedures and participants, the most common value was 4999. Neurosurgery selected significantly higher epidural values than pain management (P=.025), PMR (P=.029), and PA/NP (P=.04); higher facet injection/medial branch block values than PMR (P=.03) and PA/NPs (P=.01); and higher radiofrequency ablation values than PA/NPs (P=.02). Physicians not accepting lien payments showed significantly lower values across all specialties and procedures.
Discussion:
The range of reported reasonable costs by respondents reflects a discrepancy between physician expectations and existing reimbursement models, indicating a lack of a standardized value for procedural pricing. Medicare's estimated 1000 for radiofrequency ablation are below both physician-perceived reasonable costs and the inflated charges often found in lien-based cases. In contrast, personal injury billing can reach as high as $20,000 for an epidural injection, a cost category that only 2.9% of survey respondents chose.
Conclusion:
This survey highlights healthcare providers' perceptions of reasonable costs for procedures, possibly assisting in refining reimbursement models, ensuring consistency in legal proceedings, and maintaining proper accessibility and compensation for patients and providers.
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