A Bill Of Health That Doesn't Add Up

By CAROL GENTRY The Tampa Tribune

Published: Aug 26, 2007

TAMPA - Humana, one of the nation's largest health insurers, says it has to pay about $90,000, including doctor bills, each time a member has a heart bypass operation at Brandon Regional Hospital.

If the patient had the same procedure at Tampa General Hospital, the insurer says it would pay about $45,000 - half as much as at Brandon.

The company would pay even less for the same surgery at Bayfront Medical Center in St. Petersburg: $30,450.

The price difference may be surprising, but it is common, according to a comparison of costs in the Tampa Bay area based on data Humana allowed the Tribune to review.

What may be more surprising, though, is that paying high prices does not guarantee the best treatment.

Case in point: Even though bypass surgery costs considerably more at Brandon, the other two hospitals received higher scores for effectiveness from WebMD Quality Services, which analyzes hospital-patient data and sells the analysis to Humana and other health insurers.

A review of WebMD's analysis of 33 procedures at Bay area hospitals found that those with the highest costs are seldom top-rated for quality, according to Humana's member Web site. WebMD ranks hospitals' quality performance using mortality rates and other data such as major complications. The Tribune reviewed data for hospital inpatients in 2005.

Humana, which has 200,000 commercial health plan members in the Bay area, plans to expand access to its cost and quality database nationwide Oct. 1. Doctors' payment information will be available online in October, and their effectiveness ratings will be available in 2008.

It will be coupled with an advertising campaign. The message: "In the very complex world of health care, cost and quality don't always go together," said Tom James, physician adviser at Humana headquarters in Louisville, Ky.

To prove it, the company is making public what it pays for health care - not what a hospital lists as its charges, but the real cost, which typically is secret. Prices in the database include the total payment from Humana and patients to doctors and hospitals. Humana executives say they hope members and employers who pay most of the cost of coverage will review the data and see the price differences.

"It's all about power to the consumer," said Wadida Murib-Holmes, director of special projects for Humana.

The data Humana has opened up in Florida haven't drawn a lot of attention from members, Humana said.

But that is likely to change as more large employers begin using cost and quality data to alter coverage for their employees.

Health insurers, who were painted as the enemy a decade ago when they tried to rein in spending with managed care, gave up and contracted with almost every hospital again. But employers didn't like the resulting price increases, which experts say run 2 percentage points higher than the rate of inflation. They demanded price restraints.

So insurers are taking a different tack. Instead of dropping the pricey hospitals and medical groups from their networks, they're using information and financial incentives to change public perception - and behavior.

Some are using tiered payments, which have become familiar in prescription drugs, for other parts of the health care system. This means patients have to pay more if they choose a doctor or hospital the insurer deems less effective or efficient.

Patients' loyalty to their doctors could fray if the tiers result in big out-of-pocket costs.

Reliability Of Reports Challenged

Humana, which has 11 million members nationwide and booked a profit last year of more than $600 million, is hoping other insurers and employers join the campaign to disclose health care costs to consumers.

The federal government backs the movement. Its campaign for "value-driven health care," sponsored by the Department of Health and Human Services, has drawn statements of support from hundreds of companies.

Some medical and hospital groups, meanwhile, are pushing back. This month a Connecticut medical group sued Cigna Corp. of Philadelphia and UnitedHealth Group of Minnetonka, Minn., saying the companies use questionable data to designate those with the best outcomes. The companies declined to comment.

Doctors who filed the suit accuse insurers of favoring those with the lowest costs to save money.

Even physicians who favor the idea of giving patients access to more information question the reliability of data that attempt to measure quality by analyzing insurance claims.

"Nobody knows what quality is to begin with," said David Keefe, chairman of obstetrics and gynecology at the University of South Florida. "They try to [measure it], but it's almost impossible because there's so many variables." Reliable ranking systems have not yet been developed, Keefe said.

Humana and other large insurers that are offering the data to their members disagree, saying the data analysis is sophisticated and accurate.

Brian Klepper, a Jacksonville-based health care consultant and president of the Center for Practical Health Reform, said companies that analyze hospital data are doing a better job of allowing for differences in hospitals' typical patients. Hospitals that treat poorer, sicker patients are no longer being penalized as much, he said.

Helen Darling, president of the National Business Group on Health, a nonprofit organization of large employers, said members support the movement to open health care cost and quality information and use it as leverage to improve care and control costs.

"This information has historically been difficult to get," she said. "Those who have the information have no incentive to let it get out. And the ones who care about it, like employers, don't have the information."

When comparisons of costs or patient outcomes are published, hospitals and doctor groups named as high priced or poor performers get rattled. Hospital boards tend to demand an accounting. "Nobody wants to look like a jerk in public," Klepper said.

The Tribune's Findings

Humana and two other companies that favor providing cost and quality data to consumers allowed the Tribune to review the information they make available online to members in the Bay area. The others were UnitedHealthcare, the nation's second-largest carrier, and Blue Cross and Blue Shield of Florida, the largest health insurer in Florida.

Both provide rankings of local hospitals by procedure, but neither provides as much cost information as Humana. The Tribune decided to focus on the Humana site.

Some findings:

•Costs can vary - a lot: Heart catheterization, a procedure to determine whether surgery is needed, cost about $20,000 at Florida Hospital Zephyrhills, almost four times as much as the $5,850 it cost at Tampa General.

•Location can matter: In general, hospital costs tend to be lower in Pinellas County than Hillsborough. And costs in both counties tend to be less than in Pasco.

For example, a stroke-prevention procedure known as carotid endarterectomy cost Humana more than $30,000 at Community Hospital of New Port Richey, the insurer said. Equally good results were reported at University Community Hospital in Tampa, where the cost was about $5,000.

Meanwhile, costs for procedures at hospitals in east Pasco County are higher than elsewhere in Pasco. For example, the $20,000 Humana said it paid for heart catheterization at Florida Hospital Zephyrhills is two to three times higher than what it paid at other hospitals in Pasco - and far more than in Pinellas and Hillsborough.

• A hospital's scores can vary widely by procedure: Regional Medical Center Bayonet Point, which scored low on hip replacement, excelled on heart catheterization. For the same heart procedure, Morton Plant Hospital received one star, but it rated high on hip replacement surgery, landing three stars.

• Price often has no relationship to quality: Usually the highest price for a procedure occurred at a facility that received an average score from WebMD on effectiveness. And sometimes the highest-price hospital received a low score.

"In fact, there's pretty good evidence that the more expensive hospitals aren't as good because they do more to you," said Darling, the president of the National Business Group on Health. "And you're in a market that has some of the highest use in the country."

Consumers And Data

As more insurers open up hospital cost and performance data, will consumers use the information to comparison shop?

Humphrey Taylor, chairman of the Harris Poll, doubts it. Patients don't shop for a hospital the way they do for a car, he said. Even when ratings systems are available, he said, "the evidence is that very, very few people" use them.

In fact, Humana says only about 15 percent of its members have gone to its site ( www.myhumana.com) in the year since the company began posting cost and patient outcome information in some of its markets. Employee benefits managers say most of that 15 percent go online to check only their balance in flexible spending accounts.

"It's a laborious process to get people to change their health care buying habits," said Christina Swanson, benefits director for Hillsborough County government.

But that raises a question: Why have Americans, who have signed up in droves for e-mail alerts on cheap airfares and pore over mutual fund rankings in newspapers and online, been slow to embrace comparison shopping for health care?

The obvious answer, consultants say, is that it has seldom made a difference to patients whether they're going to a low- or high-cost provider. And when health insurers tried to manage care a decade ago by leaving high-cost hospitals and doctors out of their plans, "there was a big brouhaha," Darling said.

"People said they wanted to have a choice. Health plans said, 'OK, if you don't really care about the absurdity of this situation, we'll keep contracting with them all.'"

Now that information on cost and performance quality is becoming more available, she said, employers "can actually look at the data and say, 'What's wrong with this picture?'"

Reporter Carol Gentry can be reached at cgentry@tampatrib.com or (813) 259-7624.