Raw numbers for treating my basal cell carcinoma at three hospitals

The morning-after edits, originally marked in italics, have been “accepted” (to borrow Word’s term) to show the final text.

Here are the results of my cost shopping research to get my skin cancer (basal cell carcinoma, aka BCC) removed. The first edition was done in a hurry because the #bcsm (breast cancer social media) Twitter chat was happening, discussing costs and shopping, and they asked to see it.

It started in February when I decided to be proactive about finding out what this would cost me. I have $10,000 deductible insurance, so this is all coming out of my pocket. In previous months I’d gotten sick & tired of getting unexpected medical bills, and people at the hospital and insurance companies having wrong answers or no answers about “What’s this going to cost?” (CT scanshingles vaccines)  So, this time I published an RFP (request for proposals), the same way any business would do when making a substantial purchase decision. The RFP started:

Summary: I seek a care partner to remove a basal cell carcinoma (BCC) from my left jawline, under the ear. For a brief introduction, see blog post and photo (low quality) at http://bit.ly/ePDaveBCC.

I’m educating myself about the condition, I want to explore the available treatment options, and I’m “shopping” for a partner to do the work and follow-up with a good combination of quality, partnership, and cost.

It was a crazy thing to do, because hospitals don’t have RFP response departments (as many businesses do), and I was sure my request was largely uninformed. But I sure learned a lot from the comments on that blog post.

The RFP continued…

A key factor in my choice of treatment partner will be absolute clarity about billing.

I’m self-employed with a high deductible insurance plan ($10,000) in New Hampshire’s high risk plan (NHHP, New Hampshire Health Plan), so it’s a very high priority to know what the costs will be and to have a guarantee that no unexpected charges will be billed if the case proceeds as expected. …

If you don’t know what your costs are, don’t bid: you may be personally responsible for America’s out of control health costs.

Well, I got no responses. (Lots of comments and discussion, but no bids per se.)

So eventually, I started calling around to get prices.

This was hard.

The first challenge was finding out whom to ask. As I say, hospitals don’t have “RFP response” departments, or price quote departments, so at each provider it took a while to find the right person.

  • At two places, when I asked about trying to find out costs, the person on the phone referred me to their financial aid phone.
    • In all cases I wasn’t nearly poor enough for aid. I don’t object – I’m not poor – I’m just noting that the apparent assumption was that if I was asking about costs, I must be poor.
    • I speculate that this is because those questions usually come from the uninsured, who, many assume, must be poor.
  • At one provider there were two separate financial aid numbers – one for the hospital, one for the physicians – in different cities. (You may not know that most modern hospitals are like shopping malls, with separate bills for the facility and the merchant (doctor). That’s one more reason no one party feels responsible for the total cost.)
    • There are exceptions, I’m told; at some hospitals the doctors are employees.
    • But you have to ask, and ask, and ask again: “What other charges could there be?” One hospital’s prices seemed to be half as much as another’s, until they realized I wanted the whole cost, including facility charge.
  • A whole separate issue is the list price compared to the actual price, through your insurance company, if you have one.
    • In March I blogged a taste of that issue, re my semi-annual CT scan. (btw, I just got that scan last Friday – more to come.)
    • In my case, it had become clear that Mohs surgery is clearly the best and is substantially more expensive, so I didn’t take another pass through the loop trying to find the with-insurance price for each option.

Having gone through this, I’m willing to say: for all practical purposes there’s a big sneaky shell game going on behind a smoke screen. I don’t know if it was designed that way, but it’s ended up no different from what a sneaky shell game would look like – especially, the difficulty of finding out what anything would cost.

One thing I do know: the common statement “Don’t worry, insurance will cover it” is a poison. Behind that poison, fishy amounts of money can change hands.

Mind you, this was a pretty simple procedure: no anesthesia, no hospital stay, no $300 aspirins – just come in and get it done. But nobody I spoke to – in dozens of phone calls – felt responsible for telling me what the total cost would be.

If we speak up and ask, I’m sure hospitals and insurance companies will start to provide answer departments, especially if we vote with our feet when they can’t answer. But a lot of them think we won’t leave, as long as we’re buffaloed into thinking their doctors must be the best in the world.

Note: I have no hard feelings against any of the people I talked to at the hospitals, once I found the right person, and I’m grateful for the work they did to help me. I know my questions were something they’ve probably never been asked before. Let’s change that. Let’s ask ‘em: “What’s this going to cost?” And let’s not accept “I don’t know” as an answer.

Here’s last week’s post about my decision: in the end I chose to get neither of the options I’d researched (Mohs or excision), but the simpler ED&C, which took 15 minutes in the doctor’s chair. 15 minutes, total $616.

That post links to earlier posts in the saga.

The process

In the table below, I’ve removed the names of the hospitals because in the end they weren’t important, and this exercise is about the process, not the specifics.

Some notes about the process:

  • All three hospitals immediately recommended Mohs surgery. “Basal cell on the face? Get Mohs.” None mentioned other options until I asked, sometimes until I asked repeatedly.
    • All of them said that all their Mohs surgeons were excellent. :-)
    • As detailed in my results post (link above):
      • Simple excision (“cut it out”) is also an option. I learned about this mainly through the grapevine – comments on the blog, and personal comments from people I met at conferences.
      • Mohs does indeed have the best efficacy: 1% recurrence rate, vs. 10% for excision. Much better appearance, too, which most people agree is an issue for lesions on the face. But, everything has a cost, so I wanted to know my options.
  • Mohs surgery is done in an unpredictable number of stages: they slice out a part, look at it under the microscope; if they didn’t get it all, they go back. Total cost depends on how many stages are required to get it all.
  • My insurance company told me that if I want to be sure my out-of-pocket cost would count against my deductible, I’d better find out what CPT (billing) codes the provider would use, so I had to go back to them and get those answers too.
    • I was amazed to learn that different hospitals bill things differently.
  • Note that there’s a separate charge for cutting out the cancer and for “closing” (stitching it up). Understandably, more complicated closing has a separate price, which means it has a separate billing code.

What I found

Yes, there’s lots of inconsistency in how different providers charge for the same thing. Not just the amounts, but the split between physician and facility charges.

I’ve heard that in some cases you can get the same physician to do the same work in his/her own office, avoiding the facility charge. I also believe that some hospital systems don’t have a separate charge, because the doctors are employees, not independent businesses.

Anyway: the numbers reported below are what I was told by each provider, so if they’re inconsistent, all I know is, it’s the best information I could get out of them. Eventually I figured although the info I had might not be the actual bills I’ll get, I had enough to make my decision.

Facility 1

Facility 2

Facility 3

Contact for cost info (redacted) (redacted) (redacted)
Taxpayer ID No. (redacted) (redacted) (redacted)
Also need a new-patient  appt 99201, ~$200
“p” = professional  charge only; all other prices include facility charge (“f”) if any

Facility 1

Facility 2 Facility 3

Mohs

CPT

Cost

CPT

Cost

CPT

Cost
Stage 1 17311 $2000
($1444p)
17311 $1900;
allowable: $4597
17311 $1904
($1,178p)
Additional stages 17312 ($673p)$1600 17312 -15 $1400 17312 $1752
($627p)
Total if 3 stages $5200 $4700 $5408
Pathology billing May cost extra No extra May cost extra
Closing – simple Intermed:
12051
$552 12001- $900 12001-18 $1246
($278-$686p)
Closing – complex $2700 12018 $2900 12051 $1246
($492p)
Total – Minimum / simplest case $2000
+  552
$2552
$  200
$1900
$  900
$3000
$1904
$1524
$3428
Total cost for 3 stages and medium repair $5200
+$1600
$6800
$  200
$4500
+$1900
$6600
$5408
+$1738
$7146

Excision
(not Mohs)

CPT

Cost

CPT

Cost

CPT

Cost
(Varies depending on complexity) 11640-11646 $750-$2500 total Simple (<=1 cm):
11641   $747 incl repair

Bigger lesions:
11642  $909+repair
Repair:
intermed 12051 $836 complex 13131 $1153

Total $747-$2062

Simple:
$357p + 960 f =$1317

up to $4010
($1190p + $2820 f)

So, Mohs is around $6-7,000 for three stages, or $3,000 +/-$500 for one stage; and excision is usually a lot less.

Understandably, nobody would take a guess at how many stages of Mohs I’d need without having me come in. Interestingly, though, based on the photos on my blog, a couple of dermatologists dropped me notes saying “Excision should be fine for that.” I didn’t take that as medical advice, but it was one input in my thinking. (Specifically, if my chosen dermatologist examined me and pointed out something new, that would trump a snapshot on a blog!)

The decision

After all this, I decided on the provider in the center column, who was closest to home. On my first visit, I explained that I’m the kind of patient who likes to understand his options, so I ask a lot of questions. He welcomed it – and noted that if cost was a key concern, there was a less expensive option, ED&C, that for my kind of lesion would be just as effective. That’s what I chose, as I reported last week. It was $616, all in.

As I said in that post, it’s only got about a 92% cure rate, not the 99% of Mohs. But if this skin cancer on my jawline does come back it’s not likely to get out of control; I can easily keep an eye on it. So would I take another $6,000 out of my pocket today for the more expensive treatment? My choice is, no.

And that’s the point: it’s my choice. But I can’t make an informed choice if I don’t have the, um, information.

So have some fun: next time you need something done, call your hospital and ask the switchboard, “I’d like to find out how much something’s going to cost. Who would I talk to?” As Arlo Guthrie said in Alice’s Restaurant, “If enough people do it, they might think it’s a revolution!”

And I say: don’t insult patients’ choices if we can’t get good information. Give us the data – then we’ll see.

_____

Update April 25, 2013:

This post came up again today in the context of my new post The Reality of shopping for health insurance. I realized I’d never added some additional costs that arose downstream, bringing the total to $868.  The biggest was a shot of cortisone I had later when the scar seemed to not go down as it should, because I kept picking at it. (Oy; reality.) The cortisone cost $30; the injection itself carried a bill of $200. At the time I asked “What will this cost?” and the doc said “You being you, you’re more likely than me to know the answer to that.” :-) I opted not to delay, knowing the risks. All in all I’m happy with the outcome, though NEXT time I will insist on hunting down the cost first.

21 comments to Raw numbers for treating my basal cell carcinoma at three hospitals

  • Marie Bismark

    Interesting article Dave. By way of comparison, my dad recently paid for his own prostate cancer treatment in New Zealand. No problem receiving accurate quotes from hospitals for each of three options (radiotherapy, radical surgery, laparoscopic surgery). Also received advice on the length of waiting lists for public vs private care. Final bill was clearly itemized to the last $5 item and was within a few hundred dollars of the original quote. Glad you are recovering well.

  • bev M.D.

    Hi Dave;

    I like your decision for treatment, and your exposition of the process is quite illuminating! I do want to know if the ED&C involved sending any tissue to pathology, as that will incur additional expense. However, even if you have a recurrence and it costs another $616+ to re-excise, you could have several re-excisions before you approached the cost of Moh’s surgery, huh.
    I hasten to say for anyone with a similar issue that location, size and growth characteristics are all factors in deciding the type of surgery to have; everyone agreed at the beginning that your lesion was in a pretty low risk category.

  • Great article and quite a maze you went through to actually get prices. Can you imagine if you had to go through the same process to buy anything in the non-medical world.

    Related story – a friend of mine had a brother who was a dermatologist. He got sick and tired of dealing with insurance companies so he went to a payment in full for services model. But, and this is the important but, he gave everyone the price he would have given the insurance companies for treatment. He actually had a printed list of prices for different procedures. Result – Far lower office expenses, happier patients and a much simpler life.

  • sherry reynolds @cascadia

    Another quick way that people can get a ball-park idea for common procedures is to use Healthcare BlueBook – http://healthcarebluebook.com/page_Results.aspx?id=17&dataset=MD&g=Skin%20Lesion%20Removal%20%28malignant%29

    For a skin cancer removal as an outpatient it gives a cost of $779 (in my zip code). It only took me about 15 seconds to find the cost and break-down although it doesn’t include MOHS surgery for comparison.

    They can also negotiate prices for people

    Disclosure: I have no affiliation with them)

    • e-Patient Dave

      Sherry, this is great but I’m puzzled: it doesn’t say what kind of removal procedure it is. Also, I didn’t have any anesthesia (as their page suggests), just a shot of Lydocaine – so I’m guessing the prices they listed are for excision.

      You’re right, though, that’s a heck of a lot quicker than what I went through!

      I wonder what HCBB would say about the range of complexity reflected in the figures I posted. The $779 you found (or $819 in my zip code) is in the lower range for the quotes I got, but the quotes ranged much higher.

      I wonder, too, what CPT codes they were assuming.

      So, now I’m starting to sense a desire for two different things: what are my options (which HCBB is not), and what should it cost (which HCBB is).

      Too bad the Business Week piece didn’t include FairCareMD.

      Thanks for this! I wanted to capture it in comments here for future reference.

  • Adnan Chhatriwalla MD

    Dave, your blog is both interesting and insightful. I am an interventional cardiologist researching methods to increase patient participation in individualized decision making. For example, we estimate individualized bleeding and restenosis risks for each patient undergoing coronary angioplasty and PCI at our institution, and I use these risk estimates when making decisions regarding the use of bleeding avoidance therapies and drug eluting or bare metal stents. I am interested in better educating patients about their treatment options, better assessing patient preferences, and influencing physicians to be more responsive to their patients’ preferences. The goal of this work is to provide better, more individualized, and more cost-effective health care. If you are interested, I would like to discuss our ongoing projects with you. I can be reached at achhatriwalla@saint-lukes.org.

    Best regards, and best of luck to you,
    Adnan

    • Thank you, Dr. C! I’m at the St. Louis airport right now … I’ll drop you a note off-blog.

      You may want to consider joining our Society for Participatory Medicine. It’s just $30 a year, and you’ll find a number of other physicians who are involved in similar initiatives. http://www.participatorymedicine.org/join-us

      • Barb

        Would this info (option) be available in N.C ? Interested as needed for relative
        Inquiring his options on family medical ins and care..Costs are a huge concern ..
        I just read the article ..
        He sure had to endure a lot of hoops for what should be ready available
        Answers…Thanks in advance Barbara

        I

        • e-Patient Dave

          Hi Barb –

          I can’t say what’s available anywhere; I would just encourage everyone to do what I did: ask what their options are, ask if there are other options, and keep asking until satisfied. I had two clinicians look at it – the one who diagnosed it and they one who ultimately treated it.

          May I ask how you found this site?

          I’m no doctor but I heard repeatedly (including from dermatologists) that basal cell carcinoma is not fast growing so unlike some cancers there’s no inherent rush. But I hasten to add that I have no idea what condition your relative is in. Also, the doctor who suggested ED&C for me said it’s not appropriate for cases that seem deeper. Another factor for me was location – on my face, so if it came back I would spot it quickly.

          Lots to think about, take into account, and take responsibility for. That’s always how it is when we start to participate in decisions that others used to make for us, eh?

  • This was a great story, and illustrative of how difficult it is to be an informed patient. Patients have so few tools to navigate the medical billing process, and we often see the unfortunate results in healthcare-related financial hardship. CoPatient has worked with patients who received as many as 11 different bills for a single episode of care at a single facility, so I can’t imagine how the average person is expected to deal with the complexity. I really hope to help patients that aren’t as informed and proactive as you when they end up with unexpected bills.

    Rebecca Palm
    http://www.copatient.com
    Advocating for the healthcare consumer

  • BTS

    Hi Dave

    What I can say about basal cell and other cancers, I have just had a basal cell surgery yesterday from my face ( right) cheek and how the dermatologist had to make a safety margin and I have a few stitches near my eye.

    The reason that this has happened to me is that I haven’t really practiced Nichiren Shoshu Buddhism correctly and holding on to negative attachments like anger, ego; forgetting about the four absolutes, being born, grow old, suffering and death, in the Lotus Sutra interpreted by Nichiren Daishonin best English translation by Burton Watson, if I put other attachments and don’t take reasonability for my thoughts, actions and deeds then I will continuously get sick or any other negative thing could happen to me. But if I am a sincere envoy of the Buddha informing others about this practice and if they want to become a Buddhist I can show them the path they take or help teach them Gongyo (the Hoben chapter (2) and the whole (16th chapter of the Lotus Sutra learning this in phonetics, absolutely I will prolong my life and the biopsy will show no more cancer and I will keep all the parts that I was born with because I do have a mission and when my mission is over I will die, hopefully at old age with a good quality of life.

    Please read Lotus Sutra you can find it on the internet.

    Sincerely

  • M. Eiten

    I found your article while searching for the same information. Unfortunately, I’ve already had my procedure and neglected to ask about cost beforehand. I went to a large derm clinic in Peoria, Il. for a MOHs procedure. My bill before insurance was about $8000 for just one stage removal. Funny thing is I had the same procedure done there in 2007 and it was about half. I’ve been on the phone with billing a couple times and am waiting for a nurse to review and call back. I’m getting nowhere with them.

    • e-Patient Dave

      Holy crap! Do you dare point them to this post? Here’s a short URL: http://bit.ly/daveBCCcosts

      I’ve started telling people I’m going to blog my experience about costs, including naming them. Amazing how quickly that changes some people’s behavior. You might “offer” to do the same for them. What do you have to lose?

      • e-Patient Dave

        And, btw, who’s your insurance company and what do THEY say about this?

        I’ve found that some companies want to reduce spending, and some really don’t! What’s up with that??

  • […] E-patient Dave’s awesome blog post about his experience trying to find out how much it would cost to remove his basal cell carcinoma.  Looks like it will be awhile before the patient information necessary to make free market principles work in healthcare are available! […]

  • […] e-Patient Dave deBronkart has a terrific example of how shopping for healthcare can be done, even in the face of “what?” – click the link for the full story there. Patients acting on their own behalf to determine their economic exposure before they get medical care might begin to bend the healthcare cost curve IF they can get the price information. […]

  • […] to the utterly crazy difficulty determining what a medical procedure will cost as reported by e-Patient Dave and WBUR radio. Straightening out this problem goes way beyond the doctors and hospitals, and […]

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