Aetna shows HSA patients what doctors charge

Departing from standard industry practice, Aetna in August launched an experiment enabling its members to access the prices it negotiates with physicians so they will know what medical services cost before they walk into a doctor's office.

Under the test, every Aetna member can access a secure Web site listing the rates the health plan negotiated with 5,000 primary care and specialist physicians in the greater Cincinnati area, including northern Kentucky and southeast Indiana. If the project goes well, Aetna will expand it to the rest of the country, said Dexter Campinha-Bacote, MD, medical director for Aetna's north-central region.

"The goal is to provide information to individuals who are in consumer-directed health plans so they can make better informed [health] decisions," Dr. Campinha-Bacote said.

Consumer-directed health plans, or CDHPs, typically pair a tax-exempt health savings account with a high-deductible insurance plan. The number of people nationally who have HSAs is small but growing as more employers use them to shift health costs to employees, under the theory that employees will make more cost-effective health care decisions if they have to spend more of their own money.

Aetna's test, which primarily targets members with HSAs, is thought to be the first in which an insurer makes a fee schedule transparent to patients before the visit. But how will this initiative affect business for physician practices?

Under the plan, any Aetna member can access the rates the insurer has negotiated with doctors. But individual doctors are told only their own rates. This raises questions about what physicians can do to ensure they are acting within the law and not inadvertently breaching their Aetna contracts if they become aware of the rates their colleagues negotiated with the health plan.

One such question involves antitrust issues. For example, would it be a violation if a patient gives you other doctors' price lists or access to Aetna's Web site and you asked the plan for higher rates when your contract came up for renewal?

"That's not a violation," said Bill Kopit, a health care antitrust attorney at Epstein Becker & Green in Washington, D.C. "The fact that people are aware of price information is in itself not a violation unless it's part of a scheme." But if physicians met and agreed to ask the insurer for higher rates based on the new information, that would be considered price-fixing and thus illegal, Kopit said.

Another question is whether you can lower your price to match another doctor's, at the request of a patient. That answer is no, because when you signed your contract with Aetna, you agreed to certain reimbursement rates, Dr. Campinha-Bacote said.

Yet another issue is whether rates are guaranteed when patients walk in the door. Rates change every October, so patients might have to pay a different price than they expected, depending on when they looked up the rate information and when they sought treatment.

Although some members might use the rate information to choose a physician solely on the basis of cost, that's not Aetna's intention, Dr. Campinha-Bacote said. The plan hopes its initiative will spark a more substantial dialogue between patients and physicians, he added.

Putting it in context

So far, reaction to Aetna's initiative has been mixed. Some view it as a step in the right direction in terms of providing consumers with rate information that could help them spend more wisely, but they also say the insurer should provide a better context around which these numbers could be considered.

"Providing patients with information to help them make informed health care decisions is a laudable goal, but the AMA is concerned that Aetna's program oversimplifies the issue," said AMA Chair Duane M. Cady, MD. "It does not provide patients with a clear picture of their total out-of-pocket costs, because it does not include information on hospital, laboratory and other facility costs, which often are significantly higher than physician services." In general, the AMA supports HSAs as a tool to expand health coverage.

Paul Ginsburg, PhD, president of the Center for Studying Health System Change, a Washington, D.C.-based nonpartisan think tank, questioned how useful the price lists would be to consumers, because there's little price variation in the rates health plans pay in-network doctors. "I think what patients who are in CDHP arrangements most need to know is ... how much it will cost them if they decide to go out of the network," Dr. Ginsburg said, noting that what physicians charge and what insurers pay are two different rates.

Molly Katz, MD, president of the Ohio State Medical Assn., believes Aetna should explain to patients why its reimbursement rates vary. Doctors in large groups might get higher rates than those in small groups because they are larger. "It doesn't mean you're providing any different service, but it does mean that you have a different situation," said Dr. Katz, a Cincinnati gynecologist.

The disclaimer that Aetna posts on its Web site advises members to use the rate data in conjunction with other information about their doctors, Dr. Campinha-Bacote said.

The plan will consider adding a note informing patients that price is not a reflection of the quality of a physician, he added.

Still, some Cincinnati physicians doubt that the Aetna program will have much impact.

"For an established practice like ours, it's not going to make a difference because ... patients are going to want the [existing] relationship rather than save $4 or whatever" by going to a new physician who may be less expensive, said Michael Todd, MD, a family physician at a four-doctor practice.

"For a new patient who may be looking for a doctor, it may have an impact, but if you're a new practice, the last insurance company you want in your panel is Aetna," because it pays less than other commercial insurers in the Cincinnati market, he said.