When the price is not right

What happens when you have a wide variation in pricing and the potential for a flood of demand? Scrutiny, hopefully.

The company Castlight Health released findings this week from its analysis of pricing paid for commercially insured patients for four procedures. One was a lipid panel, the kind ordered to gauge cholesterol levels in patients. The analysis found huge variation, both locally and nationally.  

While Dallas had an average price of $47, its outlier high was $343. The price for a lipid panel in Birmingham, Ala., averaged $17 and ranged from $15 to $31.

The analysis also looked at head CT scans, lower back MR imaging and a primary care visit. A head CT could be as high as $1,646 nationally or as low as $333. MRIs were all over the map, too, at nearly $3,000 or just above $500. Visiting a primary care physician was relatively pricey in San Francisco, at an average cost of $251, yet only $117 in Fresno, Calif.

Recent recommendations for reducing the risk in atherosclerotic cardiovascular disease, if followed, are expected to increase the population of adults eligible for statin therapy by many millions in the U.S. Some estimates go as high as almost 13 million. While the U.S. guidelines did away with aiming for low-density lipoprotein cholesterol targets, they do call for testing to measure effectiveness and adherence.

This week, a group of prominent British physicians challenged the National Institute for Health and Care Excellence (NICE) in a letter over its proposed cholesterol guidelines, which would make anyone with a 10-year risk of cardiovascular disease of 10 percent or higher eligible for statin therapy. NICE is sticking with its recommendation.

First, being eligible and getting statins are two different things. The American Heart Association and the American College of Cardiology recommend using a qualifying risk score as an opportunity to discuss risk factors and modifiable behaviors with patients. For some, statin therapy clearly will be medically beneficial. For others, the physician and patient may decide another course of action. Lipid panels, to some degree, likely will be part of the equation.

Castlight Health helps employers manage their staff’s health benefits. Insured patients often don’t see the bill, and unless their co-pay is high, probably aren’t too engaged. But employers looking at the upward trajectory in benefit payments are.

Much of the discussion about the cholesterol guidelines has focused on the potential for under- and overtreatment. Ultimately, the guidelines are designed to prevent MI, stroke and cardiovascular-related deaths, which is laudable. That goal should not be sidetracked by price gouging.

A difference in pricing of many hundreds of dollars for a lipid panel seems ridiculous. Castlight said it was trying to bring transparency to healthcare pricing. No doubt there was an element of marketing driving its public release of results as well. Nonetheless, we need more of this kind of scrutiny to ensure that care is equitable and affordable, now and in the future.

On another note, be sure to check our coverage next week of MedAxiom’s Cardiovascular Service Line Symposium. This is an in-the-trenches event designed to help physicians, administrators and others build, maintain and improve their service lines. There will be real-world examples of what works and what doesn’t, insights on today’s challenges and a look at what lies ahead. Stay tuned.

Candace Stuart

Cardiovascular Business, editor