How much for an MRI? Well, that depends

Liz: All right, so I’m Liz Salmi, and I am a person living with brain cancer in Sacramento, California.

Dan: Liz may sound kind of upbeat for someone living

with brain cancer.

That’s partly because she’s got the hang of things. She’s been living with brain cancer for more than 10 years, and she’s the kind of person who just likes a good, tough project, like she used to be in a punk band

riding around the country in a van, sleeping on people’s floors, playing shows since her diagnosis. Could almost say dealing with cancer has been that kind of project, a way to channel a lot of pissed off energy to connect with people.

She’s blogged about her treatment and she’s really immersed herself in learning about medical stuff and all of that led to a new career for her. So I had her do another take of her introduction.

Liz: So my name is Liz Salmi and I’m a person living with brain cancer in Sacramento, California. And today I work on a really cool research project called Open Notes.

And Open Notes is all about encouraging clinicians and doctors to share the notes that they write with the patients that they’re caring for.

Dan: So as a medical consumer, Liz is pretty well informed, but when she took that job a couple years ago, she had to learn something new health insurance. Until she took the job with open notes, she had a kind of a health plan called an HMO, where one organization provides all your care and as long as you see only their doctors, you don’t pay very much.

And she liked their doctors, so you know, that really worked for her. But Open Notes didn’t offer that plan, so she was gonna need regular health insurance. More choices. More confusion and one expense. She knew she would have an MRI every six months to make sure the cancer’s not growing on her old plan.

The HMO, she paid 50 bucks for each MRI.

Liz: At one point it was $25, and then a year later it was $50. And I remember being like. What, $50? That’s outrageous. It has doubled,

Dan: as you can probably tell from Liz’s tone. Just there. Back then, she had no idea what outrageous really meant. No idea what an MRI could cost.

This is an arm and a leg, a show about the cost of healthcare. I’m Dan Weissman and Liz was gonna find out an MRI. Like a lot of things in healthcare could cost just about anything, literally anything.

As Liz was picking insurance to go with her new job, she thought maybe she could pick a health insurance plan that would help her keep the price of an MRI Manageable for her. So she called a friend who was a health insurance expert, because that’s the kind of friend Liz has these days and asked for help.

Liz: So I said, Hey, uh, can you take a look at what I’m being offered here and how does this work? And what is a deductible and what does a copay

Dan: and what does all that mean An M MRI is gonna cost me, but even with her super smart friend. They couldn’t figure out what an MRI would cost on any of the new plans,

Liz: but I did know, hey, it’s probably a good idea to pick the best plan possible, maybe the most expensive plan possible, because brain tumors and brain cancers are one of the most expensive diseases to have.

Dan: You’re likegive me the most expensive car I’m gonna put a bunch of miles on.

Liz: Right, exactly. Like if I need another brain surgery, that that’s gonna be pricey.

Dan: She gets the most expensive plan, picks a new doctor. A few months later, Liz gets her first MRI at the University of California Hospital, and a couple weeks after that she gets an email from the hospital saying she’s got a bill.

So she logs into the hospital website, takes a look.

Liz: I see that the bill says $1,600.

Dan: That sounds like a lot.

Liz: It, it is a lot. That’s, that is bananas. A lot. That is. My husband and I have no kids, but we love to go to Disneyland and we always make it a a big deal where we buy the three day pass and we go to, it’s, we take Disneyland really seriously.

$1,600 could pay for four nights in a hotel, two of us to fly down Southwest and fly back and the tickets to Disneyland and all of our meals, which we usually do. You know, once every year, a year and a half or so, it’s like a thing that you saved for all year, right? Yeah. And, and, and actually it’s, it’s a little less than that to go to Disneyland.

So $1,600 is a really good Disneyland trip. And so I was like, what? And I, I, I got angry, but then I was like, oh, you know what? This is probably the full amount. That UCSF is charging UnitedHealthcare and so my portion must clearly be a fraction of this. Uh, what did my friend say about copay and all that stuff?

And don’t I have to, isn’t my part just like 20% of a thing? Like I was trying to remember how that works.

Dan: So she logs into the website for her new insurance to find a statement about the MRI.

Liz: And then clearly my portion will be shown there, and that’s what I should be paying, not the $1,600 thing. So I click the link and I see what is actually billed and what UCSF charges.

UnitedHealthcare is actually $9,800 for an MRI Jesus. Right. Wow. And so, wow, my portion really was $1,600 and I was like, no way.

Dan: Liz had been lurking in a Facebook group about the cost of healthcare,

Liz: and I thought, Ooh, I’m gonna do a screenshot of this bill and share it in that Facebook group. ’cause clearly something is wrong here and somebody on the internet will tell me that I really don’t have to pay $1,600 and all I need to do is ask this one question and magically I won’t have to pay this money anymore and I’ll go to Disneyland.

And so I, I, I took a screenshot, crossed out identifying info and just said, Hey, what? Is this really what I have to pay? And everybody’s like, yeah, yeah. That is your, your portion. Sorry to break it to you, so I’m glad you’re laughing. Okay. Fortunately we could, we could pay the $1,600, uh, you know, once a year.

We don’t, we don’t wanna pay that twice a year.

Dan: And she gets these MRIs. Twice a year,

Liz: So I’m thinking, holy shit.

Dan: The whole thing brought to mind stuff for new colleagues. The health policy nerds like to talk about.

Liz: They talk about, well, you know, we want these smart consumers to really call around. And I thought, oh, this is what they’re talking about. And I was like, this sucks. And then was like, all right, I’m gonna do that.

I’m gonna call around and see where I can, you know where I can get the best deal.

Dan: She starts comparison shopping, starts calling around to other hospitals, getting prices,

Liz: and then I called a place, and I won’t say it’s name, but essentially it was like, MRIs are us. And the quote I got from them, from my portion that I had to pay, they were telling me over the phone was $98.

Dan: Oh. Okay, nine,

Liz: eight, we’re in, we’re in the two digits. And I was like, what? Like this seems too good to be true. Mm-hmm. But I’m gonna try it.

Dan: She signs up, the day comes, she goes to MRIs, are us pays. Actually it’s 87 bucks. Puts on a gown, gets the scan.

Liz: I leave the room, I put my clothes back on, I go out to the lobby and then they said, alright, here’s your scans.

I mean, they’re literally handing them to me. Within that time, it took me to put my clothes back on. Mm-hmm. My scans and they handed me a bag with two chocolate chip cookies in it. I was like, what? Like and cookies.

Dan: So I’m, I’m like, Hey, the system worked. You were a smart consumer. You shopped around, you got a great deal.

And Liz is like, no, no, no, this, this is not a system that works

Liz: because most people facing a cancer diagnosis, it’s suddenly like, all right, you’re going into brain surgery tomorrow and there’s no shopping around, there’s no time. It is an emergency. I’m in a really unique situation of. I know a lot of shit at this point, and I have the luxury of time, so I am coming from a place of, I would say, you know, patient privilege, but it still took me lots of work and it still took me lots of work.

Dan: Yeah. Prices are so all over the place. You gotta watch your back and then some, and of course this raises another question, which is why. Why do these two brain MRIs, the exact same procedure for the same patient in the same city, have two totally different price tags and Liz’s experience isn’t even the weirdest example.

Try this one. Two price tags for the actual same exact MRI, not two identical MRIs. One MRI two price tags, thousands of dollars apart. That’s in just a minute on an arm and a leg right after the break.

Dan: This season of an Arm and a Leg is a co-production of Public Road Productions and Kaiser Health News, an independent nonprofit newsroom that covers healthcare in America. Kaiser Health News is not affiliated with the giant healthcare provider, Kaiser Permanente. We’ll have a little more on them at the end of this episode.

Okay. Back to our MRI one. MRI. Two price tags, thousands of dollars apart. This is from a listener named Jim and his wife Allison. They have a new baby. Their son Grant was born in December and he was a few weeks early and his lungs were a little bit underdeveloped. So the doctors took him off to the NICU for a few days.

Jim: They had him hooked up to a syringe, giving him an IV of fluids. They had to, you know, uh, they had to put ’em under the jaundice lights and uh, all of that sort of thing. And so it was hard for us to, to see that. We’d obviously go and. Spent as much time with him as we could.

Dan: That was no fun. But after a few days, they all went home together.

They were all okay. And then a couple months later, Allison noticed something about baby grant’s Eyes. One pupil’s bigger than the other doctor orders an MRI. Good news. Everything’s fine. And then the bill comes, and Jim has great insurance. He actually works for Google, but this bill. Is weird ’cause the total, the part before insurance kicks in, it’s almost $26,000.

And they’ve got something to compare this to because the bills from grant’s birth and the three days in the NICU and the mom’s recovery in the hospital are all coming in around the same time. And that $26,000 MRI. It is in the same ballpark as all of that put together.

Jim: It was uh, right around $29,000 for the birth.

My wife’s recovery and grant’s NICU stay for, uh, three days. That is wild. That is wild.

Dan: And you wrote to me. I did. Yeah. And you were like, help me. Yeah, help me. I don’t understand. Yeah. I’m not in financial distress. I’m just very confused. In Vex, I looked at the bills, did a little Googling, and I noticed a couple things.

First I found out that MRIs at St. Louis hospitals are like. Notoriously expensive. A couple years ago, one insurance company said they just would not pay for MRIs at hospitals in the St. Louis area. They would only pay for MRIs at independent MRIs are US type places. ’cause the hospitals were charging up to five times as much.

I noticed something about the bill itself for Baby Grant. It actually lists three MRIs and Jim says That’s right. The whole thing took more than four hours.

Jim: They said that they didn’t get the right angle on one of them, and then some of them came out blurry. Uh, and so they, they didn’t come back and consult us or anything.

They just. Did the test and came back and said, things are taking a little bit longer, but everything is fine.

Dan: And this leaves me thinking, huh? I mean, say I go to a restaurant, they burn my steak, it has to be done over. And then the second one’s messed up too. They do a third one. They do not charge me for three steaks.

They might tell me the whole meal’s free actually. And they’re really sorry I had to wait. But here, those first two pictures, ones that didn’t come out, they’re on the bill. Jim and Allison got in touch with the hospital,

Jim: so we wanted to make sure that this was actually correct because it seemed insane.

Dan: After some phone tag, the folks at the hospital say they’ll check to make sure everything’s coded correctly. A couple weeks later, they send a letter.

Jim: They said, we noticed that while the procedures were coded properly, the costs were a little bit out of line with what we saw with another local children’s hospital, and they like to be in line with what other hospitals charge.

And so they did an adjustment on our bill

Dan: and the way they did that was pretty straightforward. Or maybe, depending on how you look at it, really weird. ’cause what they did was they took the part that Jim would be on the hook for after insurance, about 2100 bucks. They zeroed it out.

Jim: They put in two line items that negated those charges.

So our out of pocket ended up being $0.

Dan: I mean, here’s what’s weird about it. The total charges didn’t change at all. The ones on this new bill are exactly the same as the ones on the old one, and Jim’s insurance is paying exactly the same under this new bill, but because the hospital added those two line items and they’re labeled customer satisfaction.

Jim is now paying zero.

Jim: Lucky for us, it, it worked out. Um, lucky for us, we we’re not in a position where it would’ve caused a hardship had it not worked out, but it still sort of boggles my mind how this could happen in the first place.

Dan: The thing is, this adjustment makes the bill look even fishier than it did before. ’cause if they could just knock 2000 bucks off. How much more could they knock off if they wanted to?

I called the St. Louis Children’s Hospital to get their version of all this in an email. They said there seemed to be an error with the first bill. Okay, sure. And they said the charges on that bill reflect what the procedure actually cost them to do. Okay. So where’s the error then? I don’t know. But add this to Liz Salami’s experience in California and.

It’s getting pretty hard to believe these prices are based on how much things cost. So that leaves us with the big question, how on earth do these prices get sent? Well, I got to talk with somebody who has spent years looking into this. Elizabeth Rosenthal. She was a reporter at the New York Times for more than 20 years.

The last bunch of them looking at the cost of healthcare, and then she wrote a book called An American Sickness, how Healthcare Became Big Business and How You Can Take it Back. And These days, Elizabeth Rosenthal is my colleague, which is pretty awesome for me. She is the editor in chief at Kaiser Health News, our co-producers on this season of an arm and a leg.

Oh, also she’s an md. So she has been asking about crazy prices in medicine for a long time, and she says MRIs are a particularly crazy example.

Elizabeth Rosenthal: What I like to say about tests like MRIs is they’re like booze at restaurants, right? You can take a cheap bottle of wine and mark it up as much as you want. I was looking into MRIs in other countries when I wrote my book, and you know what they cost in Japan between one and $200, same machines.

Uh, same technology, and we have allowed their prices of these things to just go haywire.

Dan: She says it’s gotten way worse in the last 20 years.

Elizabeth Rosenthal: Uh, one of the things that surprised me when I started looking into hospitals for the book was that in the early two thousands, a lot of hospitals were kind of running on very thin margins, and they started calling in.

Consultants like Deloitte, McKinsey, and you know, the consultants looked at these hospitals the way they would look at a chicken processing plant. Like how can you squeeze more money out of what you do? And basically what they told them is, look, you’re given away all this stuff for free. You could charge, you know, by the minute for the recovery room you, you could charge anything you want for an MRI,

Dan: anything you want $10,000.

25 or what the heck? We’re feeling generous today. We’ll knock off a couple thousand for a test that costs maybe 200 bucks total in Japan. All part of the system were crazy prices for everything or actually built in

Elizabeth Rosenthal: when I was still at the New York Times and I asked the CEO of one of the. In California, like, why you charge so much for a hip replacement.

He literally said, because sometimes a a, a Saudi Sheik comes in with a suitcase full of cash,

Dan: and the more ridiculous a hospital’s sticker price is, the easier it is to let the insurance company act like a hero. For negotiating a discount.

Elizabeth Rosenthal: So you know, they can get a, a claim for $25,000. Say we argued on your behalf and we got it cut down by, you know, 50% and it’s still outrageous, right?

Dan: I tell Elizabeth Rosenthal, she’s kind of bringing me down, but she says, no, this is about.

Empowerment, getting armed with a lot of knowledge together so we can be ready to duke it out, whether that’s on our own behalf or helping a neighbor or getting involved in the political process. Great. I’m in

next time on an arm and a leg Prescription. Drug prices. ’cause yeah. Now that we’re good and mad, let’s see if we can amp things up a bit. And for some perspective, we’re gonna start with a scene from a classic movie. See if you recognize it, the movie is super famous, but this scene’s kind of a deep cut,

Actor: Mr. Goer, you don’t know what you’re doing. You put something bad in those capsules. It wasn’t your fault, Mr. Goer. Just look and see what you did. Look at the body you took the powder from. It’s poison. I tell you it’s poison. I know you feel bad and.

Don’t do my story again. Don’t my story again. Oh God, sorry.

Dan: That just gets me bawling every time, which seems about right for a starting point.

And if that scene didn’t ring a bell, I’ll catch you up next time.

Till then. Take care of yourself. This is an arm and a leg show about the cost of healthcare.

Both of the stories in this episode came straight from listeners. You are my best sources, your stories, your tips, your questions, do keep them coming. Armand a leg show.com/contact, and you can send voice memos to stories@armandlegshow.com. Here’s one from Aaron.

Aaron: Hey there, arm and a leg show. I am loving your podcast so far.

I cannot tell you how much of a relief it is to hear people, frankly, discussing things that I quietly worry about at night. Um, I’m someone with multiple pre-existing conditions and it stresses me out all the time. I’m fearful all the time that something will happen and I will get. Deeper and deeper into debt because my body has needs that I can’t meet.

Um, I just wanted to cheer y’all on. Thank you. Thank you. Thank you for what you’re putting into the world.

Dan: Thank you. This episode was produced by me, Dan Weissman. Our editor is Whitney Henry Lester. Our consulting managing producer is Daisy Rosario. Our music is by Dave Weiner and Blue dot sessions. Adam Raimundo is our audio warlock.

Our intern is Daniel Fernandez. This season of an Arm and a leg is a co-production with Kaiser Health News. That’s a nonprofit news service about healthcare in America. That’s an editorially independent program of the Kaiser Family Foundation. Kaiser Health News and a foundation are not affiliated with Kaiser Permanente, the big healthcare provider.

They share an ancestor. That’s it, and it’s a fun story. You can check it out at Arm and a leg show.com/kaiser. Diane Weber is National Editor for broadcast, and Tony English is Senior Editor for Broadcast Innovation at Kaiser Health News. They’re editorial liaisons to this show. Second to last, thank you to some of our new backers on Patreon.

I literally could not make this show without you. Pledge two bucks a month or more. You get a shout out right here. Thanks this week too. Chris Reeves, Kent Doherty. Hal Slinger. Samuel Handelman, Sarah y Ina Tyso, Joni Friedman, Amy Schumann and Larry Stoller. John Caru. Andrew Kelsey, Cade Walker. Rin Carol.

Kenneth Robbins. Jeff Ronstadt, Kere Summers the Gaffer family. Elizabeth Snow. David Bowl. Benji and Tony Burns and one person let me know I garbled their name last time. So a redo. Thank you to Dr. Braden Johnson. Thank you so much. Finally, special thanks this week to Liz Salmi for permission to use bits of the song.

I’m Sick from the album Mercury Project by her old band, lucky Strike. That’s L-U-C-K-I-E. Strike. No.