How Much Will This Office Visit Cost Me? Identifying the Services for the Top Three Reasons for a Physician Office Visit

Summary: As co-payment and co-insurance amounts increase to offset rising health insurance benefit costs, consumers are paying more for health services. This study identifies the average allowed amount and average paid amount Blue Cross Blue Shield of Texas commercial plans paid in 2011 for the collection of services for the three most common reasons consumers visit a physician office. This study also outlines the history of bundled payments for health services over the past several decades. Research found little analysis has been completed for services provided in the physician office. The study also identifies price transparency and technology advancements are intersecting to make tools available on the internet for consumers to use. However, these innovations are compromised by the complexity in defining “prices” for services across health insurance plans, claim systems and providers. Further, while the health industry has a long history of reimbursement fees paid based on a unit of service, it has only recently become concerned with aggregating data into a way that is meaningful to consumers and can control costs- primarily for high cost hospital inpatient services. Exploratory Factor Analysis was used to group the collection of services for the three most common reasons consumers visit a physician office: routine medical exam, routine gynecological exam and hypertension. The average allowed amount and average paid amount were calculated for each service. Results show that the collection of services for the top three reasons to visit a physician office include a physician examination and some laboratory services, depending on the type of visit. The average amount paid by the insurance company for these three collection of services in 2011 is $124. It would be valuable for additional research to consider the impact of chronic care conditions over the period a year or more of claims and the claims from visits at urgent care clinics. Finally, another approach to identify the collection of services would be to obtain a clinical opinion of what is generally provided; then use that definition to analyze the frequency, allowed amounts and paid amounts