By the time someone suggested that Mike Wang get a lower-back MRI, he didn't have the time or energy to think about how much it would cost.
He was in pain after weeks of failed physical therapy for a back thrown out during a softball game, and anxious for answers.
"I felt like getting to a diagnosis had been so dragged out, I wasn't really in a place to make thrift-minded decisions," said Wang, a 40-year-old business consultant from the Graduate Hospital neighborhood of Philadelphia.
Anyway, it never occurred to him that the price might be different, depending on where he went, or that shopping around was an option, Wang said. He had insurance, so he didn't think much about comparing prices.
The shroud of mystery around health-care costs has hidden from many consumers the fact that prices vary widely, even for relatively straightforward services such as an MRI. An Inquirer analysis of cash prices — the amount charged to patients without insurance — for more than 30 procedures by dozens of local providers found prices that vary by thousands of dollars.
Paid in cash, the price for a lower-back MRI, including facility and doctor's fees, ranges from $369 to $1,385.
Cash prices don't necessarily reflect what most people will pay for care because insurance companies, Medicare and Medicaid negotiate their own rates, and uninsured patients paying cash may qualify for discounts. Not all services are shoppable – in an emergency, no one is comparing prices. Nor should price alone determine where you get care.
But Americans are spending more out of pocket on health care than ever before — $352 billion in 2016 — and the need to talk about cost is paramount. It is nearly impossible to compare prices paid by insured individuals because each plan is different and most are reluctant to share price information. Cash prices offer a window into the cost enigma.
"There's a general lack of awareness about how often prices vary," said Antoinette Kraus, director of Pennsylvania Health Access Network. "As we see folks work within a system where they have more skin in the game, so to speak, it's important to be able to figure out what is the cost of coverage."
Wang had his MRI three years ago and doesn't remember how much it cost, though he knows his insurance covered at least part of the bill. The scan showed a herniated disk that kept Wang, a pitcher and captain of his softball team, off the mound for years. As of this past summer, he was back in the game.
Since then, Wang said he has tried to become a more savvy health-care consumer, to find the best value for his family of five. But it's difficult to find the resources he needs. "I'm willing to do the work, to be responsible in my consumption of health care," he said. "All I'm asking for is access to the information I need as an individual to make decisions."
Through Philly Health Costs' online tool, called Philly Price Check, users can search for a service by its name or specific medical billing code and find prices across dozens of providers. The prices listed were provided to ClearHealthCosts by health systems and medical facilities surveyed over the phone by researchers asking how much the service would cost if a patient wanted to pay in cash, without using insurance.
For any given procedure, prices vary widely.
A complete blood cell count, a common test used to evaluate overall health, could run you $11 or $118, including the fee charged for drawing blood, depending on which lab taps your vein.
A colonoscopy with facility, doctor's and anesthesia fees can cost $750 or $1,955 – or far more, considering that one provider said it charges more than $4,000 just for the facility fee.
People expect prices to vary somewhat, the way a bag of grapes might cost more at Whole Foods than at a discount grocer, said Anne Weiss, a managing director at the Robert Wood Johnson Foundation, a health policy organization. But many patients are unaware that prices can vary so drastically, she said.
"Most things you buy — and I'm talking about the same thing, not a Mercedes versus a Scion — the price for most things doesn't vary by a factor of three," she said.
A lower-back MRI without contrast, for example, is commonly prescribed to investigate pain in the lower back and legs. Despite a relatively uniform scanning procedure, and quality and operation standards regulated by an accrediting body, cash prices in the Philadelphia area ranged widely.
Cooper University Hospital in Camden charges $369. Across the river in Philadelphia, the price tag was $1,385 at Pennsylvania Hospital. Both charges include the facility and doctor's fees.
There are a number of factors that could make one MRI different from another, said Anthony Scuderi, a radiologist in Western Pennsylvania who has been in practice for 25 years.
Newer machines have more advanced technology that can yield a sharper image. Others designed to scan faster may sacrifice image quality.
But these differences don't necessarily affect the clinical diagnosis made based on the scan, he said.
"Routine lumbar spines, there's no reason why that number shouldn't be closer," Scuderi said. For a routine lower-back MRI, patients lie still on a padded table that is rolled into a long tube at the center of the MRI machine. There, magnetic fields and radio waves are used to create images of their bones and soft tissue, giving doctors the ability to see details beyond what an X-ray can offer. The procedure typically takes 30 minutes.
The American College of Radiology accredits imaging facilities and inspects their machines to ensure that each meets quality and operation standards, said Scuderi, who chairs the group's committee on MRI accreditation.
Patrick Norton, vice president of public affairs for University of Pennsylvania Health System, said Pennsylvania Hospital and the system's other facilities offer discounts to uninsured patients not reflected in the cash price.
"The University of Pennsylvania Health System is committed to making health-care costs transparent and affordable for patients regardless of their insurance status or ability to pay," Norton said in a statement.
Cooper declined to discuss details of its approach to self-pay pricing other than to say the system "strives to provide the highest quality health care at affordable costs for our patients."
Not only do prices run the gamut, but they also can be difficult to compare because what's included in the quoted price can vary significantly from one facility to another.
For example, on the surface, Inspira Health Network's price for a lower-back MRI appears to be the cheapest, at $172. But the New Jersey-based health organization's price covers only the facility fee. A reading fee is charged on top.
Inspira declined to discuss details of its approach to self-pay pricing other than to say it adheres to New Jersey regulations that prohibit facilities from charging uninsured patients more than 115 percent of the Medicare rate.
At $2,689, Main Line Health has the highest cash price for a lower-back MRI. The price includes a facility fee and a 40 percent discount for self-pay patients.
Main Line Health initially quoted ClearHealthCosts a price of $4,481. But when an Inquirer reporter called to find out about that high-sounding price, a spokeswoman said that didn't include the self-pay discount, demonstrating how difficult it can be to pin down exact prices.
Even $2,689 isn't the price all cash-paying patients would pay, said Bonnie Graham, Main Line's vice president of finance.
If they still can't cover the bill, patients can work with Main Line's financial counselors to establish an interest-free payment plan.
A new electronic record-keeping system being launched next month is expected to help streamline bills to make them more user-friendly.
"We know this is an important conversation for patients in the community, that they understand their health care and how they can have benefits that are affordable," Graham said.
Patients need to tread carefully when comparing health services on price, said David Blumenthal, president of the Commonwealth Fund, a philanthropic organization that focuses on health and social issues.
"Transparency is important, but it needs to be well-informed transparency," he said. "And price alone isn't going to do the job."
Patients should also consider quality, comfort and how any given service will fit in with the rest of a treatment plan.
But evaluating quality is a major challenge.
There's a common misperception that a more expensive service will be of superior quality, Blumenthal said.
Numerous studies have shown that there is no clear correlation between cost and quality.