Self-pay laboratory charges for iron deficiency diagnosis in the Boston and New Haven metropolitan areas

The economic inequality of healthcare has been well documented. Out-of-pocket costs, which include laboratory costs, contribute to the financial burden that patients must bear for healthcare. This is particularly true for those patients living with a condition that requires frequent laboratory monitoring. Such is the case for those suffering from iron deficiency and iron deficiency anemia. Anemia accounts for 68.4 million years of life lived with a disability.¹ Data from Scripps-Kaiser and the National Health and Nutrition Examination Survey highlights the prevalence of anemia in the United States to be highest in Black women (or those who menstruate).² Recent data from Canada showed the correlation between anemia and socioeconomic status with lower household income associated with the greatest odds of anemia.³ Various factors contribute to the burden of anemia in women of color, including disproportionately higher rates of heavy menstrual bleeding (HMB) from fibroids.⁴ HMB, defined as greater than 80 mL blood loss per month or excessive menstrual blood loss that interferes with a woman's physical, emotional, social, and material quality of life, depletes iron stores leading to iron deficiency.⁵ HMB has been reported to affect between 10% and 30% of reproductive age women in the United States, with a symptom duration of years commonly reported.⁶ These numbers are even higher in persons with a bleeding disorder or on anticoagulation.⁷ Iron deficiency leads to fatigue, impaired cognitive function, and decreased mood, leading to loss of quality of life and personal productivity.⁸

HMB and resultant iron deficiency require frequent healthcare visits and laboratory monitoring. The correlation between race, income, and healthcare spending are profound. One study found Black insured participants were more likely to reduce spending on basic needs, leisure activities, and skip medications to cover the cost of medical care compared to non-Black participants.⁹

To address disparities in healthcare access and affordability, it is necessary to understand the financial implications of obtaining necessary testing. Federal regulations require hospitals to post charges for procedures and laboratory tests. Charge data are available as master files or as on-line calculators for a limited number of tests. Price estimates can also be directly requested from financial service offices. Price estimates may include a discount for self-pay. We set out to determine the self-pay charges for iron deficiency and anemia testing including a complete blood cell count (CBC) and a serum/plasma ferritin at major medical centers in Boston, Connecticut, and two national laboratories.

In this cross-sectional study, we manually collected laboratory charges from hospital web sites for major hospital systems in the Boston and Connecticut metropolitan areas (25 hospitals) and two major national laboratories (Quest and Labcorp) for a complete blood count (CPT code 85027) and serum/plasma ferritin (CPT code 82728). If on-line charge data were not complete, estimates were requested directly from the designated customer service office. Data were collected between January and April 2024. STROBE reporting guidelines were followed.¹⁰ Since this study collected and examined publicly available data with no patient-specific information, neither informed consent nor institutional review board approval are required. Descriptive statistics were used to characterize price variations.

There is substantial variation in both full and discounted charges within and between the largest healthcare systems in Boston and Connecticut (Table 1) and two major national laboratories (Table 2). The full charge varies between $27 and $160 for a CBC and $58 and $328 for ferritin. Discounted charges for self-payment vary between $8 and $105 for a CBC and between $17 and $161 for ferritin. The full charge for an iron deficiency screening panel varies between $51 and $417, while the self-payment discount rate varies between $24 and $237. These costs do not account for the cost of venipuncture, which is often applied as an additional cost. Within the Boston metropolitan area, Boston Medical Center and St. Elizabeth Hospital provide the lowest discount rates, while Massachusetts General Hospital/Brigham and Women's Hospital and Dana Farber Cancer Institute have the highest. In Connecticut, St. Vincent's Medical Center within the Hartford Healthcare system offers the lowest discounted charges while L&M Hospital in the Yale New Haven Healthcare System has the highest.

Price variability for laboratory testing is not new; however, it can exacerbate health inequities, especially for those who are self-pay or middle-class with employment-based healthcare insurance or “good insurance,” who must pay the out-of-pocket laboratory costs. For 488 hospitals in 49 US states, the median price for a CBC is $58 with an interquartile range (IQR) of $28–$92.¹¹ Another study reported charge variations for CBC between $10 and $2706 among 77 top US hospitals.¹² It is however surprising to see a more than 6-fold difference in full charges and an almost 8-fold difference in discounted charges for an iron deficiency anemia panel among hospitals and laboratories within the same healthcare system or metropolitan area, using similar instruments/technologies and facing similar competitive challenges for personnel and other costs.

In Massachusetts, High Public Payer Hospitals receive more than 63% of gross patient service revenue from government payers and free care. Both Boston Medical Center and Tufts Medical Center, which offer the lowest discounted prices on testing, are part of this group. Faulkner Hospital, Lahey Hospital and Medical Center, and Steward St. Elizabeth's Medical Center are also part of this group. Even more striking are the pricing differences within the same healthcare system. For instance, L&M Hospital and Greenwhich Hospital are both part of the Yale New Haven Health System. However, L&M Hospital, which is situated in an area with the 12th lowest median household income in the state, charges the highest discounted rate for iron deficiency anemia testing. In contrast, Greenwhich Hospital, located in one of the wealthiest areas in the United States, offers the lowest discounted rates for the same tests. This is problematic since socioeconomic disparities have a significant influence on health outcomes.¹³ Patients from lower-income areas, such as that served by L&M Hospital, face a challenge of having higher laboratory costs and fewer resources, which could deter them from seeking necessary care. In contrast, in the Boston area, patients might want to seek specialized care at MGH, but are also deterred due to higher costs.

It is worth noting that within hospital groups tiered charges are provided for urban and suburban facilities. National laboratories offer multiple tiers of programs: charges for consumer-driven direct ordering of tests are lower than the discounted ones for physician-ordered tests. The two national laboratories have dedicated financial assistance programs for uninsured: posted charges for the LabAccess Partnership offered by LabCorp are lower than the other two tiers ($51 vs. $78/$126). Additionally, hospitals listed in Table 1 may offer further financial support programs to eligible individuals on a case-by-case basis. Overall, the variability in laboratory costs within and between healthcare systems leads to an uneven burden of healthcare expenses, and in some cases portends a misalignment between healthcare pricing and community income levels, exacerbating already existing barriers and perpetuating health inequity.

CB generated the hypotheses; LVD and CB collected primary data, and cowrote the manuscript.

The authors declare no conflicts of interest.