The morning-after edits, originally marked in italics, have been “accepted” (to borrow Word’s term) to show the final text.
Here are the results of my cost shopping research to get my skin cancer (basal cell carcinoma, aka BCC) removed. The first edition was done in a hurry because the #bcsm (breast cancer social media) Twitter chat was happening, discussing costs and shopping, and they asked to see it.
It started in February when I decided to be proactive about finding out what this would cost me. I have $10,000 deductible insurance, so this is all coming out of my pocket. In previous months I’d gotten sick & tired of getting unexpected medical bills, and people at the hospital and insurance companies having wrong answers or no answers about “What’s this going to cost?” (CT scan, shingles vaccines) So, this time I published an RFP (request for proposals), the same way any business would do when making a substantial purchase decision. The RFP started:
Summary: I seek a care partner to remove a basal cell carcinoma (BCC) from my left jawline, under the ear. For a brief introduction, see blog post and photo (low quality) at http://bit.ly/ePDaveBCC.
I’m educating myself about the condition, I want to explore the available treatment options, and I’m “shopping” for a partner to do the work and follow-up with a good combination of quality, partnership, and cost.
It was a crazy thing to do, because hospitals don’t have RFP response departments (as many businesses do), and I was sure my request was largely uninformed. But I sure learned a lot from the comments on that blog post.
The RFP continued…
A key factor in my choice of treatment partner will be absolute clarity about billing.
I’m self-employed with a high deductible insurance plan ($10,000) in New Hampshire’s high risk plan (NHHP, New Hampshire Health Plan), so it’s a very high priority to know what the costs will be and to have a guarantee that no unexpected charges will be billed if the case proceeds as expected. …
If you don’t know what your costs are, don’t bid: you may be personally responsible for America’s out of control health costs.
Well, I got no responses. (Lots of comments and discussion, but no bids per se.)
So eventually, I started calling around to get prices.
This was hard.
The first challenge was finding out whom to ask. As I say, hospitals don’t have “RFP response” departments, or price quote departments, so at each provider it took a while to find the right person.
- At two places, when I asked about trying to find out costs, the person on the phone referred me to their financial aid phone.
- In all cases I wasn’t nearly poor enough for aid. I don’t object – I’m not poor – I’m just noting that the apparent assumption was that if I was asking about costs, I must be poor.
- I speculate that this is because those questions usually come from the uninsured, who, many assume, must be poor.
- At one provider there were two separate financial aid numbers – one for the hospital, one for the physicians – in different cities. (You may not know that most modern hospitals are like shopping malls, with separate bills for the facility and the merchant (doctor). That’s one more reason no one party feels responsible for the total cost.)
- There are exceptions, I’m told; at some hospitals the doctors are employees.
- But you have to ask, and ask, and ask again: “What other charges could there be?” One hospital’s prices seemed to be half as much as another’s, until they realized I wanted the whole cost, including facility charge.
- A whole separate issue is the list price compared to the actual price, through your insurance company, if you have one.
- In March I blogged a taste of that issue, re my semi-annual CT scan. (btw, I just got that scan last Friday – more to come.)
- In my case, it had become clear that Mohs surgery is clearly the best and is substantially more expensive, so I didn’t take another pass through the loop trying to find the with-insurance price for each option.
Having gone through this, I’m willing to say: for all practical purposes there’s a big sneaky shell game going on behind a smoke screen. I don’t know if it was designed that way, but it’s ended up no different from what a sneaky shell game would look like – especially, the difficulty of finding out what anything would cost.
One thing I do know: the common statement “Don’t worry, insurance will cover it” is a poison. Behind that poison, fishy amounts of money can change hands.
Mind you, this was a pretty simple procedure: no anesthesia, no hospital stay, no $300 aspirins – just come in and get it done. But nobody I spoke to – in dozens of phone calls – felt responsible for telling me what the total cost would be.
If we speak up and ask, I’m sure hospitals and insurance companies will start to provide answer departments, especially if we vote with our feet when they can’t answer. But a lot of them think we won’t leave, as long as we’re buffaloed into thinking their doctors must be the best in the world.
Note: I have no hard feelings against any of the people I talked to at the hospitals, once I found the right person, and I’m grateful for the work they did to help me. I know my questions were something they’ve probably never been asked before. Let’s change that. Let’s ask ’em: “What’s this going to cost?” And let’s not accept “I don’t know” as an answer.
The process
In the table below, I’ve removed the names of the hospitals because in the end they weren’t important, and this exercise is about the process, not the specifics.
Some notes about the process:
- All three hospitals immediately recommended Mohs surgery. “Basal cell on the face? Get Mohs.” None mentioned other options until I asked, sometimes until I asked repeatedly.
- All of them said that all their Mohs surgeons were excellent. :-)
- As detailed in my results post (link above):
- Simple excision (“cut it out”) is also an option. I learned about this mainly through the grapevine – comments on the blog, and personal comments from people I met at conferences.
- Mohs does indeed have the best efficacy: 1% recurrence rate, vs. 10% for excision. Much better appearance, too, which most people agree is an issue for lesions on the face. But, everything has a cost, so I wanted to know my options.
- Mohs surgery is done in an unpredictable number of stages: they slice out a part, look at it under the microscope; if they didn’t get it all, they go back. Total cost depends on how many stages are required to get it all.
- My insurance company told me that if I want to be sure my out-of-pocket cost would count against my deductible, I’d better find out what CPT (billing) codes the provider would use, so I had to go back to them and get those answers too.
- I was amazed to learn that different hospitals bill things differently.
- Note that there’s a separate charge for cutting out the cancer and for “closing” (stitching it up). Understandably, more complicated closing has a separate price, which means it has a separate billing code.
What I found
Yes, there’s lots of inconsistency in how different providers charge for the same thing. Not just the amounts, but the split between physician and facility charges.
I’ve heard that in some cases you can get the same physician to do the same work in his/her own office, avoiding the facility charge. I also believe that some hospital systems don’t have a separate charge, because the doctors are employees, not independent businesses.
Anyway: the numbers reported below are what I was told by each provider, so if they’re inconsistent, all I know is, it’s the best information I could get out of them. Eventually I figured although the info I had might not be the actual bills I’ll get, I had enough to make my decision.
|
Facility 1 |
Facility 2 |
Facility 3 |
||||
| Contact for cost info | (redacted) | (redacted) | (redacted) | |||
| Taxpayer ID No. | (redacted) | (redacted) | (redacted) | |||
| Also need a new-patient appt 99201, ~$200 | ||||||
| “p” = professional charge only; all other prices include facility charge (“f”) if any | ||||||
|
Facility 1 |
Facility 2 | Facility 3 | ||||
Mohs |
CPT |
Cost |
CPT |
Cost |
CPT |
Cost |
| Stage 1 | 17311 | $2000 ($1444p) |
17311 | $1900; allowable: $4597 |
17311 | $1904 ($1,178p) |
| Additional stages | 17312 | ($673p)$1600 | 17312 -15 | $1400 | 17312 | $1752 ($627p) |
| Total if 3 stages | $5200 | $4700 | $5408 | |||
| Pathology billing | May cost extra | No extra | May cost extra | |||
| Closing – simple | Intermed: 12051 |
$552 | 12001- | $900 | 12001-18 | $1246 ($278-$686p) |
| Closing – complex | $2700 | 12018 | $2900 | 12051 | $1246 ($492p) |
|
| Total – Minimum / simplest case | $2000 + 552 $2552 |
$ 200 $1900 $ 900 $3000 |
$1904 $1524 $3428 |
|||
| Total cost for 3 stages and medium repair | $5200 +$1600 $6800 |
$ 200 $4500 +$1900 $6600 |
$5408 +$1738 $7146 |
|||
Excision (not Mohs) |
CPT |
Cost |
CPT |
Cost |
CPT |
Cost |
| (Varies depending on complexity) | 11640-11646 | $750-$2500 total | Simple (<=1 cm): 11641 $747 incl repair Bigger lesions: Total $747-$2062 |
Simple: $357p + 960 f =$1317 up to $4010 |
||
So, Mohs is around $6-7,000 for three stages, or $3,000 +/-$500 for one stage; and excision is usually a lot less.
Understandably, nobody would take a guess at how many stages of Mohs I’d need without having me come in. Interestingly, though, based on the photos on my blog, a couple of dermatologists dropped me notes saying “Excision should be fine for that.” I didn’t take that as medical advice, but it was one input in my thinking. (Specifically, if my chosen dermatologist examined me and pointed out something new, that would trump a snapshot on a blog!)
The decision
After all this, I decided on the provider in the center column, who was closest to home. On my first visit, I explained that I’m the kind of patient who likes to understand his options, so I ask a lot of questions. He welcomed it – and noted that if cost was a key concern, there was a less expensive option, ED&C, that for my kind of lesion would be just as effective. That’s what I chose, as I reported last week. It was $616, all in.
As I said in that post, it’s only got about a 92% cure rate, not the 99% of Mohs. But if this skin cancer on my jawline does come back it’s not likely to get out of control; I can easily keep an eye on it. So would I take another $6,000 out of my pocket today for the more expensive treatment? My choice is, no.
And that’s the point: it’s my choice. But I can’t make an informed choice if I don’t have the, um, information.
So have some fun: next time you need something done, call your hospital and ask the switchboard, “I’d like to find out how much something’s going to cost. Who would I talk to?” As Arlo Guthrie said in Alice’s Restaurant, “If enough people do it, they might think it’s a revolution!”
And I say: don’t insult patients’ choices if we can’t get good information. Give us the data – then we’ll see.
_____
Update April 25, 2013:
This post came up again today in the context of my new post The Reality of shopping for health insurance. I realized I’d never added some additional costs that arose downstream, bringing the total to $868. The biggest was a shot of cortisone I had later when the scar seemed to not go down as it should, because I kept picking at it. (Oy; reality.) The cortisone cost $30; the injection itself carried a bill of $200. At the time I asked “What will this cost?” and the doc said “You being you, you’re more likely than me to know the answer to that.” :-) I opted not to delay, knowing the risks. All in all I’m happy with the outcome, though NEXT time I will insist on hunting down the cost first.
Interesting article Dave. By way of comparison, my dad recently paid for his own prostate cancer treatment in New Zealand. No problem receiving accurate quotes from hospitals for each of three options (radiotherapy, radical surgery, laparoscopic surgery). Also received advice on the length of waiting lists for public vs private care. Final bill was clearly itemized to the last $5 item and was within a few hundred dollars of the original quote. Glad you are recovering well.
Fascinating, Marie – thanks!
I understand what u were trying to accomplish but from someone who has had
Recurrent basal cell – I can only say this is
Nothing to fool around with. My advice to
Everyone is run don’t walk to your Moh’s dr
And get it off asap. Worry about the money
Later. Ditto for squamous cell. Spend your
Time organizing a group at work that pressures administration to negotiate lower
Deductibles for your insurance. That will help
You more in the future for all your illnesses.
Best of health to all.
Hi Richard – strange that you disagree with the dermatologist who ultimately treated you (and gladly shared the outcomes data with me). Are you a dermatologist? If not, on what basis do you say “run don’t walk to a Mohs doctor”?
Every doctor I talked to (and virtually every clinician on this thread) said basal cells are NOT an emergency – on what basis do you say “get it off asap”?
Do you have a stake of any sort in getting reimbursement for higher fees or lower deductibles?
Hi Dave;
I like your decision for treatment, and your exposition of the process is quite illuminating! I do want to know if the ED&C involved sending any tissue to pathology, as that will incur additional expense. However, even if you have a recurrence and it costs another $616+ to re-excise, you could have several re-excisions before you approached the cost of Moh’s surgery, huh.
I hasten to say for anyone with a similar issue that location, size and growth characteristics are all factors in deciding the type of surgery to have; everyone agreed at the beginning that your lesion was in a pretty low risk category.
Great article and quite a maze you went through to actually get prices. Can you imagine if you had to go through the same process to buy anything in the non-medical world.
Related story – a friend of mine had a brother who was a dermatologist. He got sick and tired of dealing with insurance companies so he went to a payment in full for services model. But, and this is the important but, he gave everyone the price he would have given the insurance companies for treatment. He actually had a printed list of prices for different procedures. Result – Far lower office expenses, happier patients and a much simpler life.
People keep referring to this blog post, even 3+ years later, so I just want to add:
HUZZAH to your friend’s brother! Rage against the machine!
I’m getting ready to start my journey down this rabbit hole! Today I was informed of 2 positive biopsies on my face.
Steve, I applaud your friend’s brother. The system is – in my opinion – a scam. It goes against the fundamentals of free enterprise. If I ask a Dr. to do a procedure on me, it is me that is obligated to pay him. If I have insurance, it is up to me to get reimbursed for the costs.
I understand that most of us cannot afford a large medical bill up-front, but allowing the insurance company and Dr. to “arrange” for payment results in us – the patients – relinquishing the responsibility, accountability, control, and authority of the service we should expect and receive. There has to be a better way.
Too many services are going the way of the health insurance model (car insurance to name one). Basically, because we, the consumers, are tricked into letting the Dr. and insurance deal with it, and we just get the result – we owe $XXXXXX. If you question it, you are given a lot of mumbo-jumbo explanations that are usually wrong, but are designed to confuse you and to discourage you from getting clear explanations. I commend Dave for not only doing his homework as a responsible consumer of a service, but doing it before he incurred the costs, therefore keeping the control over his decision.
The system is royally obfuscated. Don’t know if it is intentional or not, but my skepticism leads be to believe it is not accidental. I learned this about 26 years ago, when we had our first child. I’m self-employed and have insurance with a high deductible – $5K (very unusual at that time). My very good friend also was having his second child at the same time (within 2 months).
He negotiated a cash payment for ALL costs of delivery with hospital (anesthesiologist, hospital room medicines, lab work, etc.) & doctor. He paid a total of $5,600.
The bill submitted to insurance company for my wife’s treatment, $12,600 by the hospital and Dr., was for essentially the same service! We paid our deductible of $5,000 + 20% of $7,600 ($12,600 – 5000). The 20% was $1,520. Our total payment was $6,5520 with insurance, my friend paid $5,600! Of course, we also paid monthly premiums of over $500 for a family of 4 at the time if my memory serves me correctly. That was when I realized how screwed up the system is!
The model Steve’s friend uses, is a much better model. If a procedure is going to incur high cost, the patient, not the Dr, can and should get pre-approval in writing from the insurance company, and use this pre-approval letter to negotiate for the Dr. for delay in billing until the insurance payment is received by the patient – not the dr.
The only exception to this model is in the case of emergency treatment, where the patient is incapacitated, or there is no time for the insurance company to be contacted prior to treatment.
One of the reasons the health care system in the USA is so broken (I’m only speaking from a cost point of view, is because the checks-and-balances inherent to a free market have been bypassed, and this has allowed insurance companies to dictate to us – the patients – and to the doctors the terms under which the services may (or may not) be performed. Remember, we, the patients, are the customers of the insurance companies, we pay them! We are also the Dr.’s customer, we pay him/her. There is no relationship inherent between the doctor and the insurer.
Another quick way that people can get a ball-park idea for common procedures is to use Healthcare BlueBook – http://healthcarebluebook.com/page_Results.aspx?id=17&dataset=MD&g=Skin%20Lesion%20Removal%20%28malignant%29
For a skin cancer removal as an outpatient it gives a cost of $779 (in my zip code). It only took me about 15 seconds to find the cost and break-down although it doesn’t include MOHS surgery for comparison.
They can also negotiate prices for people
Disclosure: I have no affiliation with them)
Sherry, this is great but I’m puzzled: it doesn’t say what kind of removal procedure it is. Also, I didn’t have any anesthesia (as their page suggests), just a shot of Lydocaine – so I’m guessing the prices they listed are for excision.
You’re right, though, that’s a heck of a lot quicker than what I went through!
I wonder what HCBB would say about the range of complexity reflected in the figures I posted. The $779 you found (or $819 in my zip code) is in the lower range for the quotes I got, but the quotes ranged much higher.
I wonder, too, what CPT codes they were assuming.
So, now I’m starting to sense a desire for two different things: what are my options (which HCBB is not), and what should it cost (which HCBB is).
Too bad the Business Week piece didn’t include FairCareMD.
Thanks for this! I wanted to capture it in comments here for future reference.
What a great find. Thanks Sherry and Dave! As of 2020, HCBB has Mohs pricing. Link as of today: https://www.healthcarebluebook.com/ui/proceduredetails/761
George, there’s only a single price listed there and no discussion of how many stages, simple or complex close, etc, as described in my post. Do you work for them? (The email you registered with is not HCBB.)
If you do, can you clarify what this is a price for, and what region this price is for? I’m sure NYC is vastly different from Butte, Montana. Also I think the price agreement on the page is interesting – for this audience can you provide a link to where people can learn more on the site about how to use those agreements?
If you don’t work there, then never mind…
Dave, your blog is both interesting and insightful. I am an interventional cardiologist researching methods to increase patient participation in individualized decision making. For example, we estimate individualized bleeding and restenosis risks for each patient undergoing coronary angioplasty and PCI at our institution, and I use these risk estimates when making decisions regarding the use of bleeding avoidance therapies and drug eluting or bare metal stents. I am interested in better educating patients about their treatment options, better assessing patient preferences, and influencing physicians to be more responsive to their patients’ preferences. The goal of this work is to provide better, more individualized, and more cost-effective health care. If you are interested, I would like to discuss our ongoing projects with you. I can be reached at achhatriwalla@saint-lukes.org.
Best regards, and best of luck to you,
Adnan
Thank you, Dr. C! I’m at the St. Louis airport right now … I’ll drop you a note off-blog.
You may want to consider joining our Society for Participatory Medicine. It’s just $30 a year, and you’ll find a number of other physicians who are involved in similar initiatives. http://www.participatorymedicine.org/join-us
Would this info (option) be available in N.C ? Interested as needed for relative
Inquiring his options on family medical ins and care..Costs are a huge concern ..
I just read the article ..
He sure had to endure a lot of hoops for what should be ready available
Answers…Thanks in advance Barbara
I
Hi Barb –
I can’t say what’s available anywhere; I would just encourage everyone to do what I did: ask what their options are, ask if there are other options, and keep asking until satisfied. I had two clinicians look at it – the one who diagnosed it and they one who ultimately treated it.
May I ask how you found this site?
I’m no doctor but I heard repeatedly (including from dermatologists) that basal cell carcinoma is not fast growing so unlike some cancers there’s no inherent rush. But I hasten to add that I have no idea what condition your relative is in. Also, the doctor who suggested ED&C for me said it’s not appropriate for cases that seem deeper. Another factor for me was location – on my face, so if it came back I would spot it quickly.
Lots to think about, take into account, and take responsibility for. That’s always how it is when we start to participate in decisions that others used to make for us, eh?
This was a great story, and illustrative of how difficult it is to be an informed patient. Patients have so few tools to navigate the medical billing process, and we often see the unfortunate results in healthcare-related financial hardship. CoPatient has worked with patients who received as many as 11 different bills for a single episode of care at a single facility, so I can’t imagine how the average person is expected to deal with the complexity. I really hope to help patients that aren’t as informed and proactive as you when they end up with unexpected bills.
Rebecca Palm
http://www.copatient.com
Advocating for the healthcare consumer
Hi Dave
What I can say about basal cell and other cancers, I have just had a basal cell surgery yesterday from my face ( right) cheek and how the dermatologist had to make a safety margin and I have a few stitches near my eye.
The reason that this has happened to me is that I haven’t really practiced Nichiren Shoshu Buddhism correctly and holding on to negative attachments like anger, ego; forgetting about the four absolutes, being born, grow old, suffering and death, in the Lotus Sutra interpreted by Nichiren Daishonin best English translation by Burton Watson, if I put other attachments and don’t take reasonability for my thoughts, actions and deeds then I will continuously get sick or any other negative thing could happen to me. But if I am a sincere envoy of the Buddha informing others about this practice and if they want to become a Buddhist I can show them the path they take or help teach them Gongyo (the Hoben chapter (2) and the whole (16th chapter of the Lotus Sutra learning this in phonetics, absolutely I will prolong my life and the biopsy will show no more cancer and I will keep all the parts that I was born with because I do have a mission and when my mission is over I will die, hopefully at old age with a good quality of life.
Please read Lotus Sutra you can find it on the internet.
Sincerely
I don’t see what this has to do with consumers trying to find the cost of surgery… am I missing something?
I found your article while searching for the same information. Unfortunately, I’ve already had my procedure and neglected to ask about cost beforehand. I went to a large derm clinic in Peoria, Il. for a MOHs procedure. My bill before insurance was about $8000 for just one stage removal. Funny thing is I had the same procedure done there in 2007 and it was about half. I’ve been on the phone with billing a couple times and am waiting for a nurse to review and call back. I’m getting nowhere with them.
Holy crap! Do you dare point them to this post? Here’s a short URL: http://bit.ly/daveBCCcosts
I’ve started telling people I’m going to blog my experience about costs, including naming them. Amazing how quickly that changes some people’s behavior. You might “offer” to do the same for them. What do you have to lose?
And, btw, who’s your insurance company and what do THEY say about this?
I’ve found that some companies want to reduce spending, and some really don’t! What’s up with that??
I’m getting one looked at right now, wondering if I cN afford to hVe
Darn cell phone typing Getting my forehead one looked at now cost is something they are looking at and will fix price for me before the commitment to procedure. Then again, a trip to a Thailand for the actual removal could be fun. My 20% for the biopsy came to $92 the rest don’t know yet.
Brad, I hope you’ll come back and let us know how it turned out. See also Hiram Arroyo MD’s comment today, below, about cryo.
Dave; As a Dermatologist and Cryosurgeon I have to congratulate you for your extraordinary research job. Just the cost of your invaluable time spent in investigation! That’s a lot of money! Your decision, based predominantly on costs, but also on the rarity of metastasis spread of your tumor, was a good one. At $868, including treatment of your complicated scar, vs $6,000 for the highest percentage Mohs Micrographic Surgery, is indisputable. No doubt, among the procedures you considered E&C is the cheapest.
Nevertheless, although understandable, it is a pity that you did not include Cryosurgery for your small BCC of the jawline area. Cryosurgery is a worldwide excellent modality for Skin Cancer. Cure rates for such a lesion is around 96 to 98%,only bettered by the very expensive Mohs(99%). Unfortunately Dave, Modern Cryosurgey, which was developed in the USA during the fifties, is very rarely practiced for skin cancer in the States. Most Dermatologists are not trained to treat cancer by freezing, they are trained in surgery and most Surgeons do not even know the method.
In Europe , Asia and the rest of the world it is an increasingly popular cost effective method for this. So if you unfortunately develop a new lesion, you can fly down to Puerto Rico, it is a US. territory, and we can freeze the tumor in 5 minutes with a cost of $150 US Dollars, a 96 to 98% cure rate, and most likely a white spot, no scar. By the way,your trip and stay could probably be payed by the cost of your well researched E&C treatment. Best Regards
Hi – good to meet you!
You’re right, I didn’t research cryosurgery at the time. I’m aware of it (I’ve had it done before), and I know it was briefly discussed during this episode, and it was indeed listed as one option in the journal article my dermatologist shared with me comparing the options. (See my later post on the final decision, which I did link to in this post.)
Last year I had two more basal cells on my back, and they were removed with cryosurgery. When I have my next follow-up visit in June I’ll discuss with the doctor why that one was chosen.
Thanks for your contribution to this discussion – much appreciated!
well here we are running scarred of the american medical system, and with good reason.
the old saying ‘ no cops without robbers ‘ comes to mind when i think about cancer. how many millions have been made by the various medical professionals over the fear of cancer. but i digress.
my recent experience is as follows .
Because of a good size squamus cell tumor – lump that developed in my left ear 12 years ago, which i had removed by one of the leading plastic surgeons in Changmai Thailand, i am always concerned (fearful) that other cancer cell tumors will form somewhere on my body . with that in mind i recently went to a highly rated Dr of Dermatology at a hospital in chicago.
i went on line of course looking for a Dr. of Dermatology on the north side of chicago .
i made an appointment to have my whole body looked at for $170.00, especially a suspicious small growth with small crust on top that would come and go over the last year.
fortunately or unfortunately depending on ones point of view, only one other suspicious spot – lump – growth was found . i could go into some detail about the office staff, the students proctoring the doctors procedures, etc, but it would take up more space than you have. the doctor himself was very knowledgable BUT in a huge hurry when i arrived and in a bigger hurry to have me agree to surgery AND the biopsy that went with it to remove ?, the two spots, one on my ear that i could see and touch and the other one on my butt that he found but i was totally unaware of .
i had to be very clear to the doctor himself that i needed time to think about it after being told that the two spot removals and biopsies would cost me about $ 600.00 including as it turns out the removal of the two stitches on my butt after the surgery. based on the amounts payed by a few of the people writing on this sight, that sounds like i got off cheap, but wait.
about one week later i get a call from one of the office staff who’s broken english enhanced her urgency to have me make an appointment to have the lump spot on my ear removed because the biopsy result came back positive for basil cell on my ear, but negative on the other bump which is still sore as i sit her !
the office worker, who ever she was, was very pushy,
telling me that it was important that i make an appointment asap . i’ll be returning in a few days to have the novice done stitches removed and will at that time tell them to F… off ! Why ?
when i asked the broken english office worker the cost to have the now nearly invisible growth removed and for some details about the procedure, the procedure itself was described to me as the same procedure one has when having a wart removed AND that the cost would be between $ 1500.00 and $3000.00 !
i will be going out of country to have this taken care of.
at the moment i’m looking at mexico, puerta rico, thailand or india, thailand or india in november, mexico or puerta rico sooner if i can find a dermatologist there.
the american medical establishment, ‘ the medical system ‘, is terrible . it has been for years.
so i thank you sir for hosting this site and giving myself and others the opportunity to share our experiences. two final thoughts if i may.
i see the biggest problem being the fact that very few people question the medical costs IF they have medical insurance which makes it all to easy for the medical community to over bill and passing on outrageous prices without explanation. in my case i had to get in the doctors face and in the nurses face somewhat to get something of a description of what they were doing and why . they were not at all generous with there time or explanations.
they did not want to be bothered explaining their actions .
we need a better system of medical coverage in the u.s.
please vote for whomever you believe takes that need seriously . it is reported that the average dermatologist in the u.s. makes between $ 200,000 to $ 400,000 a year.
lastly, i’m looking for a recommendation to have the spot on my ear removed OUTSIDE OF THE U.S. !
mike
Europe is cheaper:
*ticket cost
*cost of doctor
*cost of dermatologist
*cost of surgery in hospital
I think I’ll be going to Costa Rica.
Ticket and treatment,
about $ 700.00. Or 1/4 of the treatment here in Chicago.
I had a BCC surgery six weeks ago they told me they got all the cancer out. I have since noticed a small sore in the same spot that is not healing ( similar to the original bcc). After shelling out my portion of the surgery ( $1,700 of the Total Charge of $9,917) If this new sore is bcc should I be expected to incur about the same cost? Is this too much cost for this surgery?
I have no idea, Jerry – sorry. I had enough trouble figuring out my own costs, and one thing I learned was that it all varies widely!
Two years ago, I had six weeks of radiation through Florida Hospital in Orlando. he longest appointment took about 2 hours as they formed a iron mask for my face. After the mask was completed, I went in Monday-Friday morning’s for six weeks. It took only 5 minutes a day, but cost $55,000.
Thanks for this update. Important questions:
– Was this for a basal cell, as I had? What did they tell you about how advanced it was?
– Did they tell you what it was going cost?
– Were you offered any alternatives?
– Was the mask really iron? My understanding is that iron wouldn’t block the radiation; might it have been lead?
– Did the treatment work? (Is the skin cancer gone?)
In any case six weeks sounds absurd for something that’s normally handled in a day! If you have a copy of the bill(s) they would make fascinating photos here.
Hi Dave,
I have a similar BCC as you in just about the same place. I have called my insurance company and local providers to ask about cost. Nobody can give me an answer. I have called the nurse help line for my insurance company and asked about other treatment options. They didn’t even know about Mhos (!) and basically said I should just do what the doctors say.
I’ll save you the details because clearly you already know how this story ends. I did want to personally thank you for taking the time and effort to document everything and run this blog. It has been very informative to me and I think you have literally saved me thousands. I will be asking about ED&C immediately!
I’d love to buy you a beer or a cup of coffee as a way to say thank you. I will put in my email below so if you send me a note I will figure out a way to do just that.
Thanks again!
Great to hear from you! Amazing how this post continues to be by far the most-viewed page on this website!
Note carefully that ED&C is not for everyone – the paper he shared with me says its recurrence rate is clearly not as good as Mohs or excision, but the whole point is that it’s a quick and inexpensive thing to try, for apparently-not-bad cases where it’s easy to keep an eye on it.
Here we are 4-1/2 years later and I’m as fine as my face is ever gonna be… :-) I did get more basal cells (on my back) and had them cut out.
Hi Dave
Just a word from Coffs Harbour in Australia. Interested to see the costs incurred in treating removal of BCC. Just had mine removed in my forearm. Had it excised here after having the diagnosis through biopsy, then “frozen” to shrink the carcinoma and today had the carcinoma removed. It was a considerable size and has required 8 stitches. All of this at no cost and covered under our public health system. Very grateful.
I am beyond frustrated. Need a dime-size basal cell excised from the back of my neck along with a stage 1 melanoma located two inches next to it.
Surgeon gave a choice of having both done at once under anesthesia or each separately 6 weeks apart.
Asked about cost and her response was “don’t worry, it’s covered by insurance.” Asked her assistant who had no clue. Asked at the front desk, got blank stares.
Calls to the insurance company were a waste of time until one person said to get the specific name of each procedure and the billing code if at all possible and they would tell me the negotiated charge.
Nobody on staff at the surgeon’s office would tell me the procedure name other than “excision.” Claimed they wouldn’t know until afterwards when the bill was prepared. No, they couldn’t give me any idea or dollar range. Didn’t know if it would be more or less than 5k or 10k.
I’m now thinking that the surgeon hasn’t actually done any of these type of excisions. Why else would her staff be so clueless?
Going to try to find someone else, but wondering if I’ll just run into more of the same of “don’t you worry your pretty little head about it” attitudes.
Have you considered going to your local newspaper or TV station about this? Or your legislators?
If you read my entire set of posts about this, you’ll understand why I’m not the LEAST bit surprised. The people out front shuffling the papers and answering the phones often have absolutely no idea what goes on in the dirty work in the back room, where billing happens.
During my own episode I asked my insurance company if they could at LEAST tell me what the last 50 cases like mine had averaged – so I could help keep their costs down! And they said THEY DON’T HAVE THAT INFORMATION. It turns out they don’t work for the ACTUAL insurance company – they’re a separate company hired to talk to customers like me, and to KEEP ME AWAY from the people who have the information!
It’s flat-out crooked. You have every right to demand consumer protection.
If you can stomach it, this NYTimes heartbreak of a story (spoiler alert, it ends up more or less ok in the end, after a year or more—if you don’t count the psyche damage). https://www.nytimes.com/2017/03/29/magazine/those-indecipherable-medical-bills-theyre-one-reason-health-care-costs-so-much.html?smid=fb-share
That is SICKENING, Bart! How timely – and how SICKENING. How do the people responsible for this sleep at night??
As a DPC physician I removed, completely, two basal cells from a patient’s neck and chest last week. Total cost: $185 for pathology, $10 for suture and $60/month for full spectrum medical care. We CAN do much better!
Samantha– if you have melanoma the procedure you need is very import and more in depth than some basal cell cancers. And basal cell cancers that need wide excision or melanomas (which always need wide excision) on certain parts of the body– esp the face –can be extremely complex. In these instances the cost is hard to control and even harder to figure out!!! Not to say that’s ok, but it is the state of affairs right now.
I do have two ideas you might try:
1) look at DPCfrontier.com to see if there are cash price primary care doctors in your area. If there are, a DPC doc may know how to navigate pricing conversations with a specialist
2) see if the surgery center of Oklahoma could help you. They have published cash prices for procedures. And
3) there are growing sites like medibid.com where you can try to “bid out” procedure prices. Hope this helps!
DPC docs are an amazing resource.
Not only can Surgery Center of Oklahoma do it as well, but the Free Market Medical Association has other members who can help with this type of issue. You can use our free online search tool or call us! It shouldn’t cost more than a couple hundred dollars like the MD above said.
dr. Julie, I have had skincancer removal many times and I am now in Spring Texas and am in need of it again and don’t have very good insurance and need some help if you could help assist me you can email info at
rcandield@Hotmail.com
1st – glad it worked out for you.
2nd – Excellent post. I read thru it all. My mind kept wrapping around the idea of self-responsibility vs 3rd party control (Govt. or Ins). Sadly realized how the system just doesn’t want questions. Keep up the work.
Unfortunately in this case one great entangler is that the insurance companies too often are abusing capitalism by bending government to protect insurance’s interests. The existence of private / confidential / inscrutable secret pricing agreements is one example. It’s abundantly clear (across the decades and administrations) that if the industry were regulated for CONSUMER interest, those agreements would not be allowed.
Hi, deB!
A similar thread has been unfolding, in part thanks to Consumer Reports. Albendazole is a dirt-cheap medication that has been out of patent for a few eons. It’s effective against a variety of worms, and its most common prescription in the US is four daily doses for pinworms. The last time I prescribed it (perhaps 20 years ago), it was less than 25 cents a dose.
But now it is $50 to $200 a dose, and this inflation has happened with most physicians completely unaware of it. For starters, no physician would imagine that a cheap common drug might suddenly for no good reason increase in price by two orders of magnitude. But more importantly, physicians don’t get information about costs of drugs unless they go digging. Similarly, the patients (or parents, in the usual case of pinworms) may only see the co-payment amount, and have no clue what the gross amount for the drug had been unless they read every line of the insurance EOB when it arrives.
The story, here, is very reminiscent of pyrimethamine and Martin Shkreli. Because the drug is not much of a money maker, the generic providers gave up on it until there was only one left. Armed with a monopoly that could prove temporary, the one remaining manufacturer took a “what the market will bear” approach rather than “what is reasonable and customary.”
The net result was that physicians were prescribing a drug that they thought would cost a couple bucks; families were getting hit for $30 in co-payment if they were well insured, and with bills for a couple hundred bucks if they were uninsured or had not yet met their deductible maxima. Only if the patients came back to the physician with a complaint did the doc find out.
When I read about this a couple weeks ago, I searched a few databases. The drug costs 6 or 7 cents in India, and generally between 77 cents and $1.33 in Canada. It’s $64 at WalMart (for four doses) today, and the Wikipedia entry author was quoted $560 at a retail pharmacy in Raleigh.
So the people making the decisions don’t have clear information, and there are folks out there milking the system.
Hi. Just had MOHs on my nose with recon plastic surgery, skin graft from shoulder,
. All follow up visits… 4400 gbp
Done in a clinic in London. May 2017
All drugs free of course ….
Hi Patty – thanks for the info – in the NHS do you get an itemized bill, showing the charge for the plastic surgery separate from the MOHS itself?
Am I guessing correctly that this was at a private clinic, going beyond the NHS’s “free at the point of care” health system? I have a general impression that anyone can get care for almost anything, but that people who can afford it may also buy services at private clinics and hospitals.
Like Patty, a few months ago I had a 2 stage Mohs surgery on my nose with reconstruction (but using skin from the bridge of my nose) and the costs were similar. However, the London clinic costs were about 10% higher than a dermatologist’s clinic in NZ who had her Moh’s certificate from a University in the USA. My treatment included biopsies, all pathology costs and follow up treatments for 6 weeks post surgery. Yes, I could have had “free” surgery in hospital on the NZ healthcare plan, but chose Mohs for my reasons that I wanted pathology accomplished at the time of surgery, which does not occur in NZ hospitals as it is a cost saving to sew up the patient and cut again, and again and again if need be. My GP told me that happened to another of her patients who had 4 or 5 surgeries on one BCC! I like to “nip problems in the bud”, and am extremely grateful that I can choose a specialized surgeon when need be. Healthcare is a blessing and I am so grateful that the USA government will now work together to make it affordable for the masses.
Signed “An American Down Under for 22 years”
I agree. Heard the same advice. Had Mohs. Had very good Blue Cross. However, I was never informed of my portion of the cost. Over $1,000 was reported as delinquent to credit bureaus & has left a mark on my credit. Never received the bill they stated they mailed. The office sent it to collections without even attempting to make one phone call to inform me. Why isn’t it a requirement for the Surgeon to inform the patient of the cost to them ? I may have chose to go elswhere, such as a University. They offer services at lower or no cost to train Surgical Residents.
Wow! You did some serious research. I used to try to figure out costs, back when no one in the family was ill much, but we’ve had 5 straight years of my cancer, hubby’s cancer, son’s various illnesses, etc. I had mohs surgery last week, melanoma suregery last month. I don’t give a hoot what it cost. We have an HSA and meet our family deductible by April past 5 years. Every year I think we will build us our HSA savings. Wrong! I guess the moral is, if you are going to get sick, do it all in one calendar year. Hope your excision was successful.
Agreed about “all in one year.”
Ultimately I didn’t get the excision – had it burned & scraped off with a needle! https://www.epatientdave.com/2012/05/10/decision-just-scrape-it-off-edc/ 90% cheaper than the highest estimate!
I had 3 stage moh’s procedure for basil cell with 6 inside stitches and 36 outside to close, about 1″ from my eye 5 days ago. Last year I had Moh’s for a melanoma ½’ from my eye. Both cost me nothing. If you are a service connected, war time, veteran, it will be covered. I was sent to a private hospital, the same doctor did both procedures. I am grateful for the kind treatment afforded to veterans in Cleveland. After seeing my dermatologist and being biopsied both times, they made appointments for me to be done within a month after the biopsy.
Interesting article I like your decision for treatment. Thanks for sharing
[MODERATOR COMMENT: This is a perfect example of a fraudulent “comment” being left on the web by what’s called a “black hat” marketer – black hat in the sense of “the bad guys.” Low-life marketing companies can be hired to go around the internet placing fake comments that contain a hidden URL, which they hope will make Google think the URL must be popular. It’s 100% fraud. In this case, the hidden URL is for Park Avenue Dermatology in Florida. Would you want to get medical care from a doctor who uses scam marketing? Not me … I’m removing the URL (which was hidden under the Squamous Cell line above), but I’ll leave this comment for educational purposes.]
I’m really worried about skin cancer. I didn’t think much of it when I got a pain in my knee at the side and there was a lump there. Then 6 months ago I got a hard lump on my bone on my elbow and another one on the other elbow. Now I’ve got a big hard lump on my shoulder blade. I went to the doctor’s and she said nothing to worry about, but she said we had to do a blood test. The lumps are really painful.
Dave have you been back to have the area rechecked and are there new areas that they have found more basal cells? What is the procedure called that you went with?
I went with a quick, simple, relatively cheap procedure called ED&C. The post about the decision and my thought process is here https://www.epatientdave.com/2012/05/10/decision-just-scrape-it-off-edc/
Yes, I’ve been back for regular follow ups and had two more basal cells removed from my back.
Yes, I’ve been back for annual checkups, and have had two more basal cells removed.
The procedure I chose for the original one is called ED&C. It’s described in this post. https://www.epatientdave.com/2012/05/10/decision-just-scrape-it-off-edc/
Hello
I was recently seen by a doctor in France for a piece of skin that kept bleeding on occasion .I had it for 1 year on the upper right side of my forehead.
The doctor scheduled me an appointment with a dermatologist a few days later.I went in and her diagnosis was a Basal cell Carcinoma.She suggested it to have it removed which I agreed and had a surgery a few days later at the Hospital.
This was a 45 mins surgery with Anesthesia with a Plastic surgeon and the Dermatologist from the hospital.
As of today it has been a week since the surgery and I am doing well.I am a french citizen living in the U.S for the last 25 years so knowing that I was going to go on vacation to France I would have it check there because of the pricing offered on health care.
Total cost out of pocket and no insurance was:
Doctor-27$
Dermatologist-33$
Hospital surgery-275$
This happened in 1 week.If you are looking for a physician at normal prices, buy a ticket and go have it done over in France, The government even have plans to help pay for it.
Have a good day!!!
Hi Mikael – thanks for this. What kind of surgery was it? Mohs, excision, or something else?
I don’t have the technical term with me but I do have stitches and it was burned and scraped off .
Okay, that sounds like the option I chose: ED&C. The price was approximately $616 (with no insurance involved).
Here’s the blog post that summarizes the costs of all the options. At bottom I’ve added a direct link to the final cost number.
Thank you for this comparison!
Wow! I have to comment. I just got off the phone leaving a message saying, “I have a high deductible and will be basically paying out of pocket. Please tell me the worst case for how much this will cost.”
Then I googled cost of mohs surgery and got this post. Thank you 1,000x for putting this out there!!! Very informative even if prices have gone up considerably over the years. I didn’t even know what ball park this surgery would be in. Thanks again!
CBP, we’d all love it if you could come back and let us know what they say yours will cost, and what it eventually does cost. Thanks for writing!
Interesting article Dave I’m a Mohs Surgeon and have always had an interest in cost analysis.
Some factors to consider:
1) Hospital setting vs out-patient setting.
If done in the outpatient setting the cost is typically 50% less than the hospital as the hospital bills it’s own fee (usually the equivalent of the physician fee for CPT code).
Example Medicare pays roughly $650 for 17311 code (first stage of Mohs) and $380 for 17312 (each subsequent stage of Mohs).
The national average is 1.5-1.6 stages of Mohs. So the average Mohs case requiring 2 stages will cost $1,050. So you can see that the hospital is also quoting the included hospital fee.
As far as I know most Mohs surgeons do Mohs out-patient which is why there is a significant cost-savings to both insurers and patients. This is what I do.
2) Multiple surgery reduction rule:
The reconstruction of the cancer removal is typically reduced 50% by insurers. Don’t ask me why it takes no less effort, training and skill to do the reconstruction after Mohs surgery but insurers will try to find ways to not pay physicians for decades. There rationale is that “the surgical tray is already set up, the patient is there, and you don’t have to schedule another appointment so we think it should only be worth half” which is like you going to work and getting your full pay for the first hour and the half your pay the remaining hours because you didn’t have to drive to work the second hour and you’re already there. Nonetheless a reconstruction on the cheek that is intermediate 12052 code reimburses $290 and a complex repair 13132 reimburses $465.
Overall cost:
17311/17312 Mohs codes $1050
Repair at 59%= $145 or $230
Total cost by Medicare rates is maximum $1,280.
3)One thing not mentioned is the histologic subtype of basal cell carcinoma and the size. Both of these have implications on recurrence rates. Recurrence rates for BCC treated with ED&C on the head and neck are much higher than what is often touted as the ED&C recurrence rates.
Total cure rate for all BCC at all body locations may be 90-92% depending on the study or studies that are analyzed. However the 5- year cure rate for a non-aggressive BCC on the anatomic location where yours was is about 78% if it’s larger than 1 cm. If it’s any other BCC subtype (infiltrative, morpheaform, sclerosing), aggressive subtypes, the cure rate is lower. So much lower that no surgeon would do ED&C on these types today except maybe Dermatologists that don’t have the training and experience Mohs surgeons have.
Additionally, 10-year cure rates are even lower, in the few studies that follow patients out to 10 years there is another 15-20% that recur during this time period. Essentially you are looking at a 58-63% cure rate at 10 years.
4)Lastly most skin biopsies are shave biopsies which is just a small sample of the top of a lesion. A potentially larger lesion or more Agressive lesion May be deeper. Like the top of an iceberg. So the histologic subtype May actually be more aggressive than the biopsy report reveals which would lower the cure rate with ED&C.
A 2010 study by Izikson and colleagues of The Roswell Park Cancer Institute examined 513 consecutive cases of primary NMSC. In 21.1% (108 cases), intraoperative examination revealed an aggressive subtype that was not diagnosed by biopsy alone.
One year study from Cleveland Clinic examined 323 cases spanning a 1-year period which included 296 patients. The researchers found that 33% (108 cases) were more aggressive on Mohs sections than on initial biopsy.
These results suggest that treatment modalities without margin control may not provide adequate treatment for a number of NMSC based on biopsy histology alone.
This is from the Silverman study. They Examined 2314 primary BCC treated by ED&C from 1955 through 1982 at NYU Skin and Cancer Unit. The categorized them based on High, Middle, and Low risk anatomic locations.
Recurrence rates are as follows:
Low risk areas (neck, trunk, extremities)= 3.3%
Middle risk areas: (scalp, forehead, pre/post-auricular, malar)
Less than 1 cm= 5.3%
More than 1 cm= 22.7%
High risk areas: (nose, paranasal, nasolabial groove, chin, mandible, perioral, periocular, canthi, ear)
Less than 6 mm= 4.5%
Greater than 6 mm= 17.6%
High and middle risk areas we would never treat with ED&C today, the standard of care is Mohs surgery
Although the study did not look at histologic subtype of BCC but it was one of the first and the largest studies of its day and the data from these researchers is where we get our “99% cure rate” for Mohs surgery.
Christopher Wolfe DO, FAAD
Dermatologist and Mohs Surgeon
Great to meet you, Dr Wolfe! I always love engaging with people on the front lines, and more than once I’ve been whispered to by docs who’ve said they can’t speak publicly.
I was treated outpatient, but within the hospital. My understanding is that this usually (or often?) incurs the facility charge. Do you do it in your own office, or outpatient at hospital?
I’m amazed that in my months of research and over 100 comments on all my posts, nobody mentioned the surgery reduction rule. Is that new since 2012 when this all happened?
Re the different options – did you see my earlier post with the brief discussion with the Mohs surgeon on recurrence rates? He was only about to cite a 1989 paper – I’d be curious what you think about those stats in my circumstance compared to yours here.
Thanks for taking the time for all this – much appreciated!
This article was very helpful in many aspects for me. I have seen very few articles in his aspect despite being associated with medical billing for a considerable amount of time. However, this article has come as a surprise to me and I will definitely go through this article again in the future.
(Heads up I treat skin cancer for a living) so: Unfortunately when one chooses to pinch pennies on SURGERY FOR CANCER ON YOUR FACE what you don’t grasp is: BCC recurs often when treated with (cheaper) EDC (scraping) or excision; I have seen patients with recurrent BCC that slowly invaded under the skin and destroyed facial nerves, causing irreversible facial asymmetry and loss of function. Now, think about all the things you spend money on: car, house, etc. Your face is not worth $10k but your car is? One of those, you will have forever. I don’t disagree with you seeking low cost providers (I am one) but choosing the cheap, lower-success option, with a bigger riskier scar (needed cortisone shot for keloid from EDC) – I can see that for the back but not the face.
I have done skin surgery in 30 countries (missions) and fine it odd how Americans don’t appreciate the value of their body.
Hi Michael – thanks for the comments!
I want to clarify some things, which may not have been apparent if you didn’t click through the many links in this post.
First, as my RFP said, I never sought low-cost providers. I only followed the common advice to patients to ask what other options are available. As in any other buying decisions, I believe in knowing the pro’s, cons, and price of the different options. Importantly, nobody offered anything other than Mohs. I did blog that it’s universally said to be best for BCC on the face – I didn’t question that. I just wanted to know about options.
Yes, part of my motivation was price, because it was 100% self-pay for me. But it was explicitly not my main criterion.
That makes me wonder why you say “Americans don’t appreciate the value of their body.” I hope you’ll come back and explain that! :-)
Regarding recurrence, I hope you saw above that I did discuss it with my surgeon – and even asked him for the paper with the numbers he cited.
You mention the bigger scar being more appropriate for the back, not the face. Perhaps cosmetically, but that advice contradicts my surgeon’s – he said BECAUSE recurrence is greater for ED&C, it’s better not to do it on the back, where it would be harder to spot anything fishy. :-)
To be clear, being an empowered patient and consumer does not mean rejecting medical advice; it means partnering with professionals and being informed and responsible. It means being thoughtful. In this case we are eight years later, my jaw is fine, I had five years of annual follow-up, and I saved thousands of out-of-pocket dollars.
So, given all that: why the hell did you say “What you don’t grasp is…”? :-)
Hi. Here in the UK, due to Covid, private hospitals have taken National Health Service patients and been well paid. My ulcerated Nose BCC surgery (cut and paste) was arranged through insurers nearly 5 months ago but cancelled with no date for more months. MOHS was not mentioned.
So I got a quote from Germany for more than 10,000 dollars for MOHS removal as an in patient at their top 5 hospital.
My insurers say they don’t have to pay anything. because treatment abroad isn’t covered. I pay 10,000 dollars a year premium
Any comments or advice please? (treatment offered is as below)
Richard
Initial presentation in the clinic, taking clinical history and physical examination
Review of medical records
General dermatological examination
laboratory tests: complete blood count general urine analysis biochemical analysis of blood TSH-basal, fT3, fT4 tumor markers indicators of inflammation (CRP, ESR) indicators blood coagulation
PET CT scan (on indication- price not included) Preoperative care
Mohs micrographic surgical removal of BCC Histological and immunohistochemical examination of the resected tissues
Symptomatic treatment
5 days in patient
Hi, Richard. I’m afraid I’m in no position to judge anything medically, so I can only reply as a casual reader. Having said that:
FIVE DAYS IN-PATIENT??? It’s a same-day outpatient procedure. Other than that, I have no useful information. Sorry!
Btw, Mohs is the surgeon’s name – not an acronym – no need to capitalize :-)
Hi Dave. Thanks fort helpful commenting.
Regarding mohs I was following this definition : Mohs surgery is a precise surgical technique used to treat skin cancer. During Mohs surgery, thin layers of cancer-containing skin are progressively removed and examined until only cancer-free tissue remains. Mohs surgery is also known as Mohs micrographic surgery
I agree that you can’t make an informed choice without information. If a treatment service tried to get me to hire them without looking at other places then I would mark it off my list completely. They should work on becoming better than their competition instead of just trying to prevent people from seeing other options.