Download the full report.
As COVID-19, a novel coronavirus, spreads across the United States and testing is increasingly made available to diagnose it, one major concern is the individual out-of-pocket cost for being clinically evaluated. Some symptomatic individuals may not seek care due to concerns about their ultimate total cost.
We have witnessed unprecedented action to avoid this dynamic. Congress approved and the President signed into law a coronavirus relief package, The Families First Coronavirus Response Act, that includes requiring private health insurance plans to waive the costs of the testing for COVID-19 and the visit to the doctor to receive those tests. The Centers for Medicare and Medicaid Services (CMS) also announced the coronavirus test will be covered by both Medicare and Medicaid. Many private insurance plans and telehealth companies have also pledged to provide virtual visits with doctors at no charge.
Even with these efforts, an individual walking into a healthcare facility exhibiting symptoms of COVID-19, whether it’s their primary care provider’s office, an urgent care center, or an emergency room, could end up being responsible for some out-of-pocket costs. Why? Because healthcare providers need to administer other tests to rule out common conditions that present with respiratory symptoms, like influenza or bacterial pneumonia, in addition to performing a coronavirus test. This is medically necessary to ensure individuals get the right treatment and it is unclear whether all of these costs would be fully covered by insurance.
People who are symptomatic and seek care may be billed for a visit with a doctor, an influenza test, a chest x-ray, and bacterial, viral, or blood culture tests. These costs can add up very quickly, particularly for people with no insurance or who have high-deductible health plans.
While questions remain about what will be covered under the coronavirus relief efforts, Castlight conducted an analysis to estimate the costs for seeking care in different markets and different sites of care. This analysis is based on real-time cost data from Castlight’s health navigation platform for commercially-insured populations living in major metropolitan areas across the country, including those that have been most impacted by coronavirus to date.
We evaluated the cost of care in the following cities and their surrounding metro areas:
Boston, MA | Chicago, IL | Cleveland, OH | Dallas, TX | Houston, TX | Los Angeles, CA | Miami, FL | New York, NY | Salt Lake City, UT | San Francisco, CA | Seattle, WA | Washington, D.C.
- Costs depend on severity of symptoms. For example, a patient in Seattle exhibiting a fever and a cough with no chest pain who goes to a primary care doctor for an evaluation can expect an average cost of $197. But if the symptoms include a high fever, cough, chest discomfort, and shortness of breath, the primary care provider will likely order lab tests and a chest x-ray, increasing the cost of a primary care evaluation to an average of $1001 in this metro area.
- Costs vary widely depending on the site of care. Even without symptoms severe enough to warrant any lab testing, a diagnostic evaluation can cost someone living in the New York metro area $0 to $100 for a telehealth visit, $100 to $450 for a primary care visit, $250 to $514 for an urgent care visit, and $506 to $4985 for an ER visit.
- Costs vary between markets. For a primary care visit, a standard set of lab tests, and a chest x-ray, the cost of an evaluation averages $1001 in Seattle, $2493 in San Francisco, and $3153 in Miami.
- Costs vary within markets. In Los Angeles, the cost for a primary care visit and standard lab testing ranges from $304 to $4447—roughly a 14-fold difference. In Dallas, the cost for the same services ranges from $193 to $4308—a 22-fold difference. Similarly, in Miami, these services range in cost from $354 to $5729—a 16-fold difference.
How did we calculate costs?
We estimated costs for people who sought care at different sites: primary care doctors, urgent care clinics, emergency rooms, and telehealth providers. For each, we considered what their diagnostic evaluation might include depending on the severity of their symptoms:
Mild: Asymptomatic people or those with a mild cough or low-grade fever might simply have a visit with a doctor and receive a recommendation to stay at home and rest.
Moderate: People with symptoms consistent with COVID-19 (high fever, cough, shortness of breath) may have a visit with a doctor and lab tests such as a comprehensive metabolic panel, influenza test, complete blood count, and bacterial and viral cultures, in addition to the COVID-19 test. These tests will help their provider rule out other conditions and recommend the right course of care.
Severe: People exhibiting severe respiratory symptoms, like significant trouble breathing and high fever, may need all of those tests in addition to a chest x-ray to determine if they need to be admitted to the hospital.
What did we find?
Costs vary depending on the site of care
Many individuals have access to telehealth through their employers or health plans. Co-pays for this service range from $0 to $100, though some insurance carriers have waived costs for telehealth visits. Individuals with mild symptoms may be able to have a video visit with a telehealth provider or call a nurse hotline at no cost to rule out the need for further testing. Most of these individuals will be told to self-isolate, rather than come in for an evaluation, incurring no further costs. If they do need further testing, they will likely be directed to a local primary care provider or urgent care center.
If someone with mild symptoms seeks an evaluation with a primary care provider in New York City, their out-of-pocket costs could range from $100 to $450 with an average cost of $235. In contrast, if a person seeks care at a primary care provider in New York City with more severe symptoms, their costs could range from $385 to $2805 with an average of $1220. Although the average costs for a primary care office visit are highest in San Francisco, lab tests and x-rays are highest in Miami.
If someone with mild to moderate symptoms seeks an evaluation at an urgent care center in New York City their out-of-pocket costs could range from $250 to $514 with an average of $352. However, if a person seeks care at an urgent care center in New York City with more severe symptoms, their costs could range from $535 to $2870 with an average of $1336. Miami and San Francisco have the highest urgent care costs among the included cities.
If someone with mild symptoms seeks an evaluation at an emergency room in New York City, their out-of-pocket costs could range from $506 to $4985 (average $2321). If a person seeks care at an emergency room in New York City with more severe symptoms, their costs could range from $791 to $7341 (average $3305). The average out-of-pocket costs for a visit to an ER for someone with moderate symptoms ranges from $1793 in Seattle to $3997 in Miami.
The primary source of data used for this analysis is a subset of 2.5 billion de-identified medical claims for primary care, urgent care, emergency room, lab tests and x-ray supplemented with:
- Provider directory data (e.g., which doctors provide which type of care).
- Provider rate sheets.
- Publicly available data.
The costs provided are for a member in their deductible phase seeing in-network providers. The ranges provided are for the 5th to the 95th percentile of costs in that metropolitan region.
The components of an evaluation for a patient seeking care associated with COVID-19 depend on their symptom severity and site of care. The procedures and services we included are:
- Site of care: telehealth visit, primary care visit, urgent care visit, ER visit.
- Care for moderate COVID-19 symptoms: initial cost of a provider visit, influenza test, sputum culture and sensitivity, blood culture and sensitivity, complete blood count, and comprehensive metabolic panel.
- Care for severe COVID-19 symptoms: initial cost of a provider visit, all lab tests listed above, and a chest x-ray.