The Silent Majority

There is so much entropy in health care right now.  So much finagling, so much shifting, so much arguing, so much uncertainty, so much shock.  Shock at prices, shock at waiting times, shock that doctors don't know how to increase referrals, shock that doctors aren't doing more to help.  What gives?

In triage, you don't spend time with the expectant.

Doctors are keeping their heads down.  They are still seeing patients.  They are still going to work and taking the calls. 

But they are tired.  They are frustrated by the system that puts the system of care before the people doing the caring and those needing care.  They are tired of the empty promises.  Like the promises that staring at a keyboard will fix things, do things better, save money.  It's complicated, this health care thing, right?  We are told we need more automation.  We need more quality managers.  We need more safety officers to see more people with less to keep it safe.  We need more administrators to implement the rules: more people willing to take less to make it work.  Complicated, I tell you.

But the promises, we're learning, have been part empty, for they have enriched the system for the system's sake while leaving the people the system is supposed to help, increasingly broke.  We're $500 billion over budget so far and counting. 

Promises are for politicians and business people.   Real health care workers don't make promises, they do the best they can with what God gave us.  As patch after destructive patch of interweaving laws and back-slapping favors are handed out in Washington, corporate board rooms, and union meeting halls, a silent health care majority watches from their peripheral vision, trying not to notice, trying not to be disgusted, for the work for them never ends.  The silent majority is waking to the fact that the business part of health care was, is, and somehow forever shall be, broken.  There is simply too much money involved, too much economic return that can still be made, too many opportunities to deceive others for personal gain, too many people, too many workers, too much of our economy, to accept that things will ever really change.  Too very, very big...

... to fail.

Like Detroit.

I sit before a computer screen that says "Order entry:"   I no longer need a pen thanks to handsome government subsidies and a push to centralize and nationalize.  Let others do the deciding.

I type in an order.

Five choices instantly appear based an a sophisticated word-search algorithm.  I find what my patient and I, as their caregiver, need.  I click on the item.

But a price never shown.  So there is never a discussion about cost.   That's the intent.  There is never a word about the difference of retail price and what it really costs or what you'll really have to pay.  Like a shopping spree without the prices.  Because, according to others, doctors should not think of these things when health care is involved, nor should Congress - it's about your health, remember? 

So thousands and thousands of your dollars are put at risk, dear patient, with a single click of a button. Courtesy of government subsidies.  And you will never know.   Nor will I, as I load the gun of your economic destruction.

So efficient.  So clean.  So tidy.

How was I supposed to know I ordered a collection agency for you, too?

But the silent majority is stirring.  They are upset they must pay their mandate, upset the corporate guys don't.  The are seeing the bills, the denials, and the undecipherable bills.  They are seeing the cost.

The Silent Majority is stirring.

Because they have a check box, too.

In November, 2014.

-Wes

The Infinite Loop

Doctor's can't help fix the health care cost problem because they are kept uninformed about prices or (worse) not allowed to disclose prices to patients or journalists (or health care researchers) once those prices become known to them lest they lose their job.

So, for example, there might be a technology a doctor wants to use to make a diagnosis on one of his patients.

Later he learns that his patient was charged many thousands of dollars for that simple diagnostic test because his patient informs him that the insurance company considered the test "unproven or experimental" and refused to pay for it.

Not only is the charge for the test exorbitant relative to the work required to perform it, but the doctor also learns that every local insurer will not pay for the simpler test he ordered but will pay for an invasive surgical procedure to gather the same exact same data at ten times the cost.

What should the doctor do now?

Should they refer future patients for the diagnostic surgical procedure that pays him and his employer well yet costs the patient very little, or should they do the least invasive and safest test to gather the data knowing their patients will be left with a hefty overpriced bill that will not be covered by their insurer?

For the solution to this problem, I'd refer the reader to the first sentence of this piece.

* * *

In the past when the majority of doctors were independent from large health care systems, doctors could advocate for their patients and move them to other centers that offered cheaper prices or had superior services.  Now it is estimated that nearly 75% of physicians will be employed by hospitals or large health care systems by 2014.  This may sound reasonably benign and irrelevant until patients contemplate what they are trusting their doctors to do.  

If the issue of quality and price transparency are important parts of our health care reform discussion, then another solution for reform than our present construct will have to be developed.

After all, with the passage of our new health care law (and its "accountable care organization" construct), it is becoming crystal clear that we have approved a system that perpetuates the impossibility of doctors serving as true advocates for their patients.

 -Wes

What's Missing in Scientific Journal Articles on New Innovations in Medicine

My perspective on scientific publications has been greatly affected by my experience with this blog and social media in particular.  The ability to serve as author, reviewer, advertiser and marketer can be easily achieved in this space thanks to the power of self-publishing.  But with this new platform comes new responsibilities and for those of us who chose to work with people daily, perhaps none is as great as maintaining the trust of our patient readers.

This week's New England Journal of Medicine opened my eyes to another revelation in scientific reporting where doctors have not been completely honest with our patients.  While few are as enamored with scientific innovation as myself, I find there is an gaping hole in scientific discourse that doctors have not forced to the surface when new innovations arise.

What's that hole?

Cost.

In an era where scientific discovery has only been eclipsed by price inflation, doctors have not taken responsibility for insisting this cost of any new innovation's impact on our health care system be disclosed in scientific articles reviewing the medication's risks and benefits.   We have not insisted that major medical journals reveal which articles are provided free to the public through tacit collusion with their pharmaceutical sponsors.  (While the exact price might not be known at the time of publication of these articles, the estimated cost to our health care system can probably be guessed depending on the novelty of the medication or device and the expected return on investment a manufacturer would hope to achieve.)  To be fair, most reputable journals do require disclosure of manufacturer's sponsorship of the reported trial, but no where do the journals report the money they receive from those same manufacturers for making favorable articles about a drug or device open access to the public.

Take this week's New England Journal of Medicine.: Three articles appear on our new novel oral anticoagulants that lack cost information and disclosure information from the journal regarding if they paid for the article to be open access:

Apixiban for Extended Treatment of Venous Thromboembolism: The article is open access and not a word about the cost of the drug.  Did Bristol-Myers Squiibb or Pfizer (or both) pay to be sure this article was open to all?

Extended Use of Dabigatran, Warfarin or Placebo for Venous Thromboembolism: The article is open access and not a word about cost of the drugs.  Did  Boehinger Ingelheim pay to be sure this article was open to all?

Rivaraoxaban for Thromboprophylaxis in Acutely Ill Medical Patients: The article is open access and not a word about the cost of the drugs.  Did Bayer Healthcare Pharamceuticals and Janssen Research and Development pay to be sure this article was open to all?

Increasingly I find the cost of these novel oral anticoagulants relative to warfarin factors in to conversations I have with patients during their decision about which drug to start.  Granted, it is just one factor, but an important one.  I also find the deluge of pharmaceutical benefit manager denial letters to be a real thorn in my side as I have to constantly justify to payers why one drug has better benefits for an individual patient than another.  Not being armed with cost information puts me at a disadvantage when speaking with these deterrents to care.  The reality is this: we simply HAVE to have honest discussions with our patients about cost these days, especially since more and more costs for care are being shouldered by our patients than ever before and the financial impact of their care has huge psychological implications.  If I have to disclose everything about my relationship with industry thanks to the Sunshine Law, our scientific journals should do the same.

It is for this reason that we should insist on at least relative cost information of new technologies appear in scientific reporting, especially when the cost of new innovations exceed existing innovations by over a factor of 10.  In this era of health care reform and growing cost concerns, patients (and their doctors) deserve disclosure of at least a relative benchmark of price so we can make the best informed medical treatment decisions with our patients that benefits not only their physical well-being, but also their psychological and social well-being too.


-Wes

What If Obamacare Were Found Unconstitutional?

Health care is a sensitive issue politically.

And as things would have it, it now is a sensitive issue legally.

So my thoughts now are not meant to be partisan, but rather a "ground-floor" perspective on what would happen if the Patient Protection and Affordable Care Act were found entirely unconsitutional.

What would happen?

Would a bunch of post-college aged kids ages 21-27, promised insurance beginning this year, suddenly no longer be eligible for care? Probably not. Most insurance policy constructs last a year, so changing coverage would take a while. Still, there will remain a need for some type of insurance coverage for this group outside of classic employer-based insurance since jobs are few and far between for this group. Irrespective of whether the PPACA is enacted or not, employer-based insurance is becoming a thing of the past.  (Update 26 Jun 2012: the nice insurance industry has found this provision to be both popular and highlly profitable since young folks rarely get sick, hence they will continue this provision, even if the PPACA is struck down)

Would doctors who sold their practices lock, stock, and barrel to large health care organizations be able to disband from these large health care organization superstructures (and their associated non-compete clauses) to restablish independent practices? No way. For doctors who performed imaging procedures in their offices at a discount to what hospitals charge, CMS claimed "self-referral" incentives for these procedures, and stopped paying for them in the outpatient setting (but interestingly, not for hospitals). Consequently, by banning payments to doctors for these services, independent physician practices no longer were viabile, except those in affluent neighborhoods where concierge medicine could establish a foothold. The employed physician model and more hospital consolidation seems inevitable going forward irrespective of the outcome of legal challenges to the PPACA.

What about people with pre-existing conditions? It would seem that care would be delivered as it is now for this group. Charitable care, ER care, Medicaid programs would likely have to expand putting even more pressure on our state budgets. But then, isn't this why many states are concerned about the PPACA in the years ahead anyway?

Will the electronic medical record and electronic prescribing, the cornerstone of purported cost savings and efficiencies under the PPACA suddenly disapppear? Of course not. The EMR has been wedging its way into medicine since at least 2004 (that's the last year we had paper inpatient charts at our institution). Newly minted doctors today have never manually written inpatient orders, have never had to walk to radiology to "pull the films" to see a chest x-ray, or go to the microbiology lab to review culture results. They are wired. They expect instant test results. They expect to be able to read outpatient notes. They expect to be able to find another responsible doctor in the care history of a patient. In fact, novelty patients now are those who have never had an entry in their electronic medical record: "Gee, no one's seen this guy before!" Bottom line: an unconstitutional PPACA won't derail the electronic medical record.

It has been estimated by the CBO that repealing the PPACA would cost $210 billion dollars if this occurred between 2012 and 2021. What that money would be used for is anyone's guess (legal and political PR fees?). We have to wonder. But common folk like most of us are not privvy to the intricacies of government self-serving budget-making.

So what if the PPACA is found unconstitutional?

It. Won't. Matter.

Irrespective of the outcome of the pending legal battles for or against the PPACA, we continue to have a huge cost of care crisis in America. Our problem (hate to say it) was never a need for "insurance reform." It remains a problem of costs. And the PPACA does little to help us understand where cost savings would be realized. Why is this?

The legislation was authored by powerful interest groups who were "brought to the table" to feast on the last vestiges of fee-for-service health care. To date, they continued to gorge themselves. I'm not seeing a concern about costs. I'm seeing a consolidation of monster health systems accross our land. Much as the insurance industry found profits by eating their own before, so now are hospitals. Bigger, more doctors, more huge facilities gobbling up their competitors until the last Great Health System can claim the "Too-Big-To-Fail" prize. And why not? Our jobs and economy depend on it. We continue to want the best of care without compromise (though there are responsible rumblings out there about end-of-life care.) Bigger systems running more smaller systems. Not only will it be bigger, more efficient, but safer, too! Our wonderful Utopian vision of the future. Costs be damned. We've got to build for the future and the influx of newly-eligible health care customers!

There is no interest in shrinking the middle man.

Instead, our entire system is cloaked in financial secrecy as we continue to build our Health Care Hindenburg under the auspices of the PPACA, or not.

-Wes

Are Large Health Care Systems Gouging Patients?

With patients having to pay more of what's charged for their health care, comparisons between medical systems like this one in Pennsylvania, makes us wonder if bigger necessarily means better:

The Pennsylvania Health Care Cost Containment Council study looked at four regional hospitals that offer cardiac surgery: Geisinger Wyoming Valley, Plains Twp.; Community Medical Center and Mercy Hospital, Scranton; and Pocono Medical Center, East Stroudsburg.

Among the four, Geisinger Wyoming Valley carries the biggest price tag. In 2008, the average hospital charge for a coronary artery bypass graft surgery was $108,029 and the average hospital charge for valve surgery was $132,740, according to information in the report.

Having both surgeries simultaneously at Geisinger resulted in an average hospital charge of about $162,051.

Coming in as the most affordable in 2008 was Community Medical Center, according to the council's report. The average hospital charge that year for bypass surgery was about $63,767, and the average hospital charge for a valve surgery was $90,411.

Pocono Medical Center was the most affordable when it comes to having simultaneous bypass and valve surgeries - the average hospital charge was $92,352.

Hospital charges are a poor way to compare costs since they are often inflated. Worse, retrospective data that is several years old is of little use to patients seeking care today. But as patients are left to pay more and more out-of-pocket for their care, these types of data might tarnish patients' love-fest for large "branded" health care systems that historically have used their brand and market share to raise prices.

At least that's the hope to our more ardent reformers.

But there is the political reality that hospitals are large employers. Also, they are slow to publish this information lest they show their hand to insurers with whom they negotiate group prices or risk discouraging their patients from using their shiny new facilities up front. This is why patients have a tough time determining what a procedure will cost before they have it.

If we were to continue to permit personal costs to loom larger in our new health care reform era, as larger health systems' catchment areas overlapped it would be likely that the institution that moved first and most aggressively to make cost data available prospectively while maintaining quality might be the one with a significant advantage over their non-disclosing competitors.

But the costs and consequences of such an approach is unacceptable to our professional politicians. Things must be kept "easy" and "painless" for their constituents. As such, patients will soon have even less skin in the game for their care as we move forward with the "Affordable" Care Act in 2014, allowing this ridiculous, unrelenting upward cost spiral will continue. Bundled government payments for services won't be enough since they'll likely be negotiated to keep prices artifically inflated.

Don't think so?

Just look at the construction going on right now at area hospitals around the country. I would say our big, branded hospital systems are loving their prospects in the years ahead.

-Wes

Tomorrow's News

Tomorrow marks the day that $125 million in ad spending will commence to convince folks they really DO like the new health care reform law recently passed.

With that kind of government and special-interest spending, it looks like direct-to-consumer Viagra ads on the Nightly News will seem be a bit, er, limp.

To kick things off, a pro-Dem group will air a $2 million dollar ad campaign touting the law's benefits:

"The ad campaign launching Wednesday will focus on the theme “Not Anymore,” showcasing how health reform combats existing insurance practices. The ads will highlight the industry reforms coming online Sept. 23, such as provisions that bar insurers from denying coverage to children younger than 19 who have pre-existing conditions.

“The idea is you don’t have to worry about the stability of your coverage anymore,” said Health Information Campaign communications director Erikka Knuti. “These are all things that you don’t have to be concerned about now with the new law.”

And yet this ad campaign will fail to mention what the health care law has already done to insurance premiums:

Health insurers say they plan to raise premiums for some Americans as a direct result of the health overhaul in coming weeks, complicating Democrats' efforts to trumpet their signature achievement before the midterm elections.

Aetna Inc., some BlueCross BlueShield plans and other smaller carriers have asked for premium increases of between 1% and 9% to pay for extra benefits required under the law, according to filings with state regulators.

These and other insurers say Congress's landmark refashioning of U.S. health coverage, which passed in March after a brutal fight, is causing them to pass on more costs to consumers than Democrats predicted.

Look, as one much more astute health care policy analyst has noted, you can't have your cake with insurance for millions more beneficiaries and and eat it too with lower costs, no matter what the politicians and advertisers would like us to believe. Oh sure, we can work to cut waste, and that always helps to cut costs, but how long has Medicare been existence without an ability to prevent such fraud in a meaningful way?

There is no place is easier to hide money than in a bureaucracy - just ask Don Berwick, our now head of CMS, who managed to receive over a whopping $1.4 million (Source, IHI's most recent Form 990) toward his retirement in just six short years from sources with interests in health care that he recently refused to disclose to the Senate Finance committee chairman.

See how technicalities can play to your favor in governmental bureaucracies?

No matter how we cut this, the lack of financial transparency, governmental and special interest inner-dealings, and political side-games spell disaster for this new law's ability to control health care costs and we haven't even gotten out of the gate.

And all the advertisements in the world will not change these sad facts.

-Wes

References:

Senator Grassley's letter to Dr. Berwick
Dr. Berwick's response to Senator Grassley

Hospital Monopolies Get Pushback

From the AMA Medical News:

A Peoria, Ill., ambulatory surgery center will get its chance to try to prove allegations that the dominant area hospital improperly manipulated an exclusive contract with an employer health plan to edge the surgicenter out of the market. Without addressing the case's merits, the U.S. District Court for the Central District of Illinois on Dec. 30, 2009, allowed Peoria Day Surgery Center's antitrust lawsuit to proceed to trial. The court said it heard enough evidence that OSF Saint Francis Medical Center's actions could harm local competition and, ultimately, health care access. The trial is expected to begin March 8.

It is no secret that monopolies can lead to higher health care costs, but how that occurs is interesting. From a report by the Attorney General of one of the highest health care cost states in the US, Massachusetts:

... our preliminary review has revealed serious system-wide failings in the commercial health care marketplace which, if unaddressed, imperil access to affordable, quality health care. In brief, our investigation has shown:

1. Prices paid by health insurance companies to hospitals and physician groups vary significantly within the same geographic area and amongst providers offering similar levels of service.



2. Price variations are not correlated to (1) quality of care, (2) the sickness or complexity of the population being served, (3) the extent to which a provider is responsible for caring for a large portion of patients on Medicare or Medicaid, or (4) whether a provider is an academic teaching or research facility. Moreover, (5) price variations are not adequately explained by differences in hospital costs of delivering similar services at similar facilities.



3. Price variations are correlated to market leverage as measured by the relative market position of the hospital or provider group compared with other hospitals or provider groups within a geographic region or within a group of academic medical centers.



4. Variation in total medical expenses on a per member per month basis is not correlated to the methodology used to pay for health care, with total medical expenses sometimes higher for globally paid providers than for providers paid on a fee-for-service basis.



5. Price increases, not increases in utilization, caused most of the increases in health care costs during the past few years in Massachusetts.



6. The commercial health care marketplace has been distorted by contracting practices that reinforce and perpetuate disparities in pricing.

Not to say that adding a single doctor-owned surgery center is going to change downstate health care pricing much since patients remain sheltered from what is actually being paid by insurers for their surgical procedures. But as patients bear a increasingly larger portion of their health care costs, demands for transparency of pricing for elective procedures will mount. Further, as long as competition between centers exists, the wanton nature of health care service price increases by hospitals who monopolize markets has at least a snowball's chance in hell of slowing.

But then again, I'm sure that the Massachusetts AG's finding doesn't pertain to other areas in the United States...

-Wes

h/t: WSJ Health Blog

Why Aren't Doctors Asking "Why the Secrecy?"

With the turn of the calendar to the new decade, the reality of health care reform has set in for doctors and patients. Already cuts to physician salaries and patient access to care are becoming starkly apparent to those of us on the front lines of health care.

I wonder why doctors have been so ineffectual relative to the other special interests “at the table,” in the health care debate? One would think that those with the knowledge base and skill to manage their patients would be the ultimate power brokers in the efforts of health care reform. Yet here we are, watching the commoditization of our profession at the hands of lawyers and politicians in Washington, eager to avoid being perceived as the spoiler.

There appears to be a curious dichotomy, neither very effective, in physicians reactions to the current health care reform plan before our legislature.

One is an almost incredulous, trusting, beneficent universe position of denial – if I work hard and try to help people, they won’t hurt me, right? Altruism is denial’s cousin in this sense: we need to help everyone and our very beneficence will protect us from harm. I will not suffer, my patients will not suffer, and my family will not suffer because anyone can see that I ask nothing. Selfless quality doctors by definition have no interest in protection of income, of time, of the profession – just appeasement glorified as humanitarianism.

We see this as our professional membership leaders failed to ask about the details of the health bills before them nor inquired about the potential flaws inherent to comparative effectiveness research promulgated on large, unfiltered populations. Rather, our representatives capitulated and mollified themselves with platitudes: “I’m sure it will all work out, after all, 30 million more people will have insurance.” No thought about the 23 million who still won't receive insurance nor the impact that these policies to save money will have for the majority of patients that currently have coverage.

The very idea that adult professionals are normally called upon to defend and define the boundaries of their profession is an anathema to these purists. We are scientists and technicians and humanitarians after all. And so, we wash our hands of the debate in the public yard. But none of this is in fact true. Underneath is the trusting assumption that if one works hard, if one hurts no one and sacrifices one’ life for the greater good, then the world will protect us. What a lovely simple position to cling to in the remaining months or years before the reform bill is implemented. It’s a stubborn adolescent holding on to a fair universe.

The other popular position appears to be one of extreme passivity and martyrdom. The chief marker of this syndrome appears to be comments about seemingly catastrophic events in a tone of voice normally reserved for the weather. Our pay is set to be cut 21% while 30 million more people will expect to be seen. Pay for performance measures will be the norm, despite no proof of their utility at improving care. Gosh, doctor, it looks you’ll just have to be employees now. Never mind that the majority of doctors serving patients are not employees of large hospital systems. "Yep, we lost the farm in ’23, as your mother got sick and of course they repossessed the truck…”; the resigned laconic language of hard times. “Nothing I can do about it” has become doctors’ new tag line.

Passivity or denial. As if doctors have no power.

Sadly, as a political force perhaps we don’t. Harnessed with guilt about harming our patients if we set any reasonable boundary whatsoever, perhaps we are hogtied. We are the ones with the skills. We are the ones with the lifesaving relationships. And yet, as a profession, we feel powerless in this debate.

It is interesting to wonder about the source of this empowerment paradox.

To reinforce this observation, in the midst of the final negotiations that will affect every American's health care, a lonely voice in the sea of rhetoric came forth to insist on transparency to the negotiations to consolidate the most important piece of legislation that will affect every one of our patients' lives. Sadly, it was not the AMA or a collective of physicians voices like SERMO, but C-SPAN.

If we as professionals have any gonads or interest in what will ultimately affect the health care of every American across our country, then we ALL should join C-SPAN in their insistence that “all important negotiations” affecting the reconciliation of the final health care bill be televised publicly.

Mr. President, are you listening?

-Wes

The Challenge of Health Care Reform

... was eloquently outlined by economist N. Gregory Mankiw, in his article that appeared in the New York Times this morning. He uses the primary prevention of heart disease by taking daily statin drugs to lower cholesterol to make his point about the costs of prevention that leads him to ask a central, but very complicated, question festering in the background of much of the health care debate:

"Despite all the talk about waste and abuse in our health system (which no doubt exists to some degree), the main driver of increasing health care costs is advances in medical technology. The medical profession is always figuring out new ways to prolong and enhance life, and that is a good thing, but those new technologies do not come cheap. For each new treatment, we have to figure out if it is worth the price, and who is going to get it.

The push for universal coverage is based on the appealing premise that everyone should have access to the best health care possible whenever they need it. That soft-hearted aspiration, however, runs into the hardheaded reality that state-of-the-art health care is increasingly expensive. At some point, someone in the system has to say there are some things we will not pay for. The big question is, who? The government? Insurance companies? Or consumers themselves? And should the answer necessarily be the same for everyone?"

In answer to his Big Question, I'd vote for the consumer (and I mean the patient rather than hospitals) since they have to pay the tab one way or the other. To that end, price transparency of goods and services should be required for anyone involved in health care delivery. In short, every effort should be made to empower patients in such complicated decision making.

Until then, special interests will continue to wield far too much influence (and price pressure) over those most affected most by the health care delivery transaction.

-Wes

Circular Reasoning

Here's a dumb thought: If you want to save costs on medical devices to the federal government, require a tax fee concessions of $4 billion dollars from the medical device companies to fund a health care overhaul.

Now either that $4 billion will get added to the cost of devices (and the patient/insurer's tab) or the device companies will decide that they must pay the fee to maintain their current pricing.

Government pressures hospitals and doctors by paying less, so hospitals keep the heat on medical device makers to lower costs so they can make their margins.

It all sounds good, right?

But according to one analyst, it seems device makers would rather pay the fee than make their prices transparent:

But the mechanism for how devices companies might pay matters more than what they pay, according to Morgan Stanley analyst David Lewis. "A 'flat tax' is preferable, in our view, to targeted industry fees as our larger concern is the creation of more infrastructure intended to catalyze pricing transparency," he said.

And so, with the fee, the government pays itself while the medical device prices continue to remain inflated.

Why do the patients always seem to lose with these government-mandated scenarios?

-Wes

Health Care Cost Comparisons

If you're uninsured and need a radiology test or medication, what might it cost here in Chicago? Thanks to Leslie's List, you can compare different centers head-to-head, albeit with some limitations:

BE AWARE! The prices quoted here may be in error for a multitude of reasons, including: erroneous information given by radiology center staff, improper recording of the information by Leslie's List(TM) staff, improper entering of the data into the database, and price changes made by the radiology center since we last called them.

Leslie further clarifies what the prices mean:

"Just wanted to clarify the pricing of the testing included on our site. We always ask what physician reading fees are, as we realize that can tack on another 10-20% or so to the total charge. In many cases, the fee is included. In other cases, okay I'll just say it- often in the large hospital facilities- noone was ever able to tell us what the fees were, even after several calls to different deparments in the hospital. So in those cases, the fee is not included. In LesliesList.org you can click on the individual sites on the search results and you can see the breakdown of charges. Lastly, we only include radiology tests that each radiology site is fully accredited to do by the American College of Radiology."

Although the number of centers is limited, it demonstrates the wide price differential between centers. CT of the chest with and without contrast can vary between $543 and $2498, depending on where its performed.

What I also found was that the type of CT (16- or 64-slice) was not mentioned in the site (newer scanners might have different prices), but still, I found this site easy-to-use and informative.

So go ahead, check it out and compare. It might just save you a bundle.

-Wes

h/t: The Chicago Tribune's Triage blog.

A Step Toward Transparency

Massachusetts is setting a new bar with their website "My HealthCare Options". As reported in the Boston Globe:

"Brigham and Women's Hospital, Massachusetts General Hospital, Children's Hospital, Boston, and a few others are, on average, paid about 15 percent to 60 percent more than their rivals by insurers such as Blue Cross and Blue Shield of Massachusetts and Harvard Pilgrim Health Care. The gap is even more striking for individual procedures, which can be two or three times more expensive in one hospital than in another."

It will be interesting to see if the stark price differential between centers affects where people seek their care. How important will "brand name" become when people are saddled with higher and higher proportion of their direct health care costs?

But what is clear is a precedent for reporting this data is established. As we consider this step, will patients actually use the information? Will it really affect their decision-making or where they seek their care? Will their trust in their doctor take a back seat to price? Will patients, finally seeing what a procedure costs, delay their care or do without entirely?

On first glance, the website seems understandable and easy to use. But to find the actual cost ranges for procedures, the patient has to "drill down" deeply in the site to see the actual cost estimates side by side. Further, the choices of procedures available to view were very limited. I could not find any information of procedures for cardiac electrophysiology, for instance, while angioplasty and open heart surgery were listed. But even with this information, patients will still be unable to decipher their direct out-of-pocket costs, since there are a multitude of insurers and "plans" out there with even more deductibles. This might serve as a deterrent to using this site, since patients still find the billing and payment cycle of today's health care far too confusing as they try to understand what they have to pay.

But this is a step in the right direction, I think. Insurers can use this data to negotiate with hospitals. Hospitals can use this site to compete against the other hospitals in town and display ads that say "The Cheepest Angioplasty in Town!" (As an aside, I wonder if people really want the "cheepest" since it might infer an inferior product. Ah, the joys of being a medical marketer...)

Unfortunately, for patients outside Massachusetts, there's still a long way to go. But I suspect other states will soon be forced to follow Massachusett's lead as the Big Boys in Washington wrestle with our ever-escalating health care costs.

-Wes

h/t: BNET Healthcare.

Addendum: 11:50 AM CST: Oh, and what about that little problem of doctor professional fees and out-of-network providers? Just because the patient knows the cost of the hospital procedure, these published costs say nothing about the "professional" costs billed separately by the doctor. (See how confusing this is to the patient?) Needless to say, we've still got a long way to go before this mess is simplified.

The Healthcare Tipping Point

The book The Tipping Point by Malcolm Gladwell makes an interesting premise: that large sociological changes are usually hatched from small incremental events that, taken collectively, disrupt sociological behaviors. Such tiny events, when they occur frequently enough, build to create a "tipping point" that changes human behavior and disrupts market and sociological trends.

I couldn't help but think I viewed a "tipping point" when reading the excellent journalistic piece reported by the Boston Globe last week, entitled, "A Heathcare System Badly Out of Balance" that describes the complicated pricing differentials between large "name brand" hospitals and their competitors in the Boston healthcare market.

But what made the writing of this piece possible was one small event. A tiny disruptor. What was that tipping point?

Price transparency.

It was the ability to compare costs that permitted the revealing report:

The insurance data obtained by the Globe, drawn from millions of medical claims collected by the state Health Care Quality and Cost Council, is a byproduct of the state's sweeping healthcare reform law of 2006. Because some hospitals treat sicker people, the data has been adjusted to reflect the cost of care for an average patient.

The law calls for the council to post insurance claim information on the web so that the public can see the disparities.

But transparency, as the authors point out, was not easy to come by and verify.

But a year and a half after the law was passed, the council has still not published its findings because of disputes with medical groups about how the numbers should be presented and whether they are accurate in every detail.

"Apparently, this subject is the equivalent of the third rail," said Gregory W. Sullivan, the state's inspector general and a member of the Quality and Cost Council.

However, council officials say privately that the data, after months of review by the hospitals, is generally accurate. Partners said it has raised concerns "about the data and methodology" with the council. But other hospitals contacted by the Globe either confirmed the data's accuracy or would not comment on it.

It is important to realize that price transparency did not always change peoples' perceptions or actions (particularly if they did not have to pay for services through insurers). But for others with high-deductible insurance policies who bore much of the cost for tests themselves, price mattered.

In the days ahead as policy makers meet to hash out details of our new health care strategy for the future during these harsh economic times, insisting on verifiable price transparency from all parties will serve as a powerful incentive to improve quality while reining in costs to the ultimate health care consumer: the patient.

-Wes

The Complexities of Controlling Costs in Healthcare

Jim Stergious of the Pioneer Institute wants Massachusetts hospitals to do their part to help pay for the estimated $153 million budget shortfall for the Massachusetts universal healthcare plan:

We are already well into the new fiscal year, and negotiations with the federal government continue over whether it will renew the waiver that facilitated the Commonwealth's healthcare experiment in the first place. It might be useful to remember that no matter how conceptually interesting, even idea-based reforms face the logic of mathematics. They have to be affordable.

The Education Reform Act of 1993 required the grit of legislators and the governor to make good on the promised massive funding increase needed to make it viable. And now we must remain faithful to the idea of the Healthcare Reform Act, or the federal government will kill it.

The government wants reform, and it doesn't want it to affect federal coffers. Reform is happening; we have successfully signed up hundreds of thousands who were previously uninsured. One has to assume that the reduction in the number of people showing up to emergency rooms without insurance is translating into less of a burden on hospitals, especially those that previously provided care to a disproportionate share of the uninsured - specifically Boston Medical Center and Cambridge Health Alliance.

To remain cost-neutral to the federal government, we have to address this year's shortfall of $153 million and a minimum shortfall of $184 million next year. In the long term, there are several things we can do to contain healthcare costs, including perhaps a hard look at certain benefits mandated in the law and increasing the transparency of cost and quality data useful to consumers.

But there is really only one way to address the costs of the legislation in the immediate term: reduce the level of extra payments to Boston Medical Center and Cambridge Health Alliance, which were granted special annual payments that began at $200 million and ratchet down by $20 million a year. These special institutional payments were meant to ease the hospitals into the new regime. They were also very much a political deal.

Paul Levy, CEO of Beth Israel Deaconess Medical Center and member of the Cambridge Health Alliance, isn't too pleased with the idea:

If we want to keep this new system in place, there are only three sources of revenue for these costs: The taxpayers, the insurance companies and through them their subscribers, and the hospitals. None of these have tremendous political support, and there will be interesting political debates and compromises on Beacon Hill as this is figured out. I am afraid, though, that Jim has mistakenly chosen to avoid the first two and then focused his solution on a subset of the last one.

He later relents to the obvious in the comments section:

Tim, of course, is correct that ultimately all flows back from the taxpayers. The policy choice before the Legislature is whether you want to collect that as a direct tax or an indirect tax. Most likely, we will see it hidden as an indirect tax, for the obvious reasons!

Yes, the obvious reason: it's politically impossible to have transparency of healthcare costs.

Unfortunately, we can't have our cake unless we're willing to eat it, too.

The question becomes: what are we eating? Transparency of healthcare costs is one avenue to understand which side of this debate should give. Until we know what healthcare really costs to deliver and avoid the bizarre game of cat and mouse between insurers and hospitals with their Byzantine price markup scheme that confuses the all-important Big Picture of costs, patients (and taxpayers) will continue to get the short shrift.

-Wes

Shaking Things Up

If you want to mess with the healthcare system of today - play with cost transparency. Carol.com does just that:

(CNN) A new Twin Cities company called Carol is trying to change that with a Web site that gives consumers a "care marketplace" to search for medical services, compare quality and price and make appointments.

Carol joins an effort to transform the U.S. health care system by putting consumers in charge and letting the market do its work.

"We want to let consumers define value," said Tony Miller, Carol's founder and chief executive officer. "We don't have care competition in the marketplace today."

The free site, which went live in January, generates revenue from health care providers who become "tenants" on the site. When a consumer sets up an appointment with a clinic or doctor on Carol.com, the provider pays the site a fee.

It is interesting to look at the responses of the nay-sayers:

But Dr. Sidney Wolfe, director of Public Citizen's Health Research Group, said the site is nothing more than advertising, and he hoped it wouldn't catch on.

"Among physicians, there's a belief that health care is too critical ... to be left to the usual marketplace," he said.

. . .

If the site becomes more comprehensive, Carol.com would be most useful to people with high-deductible plans, health savings accounts or those without health insurance, said Elizabeth Boehm, an analyst with Forrester Research who studies the health care customer's experience.

She was skeptical of the site's prospects because many people's choices are limited by their HMO.

"(Price is) just not what drives people to make their health care choices," Boehm said. "The challenge for a site like this is that while conceptually it's good ... the reality is there are only a small group of customers looking for that."

Baloney. With patients being responsible for more and more of their out-of-pocket healthcare costs, I believe this idea will catch on like wildfire.

It is interesting that the Park-Nicollet Clinic in St. Paul joined forces with the website developer. It is no secret that this healthcare system has struggled in the past to compete the competetive Twin Cities healthcare marketplace. By competing head-to-head on price, they may have found a new way to attract more patients in to their system. This in turn, may force others to follow suit or to undercut their prices (which would be good for consumers). As the company's founder and CEO, Tony Miller states:

But Miller said consumers are starting to realize that choosing cheap health care might come back to haunt them in the form of higher premiums or other increased costs. And he thinks there are plenty of people like him who might want different options for care and are willing to pay more out-of-pocket to get what they want.

He said his idea for Carol came in part from his own experience with a heart condition for which he was told he needed surgery. A second professional recommended medication, which Miller, 41, said worked.

"I had the wherewithal and some of the contacts to help me navigate and find answers in the health care system. Most consumers don't have that," said Miller, a partner in the venture capital firm Lemhi Ventures, which has invested $25 million in Carol.

Although the number of ailments are almost overwhelming to review, I found it interesting to shop by price alone for things like a root canal, asthma treatments, or what one place is charging for a cardiac CT to obtain a calcium score that throws in "free parking close to the door!"

While the number of "tenants" on the website are small now, look for this idea to grow as smaller, less known healthcare services compete head-to-head with the Big Boys of healthcare.

-Wes

How Much Do I Cost?

A patient asked me once: "How much do you cost?"

I had no clue.

Through our convoluted health care system, I have no idea what the cost of my services I provide to my patients will cost them. You see, I'm employed by my hospital system. I earn a salary from the hospital system. The amount billed to a patient is dependent on rates they set, not me. And those rates are typically inflated well above what the hospital will receive from an insurer for my services. And of that, an individual patient has to pay their co-pay, which varies from insurer to insurer, and a deductible, which varies from insurer to insurer. And how much of their insurance premiums are going to the care I provide my patients? Really, it's impossible for me to determine what I cost a patient.

And for those without insurance? OMG. I have no idea how this is handled. Seriously.

But it turns out we'd better start learning.

It seems the New York Attorney general's office has asked the insurer UnitedHealthcare to halt its planned introduction of a method for ranking doctors by quality of care and cost of service, warning of legal action if it did not comply:

Linda A. Lacewell, a senior lawyer in the office of Attorney General Andrew M. Cuomo, wrote in the letter that the ranking would apparently be used to steer consumers toward selected doctors. “To compound the situation,” she wrote, “we understand that employers may act on these ‘ratings’ to offer financial inducements such as lower co-payments or deductibles to promote ‘cost-effective’ doctors to their employees.”

Ms. Lacewell said patients might be steered toward doctors based on flawed data and UnitedHealthcare’s “profit motive.” She wrote, “Consumers may be encouraged to choose doctors because they are cheap rather than because they are good.”

But there might be a bright side to this bogus website the UnitedHealthcare wants to publish: maybe with this program I'd find out how much I cost UnitedHealthcare.

But I still won't find out what I cost my patients, will I?

-Wes