Curiouser and Curiouser: Quality. Transparency. Value?
"It would be so nice if something made sense for a change.”
Alice in Wonderland
One of the primary challenges of living in the new healthcare world is embracing the concept of value. Value in the world of healthcare means mastering the balance between improving the quality of care while simultaneously decreasing its cost. I frequently am privy to debates on what constitutes “real” quality and how is it going to be defined and by whom, but I am rarely questioned about cost. Cost would seem to be rather straight forward. Not so fast. A recent study published in the Journal of Hospital Medicine showed that only one tenth of hospitalists were within a 10% accuracy rate when surveyed about the actual cost of commonly used inpatient services, tests and procedures. Some were off by thousands of dollars. A recent article on healthleadersmedia.com referred to this phenomenon as “price opacity”. The article goes on to say that It would be almost unheard of for you, the individual patient, to be able get a clear price on a menu before the service is delivered”
One of the key tenants of healthcare reform has been the promotion of transparency, mostly focused on quality. I do agree that transparency is necessary and will ultimately lead to improved care, but if we are ever to get to truly improved value – not just improved quality – we are going to need to find a way to clear the smoke from the costs of care for physicians and patients alike.
Absolutely, Mark. Cost needs to be more on everyone's minds. I keep seeing doctors, surgeons like Atul Gawande and PCPs like Doctor Rob, complaining that being a doctor also amounts to running a business. Funny, then, that so few know the costs of the procedures they run and the tests they order. I've seen complaints from numerous uninsured and under-insured patients who, knowing their financial limitations, tried to be fiscally responsible by getting quotes before committing to expensive procedures only to have the bills come in at levels three, five, even ten times the original quote. One of my favorites was a knee surgery that was quoted at $9K but that came in at over $45K because the surgeon, at the last minute and without the patient's knowledge, shifted to a procedure that he thought would result in a better prognosis for the patient. Oh, and the procedure change also meant the doctor would make a lot more money on the operation, which of course had no bearing on his decision.
Imagine your response if something like that happened with a contractor working on your house. Sure, contractors hit cost overruns all the time, but if one quoted you $9K to build a back patio brick barbecue and then charged you $45K because he'd a bunch of fancy new features and decided to change the plans--without approval--to incorporate them. You'd be livid. You'd sue, and you'd win. Doctors whine about the cost of malpractice insurance and the terrible bloodthirsty lawyers, but try suing for malpractice in a case like that. You can't find a lawyer who'll take a case that small. You could try suing in civil court without claiming malpractice, but good luck finding a doctor who would testify against one of his own in such a situation. They'd mutter something about standards of practice and that would be all she wrote.
Doctors, not just patients, fall into a form of complacency because the insurance company covers everything. Complications arose following my back surgery. Something was causing intense neuropathic pain down my right leg. The surgeon, concerned that one of the bolts might be scraping a nerve root, ordered an MRI. The pain source turned out to be a bit of fluid that eventually subsided on its own. Afterwards, I pored over my records and found that the hospital initially reported the total charges for the MRI at just over $4K. I wondered how much this would add to my bill, and I called to obtain the insurance company's copy of the payout. I needn't have worried. The insurance company essentially ignored the MRI, considering it part of the cost of the surgery. If I'd been uninsured, however, I would have had no choice but to pay the extra four grand. The system is *****.
Accountants know the cost of everything and the value of nothing...Doctors the value of everything and the cost of nothing...Descartes