Comments on: ACP: Embracing a culture of cost-effective health care

By: Rob

Rob — Fri, 17 Jul 2009 06:05:41 +0000

I completely agree Susan. I have an HSA with Kaiser Permanente and I’m responsible for the first $2700 of costs, yet it is virtually impossible to get cost/benefit information from doctors. Even though I’ve learned to routinely ask the doctor up front to notify me of additional costs/benefits, I’m frequently ignored and later I receive a large, surprise bill.

For example, recently I went to the doctor for a sinus problem–recurring sinus infection about 1x/2 years and slight pressure on right side by upper right cheek. Up front, as usual, I explained my interest in understanding costs. The doctor explained a cat scan would be the best tool for diagnosis but expected it wasn’t cheap. The doctor explained they would order one for me and let me investigate the cost to decide if I wanted to get it. Note I was told there was nothing serious to worry about based on my symptoms. (e.g. tumor) Then the doctor sprayed a bit of numbing solution in my nostril and proceeded to stick a flexible scope up my nose. I assumed this was a fancier version of the light they stick up your nose and that it was included in the $100 I already paid for my visit since the doctor said nothing about cost. Weeks later, I was shocked to receive an additional bill for $560 for this tube up the nose “procedure”–which took about 3 minutes–that I discovered was called a nasopharyngoscopy and laryngoscopy. By the way, during the appointment, there was nothing found.

Is that legal to ignore my requests for pricing information up front and do an expensive test without telling me? It’s akin to taking your car in for an oil change and picking it up with a bill for a complete diagnosis of the car costing $100’s of dollars. I know that’s not legal.

So, do I have any grounds to deny paying this bill?

By: Robert Berry, MD

Robert Berry, MD — Sat, 04 Jul 2009 14:24:33 +0000

I have a direct-pay primary care medical practice with about 60% uninsured and 25% high deductible patients that might help with this discussion.

Since these patients have no other choice but to pay out of pocket for routine medical care, I have to justify my recommendations to spend their money – or at least try and find the most cost effective diagnostic and therapeutic strategies. While the few commercially insured patients I have sometimes demand MRI’s for their back pain, direct-payers generally want to try conservative therapy for a month or so. And in reality, MRI’s rarely lead to surgery. Same with a lot of tests we do – if we aren’t going to do something with the result, why order it?

Rather than demanding Prevacid for their heartburn, direct-payers are willing to try Ranitidine 300mg qd (for $4/mo at WalMart) and/or Prilosec OTC.

Sometimes patients don’t want to take my advice – which is their choice. When I believe that a particular test is necessary I will write the order, write on their discharge instructions to have the test, and have them sign the instructions. It is up to the patient to finance his non-catastrophic medical care. If Americans on average spend $7000/yr on their vehicles, then the vast majority can pay for their everyday medical care if their priorities were in the right place.

If it is an urgent or emergency situation (like cardiac chest pain or surgical abd), I tell them to go to the ER. If we are going to have single payer, maybe we just need it for hospitalizations. That way the decisions for routine health care will be done more economically.

Some will argue that patients cannot make these decisions. You’d be surprised. If we take the time to discuss the options and the rationale, they are certainly more able to make these decisions for themselves than some faceless, non-medically trained bureaucrat. We will either decide to let patients make healthcare decisions with their own money or have bureaucrats make decisions for patients with the patients’ money. That seems to be the choice before us now.

And primary care docs can take the time if we don’t have $160/hr overhead staring us in the face everyday. Since I don’t take insurance, my overhead runs about one-third that. I know another direct pay doctor whose annual overhead is just $80,000 year and spends 30 minutes on average with patients. Direct pay for non-catastrophic care improves quality and substantially reduces cost while enhancing the experience for patient and doctor.

Perhaps its time to include this information in the national discussion on healthcare.

By: Michael Kirsch, M.D.

Michael Kirsch, M.D. — Tue, 30 Jun 2009 13:45:32 +0000

I have an HSA, but most Americans don’t. They have no ’skin in the game’ and have little incentive to verify that the recommended tests and treatments are truly essential. Look what happens in our hospitals. If patients and families had to bear a fraction of the costs of care, then ICU patients destined for heaven wouldn’t be probed by half a dozen consultants, each one generating costs and care that won’t change the outcome.

By: Susan H

Susan H — Tue, 30 Jun 2009 13:36:54 +0000

Are you certain pts are not taking cues from docs on testing?
Any patients with an HSA or flex medical spending account is eager to AVOID extraneous testing. HSA holders are frustrated by the inability to discover pricing for recomended med services, and by the WIDE disparity in test pricing.
Give patients a little medical and price info, then let them start to decide whether the cost of the test is worth the peace of mind they perceive it will bring.

By: Michael Kirsch, M.D.

Michael Kirsch, M.D. — Tue, 30 Jun 2009 12:01:13 +0000

I agree with the above comments that the patients’ demands fuels the cycle of excessive medical care and that harried physicians comply too often. While this is a reasonable explanation, it is our obligation to the patient and to society to provide only the care that’s needed. This would spare billions of dollars and would save patients from the risks of unnecessary medical interventions. I realize how busy we all are and that ordering a CAT scan is easier than having a 10 minute discussion, but this goes to the core of our professional obligations. If we give up on this, then we’re not really doctors.

By: Jay Moore

Jay Moore — Tue, 30 Jun 2009 05:22:46 +0000

I’d like to agree with Rezmed – there is one thing that Dr. Weinberger doesn’t mention in his article, and that’s the test that is done due to patient demand. When trying to fit five or six patients into an office practice per hour, plus answering phone calls and emails, it is often too easy to simply order a marginally beneficial test that a patient requests rather than trying to convince the patient to “wait and see.” When you treat a patient as a customer in a society where success is driven by a “customer is always right” mentality, it’s pretty tough to say no very often to patients and still maintain a healthy patient base.

By: edwinleap.com | Medscape Grand Rounds for June 30

edwinleap.com | Medscape Grand Rounds for June 30 — Tue, 30 Jun 2009 04:39:25 +0000

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By: Ayse

Ayse — Fri, 26 Jun 2009 14:07:20 +0000

reliance on testing over time might have created a culture of patients that trust more the lab and radiological tests than their physicians’ opinion.

By: Rezmed

Rezmed — Fri, 26 Jun 2009 03:39:06 +0000

How about the demands by patients for explanations, reassurance and placebo testing? In many of these discussions, the desires of our patients for “stuff” – tests, procedures is not being given enough weight. Most patients want that head CT so that they can walk out knowing they don’t have a brain tumor, which the doc knew they did not have. What is worse is that patients expect much more than they did 20 years ago. I think we have to at least suspect that the patients in McAllen, were happier after all those unnecessary tests, and caths compared with the patients up the road.

Part of the solution is to have a system that can say no. Patients must start paying the cost of dupicate testing, patients must start paying more for tests and procedures that are less evidence based. In our system no one says no, and if they do they usually are taking the path of greater resistance.

By: Ayse

Ayse — Thu, 25 Jun 2009 22:14:50 +0000

i am quite familiar with Weinstein’s work; he is well-known and respected with his work in health economics and cost-effectiveness analysis. in addition to changing the culture of medical establishment, we need to change the culture of public at large. we need to better understand the opportunity costs of choices we make and stuff we demand. as a nation we should decide what is more important to us because if we like to continue our acute and chronic medical care expenses at the same speed we are, we have to give up investing and funding scientific and technological advances that made our nation a leader once upon a time. we have to learn to better take care of ourselves and let go when the time comes. we should begin thinking our loved ones left behind to carry the burden of bankrupting medical bills. we cannot have it all.
BTW I love your blog!