Why we need an economic informed consent

The next time I receive medical care, I want to know how much it will cost before I agree that it will be done — and that includes no matter who pays the bill.

And, doctor, I want you to know and I want you to care how much what you prescribe is going to cost me or somebody.

You say it is beyond your control to know? I say, insist.

Rise up, as one, and demand to know.

If I go into a department store, or a restaurant, or a bar, or a supermarket, or online for theater, or a football game, or airplane tickets, or a hotel room, I will know how much I will have to pay to obtain whatever it is I want before I close the deal.

Why have we as a society allowed medical care of all sorts to be so different? Are we just a bunch of ninnies?

Not knowing, or sometimes even caring about the price of a surgical procedure, a diagnostic test, a biopsy, an MRI, a hospitalization, an emergency room, or urgent care, or primary care, or specialist office visit is routine.

Recently, some politicians in — of all places — Florida tried to change at least a little bit of that nonsense.

But some elements of the Florida medical industrial complex rose up to smite those silly legislators. Didn’t they understand who is in charge?

I believe that we patients should, if mentally competent, and in a non-emergency, non-OR, and -ICU situation, be provided an opportunity for an “economic informed consent.”

Medical decisions are increasingly shared decisions. However, a frank discussion about the comparative costs and charges for the options, whether the payment will be by the insurance company, Medicare, Medicaid, or out-of-pocket for the patient, or shared, is usually missing.

Of course the medical marketplace does not behave like other markets; it is rigged by so many factors and groups.

Consumer-driven healthcare truly cannot grow in importance and frequency unless costs, including costs for referral, are knowable.

The attitude that “if insurance will cover it, do it” lies at the root of our problem of healthcare cost inflation. No one is held accountable.

If we as a country could widely apply the “economic informed consent,” physicians and patients would become educated together to become wiser shoppers.

Most of us in healthcare laud “transparency” — let that include economic transparency.

George Lundberg is a MedPage Today Editor-at-Large and former editor of the Journal of the American Medical Association.

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  • buzzkillersmith

    Dr.Lundberg is right that opaque pricing is indeed an evil in health care.  Add it to the problem list.

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    Agree wholeheartedly with Dr Lundberg!

  • http://pulse.yahoo.com/_3CY2U67646G7UIAHBQVTT2UP4Y Kristy S

    This article is very good, and something that I have to wholeartedly agree with as well.  I think this becomes especially important because of how expensive some treatments, tests, etc can be as Dr. Lundberg mentioned.  Also by knowing the cost it helps to further open up discussions about affordable treatments that can help take care of chronic medical conditions.  Job well done Dr. Lundberg.

  • sFord48

    So is that quote for medical care going to include a price for all the possible complications or do I get treatment for those complications for free?

    Do I have to pay for the doctor’s mistake or is the doctor responsible for giving me what I paid for?

    Other markets consider these things.

    What if a doctor provides medical care without my agreeing to the cost?

  • Chris OhMD

    Great article. Only in healthcare do we find such inefficiency – providers do not know how much tests/meds cost and patient do not know how much they owe until they get a bill 3 mths later. What other industry allows this? Good news is that I think that is coming to an end. Many startups are making both prices and treatment options transparent to the consumer (i.e.patient). e.g. http://www.castlighthealth.com/

  • http://www.facebook.com/abcsofra Deborah Murphy

    I second that! And I do ask every single time for every single test not just the cost but is it actually needed and why? Often the order every test out there isn’t always the best thing to do. I have to admit that I was astounded when my endo doc actually discussed various option on following up on thyroid cancer as compared to my particular case. CT has been one of the standards for f/u but he mentioned that the expose to ct radiation and the cost over the years can also be a concern and we discussed my personal options given recent blood workup. I love when doctors have the knowledge we want to understand and cost IS one of those pieces I for one want to know. And not just the part I must pay out of pocket but the overall billed cost. And yes, I do review every single bill sent to me for FYI…this is what the insurance paid to see if I consider it reasonable and accurate. Wouldn’t you love to have an online program to search various offerings and the costs in one’s community (like healthcare options and costs) to see what one we as patients might want to go to.

    • dontdoitagain

      Deborah, you are so right!  With my health care debacle, I did ask ahead of time what each thing would cost.  I had a broken arm that looked pretty good after I manually reset it.  I had no money, no insurance and my job wouldn’t give me insurance until I had been there a year.  The hospital told me $3,000 dollars.  My surgeon told me 1700 for the surgery. I didn’t even want any surgery in the first place, doctor convinced me that I would be a cripple if I didn’t have it!!!!  (a lie)  I declined the MRI and was accused of being a non compliant patient, but surgeon “did me the favor” of not REQUIRING an MRI, since I couldn’t pay for it anyway.  $4,700 I could budget for, right?  Not quite.  My fake “doctor” anesthesia provider (crna) decided that I could pay for his services along with sedation and general anesthetic.  Which I had declined.  My surgeon decided to be over an hour late, so I got to pay those charges, extra time in the PACU, extra money for “tiers” of nursing, lots of money for booties, blankets, radiologists, flouroscopes, blood pressure machines, cast material, all those anesthesia drugs, the LMA, tubing, etc. 

      Needless to say I was presented, not with the expected $4700, but with a bill which totalled around 15,000 bucks.  Even the surgeon’s fee went up!  It became $2300!  How was I supposed to pay this?  Nobody gave a damn.  I begged for the no-frills, which works best anyway!  I had two open femur reductions without sedation or general anesthetic by choice!  No excuse for what I got for my ORIF distal radius.  I also had to have a couple of years of counseling to get over the shock of how badly I was treated, some doctor visits to get rid of the hospital aquired kidney infection (more expense) and a second surgery to prevent the problems from the first one crippling my hand.  So $30,000 for a broken arm…  AND I sustained permanent nerve, tendon and kidney damage from these people.

      Unless our legislators put some teeth in the so-called “informed” consent and some laws pertaining to price (gouging) transparency, we are doomed.  This happened 6 years ago and obviously I have not gotten over the shabby way I was treated.  I did everything right and STILL got taken to the cleaners!

  • saraeanderson

    Lots of professionals have a fiduciary duty to their clients.  Doctors should too.  

    • http://www.thehappymd.com/ Dike Drummond MD

      WOW … now there is a cross pollination idea Sara. I am a doc with Commercial Real Estate experience and completely understand what “fiduciary” means. That is a concept that would meet with open mouthed stares of incomprehension from doctors and at the same time is a great idea to introduce to the profession. How can we make that happen.

      Dike Drummond MD

    • http://www.facebook.com/people/Michael-Rack/100001703895437 Michael Rack

      The duty doctors have to their patients is similar to a fiduciary duty:

  • http://twitter.com/Hootsbudy John Ballard

    This deserves whole pages in magazines and newspapers everywhere.
    Where do I send a contribution to make that happen?

    (Lord knows it will have to be paid for. That medical-industrial complex mentioned above has very deep pockets and will punish any media outlet that dares put it up as a PSA.)

  • Bradley Evans

    Hospitals use price discrimination. What price will they post, I wonder?

  • http://www.thehappymd.com/ Dike Drummond MD

    I totally agree that ignorance about what something (anything!) costs in healthcare is insane and at the same time it is universal.

    If you speak with an office/hospital that accepts insurance … when you ask “How much does this cost” about any procedure or service … the staff won’t know – please god don’t ask the doctor because they are the MOST out of the loop … and will not be able to find out without giving you a call in a few days. AND if they were truthful, the only honest answer is “It Depends” … on your insurance.

    In this environment, doctors are trained to charge as much as possible (with appropriate documentation of course). So if you walk in and want to pay cash and get the best deal … good luck. The most likely response you will get is … “no one has EVER asked us that question before”. Just tried to get an outpatient pre op chest Xray for an elective surgery … took the better part of two days to even find an office in the Twin Cities that could accept a check and tell me how much to make it out for. Crazy … and totally “Normal” in the current system.

    Dike Drummond MD

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    This is nice, but very hard to accomplish. Instead, how about requiring payers to publish for public access their contracted rates to all providers (by name and address and TIN), for all services (by CPT, or DRG, or name)?

    Make a web page or mobile app where one can enter Payer, Plan, Procedure and Provider (call it 4P or Peas4Patients), and voila – the dollar amounts display, including patient responsibility, if insured. For the uninsured, display highest and lowest contractuals in the area, so they have an idea where things may end up. Simple.
    Anybody volunteering to persuade payers to disclose contracts? :-)

    • http://twitter.com/Hootsbudy John Ballard

      Outstanding idea. Products come with instructions, warnings and usually written warranties. Services have “terms of service” clarifying what they can (or will) or won’t do. Financial transactions are required to have “truth in lending” and other such information. Consumer warnings and advice appear on everything from tobacco products to OTC medicines. TV drug commercials now recite a list of ominous side effects (“tell you doctor if you have thoughts of suicide”) and the list is endless….

      A consumer advisory about medical procedures is long overdue.How about a warning saying…
      “We have no way to predict how much this course of treatment will cost. The patient is therefore advised that the financial consequences of this procedure may wipe out most of his net worth leaving him and his family destitute.”

  • http://www.facebook.com/kim.ellison1 Kim Ellison

    Thank you, thank you, thank you.  The lack of pricing knowledge to consumer patients and variable pricing of healthcare providers has a hidden cost of its own.  Many times I’ve sat in physicians’ offices or in hospitals and noticed all the administrators that are needed to manage payments due to variable pricing and the diversity of insurance and other documents needed for payment.  It is quite possible that if more structured pricing were put into place the inefficiencies that drive up costs might be better contained.  This is the only industry I know of where the buyer does not know the price ahead of time.

    • http://www.facebook.com/people/Michael-Rack/100001703895437 Michael Rack

      “This is the only industry I know of where the buyer does not know the price ahead of time”.  I can think of several other industries- including the auto industry and home industries- the buyer only knows the max price (for autos, the MSRP).  I think doctors should have to publish their max prices (the undiscounted, out-of-network rate).  I personally would be willing to do so if it wasn’t an anti-trust violation.
      Michael Rack, MD

  • http://www.facebook.com/people/Ardella-Eagle/100003689610855 Ardella Eagle

    Dear me, must patients be fed like infants? Ask and ye shall recieve, people!

    There is price disclosure IF THE PATIENT BOTHERS TO ASK IN ADVANCE.  Pricing to the patient can vary dependant on the insurance, but a good biller will either know that information or be able to get it fairly easily with a telephone call.  I also find it difficult to believe that an office won’t accept first party payor.  Granted, I understand that the doctor’s office may not handle money in today’s outsourced billing enviorment, but if the patient is willing to pay, a bill can’t be too hard to generate.

    If the doctor outsources for labwork or such, why would you expect the doctor or the staff to know the pricing in a different office?  Yes, how nice it would be for an app something like what is pipedreamed about here, but comparison shopping is only relevant to those who have no insurance.  Insurance guarantees the same price at PARTICIPATING labs.

    I know from my own experience that I get information that I need and ask for.  If I ask the staff for codes so I can call my insurance to find out if a procedure is covered and what I might expect to pay on it (now there’s a Black Box that’s hard to crack open!  The fee allowance schedule), I get it.  An honest office will do it’s best to give the patient what they need.  Heck, I’ve had patients needing in-office laser surgery and asking me what their insurance will allow (if they allow) on it so that they can decide right there and then to have the procedure done.  It’s called being responsive to the patient’s needs.  When did that leave the art of medicine?

    In non-emergent situations, let start seeing some responsibilty from the patient’s end.

    • http://twitter.com/Hootsbudy John Ballard

      Question – If the doctor outsources for labwork or such, why would you expect the doctor or the staff to know the pricing in a different office?
      Answer — For the same reason that the contractor building a house should have a good idea what it will cost for, say, the electrical system or installing the plumbing.  

      Surely the primary care physician is not that different from a general contractor.  In a market-based economy the reason for expertise of professionals is precisely that: to be an advocate for the client, patient or customer. Come to think of it, YES, being fed like an infant is not a bad analogue for how a physician best cares for his patients. He or she should do for them what they cannot do for themselves, including protecting them from financial infections as toxic as any caused by viral or bacterial sources.

      • NewMexicoRam

        Oh, so the Primary care doc is the general contractor, you say?  At least contractors have the right to determine what they want to be paid from the contractee.  Primary care is TOLD what they will be paid by the insurance company.  And now those “behind inflation” fees are supposed to cover the extra work to find out all the other fees involved?  Medicare has given me a 6% raise over the last 12 years.  That’s 6% TOTAL.  And my practice is 80% Medicare.  

        No thanks.  When the patient becomes more responsible for paying what I think my actual fee is for providing the whole package, then I’ll do it.

        • http://twitter.com/Hootsbudy John Ballard

          Okay, okay. Silly me. 

          I was just using the language of the many defenders of The World’s Best Healthcare who so strongly oppose government involvement, even arguing that the “commerce clause” has been hijacked and distorted by political types with some hidden Socialist agenda. 

          I stand corrected. 

          My confusion can be explained by a naive belief that the word cost actually reflects the sum of real expenses (supplies, professional services, various overhead costs and depreciation, etc) + reasonable margin of operational profit.

          I’m just melting with embarrassment that I didn’t know about all these behind the scenes contracts and secret negotiations. I’m starting to feel like a female applicant to the Augusta National Golf Club. Perhaps the Supreme Court will overturn the entire PPACA  and members of Congress will respond by crafting an easy to read, bipartisan replacement that will make everybody happy. 

          I, for one, want more than a pony. I will need a boarding stable and at least two years’ supply of food and veterinary care to come with the package.

      • http://www.facebook.com/people/Ardella-Eagle/100003689610855 Ardella Eagle

        Mr. Ballard:

        I’m in favour of people being an active participant in their healthcare.  Part of that is being conscious of all aspects that it will involve, including financial. You likening a physician ‘protecting the patient’ is fair, but it isn’t spoon-feeding to an open mouth which was my analogy.

      • https://me.yahoo.com/a/8lPLyDsl3uS.LfDfaSVX3iw8FEhj7vq1#44b0c joe

        Mr. Ballard just what gives you the idea medicine is a “market-driven” economy? When the third party system came about each payer has different contract agreements with providers for each thing provided.  As alluded to these contracts are far from public knowledge. Heck most people I have met have little clue how much their company pays for their healthcare (not their own contribution though). Yes this is “that different” from a contractor in a market-based economy. Talk about a waste of money, I have never met a contractor with the army of billing specialists docs have just to negotiate the maze of billing agreements. I think any doc would agree that simplification would be good for them too. Should the contracts be public knowledge…sure and good luck getting the payers to agree to that. The only way we are going to have transparency in pricing is by truly going back to a market-based approach and cutting out the insurance company middleman.  The way medicine is going with INCREASED government involvement the day you think that will happen will be the same day I believe in the easter bunny. Tell me Mr Ballard given photo I suspect you have filled out a few more tax returns than I. Have the returns (and the taxcode) become more or less complex?   

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        John, the truth is that one doctor does not know what another will be paid for a procedure by the insurer. It is illegal for doctors to communicate pricing amongst themselves.
        The whole system is so complicated that most often even billers don’t really know what an insurer will end up paying them on a given claim. They just bill way higher and hope for the best.

        If we want price transparency, “someone” should force payers to disclose all their contracts to doctors and the public at large. It won’t be a pretty picture, I guarantee.

        In the meantime, if you are uninsured, go look at the Medicare fee schedule, which is public and does not vary between doctors in one geographic region. Take that number, multiply by 1.5 and more than likely, that’s what you will end up paying, unless you go to one of those monopolistic, heartless, and all powerful health systems.
        Don’t ever agree to pay the “billing” rate, i.e. what the doctor or hospital bills the insurer for, because nobody ever pays that rate. It’s a fictional number.

        • http://twitter.com/Hootsbudy John Ballard

          Margalit, do you remember some time ago our discussion of how so few medical professionals know the difference between “corporate profits” and “professional compensation,” two items that for accounting purposes are on opposite sides of any balance sheet?

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            I do, John, and this is a sad commentary on the “business” skills of those who are in business for themselves. It is also most likely the main driver for the panicky wholesale of private practice to hospitals, which is very unfortunate, because those few physicians that understand the business aspect of medical practice, seem to be able to hold out just fine, and barring unforeseen disaster, will probably survive the current wave of insanity.

  • http://profile.yahoo.com/5CKJTDJQ7RSCEDKDAGDWXI2K74 jkh

    You forget that insurers are the ones calling the shots if you have insurance. If you find out the price of a CAT scan and the doctor has told you to get one and you refuse, insurers may refuse to pay for your other medical expenses because you refused medical advice… etc. It isn’t patients or doctors running the prices and approvals for procedures, its the insurors. And when you have multiple doctors and conditions, an endo, a nephrologist, a cardio, a pulmonary, a primary – they are expected to know pricing for each others services and procedures – what there needs to be is ONE MEDICAL COORDINATOR or MEDICAL PATIENT ADVOCATE to pull all of the information, pricing, treatments, dx etc. together for the patient and family members. And to my opinion, btw, everything medical and including dental expenses are too expensive period whether paid for by the individual or the insurance companies. The out of pocket maximum and high deductible plans have not helped but will be the downfall of many more families when catastrophic illnesses or accidents occur. For now insurance companies win win — they pull in high premiums and with HDHPs they rarely have to pay out any claims!

  • bspa

    I recently had a procedure done.  I was told the insurance co. provided authorization, but it seems it only provided authorization for the doctor doing the procedure, not for the facility and not for the anesthesiologist.  Now I have a huge bill and this mistake will never be made again.

    • http://twitter.com/therealcost WhatsTheRealCost.org

      You’re right – that is a tough one to learn the hard way. It’s also an example of how complex and fragmented the delivery system is. Doctors’ offices are very good about telling us wha’ts covered, but it’s important to call the insurer ourselves to find out all the costs related to a given “episode of care.”

  • merc

    Smartest suggestion I’ve heard in years.  If Obama would get behind this, I would vote for him.  Otherwise, no vote.

  • http://www.mightycasey.com MightyCasey

    Any time you visit a doctor’s office, or an imaging facility, ask what the visit and attending activities will cost. Sure, initially you’ll be met with more blank stares than answers, but the more we ask, and push for answers, the more answers we’ll get. Patients need to act like participants in their care, not passive objects…

  • jeanne_at_clearhealthcosts

    Great piece. Neel Shah over at http://www.costsofcare.org/  and Martha Bebinger at http://healthcaresavvy.wbur.org/ are other entrants in this ecosystem, along with http://www.goodrx.com/. 
    We’re working on the problem too, at http://clearhealthcosts.com/. Look for our relaunch soon!

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