Sunday, February 12, 2012

An educated consumer is our best customer

Here's a timely piece in light of Don Berwick's comments below, an RFP issued by e-Patient Dave deBronkart for treatment of his skin cancer.

He says:

The other day I announced my new skin cancer diagnosis and discussed how I’ll blog my approach to it as an e-patient.

I’ve decided to approach exploring my options by doing what companies do when they’re shopping for a solution: they write a Request for Proposals, and let vendors reply.

Dave even includes a copy of the RFP, in Google Docs.

Sy Syms, CEO of Syms Corporation, used to say in TV ads, "An educated consumer is our best customer."  Will that be the case in health care?  Will educated patients like Dave start perturbing the system to be responsive to their concerns about cost and quality?  Will hospital and physician groups respond achieve greater business success if they work with educated patients to determine the best venues and approaches for treatment?  Or is there too much friction in the health care world standing in the way of real customer choice?

By the way, Syms declared bankruptcy recently and closed all of its stores.


e-Patient Dave said...

LOL - thanks for the mention, but are you trying to scare people away from courting the educated consumer? :-)

I humbly submit that buying clothes (especially in a down economy) is fundamentally different from choosing a partner to cut you open, safely, and do a thorough and efficient job of removing a cancer. An honest price is important, but it's sure not the deciding factor.

In a down economy consumers routinely put off buying new clothes, or they might cut corners. I don't intend to put off treatment :-), nor do I intend to cut corners!

The RFP just says what's important to me. (That's where Lean starts, as you know well.)

e-Patient Dave said...

p.s. In this hurried link-skimming world of ours, I urge people to read my approach to my treatment before jumping to conclusions about the RFP. This is not about price shopping, it's about being a responsible engaged patient.

Anonymous said...

I doubt that this guy in any way represents what is possible for the typical patient. He gets his care from one of the leading teaching hospitals in the country and talks at medical conferences and has what appears to be 1000's of people who know about his illness.

Do you really expect that typical american with an 8th grade reading level will be able to negotiate with doctors who have no idea what services even cost?

The system needs to change as much or more then patients. Healthcare is NOT a consumer product it is something you need when you are ill.

Susan Shaw said...

Love this! This flips the traditional power relationship between a patient and his/her doctor completely on its head - which is what is needed. It will be interesting to see what responses e-Patient Dave gets. And I wish him the best as he seeks out his best treatment plan.

It may have absolutely no significance but when outlining some of the criteria he wants to consider, cost is listed ahead of all the clinical factors that he wants to put in play. A consequence of the his personal health history and insurance plan? Or am I just over thinking this...

e-Patient Dave said...

Anon 10:55 - thanks, I welcome the dialog. Let's have fun.

> I doubt that this guy in any way represents
> what is possible for the typical patient.

LOL - and, so?

> Do you really expect that typical american
> with an 8th grade reading level...

This is so funny - in 2009-10 when I started speaking about being an engaged / activated patient I heard the EXACT same things: gets his care from a top hospital, he's well educated (to a point...), etc. Today we have many known e-patients and they're no longer considered unicorns; one of the most famous is Regina Holliday, who heard in a policy meeting "Well, we here are all college educated" and replied "I'm a high school graduate."

Besides, what difference does that make? Isn't that a change of subject? Do car makers, or does Apple, respond to consumer preference by saying "You're not educated enough to have a want of your own"?

re trying to negotiate with doctors who don't know what things cost: Right! I'm saying I want one who does!

Perhaps not him/herself, but WHOEVER is doing the billing, I'm sick and tired of "Gee, there's nothing we could do about what you're being charged - even we don't know how it happens." Ridiculous!

As I said in the RFP, if an organization who bills me doesn't know the costs, I'd say they might be personally responsible for our health costs being... out of control. Y'think?

Everyone in healthcare seems to feel powerless to improve things. Well, I don't.

It's perhaps a fateful precursor that just a month ago my wife and got shingles vaccines (being responsible about prevention; being "compliant") and though we tried and tried to also be responsible about costs, the result was infuriating: insane or (IMO) perhaps even criminal; pandemonium, with people in the business not knowing that since 2006 Medicare Part D (prescription coverage) has been REQUIRED to cover vaccines. That only came out (with a link to the 2006 memo) after lengthy discussion on my blog. Check it out, including the comments. I learned from that social media discussion, so I'm doin' it again. No powerless "woe is me" here.

I don't know whether to call it a shell game, a slush fund, or a cesspool. In any case I won't stand for it. Places like Mayo give you a flat price, all in, and the only reason someone else wouldn't is that they're simply not as competent as Mayo at managing things.

Re a leading teaching hospital: who says I'm going to get this done there? They are certainly on my list, but they're one of the "perps" on my shingles vaccine debacle, and a few years ago I found they'd put many ridiculous mischarges in my insurance records. The presence of a great treatment team is no assurance of equally great financial controls.

Mind you, I'm not saying the workers there are fully empowered to know what goes on. I'm saying I don't wanna be the one who takes the hit anymore.

> The system needs to change as much or more then patients.

Agree! That's why I don't understand your opening comment about me not being typical (today). The surest way to drive change in an industry is for consumers to vote with their mouths and their feet.

Perhaps those eighth graders have more power (and unfulfilled wants) than we might think. Perhaps they Care About Their Care, as the Robert Wood Johnson program said last August.:-) Anybody want to say "Jeeze, consumers, knock it off"?

e-Patient Dave said...


> This flips the traditional power relationship between
> a patient and his/her doctor completely on its head

I want to be careful - this is not in any way anti-doctor. (Nothing I do is.) To the contrary, I'm seeking to honor the *best* practice, in all the aspects that I mentioned.

Yes, my being proactive about knowing costs in advance is a consequence of learning the hard way, including recently with the shingles vaccine, per the other comment I just posted.

Anonymous said...

Dave, great job putting this out there and provoking us to think about things, again. As one who also has a 10K deductible, I certainly know why you put cost first on your RFP, for what should be a minor procedure.
My experience with my large deductible has been that doctors are shocked when I mention it, and seem unable to deal with having to modify their recommendations based on it. I wonder if you returned to BID and told them this was your first priority, would they change their recommendation for Mohs.
The other thing I wonder is if it's even to your benefit to be approaching an academic medical center for this problem. Seems like the whole issue of 'going to Mecca' for routine care comes into play here.
(Caveat: if for some reason your complicated past medical history would come into play in treatment of this lesion, then of course an AMC would be appropriate. So it's worth asking that question, even if your ultimate treatment occurs elsewhere.)


e-Patient Dave said...


Well, heck, I don't know - I ain't all-knowing - all I said is "I'm thinkin' about it, here's what I want, and I'll find out what I can.":-)

Note, too, that I said this will not be a media circus, so I'm hesitant to talk about any one provider. No one provider is the point.

Anonymous said...

Dave, I'm not singling out one provider; just trying to differentiate between AMC's (your 'medical home' is well known) and routine providers here. That's part of the whole 'educated customer' problem; patients understandably have a difficult time deciding when they need a special center and when not. So should this be part of the doctor's job, to educate on that point also?


Susan Shaw said...

Good morning Dave
Unfortunately healthcare is sometimes more like buying clothes than we would like to think. People do delay their care when they have less economic security and higher personal costs. See here for just one example:

I'm a Canadian who wishes you didn't have to think about the financial side. And I don't think the RFP is at all anti-doctor. It's pro-shared decision making, which has been shown to be win-win for both patient and physician satisfaction!

Thomas Pane said...

Very interesting Dave and good luck to you. Without overstepping into clinical advice, I do think that these types of problems are ideal for your RFP approach; straightforward (usually) and can be handled in an office or ASC setting.

I find it odd that the folks who make up CPT values have different amounts for malignant or non-malignant neoplasms. For skin excisions, the work is the same.

The caveat is how to handle any positive margins etc. which can be covered in the agreement.

oc1dean said...

An educated patient is a wonderful thing but Amy Farber in working with the MIT Media Lab has a quotable comment on that. For the past five years Farber has been battling not only her own disease but also the wall of resistance erected by those who believe that a patient can make about as much of a meaningful contribution to the process of scientific discovery as a laboratory rat.

Diana said...

Simply brilliant idea. Keep us posted on his results.

Stephen said...

Paul - Syms' customers were educated enough, in recent years, to understand that they could get better merchandise at a better price elsewhere. At some point, they forgot the other side of the equation - namely that Syms had to identify their target customers and then offer goods that would appeal.

In medicine, there is no question that an educated consumer would do better. The devil is truly in the details here for a number of reasons. In no particular order:

- Good, up to date information on who is a good physician is lacking. That is one reason so many people brag that they "Got to see the Chief" and end up with bad results. It's because the Chief is way past his (mostly still his) prime as a clinician.

- Physicians and hospitals can't compete on price, e.g., offering appendectomies at a lower price with nicer rooms. In every market, there is room for inexpensive, small cars and big luxury cars. Both get you to the same place, but the consumer decides on the level of resources devoted to the effort.

- Even with co-pays, consumers barely know what things cost. Indeed, co-pays tend to mask the true costs.

- Insurance companies barely compete and certainly not across state lines.

There's more, but that's a start.

The solution is to eliminate employer paid health plans, allow insurers to compete, let consumers go it alone or band together, allow hospitals to operate alone or ally with other hospitals and physicians (let them advertise their results and costs to draw "customers"), same for physicians - all subject only to antitrust law (means no more Partners) and fraud law, i.e., organized chaos - what made this country great. No one told Jobs to start Apple or Watson to start IBM. They have ended up with different business models but both successful. Under this regime, organizations would become lean, mean, cost-effective and capable - or die. Any subsidies would be appropriated openly, not hidden as they are now, distorting incentives. And the best set of solutions would emerge. Regulation after regulation will never do it.

Anonymous said...

If anyone is selling health, it is you, Mr. Bronkhart, who deserve to have it wrapped with the highest skill and affection, and proffered with the greatest humility.

What you teach us about care, no medical school has figured out how to provide. Perhaps because you use different currencies...

Finally, they must test their meddle at this most challenging frontier of all.

Barry Carol said...

Two of the biggest problems in learning the cost of medical services, tests and procedures ahead of time are the confidentiality agreements that preclude providers from disclosing actual contract payment rates as opposed to list prices to patients before services are rendered and a physician culture that doesn’t consider it part of their job to know or care about costs, especially when a third party insurer is paying most of the bill. Sure, doctors’ first job is to diagnose treat, consult with and advise patients. However, as the key drivers of most healthcare spending, they also need to factor the wise stewardship of society’s limited resources into their practice patterns. Cultures are hard to change but, hopefully, not impossible.

e-Patient Dave said...

Barry, thanks very much - you've posted many useful comments here but this is the first that's directly benefited me.

I get it about docs not being in on the business end of things. So I presume the BUSINESS PEOPLE would respond.

As it happens, not a soul has reached out to discuss responding, so I'm starting to do the reaching. Interesting exercise.

And re the confidentiality agreements: I have a feeling that when this is over I'll be expressing myself about what a cesspool this is - worse, it's a shell game conducted in a cesspool. I wrote about that last month when I couldn't even find out the real cost of something as simple as a shingles vaccine, let alone surgery.

I'm starting to think it's no wonder US costs are out of control - nobody can SEE them, let alone control them. Cesspool.

oc1dean said...

Think about a veterinarian, you ask for the price of a surgical procedure and they will be able to tell you the cost. An RFP to vets would take no time at all

e-Patient Dave said...

Well, to be fair, oc1dean, vets do have infinitely fewer regulations to deal with. (My wife's one, and we compare notes.)

On another site today, discussing this, a doc noted that he and his colleagues aren't allowed to charge less than they charge Medicare. (If anyone here knows that that's false, please let me know - I'm exploring, learning.) (And you never know who's saying what on the internet...)

Bart Windrum said...

Late to this party. Ancecdote: ~2005 routine colonoscopy. Got the preauth. Also got a $400 bill for the "facility." WTF? Insurance wouldn't budge. Disputed w/clinic who also wouldn't budge. Sent lead doc a letter and my doc picked it up. He dropped the facility charge. Along the way early on some gal at the clinic tells me on the phone "when you cross over from carpet to linoleum you've entered a facility." Burst out laughing, disrupting all the other cube-o-philes at the healthcare IT corp that bought the startup I'd hired onto. I mean, jeez: I was on the friggin gurney when it/I crossed over into the (in-house) facility.

Part two: needed a skin blemish frozen. Instead of DIY-ing with Dr. Schoals freeze-it hit the PC office. Bill came for over $200. THEY CODED THIS AS SURGERY. Um, I thought surgery by definition is about cutting through skin.

And the insurance would have gladly had me pay a copay indefinitely for an oxygenator, and my choices didn't even include those known to be low decibel machines. I found one online at a great price and paid cash. Because I went outside of insurance it was not even allowed against my also high deductible ($6k, not $10k like Dave's).

Researching cost options for my wife's dental implant, the moment I mentioned "my wife" instead of, for instance "me" or some proverbial entity they clammed up tight. Now I keep all our Power Documents in all our cars so I can run in, have them make a copy, and be done with clearing the HIPAA hurdles. Until, that is, her PC clinic demands to use their own friggin release form and not want to accept the one our lawyer drafted.

And on and on.

e-Patient Dave said...

Great harrowing tales, Bart.

And that sort of thing is why lately I've started to puke when people claim that lazy slug consumer/patients are a central cause of out-of-control costs.