Monday, June 29, 2015

Did you expect otherwise?

In an example of a study that was not worth doing, John Commins at Healthleaders Media reports:

Only about 25% of internal medicine residents say they know where to find costs estimates for tests and treatments and that they can share those estimates with patients, according to a survey by the American College of Physicians.

The cross-sectional survey questioned more than 18,000 U.S. internal medicine residents who took the Internal Medicine In-Training Examination in October 2012. The study was published in the June issue of Academic Medicine: The Journal of the Association of American Medical Colleges.

"I was surprised that so few of the residents knew where to find costs of tests and treatments and that so few of them incorporated costs into any clinical decision-making," says study co-author Cynthia Smith, MD, ACP's Senior Physician Educator. "Patients are picking up more of those costs out of pocket and so they start to ask 'what are the relative costs?'"

Dr. Smith shouldn't be surprised.  Over two years ago, Massachusetts passed a law--the first in the country--requiring health care facilities to make prices available to consumers.  The effective date of the requirement was October 1, 2014.  The result?

The Pioneer Institute reports:

It's very difficult for Massachusetts consumers to get information on the price of medical procedures, according to a survey of 22 out of approximately 66 Massachusetts acute care hospitals and 10 free-standing clinics.

"Most Massachusetts hospitals don't seem to embrace a culture of price transparency," said Pioneer Senior Fellow in Health Care Barbara Anthony, who authored the report, "Massachusetts Hospitals Weak on Transparency" with assistance from Scott Haller. "Most hospitals barely comply with the minimum requirements of state law when it comes to making price information available to prospective patients."

Pioneer sought prices for one common procedure - an MRI of the left knee without contrast. While it was ultimately able to get the information from all 10 clinics and 21 of the 22 hospitals, the process was time consuming, confusing and replete with long rounds of telephone tag. Anthony concludes that "busy consumers will not have the time to doggedly pursue this information and instead will likely give up in disappointment and frustration."  

The time it took to obtain the information ranged from 10 minutes in rare instances to six or seven business days, with an average of two-to-four business days. Clinics were generally more forthcoming with price data than hospitals were. A 2012 state law that took effect in 2014 obligates hospitals, physicians, and clinics to provide prospective patients with prices for a medical procedure within two days. Insurance companies are required to provide the data online in real time. 

If hospitals haven't even been able to comply with the law, what chance do residents have in answering such questions? In fact, I'd doubt whether even the 25% figure is really accurate "on the ground."  Do you believe it when the study reports: 4,187 of 17,633 respondents (23.7%) agreed that they "share estimated costs of tests and treatments with patients"? (There would also be no way for the resident to know if such tests or treatments would actually be billed to the patients, as they cannot possibly be aware of the details of the patients' insurance plans.)


Unknown said...

In 2007 as a Chief Resident in Pediatrics, I attempted to gather some basic cost information to share with my trainees. After all, it seemed reasonable that they should understand that there was a cost differential between HCT and a full CBC, UA vs UA with micro, sedated vs non-sedated MRI, etc. I was shocked at how opaque pricing was even within our own hospital, much less across different systems!
Now, as a patient with a high-deductible plan through Kaiser, I get to see those costs in my bills, and they can be pretty ridiculous. I understand that a lot of pricing opacity is due to closed insurance negotiations, but I would propose that those need to be open to public scrutiny.
Thank you for your continued efforts to point out the dark underbelly of health system and insurance price fixing!

Unknown said...

Your comment that the study was not worth doing may be a little harsh. When I was in business school, many years after practicing clinical and preventive cardiology, several physician classmates and I asked ourselves what it "cost" patients to have procedures that we do frequently (TURP for a head of urology, Various Stress Tests for me, and pacemaker implantation for a senior EP physician). None of us knew!
This study has some data, however robust or not it may be, that confirms many anecdotes that I have elicited or otherwise heard. There have been a couple of studies that when physicians are aware of the costs that they generate, they become a little more parsimonious. However, as Dr. Willett and Ms. Anthony have demonstrated getting pricing is difficult.
Hospital charges, from the "chargemaster", as you have previously pointed out are not really "prices". What would be most informative to patients might be what the patient's co-pay, after insurance payment (and associated discounts) have been applied.
Getting these data would be incredibly difficult, but should be helpful to patients (and their treating physicians).