• How the health system fails consumers

    About her own care, which she describes in JAMA, Nancy Kressin asks,

    Why was I unable to negotiate a more conservative and less costly path for my own care? How could I, as a patient, have combated the forces driving the rush to diagnosis, or garnered more support for an empirical trial of medication to alleviate my symptoms and potentially illuminate their cause? Although I am a health services researcher and medical school faculty member and am aware of the issue of overdiagnosis—enough to question whether I really needed endoscopy immediately, or whether a few more days of watchful waiting with the changed medication dosing might suffice—I deferred to the clinician’s knowledge and experience, and scheduled the test, knowing my insurance would “cover it.” Had I realized in that moment that even with this coverage, several hundred dollars of out-of-pocket expenditures were in the offing, I may have protested further, but I didn’t have that information until after I underwent the procedure and received the insurance company’s “explanation of benefits.” There had been no discussion of the cost of the procedure with the clinician.

    She points to some signs of hope in nascent and ongoing initiatives (PCORI, Choosing Wisely, etc.), but we have an awfully long way to go. In large part, there is just not enough up front discussion and planning. We’re too quick to test (and be tested) and to treat (and be treated) and too reluctant to talk (and ask questions). Yes, the incentives are wrong, but so is the culture.

    The health system has been failing consumers too long. We can do better.


    • Mostly, we are consumers of healthcare insurance, and, even then, we are mostly recipients of healthcare insurance that our employers have purchased. Nice attempt to make it look like a market though. Better title: “There are basically no consumers of healthcare.” Are you aware that your “nuance” abandons you at predictable occasions?

    • I take issue with that article on one key point — the commentator states she was upset because she didnt know that she would get hit with a huge out of pocket payment for the endoscopy.

      Really? That is HER fault, not the doctors. This was NOT an emergency endoscopy, she had plenty of time to call the insurance company, look online, and find out how much she would have to pay for the test.

      • Though I agree it is relatively straight forward to learn the extent of one’s coverage, it is famously hard to learn the price of care. To the extent the copay was a function of price (e.g., a percentage), I do not fault the author for not knowing the amount. Try it yourself. Go shop for a procedure. Go get the prices. This has been attempted by many and accomplished by few. It’s not evident to me this is the fault of doctors in all cases, but the price opacity does benefit them, so they do bear some responsibility in participating in a solution. Some are. Some aren’t.

    • I recently had an experience almost identical to the one Dr. Kressin describes except my gastroenterologist prescribed a CAT scan and a colonoscopy along with an upper endoscopy to diagnose lagging lower abdominal pain. I might add that these were prescribed before performing a physical exam or even so much as glancing at the films provided by my primary care doc. Unlike Dr. Kressin, however, I refused to undergo the procedures. Sad to see specialists selling procedures this way.

    • I work in a medical office. We try to provide out-of-pocket cost information on procedures and find it increasingly difficult to obtain that information from insurance companies — it may take multiple internet searches plus phone calls. Our fees have little or nothing to do with what we are paid or what a patient will end up paying. Because of contracts, reimbursement rates are set by insurance companies and we are forbidden to balance bill, we may only (try to) collect the deductible, out-of-pocket or co-pay determined by the insurance company, assuming we are performing the procedure for what they deem to be a medically necessary reason.

    • My experience is that if you let your Doctors know that you are paying they find cheaper alternative for you.