Here is his last paragraph:

“Before we further remove ourselves as direct consumers of healthcare -with all of our beneficial influence on quality, service, and price – let me ask you to consider one more question. Imagine my father’s hospital had to submit the bill for his “care” not to a government bureaucracy but to my grieving mother. Do you really believe the hospital – forced to face the victim of its poor quality service, forced to collect the bill from the real customer – wouldn’t have figured out how to make its doctors wash their hands?”

This is just one article in a larger number of writings recently that have started to focus on how to accurately calculate / negotiate the true cost of care (thus saving money by comparison shopping and becoming effective healthcare consumers).    Compass is thrilled by the focus on what it believes is the key to controlling healthcare costs.  Unfortunately, some of the messages in these articles are misleading.

The true cost of care is what your insurance has contracted to pay your doctor or hospital.  The hospital pricing tools sponsored by hospitals typically reflect only the charge.  The charge is generally unrelated to the true cost of care which is set by a contract with your insurance company.  Likewise, services such as New Choice Health simply use Medicare cost data and multiply it by some factor to “estimate” what insurance pays.  Insurance contracts (and thus true cost) generally have no relationship to Medicare cost information which makes these estimates very inaccurate.  To accurately anticipate your cost and evaluate healthcare service providers you must have the agreed to price from the insurance contract or fee schedule.

It is this level of market knowledge that Compass brings to the table.  We help our customers get beyond rough cost estimates and use actual fee schedule / contract data to make provider choice decisions.  When you have the Compass level of support and knowledge, you can truly be confident of your ability to assess your market options as a healthcare consumer.

http://online.wsj.com/article/SB10001424052970203674704574328570637446770.html

Compass can help patients understand their options and can point them in directions where they can get more information so they can be both an informed patient and consumer.

The primary purpose of both physicians and hospitals is to serve and heal patients, often in a time of individual pain or crisis.  The patient, usually at their weakest point, has to place an extraordinary level of trust in their care provider to treat them both fairly, kindly and efficiently according to his or her individual value system.  While there are many forces pushing healthcare providers, violation of a patient’s trust shakes them to the very core.

It is easy for a healthcare provider to turn the other way when patients are not educated consumers.  Unfortunately, many providers use this lack of understanding or transparency to take advantage of the inefficiency inherent in the healthcare system today.  By educating yourself and communicating your personal quality and financial values to your care provider, you are putting them on notice that you are trusting them to deliver on those values.  If they do not, they will violate your trust and lose your business.

The business of healthcare is such that the tremendous amount of upfront fixed costs (whether in physical buildings or delayed earnings due to extended education) dictate that healthcare providers must care for a high volume of patients to make up those costs.  This is why the loss of you as a patient is so critical – not only does a care provider lose an opportunity to serve and heal but they also put their financial stability in jeopardy as well.  This causes immediate change and it is the only form of accountability that I have seen move major organizations and established physicians to change the way they operate and practice.

Become an educated healthcare consumer and use your power to change healthcare for the better.

Why is there a price difference? Different doctors have contracted with insurance companies for different prices for the same medication.

If you are looking for a new doctor and you think you may have one of these illnesses and require an infusion medication, ask the doctor’s office staff what the “contracted price” for the medication is.

If you only have a $20 copay then the price difference may not matter to you. However, a lot of people must pay their deductible and co-insurance on infusion medications. That $2,000 difference may be coming out of your pocket.

(http://www.boston.com/news/nation/washington/articles/2009/06/30/hard_choices_on_4_big_issues_stymie_health_push/?rss_id=Boston.com+–+Latest+news)

Issue #1 – Cost – $1 – $2 Trillion over the next 10 years

Consumers as ‘Stewards’ can lower cost by including cost in the healthcare decision making process. The doctor in the exam room and their patient must talk about cost. If a doctor and patient view healthcare as spending someone else’s money, costs will never be controlled. Incentives must be aligned so that as good stewards of health and healthcare resources, physicians can offer and consumers can receive equal–and often better–care at a lower cost.

Issue #2 – Employer Mandate

Consumers as ‘Stewards’ can reduce the need for an employer mandate by purchasing insurance on the open market. For employees who currently work for companies that do not offer health insurance, there is an option to purchase private insurance. A high-deductible plan can offer premiums that are affordable to many (but not all) people, however there is the issue of no coverage for pre-existing conditions. Our company–Compass–has helped just those sort of individuals obtain coverage and find affordable care for their conditions. It is not easy, but it does work. It takes knowledge of lower-cost providers, generic alternatives and drug-company and state sponsored pharmacy assistance programs.

Issue #3 – Government Plan

Consumers as ‘Stewards’ can mitigate the need for a goverment insurance plan by making private industry practices more transparent. There are abuses in healthcare on all sides–physicians, hospitals, insurance companies, employers, the government… and on and on. The best way to correct those abuses is to shine light on them and let consumers vote with their feet. To say that medical care is “too complicated for consumers to make an educated decision” is to go against the first tenent of medical ethics–patient autonomy.

Issue #4 Benefits Tax

Consumers as ‘Stewards’ can make better use of their health insurance benefits–and the associated tax-break–rather than giving that tax-break up. Many employers provide plan choices that offer more appropriate coverage for a lower payroll deduction or even a deposit into an HSA account. Given the right tools and support, consumers can translate that benefits tax-break into money in their pocket without sacrificing access to quality care and their health.

Independent of national healthcare “reform,” each person’s own “reform” of their healthcare position from passive patient to Active ‘Steward’ will improve their health, improve their access to care and do so at a lower cost.

http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?currentPage=1

Atul Gawande has laid out the underlying cause of high healthcare costs: Overutilization.

In my opinion, he has hit the nail on the head.

I want to make as few comments as possible so that the article can stand on its own, but I can say that addressing overutilization at the patient-physician relationship level is the best way to improve quality and decrease cost at the same time.

Physicians respond best to their patients. Having the government, insurance companies or large employers dictate practice patterns and treatment recommendations will generate tremendous push-back from physicians. No matter how well “proven” or well intentioned those recommendations, the shear fact of who they are coming from will discredit them by physicians. One can say that is not right, but in practice, physicians respond best to their patients.

As founder of a patient-advocacy and price-transparency firm, I am biased toward empowering patients with the necessary cost and quality information along with a patient-advocate to assist them as the model for healthcare reform. I think it is the best way to help people be better “stewards” of their health and of healthcare resources–improving their health and doing so in a sustainable fashion for the nation as a whole.

Much is in the TV news, magazines and professional journals about physician and healthcare quality. Usually the story is that quality is BAD… terrrible in fact. I am not going to tell you if your doctor is good or bad, but there is one thing YOU CAN DO to improve the quality of care that YOU receive PERSONALLY that does not require an act of Congress, a complicated health website or an episode of Oprah.

The #1 thing you can do is: TAKE NOTES

Take notes during your doctor visit. Take notes when you are in the ER. Take notes if you are in the hospital. Always have a pen and paper in hand. If because of your medical condition you cannot take notes, have someone else take notes for you.

Studies have shown that patients DO NOT REMEMBER HALF of what their doctor tells them and often they do not understand the other half that they do remember. Doctors and their staff move very fast. Most physicians are always in a rush. Combine this fast pace with complex medical terminology and it is a recipe for miscommunication.

Here is the second thing you can do related to the first:

READ BACK THE NOTES YOU HAVE TAKEN TO THE DOCTOR

You have to confirm that what you heard is actually what he or she meant. When I ask my patients to repeat back what I have just told them… I’ll be honest, the majority of them cannot repeat back to me what they need to do. It’s not their fault. They are not stupid. It is just miscommunication.

Reading back the notes to your doctor will also make him or her s l o w d o w n. The best surgeons I have ever worked with do not rush. The best cardiologist I ever worked with at Johns Hopkins never rushed. Very smart physicians, very ‘high quality’ physicians can make mistakes when they rush. Reading back the notes is a very non-confrontational way for you to make your physician slow down and this will increase the quality of the communication.

Let me give you an example for a person with diabetes. A very common list of instructions for this diabetic person at the end of their visit goes like this, “Your diabetes is not very well controlled. Your hemoglobin A1c is 9 and it should be less than 7. I want you to take your metformin twice a day instead of once. Your blood pressure is too high as well. Your blood pressure today was 156/90 and it should be less than 130/80. I want you to start taking a new blood pressure medication called HCTZ in addition to your Lisinopril. Then I want you to come back to the office in two weeks for a blood pressure check with the nurse and get some more blood work done to make sure your kidneys are ok, because you have had some kidney problems in the past. Also, you are due to get your eyes checked by the ophthamologist, so you need to make an appointment for that as well.”

That is a lot of information. Every bit in there is a “diabetes quality measure.” It is an unreasonable expectation to think that a person is going to remember all that. Write all that down and say it back to the doctor and I guarantee you will find miscommunication.

“Why is my hemoglobin A1c 9? When I check my blood sugar it is around 200. Why are the numbers so different?” — “Well, they are on a different scale. The hemoglobin A1c is a test we use to see how you have been on average over the last 3 months.”

“What’s metformin? I take glucophage.” — “Well it’s the same thing.”

“156/90?! Oh, that’s pretty good. Usually when I check it at home it is 180/90.” — “Oh, that is way too high. We’ve checked your home BP cuff and it is pretty close to the one here. Why didn’t you tell me that before? I am going to increase the dose of your lisinopril as well to 30 mg once daily. Here is a new prescription.”

“I’m suppose to go away on vacation in 2 weeks. I’ll be gone for 5 days. Can I just wait until after my vacation to come in?” — “Why don’t you come in at least 2 days before your trip to make sure everything is ok.”

“I just went to the eye doctor last month. Do I need to go again?” — “I had no idea you went to the eye doctor. I’ll have to get in touch with Dr. Lenz to see if you had any retinopathy.”

TAKE NOTES. READ THEM BACK TO YOUR DOCTOR. You will improve the quality of your communication and you will improve the quality of your care.

My argument to this point is that rather than sponsoring comparative-effectiveness studies, there are quite a few medical situations where there is a combination of scientific evidence and expert concensus by physician societies on more cost-effective ways of delivering quality care. BUT, those cost-effect, high-quality ways are NOT IMPLEMENTED. The greatest short-term opportunity lies in the effective implementation of the existing best-practices. The old proverb says, “To know and not do is to not know.”

As an example, a very large cost-component for employers and Medicare alike is acute low back strain. The evidence and guidelines point to pain management and physical therapy for a period of several weeks prior to imaging in the absence of several “red flag” signs and symptoms. The majority of patients spontaneously recover without further intervention. BUT, the physician recommends and the patient receives the $2,000 MRI anyway.

Mr. Obama points out that there is “informational asymetry” between the doctor and the patient, but my own personal bias is that the patient then needs an advocate to support them and counter-balance that asymetry. Give the patient more information about back pain, physical therapy, medication options, imaging options and surgical options. Give the patient more cost information that is directly translated into what it costs them out-of-pocket. Work with the doctor, not against the doctor. Support true collaberation between the patient and the physician in shared decision making.

“Absolute power corrupts absolutely,” said British historian Lord Acton. I’m a doctor and even I don’t want doctors holding all the decision making power.

Perform comparative-effectiveness studies and the losers in that game will work day and night to discredit the studies the people who perform them. Support and advocate for the patient where the rubber-hits the road and you will get better care for lest cost.

Here is what I tell people to say to their doctor:

“This test could end up costing me hundreds of dollars. I’d like to check with my patient advocate first to compare some prices in the area. Can this test wait a day or two?”

Let’s run through these three sentences one-by-one:

1. “This test could end up costing me hundreds of dollars.” The doctor has no idea what the test will cost you. The doctor has no idea what the terms of your insurance are, what your deductible is, what your coinsurance is and what your out-of-pocket maximum is. All of her patients have different insurance policies, so it is impossible for her to keep track. Your doctor does not want to bankrupt you, but you have to point this out to her.

2. “I’d like to check with my patient advocate first to compare some prices in the area.” The doctor has no idea what a patient advocate is or that the prices for the test vary by thousands of dollars. But, now is not the time to get into that. The doctor is busy and will likely not ask you about these two things. If he does ask, say “My patient advocate is my assistant for healthcare issues outside of the doctor’s office.”

3. “Can this test wait a day or two?” Most medical situations are not an emergency, but some are. The doctor may think that your situation cannot wait and you need to clarify with him that using your health advocate may take a day. If you have a swollen right calf, the doctor will want an ultrasound that day to see if you have a blood clot in your leg–this test cannot wait. If you have been having shoulder pain for 6 months, the doctor may want an MRI–this test can wait a day or two (it may take a week to schedule it anyway). The decision on the timing of the test needs to be made with your physician.

Your patient advocate will then work with your doctor’s office to make sure he is ok with where you are having your test or procedure done and you will not slow down the visit by more than 5 seconds.

Talk with your doctor about cost, then work with your patient advocate and you can avoid wasting $2,000 on an overpriced MRI.

It beats the alternative, which is frustration with the “system” and anger at your doctor or insurance company when you recieve your EOB and find out you owe a lot more than you thought.