I’ve written before
about the almost comical lack of transparency in health care pricing, such as
the inability of hospitals to quote their own prices for hip
replacements or ECGs. Yet the fodder for illustrating this problem just
keeps on coming.
A recent survey
by Okike, et. alia in Health Affairs
focused on orthopedic surgeons at seven U.S. academic medical centers. The 503 respondents were asked to estimate
the cost of thirteen commonly used orthopedic devices. Only 21% of attending physicians (and 17% of
residents) could guess within 20% of the actual cost of the devices…although
I’m left wondering where the authors were able to get the “actual” costs
from! What is even more startling is
that their guesses ranged from 2% of the actual price to 25 times the
price. Eighty percent of respondents
felt that cost should be moderately, very, or extremely important in device
selection, but obviously they lack the necessary information to make such
evaluations.
I’d be curious how close the costs ranged between
the seven institutions that participated; in both the hip replacement and ECG
studies cited above, the prices ranged about tenfold for the few institutions
that could provide them. It makes one
wonder if lack of transparency on prices is often as much due to embarrassment
as any desire for secrecy.
Patients aren’t much better about costs. A recent survey
by the Altarum Institution found that only 32% of patients had asked for cost
information prior to obtaining health care services in the past twelve months,
and 35% had tried to find quality information.
Frankly, I’m surprised the numbers are that high. Eighty-one percent claimed they were
comfortable asking for cost information from their doctor, yet only 46% had
ever done so. And, really, what are the
odds they’d be able to get an accurate answer if they were bold enough to ask?
Only about a third of patients had any confidence in
their ability to reduce their costs by trying to shop for lower costs, while
slightly over half thought they could use quality information to pick better
doctors. The vast majority – 88% -- felt
costs are too high, but were fairly split about whether there is anything they
could do to impact them. Patients still
blame the usual suspects – insurance companies, pharmaceutical companies and
the government – for high costs while largely absolving themselves, their
doctors, even hospitals and lawyers.
The “good” news from the Altarum survey is that
patients strongly say they want to be very involved in their health care
decisions – 16% want to be completely in charge, 43% want the final decision
with input from their physician, and 33% want joint decisions with their
doctor.
It seems patients want responsibility but usually
still don’t take it. Everyone wants them
to assume more responsibility – as illustrated by “consumer-directed” products
from the payor side and “patient-centered” care models from the provider side –
but we’re a long way off to making that a reality. ONC has just released
its vision for “Person @ Center,” with goals for increased self-management and
prevention, seamless interaction with the health system, and shared management
of health care, all supported by technology.
It hopes the new paradigm is in
place by 2020. That seems like a long
way off for something all parties say they want, but I’m still not holding my
breath.
Forbes
calls
transparency the health care story of
2013, which had no shortage of other big health care news; USA Today lists
it as one of the key trends to watch in 2014.
Whether or not it starts to have a noticeable impact remains to be seen,
but in the meantime it certainly is becoming a nice business: some
$400 million has been invested since 2010. For example:
- Castlight Health has raised almost $200 million and is reportedly considering an IPO;
- Change Healthcare took in some $15 million in Series D funding last year;
- Healthcare Bluebook just secured a $7 million investment
- Healthsparq just bought ClarusHealth in a move to triple its access to health plans, while also claiming it can demonstrate that its online transparency tools do lower costs;
I certainly am a big supporter in transparency, but
continue to view it as a necessary but not sufficient requirement for
change. When I get medical services, I’m
not really much more knowledgeable buyer than when I get services from, say, a
car mechanic or a plumber. When I get
those kinds of services, though, I do expect to get a reasonably accurate
estimate, and – more importantly – I know I’ll be paying them with my own money,
which makes me more careful about spending it.
If a car repair or plumbing job is going to cost me thousands of
dollars, I’d get multiple estimates from reputable vendors before proceeding. People still don’t think about health care services
in that same light, and providers typically would balk at requests to bid on
expensive services.
The awful truth, though, is that the bulk of health
care spending is not from most services done on most patients, but from
high-end services done to chronically ill patients. AHQR recently
reminded us of the super-concentration of spending: the top
1% accounted for 21% of all spending, the top 5% accounted for 50%, the top 10%
accounted for 66%, and the bottom 50% only spent 2.8% of the total. It’s not even clear that diverting care for
costly patients out of hospitals to lower cost settings can make much
difference, according to a study
from Brigham and Women’s Hospital.
Transparency might impact spending from that bottom
50%, but that spending is so small that it won’t matter much. And it may not have not all that much impact for
the top 1%, or maybe even the top 10%, as these patients may not be in much
position to “shop.” So who exactly are
we targeting with it?
The Massachusetts Health Policy Commission recently
released its 2013 cost trends report, one of the key
findings of which was that 21% to 39% of health care spending in Massachusetts was
wasteful – some $14.7b to $26.9b. Those
percentages are in line with previous national estimates. I did notice, though, that adding up their
specific examples don’t even reach $2b, indicating how hard it is to pinpoint
where the “waste” actually is. There’s
no shortage of evidence (see, for example, Brill
or Rosenthal)
that what makes our health system so expensive is not the use of services as
much as the inflated prices for those services.
This is where greater transparency can help – but only if we start demanding
that providers compete on price and on value.
No comments:
Post a Comment