Summary: This essay by Dr. Robert Fogerty, an assistant professor at Yale School of Medicine, appeared originally in MedPage Today, where it launched our pricing transparency partnership with MedPage Today. Re-posted with permission.
By Robert Fogerty MD
I tossed and turned during many sleepless nights as a cancer patient. Some nights from nausea, some from pain. Some from sadness, some even from being cold without hair. There were nights where I feared my next surgery or next treatment. Nights fretting about the scan or blood work — had it spread? Would I see my graduation in 3 months? These are all predictable and were largely understood by those around me.
What many didn’t know, except for those closest to me, were the nights I stayed awake thinking about money. I distinctly remember one bill for $50,000. I was a college senior back in 2002, when doctors diagnosed me with metastatic testicular cancer. Where am I supposed to find $50,000? My job cleaning glassware in the chemistry department wasn’t going to cut it.
How will I get my treatment now that my insurance has been exhausted? What will this do to my family, will we have to go bankrupt? The financial sleepless nights were just as sleepless as the medical sleepless nights, and the concerns just as real to me.
Early in my treatment, my health insurer issued me a notice that my benefits were exhausted. Since I lived in Massachusetts, this qualified me for individual plans. I signed up for a plan, but had to pay the entire premium out of pocket each month — roughly $500 a month. Then add the deductibles, copays, over-the-counter meds, cab fare, etc. and you get the picture. We avoided major financial disaster, but it took me almost 2 years to get to medical school, and my parents never admitted it, but this was a major difficulty for them.
The financial worry never goes away; even when I see patients as a doctor, I worry about their financial burden. It’s actually very haunting to me. We talk about their nausea, their pain, even their diarrhea and penile discharge, but for some reason, we don’t talk about their checkbook. It’s totally normal for me to walk into a room, ask someone to get naked and touch them all over, but God forbid I ask them about their financial status.
The whole thing is nuts.
If we have figured out a way to watch video of the Martian surface, transplant a face, even replace organs with machines, surely we can figure out a way to prevent the crippling debt of modern medicine from victimizing the sick.
In the end, my story is a success story. My hair grew back, but my checking account didn’t — and many other patients fall into bankruptcy.
Beyond false fixes
We as a society can do better, but how? Correctly diagnosing and safely treating a disease is a very difficult task, and simply instructing providers to “do it cheaper” will not help.
What about just paying less for the same service? One major reason we have an impending primary care crisis in this country is the reimbursement system we use, which has been paying less for the same services. Any system that disincentivizes primary care has a fractured keel and promises only to worsen our situation.
Doctors, despite being charged with developing diagnostic and therapeutic plans, largely don’t know the costs associated with the care they provide. What if we simply fill in that information gap with transparent pricing? Show the doctors how much they are spending with their ordering, and let’s see what happens.
Good news here, previous work has shown that simply showing doctors the costs associated with a test can reduce test usage. This kind of transparency in price seems promising, and this shouldn’t be much of a surprise.
And yet we continue to blindfold the bus driver — or at least the navigators. A common concern with showing providers costs at the time of care is that this information will negatively impact the quality of that care. If we as a society don’t trust our physicians to safely manage cost information, why do we allow them to drive costs without this information?
Man vs. machine
It would be easy to point fingers at hospitals, physicians, insurers, drug and device companies, etc., but I don’t think that is overly helpful, and I prefer a different take on the problem.
U.S. healthcare is a behemoth, no bones about it, but it hasn’t always been that way. In 1970, healthcare was only 7% of GDP. This rocketed to almost 18% in 2010. Healthcare is indeed a giant industry, but it is one composed of millions of personal relationships formed by doctors and patients.
Care and compassion come first. It takes all my attention to focus on the person that needs me at that moment, my patient. This human being has come to me for help, and I want to help them. That was my oath, and that is where my attention is focused. It’s pretty hard for me to consider fiscal policy, ROI calculations, or debt-to-expense ratios in that moment.
These discussions still need to happen, and a majority of U.S. physicians say they have some responsibility to help contain costs. However, this cannot be the sole point of change if we are to solve our cost crisis.
Another discussion must happen at a societal level. So we must ask again, how can we have these discussions about money, when we don’t know how much things cost?
That’s like asking a tailor to hem pants without measurements. We can’t have a constructive discussion about a problem without crucial information.
Price transparency can inform both societal-level discussions, and many of the millions of patient-provider interactions. I don’t think it will solve all our ills, but it’s a start toward high quality, efficient care.
Take for example, conjunctivitis. My children have both had pink eye. Setting aside daycare antibiotic requirements for another discussion, pediatricians have prescribed two different prescriptions. One antibiotic eye drop cost us less than $3 at full price — less than my insurance copay.
The other drug was so expensive, my insurance covered most of it, but I still paid $50 out of pocket. These two drugs were equally effective and equally safe. Why would I pay $50 when a $3 remedy will do? My own colleagues had no idea of the price difference.
Modern medicine is not only about defeating disease, we need to start taking into account the often overlooked side-effect: Debilitating debt.
I think of price transparency as a kind of Rosetta Stone. Alone, it isn’t much more than a doorstop, but in context, it helps to foster a discussion we can all understand.
It provides the language that we can use to have a conversation that will forever change, for the better, how we deliver high quality, patient centered care. The key to having these important discussions is a common language, and that common language begins with price transparency.