StGabe
2761
In my case the doctor has zero incentive to try and figure out what is cost-effective for me and in most cases the less cost-effective choices will probably make him more money. If I overpay for something, he’s probably making more on it (given that he also self-refers a lot of the extra services) and if the treatment fails then we just do it again and he makes money twice.
That’s broken. And it’s no real mystery why the doctor doesn’t even know how to talk to me about cost versus outcomes.
I know this sounds really car dealership-ish, but if a patient is having the type of conversation that StGabe is describing, then it would be a really good idea to bring in that finance person to help facillitate the discussion.
I do when it’s helpful.
When we’re trying to figure out the out of pocket costs ahead of time, this can be very tricky. As I mentioned, insurance carriers and policies are multiple and always changing. To get a good idea what a patient’s out of pocket expense will be usually requires a phone call or three to the insurance carrier. I can speculate what I think an out of pocket cost might be, but it’s just a guesstimate.
I don’t have every insurance policy memorized, and I don’t know with certitude whether a patient has hit their deductible for that year, or if they are in the donut-hole. The patient may think they know these things, but really the only rock solid source of that information is the insurance company.
In general it takes a few phone calls, and then the patient will know what their out of pocket cost will be.
But, even if the insurance company says over the phone “your out of pocket will be X”, that doesn’t mean that is how it will end up when your claim is submitted. Most of the time, it is yes. But every now and then a claim will be outright denied, which means the patient is on the hook for everything. This happens rarely, but it does happen.
When that delightful circumstance happens, it usually costs me thirty minutes to hour out of my day re-educating the medical director of an insurance company and then providing published data supporting the treatment plan. That doesn’t happen often, maybe three-four times a year for me, and so far, they’ve always reconsidered things.
What does all that insurance stuff have to do with what Gabe’s asking about?
I get all that, actually. However, your numbers are all made up. They also assume that none of the 90k will also generate additional costs to the system (highly unlikely). Plus, those 90k people are now paying 1k more than they were before this system. So their costs went up. That’s 90k people paying more than they did before, while 10k people are now paying less.
Still, I get the notion of splitting risks. I just think it’s misleading to suggest that “costs go down” since some go down and some go up. Is the net effect a good one? We’ll see. I’m optimistic, personally.
I guess nothing if it isn’t covered by insurance.
If he’s asking just what the doctor bills for his services, the doctor should have access to that information (assuming the service is provided by the doctor). Either he will know it or someone in his office will.
If the doctor isn’t providing that service and is just recommending it (example: an outpatient prescription), then his information will be less reliable since it’s another party that is providing the service that is doing the billing. Another example, I recommend that my breast cancer survivors have surveillance mammography. If my practice doesn’t own any breast imaging technology or have any radiologist, then those services will be provided elsewhere. I have a pretty good idea what that will cost, but I could be wrong by 10-20% if they had changed their billing practices recently.
That’s rich, considering that they’ve been SO helpful till now.
I guess he was just clarifying that it will continue on through to the end of the year.
So nobody got their hopes up, or anything.
StGabe
2770
It’s well and good to talk about what a doctor “should” do (i.e. be more knowledgeable about the cost impact of their decisions, bring in finance people, etc.).
However that’s divorced from the reality of what a doctor will do when there is absolutely no incentive for them to do anything but suggest more treatments, do them, and make money. It’s not like they’re being completely unethical. Technically they have reason to believe that more treatment is better (although it actually turns out that in a lot of cases, less treatment offers better outcomes) and they’re never trained to think about cost. However it does end up being the case that this failure on doctors behalf creates a worse healthcare system for patients.
You can always find a doctor that does something right. For every truly atrocious doctor I’ve had, I’ve seen a really great one (for example the doctor I’m talking about right now is actually quite excellent when it comes to treatment which is why it’s pretty hard to just say, “oh well, I’ll find one that can actually talk to me about cost”). However the “best case” doctor probably isn’t part of the very real problem that exists elsewhere and so you’re basically just talking past the problem if you do that. What we’re seeing is wide differences in cost of care and effectiveness of care across the system and so what we really need to do is talk about the worst case and how to clean that up so it doesn’t bog down the entire system.
That makes sense. Thanks.
It sounds like his doc is being less than forthcoming with that information. Is there perhaps a different way one could approach the conversation to open up the information flow a bit short of finding a new doc?
StGabe
2772
And to repeat:
The answer for getting rid of the worst cases is, IMO, putting doctors on the patient side of the equation when it comes to figuring out costs. Short of going to a Kaiser model across the board there are a lot of other ways to approach this. For example we could declare doctor-owned hospitals a conflict of interest along with any instance where a doctor derives profit from doing a test they themselves prescribed. Basically we could find ways to remove any profit incentive for doctors that isn’t derived from health outcomes and relevent in some way to total cost.
I’ve consumed my own fair share of health care and paid for it entirely out of pocket without insurance. In those situations, usually at the end of the visit, I met with their billing person who laid out exactly what my bill was going to look like.
If this guy is proposing a treatment that he himself provides and he knows you are paying 100% out of pocket, and refusing to tell you what it will cost – i.e, you’ll only know the cost when you receive the bill in the mail, then I’d look elsewhere for care.
StGabe
2774
It was ignorance, not malice IMO. He just literally doesn’t have any insight into cost when it comes to his procedures. It’s simply not part of how he understands and approaches medicine (because it doesn’t need to be under the current healthcare model).
Conservative commentators keep it classy.
Conservative talk show hosts and columnists have ridiculed an 11-year-old Washington state boy’s account of his mother’s death as a “sob story” exploited by the White House and congressional Democrats like a “kiddie shield” to defend their health care legislation.
StGabe
2776
This isn’t at all what I’m talking about.
I understand the billing and I have documents from their financial people (although they’ve turned out to already be inaccurate in several cases because the doctor has done more than the documents said he would – they seem to be based somewhat on a best-case scenario).
That isn’t the problem. The problem is that figuring out the most cost-effective way to approach my problem is a very tricky, complex problem that ultimately requires an expert in the particular field of medicine. There are a lot of tricky variables in my case. I only have my case to go on and some very general statistics I’ve looked at. He has a case history of literally thousands of other patients to go off of and a much more commanding understanding of the literature. I need him to evaluate my case, the potential treatments, weigh in the cost, and figure out the most cost-effective set of treatments for me given a limited budget. It’s something that he is completely unequipped to do. Not only is he not aware of what the costs actually are for me but it’s clear he’s never approached his discipline from a perspective of maximizing the rate of success per dollar spent.
His office staff can’t do any of that for me. They can quote prices (which may or may not be accurate depending on what the doctor actually does) but they can’t try and evaluate chances of success, other factors of morbidity, ways to modify treatment to decrease the total cost, etc.
Tough to say. Some doctors are just jerks, and have a difficult time with sharing decision making. He may simply not know and have a tough time owning up his own information gap.
Most patients in my area aren’t very concerned about cost, in fact, they are extremely price insensitive. But, I will run into the occasional patient that will say something along the line of “Hey – for me to do a good job planning for this, I need to know how much this is going to cost me and how much time I’ll have to pay it.”
I can’t speak for others, but I’m responsive to that, and do the best I can to help them get some reliable numbers. As I said, if an insurance company is involved, then another bureacracy must be consulted for those numbers.
Wow, that was haunting. If I were a republican I would have been wincing with every line.
My understanding is that all of these problems are in the context of a cured/cureable malignancy. If it isn’t, then ignore the following.
Are you saying that there is some price point that you would prefer treatment plan B over A, even if B is inferior to A in terms out health outcome?
If it is, you’re right, most oncologists aren’t equipped to think that way. When we’re dealing with a cureable malignancy, we rarely consider cost. Some might even find that notion unethical. If it’s not a cureable maligancy, then a whole host of other considerations enter the equation.
I use the word “treatment plan”, but that could also be interchanged with “surveillance plan.”
StGabe
2780
It is, in fact, more complicated than that and no longer (strictly speaking) an issue of cancer.
Are you saying that there is some price point that you would prefer treatment plan B over A, even if B is inferior to A in terms out health outcome?
The mentality that cost is no object when curing certain illnesses is one of the core problems at the root of our healthcare problem.
If I had an out, like insurance or bankruptcy then I might do whatever it took and damn the consequences. However I’d just be passing on the consequences of the good/bad choice I’d made to other people.
If it was all my own money and there was a potential that I could run out and not receive care or receive substandard care (which is a more realistic scenario when considering the healthcare problem at large – where we have finite money to treat all problems) then yes I’d absolutely make considerations like that. For example treatment B might be inferior to A but the difference might be small and choosing B might leave me with enough money to try C if B/A fail.
