I don’t know what your healthcare costs

… and I’ll bet your doctor doesn’t, either.

Okay, that’s is a bit of an overstatement.  I know what my little bit of my patients’ healthcare costs are.  I know what my practice charges for office visits and vaccines and such.  I know the ballpark costs of the generic versions (which I prescribe almost exclusively) of a few common medications.  But that’s about it.  I don’t know the price of x-rays, CT scans, most blood tests or what the various subspecialists charge for their consultations.

I suspect many of my patients (or, more aptly, their parents) don’t know what their healthcare costs are, either.  For those whose insurance coverage doesn’t have a high deductible, they may see no more than whatever their copay is.  If they’re like me, they may be shocked when, after all the wrangling is done between the insurance company and whatever entity provided the service (lab, radiology department, physician, etc.), they receive a bill for rather more than they would have expected.  (Yes, it most certainly happens to me, too.)  The more of a buffer provided between the patient and the costs (or, if you prefer, the better the coverage) the more ignorance the former has about the latter.

Now, you might think it’s for the birds that I don’t know how much various healthcare menu items cost.  I would be inclined to agree with you.

Part of the problem is that there is no set price for a CT scan or any particular blood test.  Two different hospitals quite probably charge different amounts for the same services.  To an extent, that’s understandable.  When I order certain tests (like an MRI), I’m not just ordering the study but also requesting that a radiologist (or, for other kinds of test, a pathologist or other specialist) interpret the study and give me an impression.  While I can usually see the images if I choose to, I lack the expertise to decipher much of it: I’m reasonably good at reading x-rays, not so hot at CT scans, and worthless at everything else.  Since what your doctor really wants is the interpretation and not the test per se, hospitals that can reasonably claim to have better radiologists reading the studies can reasonably charge more for their services.

However, given that my practice only ever orders anything through one or the other of the two hospitals where we’re all on staff, it would be no great shakes to find out how much the charge is for a variety of commonly-ordered tests.  I will probably make inquiries to that end soon, for reasons I will get to in a minute.  But the truth is that I was never taught much about what the cost of anything was.  It was a gigantic lacuna in my medical education.  And I’m guessing my experience is the norm, not the exception.  Again, to a large degree this is understandable.  We’re trained to detect, diagnose and treat or prevent illness.  We’re taught what sorts of investigations and interventions accomplish this best.  If a biopsy is the best test, then it’s the best test whether or not it’s more or less expensive than a less reliable one.  If you’re taught that patient care is the only true consideration, then cost isn’t a factor in your decision-making.

Of course, the real world doesn’t work that way.  As anyone who has glanced at a newspaper in the past several years can tell you, healthcare costs are a huge problem in this country.  For good or ill (and my guess is that it will be a little bit of both), medical providers are going to have to pay more attention to the expense of the care they’re providing.  I’ve written before about global payment models as an alternative to the current feee-for-service arrangement, in particular about Children’s Hospital Boston’s decision to get out in front of the trend by agreeing to try using such a model with one of the major insurers in Massachusetts.  [Full disclosure:  I am on staff at CHB.]  A major teaching institution and research facility like CHB is a good laboratory to see how this model works in real life for a couple of reasons.

First (as I said in my previous post), CHB is an ideal environment for costs to skyrocket.  It’s packed to the rafters with specialists and subspecialists and subsubspecialists, all of them world-class.  (In the ecosystem of CHB, I hover around about the level of plankton.)  It is remarkably easy, and thus very tempting, to get lots of consultations to make sure you’re not missing anything.  The same holds true of just about any test you’d want to order.  If you want it, it’s there.

But Children’s and similar teaching hospitals are also the ideal setting for making lasting changes.  It’s where medical students and residents learn how to be doctors.  If they can be made aware of how to consider the expense of what they’re ordering, perhaps they will be less prone to take a shotgun approach to patient care and will be more discriminating when choosing what their patient truly needs.  And they’ll take that perspective with them when they find jobs around the country.

However, in order to really make a dent in healthcare expenditures it’ll take more than one hospital to adapt to the undeniable need for cost-consciousness.  A couple of weeks ago Pauline Chen wrote a column for the Times about a nascent program to provide educational materials for medical students about how to incorporate expense into their decision-making process:

Over the last two years, Dr. Neel Shah, a senior resident in obstetrics and gynecology at Brigham and Women’s Hospital in Boston, has been collaborating with medical educators and health care economists at Harvard Medical School and at the Pritzker School of Medicine at the University of Chicago to create a series of videos and educational materials designed to help medical students and doctors-in-training learn to make clinical decisions that optimize both quality of care and cost. With support from the American Board of Internal Medicine, these educational modules, called the Teaching Value Project, could represent a significant breakthrough in how medical students learn to be conscious of costs.

The patchwork of payment patterns that mark the American medical system makes it particularly difficult to teach young doctors. Net costs for treatments and medications vary depending on region, payer and even specific hospitals, so medical students and trainees often end up learning what is relevant only to their particular workplace. They might learn to prescribe a certain drug for diabetes because it is cheaper in their hospital formulary, only to discover later that the reverse is true in a different hospital or after policies have changed.

“When learning is haphazard like this, it’s hard for young doctors to see the entire picture,” said Dr. Vineet Arora, an assistant dean at Pritzker who is working on the Teaching Value Project.

[snip]

The Teaching Value Project uses a rough pricing hierarchy rather than exact dollar figures to gauge costs, similar to the approach at well-known restaurant or travel search sites, which helps young doctors avoid getting mired in price variations and hairsplitting details. When combined with the project’s lessons on common cost errors that doctors make, the pricing hierarchy can bring clarity to clinical decisions.

For example, a young doctor might plan on ordering an ultrasound of the heart, or an echocardiogram, for an otherwise stable patient in the hospital because the wait for inpatients is shorter. But if that doctor also knows that echocardiograms are much less expensive when administered to outpatients, he or she might instead decide to wait and order it after discharge.