Price Transparency: Waiting for the Other Shoe to Drop

the other shoe

By Bill Reid, Vice President of Business Development, SCI Solutions

Patients are tired of waiting for the other shoe to drop.

We’ve all experienced it. We get a referral to see a specialist, who then orders some tests, and perhaps a procedure, too. We think we have insurance coverage for it all – or at least, no one has told us we don’t. We believe we have sorted through all the rules, understand our remaining deductible balances, our co-insurance and our co-pays. And then we wait. We wait for the Explanation of Benefits, for the provider bills, for the other shoe to drop. We hope we were right in our math.

What a strange industry we are in. Where else, besides in healthcare, do we consume a service or commodity before we really know what it will cost us? Menus have prices, stores have tags and grocers have end caps that call out special deals. In all those cases, we show up at the end and settle up on what we basically know to be the price. If we went over our budget, we can take an item out of the cart or put back the outfit, or not have the Key Lime pie.

Yet every day, we as health consumers wait to find out what we owe, and for many Americans, we are finding out that it is way more than we thought or can afford to pay. According to a report by health consultancy Deloitte,

“Uncompensated care—the combination of bad debt and charity care—reached an all-time high of $45.9 billion in 2012, or 6.1 percent of hospitals’ expenses, according to the American Hospital Association. And healthcare trends, including increased patient cost sharing, are expected to send bad debt surging to $200 billion by 2019, according to an analysis of 2011 Medicare and Medicaid statistics.  The Deloitte report concluded that out-of-pocket healthcare expenses for consumers reached $672 billion by 2012. That amount is expected to increase substantially as more employers shift to high-deductible insurance and more people gain coverage through public health insurance marketplaces, which are dominated by high-deductible plans.” (Rich Daly, HFMA, November 21, 2014) http://www.hfma.org/Content.aspx?id=26253

The report stated that they believed that hospitals should “help patients anticipate and pay their bills.” I agree.

There really is no longer a good excuse. Patients deserve the right to know in advance the financial consequences of care. Sure, they may get the care, but at a cost they may not have been willing to abide, at least not without a discussion.

With managed referral and order processes, where a one physician electronically refers a patient to another provider, it allows us time in our industry to use technology and connected information to evaluate the costs of that care, to direct it to a better value provider and to provide the patient with an assessment of the financial impact of the care. Better yet, it allows that patient to figure out how to make it work financially. In some cases, it may be to defer an elective procedure. In other cases, it may be to seek a second opinion. And in some cases, it will be to say no.

We owe it to our patients to equip them to know, so we can all stop waiting for the other shoe to drop.

4 Comments

  1. John
    Permalink

    Bill, not so sure it is always easy to calculate the expense to treat a given patient’s condition. For common ailments, agreed, there needs to be full price transparency for bundled cost of service, eg knee replacement, strep throat, etc.

    But then there are those circumstances wherein one is not sure how much a full treatment plan may cost. For example, how does one estimate the cost of treatment for a cancer diagnosis? Treatment protocols are constantly being updated, what works for one patient, may be a complete disaster for another.

    At this particular point in time, see healthcare pricing to be similar to that of other professional services, be it consulting, legal or other. There are some fixed prices for fairly routine, well understood procedures/processes and then there is flexible pricing for everything else.

    As with much of healthcare, no easy answers

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    • wreid2015
      Permalink

      John, yes no easy answers. Given the increasing rise in financial burden facing patients, we at least owe it to them to keep on trying to make it easier to understand and to have the ability to make the right choice. Healthcare has long been subject to the ethical principles of justice, beneficence, nonmaleficence and autonomy. We need to honor autonomy and the other principles by ensuring that patients can make a choice that does the most good, be it in this case an economic one. Not saying we have the answers yet, but we owe patients the duty of pursuing a better solution.

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