MD Clarity - The Physician's Role in Patient Price Transparency

This post is by Mike Albainy, Founder of www.MDClarity.com

How much will a visit to the doctor’s office cost? It’s a seemingly simple yet perplexing question for both patients and physicians. A fundamental problem continues to be that patients and physicians do not readily have access to the expected costs of care, from lab tests to MRIs to outpatient surgical procedures. Today’s complex medical reimbursement structure makes this information elusive, in turn limiting physicians’ abilities to have a transparent discussion with patients about the impact of clinical choices on their out-of-pocket costs. While the need for transparency is nearly universally accepted, the questions of who should make this information readily accessible and how we get there have yet to be settled.

Why are estimates for care so elusive?

Simply put, medical bills are complicated. There are two key factors which determine an insured patient’s responsibility for a medical bill: what their insurance company has agreed to pay the doctor, and what their specific plan benefits include, from their deductible to coverage for specific types of procedures. Additionally, the provider’s charge structure is relevant for uninsured patients, but has little bearing in the ultimate patient responsibility for most insured patients.

The first question alone, what the insurance company has agreed to pay the doctor, is not easy to answer. Every insurance company negotiates separate contracts with each provider, and these agreements are challenging to interpret and “translate” into software accessible by medical staff or physicians due to the many unique exceptions and rules.

The question of the patient’s plan benefits can be even more challenging to answer: each insurance plan can have different deductibles and policies, and the patient often doesn’t know the status of their benefits. Do you know your deductible balance at this moment?

Coupling these two pieces of information quickly, and the time of service when a physician is with a patient, can be daunting.

There are some alternatives to providing a precise estimate to the patient. One alternative is a simple price list akin to a “rack rate” at hotels, or a generalized estimate regardless of the patient’s insurance company or benefits. Some organizations have chosen to post their charges online, but they are unfortunately not reflective of what the insurance companies actually pay and ultimately become a patient’s responsibility.

This all begs the question: who ultimately should be responsible for providing this information, accurately, to patients?

Who can deliver?

The most convenient answer has usually been that it is the patient’s responsibility to determine what their service will cost. This belief has spawned a number of websites, most of whom use some variation of freely available Medicare data, to deliver a generalized estimate of payments for care. This approach makes two leaps of faith – first, that patients will take the initiative to research healthcare prices, and second, that it is good enough to know a regional or national average instead of a precise, customized answer.

The next group, insurance companies, have made some strides in price transparency. The trend, however, is for insurers’ patient portals to not specify their rates for specific physicians, but rather use regional estimations. Furthermore, this information is non-standard, and usually only available to patients (and the more web-savvy ones at that), not others in the industry.

That leaves us with the providers as the ideal group to enable price transparency. The physician-patient relationship is the base for the entire healthcare system, and layering the cost dialogue into that existing, trusted discussion stands to reason. Physicians and other providers sit in the unique position of being able to translate pricing questions for patients into a language that makes sense in the context of the care delivery model. If correctly enabled, this could change the way physicians and patients approach medical decisions about the benefits of performing services that may have marginally more benefit for disproportionately higher costs.

So, how can they do it?

Some of the rudimentary methods above – using base charges, some variation of Medicare pricing, or payer-driven information – can be serviceable in limited situations, but not ideal in today’s more demanding, high-deductible environment. Practice Management Systems have made limited progress in the price transparency areas, but their offerings tend to work best in the most basic situations when intuitive user interfaces are not required.

Fortunately, as technology improves, recent advancements are opening new doors. For example, MD Clarity’s web-based software can be delivered as a service via the web and mobile devices to make accurate information available within seconds rather than spending unnecessary time tracking it down or, worse yet, settling for data that isn’t entirely accurate. The newest, most sophisticated software combines payer-and-plan-specific information for results that are completed customized to the provider’s practice and the patient they are dealing with. Most of all, this complex software puts the price transparency discussion squarely within the physician-patient relationship where it belongs.

Mike Albainy is a Founder of Minneapolis-based MD Clarity, a firm providing web-based solutions enabling physicians and their staffs to provide accurate patient price estimates. The software allows physicians and office staff to confidently engage in a more informed dialogue about the cost and benefit of medical service options.

Cost Awareness Anecdote: Fraction of the Pie

The following anecdote is from Eric Lespin, a patient from Alaska.

A torn meniscus. It did not disable but it impaired, and unpredictably. My stomach learned quickly to tighten at the sound of A.’s peculiar whimper in response to a crippling pain that would shoot through her at seemingly innocuous movements of the afflicted leg. We have health insurance of sorts, the type that will help you keep your home if tragedy strikes, but that does not shield you from the brunt of what most of day-to-day health care cost is about. We’re well practiced in deferring and foregoing care. Here however, we reluctantly acknowledged that a hospital would need to be visited and a doctor consulted.

Tests and a physical examination made clear that an operation was unavoidable. The doctor was a thoughtful man who conscientiously went through what the operation would entail. Surgery would take half a day, then back home by afternoon, convalescence over the following few weeks, with complete recovery the usual outcome. While not painless, the procedure seemed reassuringly routine. His tone was caring and his outlook about our case optimistic.

The admirable candor with which medical personnel have learned to speak about difficult topics concerning our bodies and our care did not extend to the costs involved. The question of what the procedure would cost, gently broached, initially baffled the staff, eliciting answer-deflecting counter-questions about the adequacy of our insurance coverage, but resulted in no quotes or estimates. With my insistence on the point, an assistant promised that a figure could be determined, if we needed it, once the surgery was scheduled. “But not before?” I was now the baffled one.

A person who linked dollar amounts to medical procedures was eventually found and I was seated at her desk. She required a billing code however, and without a scheduled surgery there was none to offer. As we danced around that issue, my concern over the cost of repairing A.’s knee was replaced by another curiosity: “Is what I’m asking not routine?” It was not. A billing code was finally lifted from the paperwork of a previous operation, and after some minutes a dollar number was produced. It was a sizeable figure, but less than what I’d been led to believe such things cost, at least in the United States. I suspected something still was not clear. “This is then what I’ll pay, roughly, to have the procedure done?” I asked in a half questioning, half confirming tone. “No, that’s just our part of it, the hospital has their charges, of course.” “But we’re in the hospital and I’m asking you for an estimate of what this operation will cost.” She explained, with some frustration, that the operation itself was only a fraction of the pie; she had no way of knowing what the hospital might charge.

This was not actually true – she was far better situated than I to know what the hospital charges would be. It was if I had asked for the price of a new car on a showroom floor and had been told by the car salesman that only the engine could be quoted – other components’ prices would need to be discovered separately, by me. In the real world, the total price for most services and products are conveyed to the consumer by the seller or provider at the end of a long chain of added values. In this case, the multiple components of the medical care provided a shield to simultaneously obscure the cost and justify its lack of availability. The billing person scribbled down a number for me to call, then asked if there was any other matter where she could be of assistance.

Hoping for a face-to-face conversation, I asked at the hospital information desk for directions to the office matching the telephone number scribbled on the scrap of paper. “That’s not in the hospital”, the information desk attendant declared, “but the call is toll-free”. We went home. For some reason, the inability to locate a price anywhere on the hospital premises for an operation that would take place there shook us as much as would have an encounter with a manifestly incompetent doctor. Though A. and I talked only briefly of the cost, or rather the opaqueness of it, we were both invaded with a foreboding that a thing so untethered to its own cost would be in some unspoken way unreliable, dangerous. That night, A. announced that she wanted to do the procedure overseas . . . anywhere but here.