Nursing News

Health Care at What Cost? Hospitals Can't Always Tell Their Patients

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By Jennifer Larson, contributor 

February 21, 2013 - Think about the last time that you bought a car. You probably did some research, visiting several dealerships, scouring websites for reviews and comparing offers. Yet, many people go into surgery without even thinking about shopping around to make sure they’re getting the best deal.

“On the one hand, it’s your health. It’s a little more complicated than buying, say, a Honda Civic,” said Peter Cram, MD, MBA, professor at the University of Iowa’s Carver College of Medicine. “On the other hand, it’s your health, and shouldn’t you be investing a little time and effort before you go and buy something, like a hip?”


A lack of cost transparency, however, can make it difficult for patients to get the correct cost information in order to make accurate comparisons.

Cram, along with Jaime Rosenthal and Xin Lu, MS, co-authored a new study in JAMA Internal Medicine (formerly the Archives of Internal Medicine) that described the efforts of researchers to suss out price estimates for one common surgical procedure, the total hip arthroplasty (THA). Only 16 percent of the hospitals that they approached were able to provide a “bundled price” estimate--with hospital and physician fees together--for the procedure. However, 47 percent were able to provide separate prices.

The complexities of cost 

Unlike would-be car buyers that have the manufacturer’s suggested retail price (MSRP) affixed to the window of every new vehicle sold in the United States--which has been mandated by law since 1958-- there’s no posted cost for would-be patients of a surgical procedure. And it might not even be easy to obtain estimates.

In the new study, Cram and his team wrote, “Obtaining pricing information was difficult and frequently required multiple conversations with numerous staff members at each hospital.” And the price estimates they procured varied “nearly 10-fold across hospitals.”

“In aggregate, our results highlight the difficulty that consumers may have in obtaining price estimates for common medical procedures, but also that that comparison shopping might yield significant price savings for savvy consumers,” they wrote.

Despite the amount of legwork it took to obtain the estimates, Cram noted that he was pleased that 60 percent of the hospitals they approached were able to give them a price estimate of some sort--and some, even from the top orthopedic programs, were very competitive price estimates. “That’s pretty good news,” he said.

“We have a long way to go in terms of cost transparency,” observed Cynthia Smith, MD, the senior medical associate for content development for the American College of Physicians.

Costs should be more transparent, and it should be easier to find out what a procedure costs, Smith said. However, it’s complicated because some procedures are elective while others are not, and insurance companies all vary on what they will cover. Their drug formularies all vary, too.

Should nurses address cost? 

Many experts say it would be a mistake for clinicians to completely ignore the financial situation that their patients are in, but it would also be a problem to focus solely on cost.

“Cost is one factor,” said Smith. “It’s not the only factor.”

Peter A. Ubel, MD, noted in a 2010 article in The Oncologist that most providers don’t talk about finances during clinical visits.

“Indeed, it is already difficult for many clinicians to find the time to help patients understand the medical risks and benefits of their treatment alternatives,” he wrote. “Including financial costs in such discussions simply makes matters even more challenging.”

But patients often do take cost into account when considering their options--when they can. And that presents a challenge for clinicians.

“This recognition of patients' preferences has raised the challenge of finding ways to communicate the costs and benefits of treatments in ways that patients not only comprehend, but can also integrate with their own values to help the clinician determine what treatment choice is best for that given patient,” wrote Ubel.

Even having some cost data doesn’t necessarily solve the issue, however, if it’s not accompanied with the data to measure and compare quality. But many expect the pressure for transparency will continue to grow over the course of the implementation of the Affordable Care Act (ACA).

In the future, clinicians may also learn how to better consider costs and their patients. Smith authored a report for the Archives of Internal Medicine in 2012 that noted that as much as $765 billion of the annual health care spending in the United States has been identified as “potentially avoidable,” and much of that could be attributed to services that are provided unnecessarily. In response, the Alliance for Academic Internal Medicine and the American College of Physicians have developed a curriculum for post-graduates to learn how to “incorporate high-value, cost-conscious care principles into their clinical practice.”

Answering patients’ cost-related concerns 

If you do have discussions with your patients about cost, it may be most useful to refer them to sources where they can get complete information. For example, you could refer them to their health insurance company to ask about out-of-pocket costs for a particular type of surgery or care.

Nurses in particular can also look to identify potential barriers for patients, including financial barriers, since “nurses are the ones who are spending more time with you,” said Helen Osborne, M.Ed., OTR/L, president of Health Literacy Consulting. “We look to our nurses to help us, we really do.”

For example, some patients may not have the health literacy skills to understand why they really need a certain type of care, she added. Others may have financial worries that might preclude them from getting care; perhaps they’re worried about their possible out-of-pocket expenses and whether they can afford them. Or some people aren’t able to concentrate on the medical details because they’re preoccupied with day-to-day concerns, like whether they’ll be finished in time to catch their bus because they can’t afford a car, or they fret about who would stay with their children if they have to spend time in the hospital.

“And on top of that, we have a changing health care system,” said Osborne.

Nurses can learn about these factors and take steps to address the concerns with the patients, Smith said. “Because every patient is different.”

Health care personnel can also direct their business office staff to help patients with questions and issues related to insurance coverage. 

Maybe health care consumers will never be able to “kick the tires” and haggle about pricing before going forward with a medical procedure, but clinicians should be able to help patients understand enough to make reasonable and prudent choices.



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