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"Doctor, How Much Do You Cost?"


Jeff Brown, MD, think it's unfortunate that doctors don't know or care what the total cost of care for one patient's illness is; so it's time for a discussion about the high cost of health care and how doctors aren't doing enough about it.

The truth is that none of us know, we don't know how to find out and, even worse, most of us do not care what the total cost of care for one patient's illness is. We leave that to the "suits" in administration, insurance companies and to the government. "We just take care of our patients." And look what a great job we, and they, have done — not!, as the kids would say.

So it's time to go on a rant about the high cost of health care again and how, individually and collectively, docs aren't doing much about it.

Health care is the only — and I mean the only — significant economic area in the average person's life where utter opacity about pricing is true across the board and is passively accepted. Sure, as long as we are in a fee-for-service model and we have a welter of codes to customize the cost of each encounter, we rationalize that it can be tough to predict what our services will cost that day — let alone the down-the-line secondary costs.

Docs and hospitals, therefore, so conveniently, get to avoid posting a fee schedule in our reception areas. "It would just confuse them and tie up the staff," I have heard. However, the Cleveland Clinic has started posting the cost of supplies in their operating rooms and that is apparently so unusual in itself that it was reported in The Wall Street Journal.

But as a rule, we docs don't even try to assess those costs and, more amazingly, our patients do not ask what our fees are! No wonder the economists just scratch their heads — our economic model is goofy and upside down. Demand follows supply, not vice-versa!

As an additional Alice-in-Wonderland twist, it turns out that average charges vary wildly. Not just locally, but region by region. The on-going Dartmouth Atlas Project (full disclosure: my alma mater) on such things is quite revealing, and if I may speak for all of us in medicine, quite embarrassing.

Yes, I know that the Feds are stringent about us not getting together to "fix" prices, but what is the point of not standardizing them if there is no requirement or demand for available up-front pricing for the consumer to compare? The Dartmouth studies also show that not only do the fees charged for the same service vary wildly, even within a network, but the amount of work done for each diagnosis varies wildly. And typically varies, again, from region to region.

For example, this one from Consumer Reports, a colonoscopy in one Midwestern city may cost anywhere from $840 to a whopping $4,481. A 500% difference! Yes, I know that patients have different acuities and medicine is larded with gray areas in diagnosis and treatment, but this comparison is after factoring out measurable differences. To allow for the widespread variations in almost all areas of medicine, various authors have chosen to come up with the euphemistic explanation of a "variation in culture and/or style" of practice. Ironically, I used to know a doc who explained his routine, out-of-context large grosses to his "style of practice."

Then, as now, let's call it what it is: greed, perhaps fear of malpractice and/or losing face with other docs for "incompleteness," and a failure to adhere to established best practices. And I am actually more concerned about the latter than I am about the former. Greed can be managed, whereas not following evidence-based best practices is a fundamental failure to live up to our moral code to do the absolute best that we can for our patients. And an accepted best practices approach minimizes both malpractice vulnerability and snooty, academic-like peer pressure.

Yeah, I know that these "standards" are a moving target, depending upon the latest study or Cochrane analysis. And there are some areas where no real consensus has been established on what is a "best" practice versus a common practice. But the subtext that hurts is that either docs are not keeping up (I know, we try, we try) or they are rationalizing the higher fees and utilization. I've seen both and I bet you have too.

Everyone knows that "the most expensive piece of medical equipment that a doc has is his/her pen." Yet, in our haste to handle our volume, and to meet all of the needs summarized above, we wield our pens without much restraint at all. Think about it; every health care dollar spent has one of our names on it somewhere in the chain. Enormous savings are available if we just keep that in mind. And probably an improved quality of care by whatever metric is in play at the moment.

Otherwise, if docs do not step up to our full responsibility in the high cost of medical care, we, and our patients, will be penalized by sub-standard care and shrinking options. These options will be ones where we only get to be players at a growing table with a shrinking voice. The advancing glacier wall of unsustainable cost will grind us down to be only pawns, "providers" in the current nomenclature. Both we and our patients will suffer. We need to realize that we can do more and we can do better individually and collectively in controlling costs while improving care. We need to wake up.

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