Health care’s four-letter word

A nurse midwife’s encounter with a patient struggling to pay a $1,400 bill and the sabotage of a graduate student’s effort to be a smart consumer have been chosen as the winners in a national essay contest about health care costs.

The writers, Tarcia Edmunds-Jehu and Brad Wright, will each receive $1,000, along with the knowledge that the personal experiences they’ve shared have helped put a human face on the abstract thing known as the cost of health care.

It’s the first time, as far as I know, that an essay contest like this has been held. I hope it won’t be the last. The sponsor, a nonprofit Massachusetts organization called Costs of Care, is working to make health care providers more aware of how their clinical decisions can affect the patient’s ability to pay. If you think patients are in financial control, consider this: According to Costs of Care, health care providers “ultimately determine how 90% of healthcare dollars are spent.”

One of the great things about essay contests is their power to illuminate real-life stories about the collision between patient care and the cost of providing that care. Reading each of these entries made me think hard about this issue. Some observations, in no particular order of importance:

– We talk a lot about the cost of health care – so much so that it has almost become one word, “thecostofhealthcare.” Yet we remain ambivalent about what it actually means. Many, if not most, consumers know health care is expensive and they recognize the need to be cost-conscious, but they don’t always connect these dots when it comes to their own care, nor do they realize how rapidly the costs can mount. Once Mike and Susan, the couple featured in the essay titled “From pain to poverty,” decided to call an ambulance and go to the emergency room, it triggered an inevitable cascade of high-cost services. How many consumers truly understand that if they show up in the ER with chest pain, they’re going to get the full monty, with all the expense this entails?

– There’s often a squeamishness over the fact that money needs to change hands when services are rendered. Many providers don’t discuss it openly with their patients, either because they don’t know how, they think it’s too sensitive, or it just doesn’t occur to them. Patients, for their part, can be reluctant to tell a provider they can’t afford a prescription medication or a CT scan. The conversation also is sometimes complicated by a belief that providers are greedy for wanting to be paid. But the math is simple: It costs money to provide health care and it costs money for consumers to receive it.

– Why are the uninsured billed the full price, while those with insurance can take advantage of the discounts negotiated by the their health plan? In Minnesota most hospitals now charge the uninsured the same rate as the largest commercial plan with which they do business, so they can receive a discount. This isn’t the case in most other states, though. The practice of charging full freight for the uninsured seems akin to Victorian-era debtors’ prison, in both cases penalizing those who are least able to pay.

– Much of the discussion about cost tends to focus on how consumers use (or overuse) health care services, how much they’re charged, and the need for price transparency. Less is said about in-network and out-of-network providers and how hard it can be for consumers to figure this out. Brad Wright, who submitted the winning essay titled “Blood test surprise,” tried to do everything right. He had health insurance and he was persistent in researching costs ahead of time – but he still got tripped up by the intricacies of in-network vs. out-of-network services. He writes, “My mistake was assuming the lab was in-network because the in-network internist I had just seen worked in the same building and referred me to the lab.”

– Although we’d like to think consumers can make rational decisions about health care spending in the same way they make decisions about buying a car or a pair of shoes, they often don’t. Emotion can enter into it, as in Mike and Susan’s case: He complained of indigestion and wanted his wife to drive him to the hospital but Susan, alarmed and fearful, insisted on calling an ambulance. If the couple had evaluated the situation more clearly, they might have realized the risk of a heart attack was probably low. But in the heat of the moment, how were they supposed to know? Which brings me to the next point:

– There’s often an enormous disconnect between the perspective of health care professionals and that of the lay public. It’s easy to criticize Mike for incurring unnecessary costs. Heart attacks are rare among 29-year-old men and a couple of antacid tablets would probably have relieved his symptoms without an expensive trip to the emergency room, or so the argument goes. This assumes, however, that Mike has the same knowledge as many health care professionals and can accurately assess his risk level, interpret his symptoms and take appropriate action. More than likely he can’t; he’s a layperson.

Ditto for some of the online reaction to Tarcia Edmunds-Jehu’s winning essay about the pregnant woman who had to pay for extra, and possibly unnecessary, ultrasounds. Some readers took the position that if the patient agreed to the additional ultrasounds, it was because she chose to do so. It’s a simplistic interpretation that ignores the possibility that the patient didn’t know, or didn’t understand, that the extra ultrasounds might be optional or that the patient may have felt pressured because the ultrasounds were recommended by a provider. And that brings me to another point:

– Patients can be held hostage in subtle ways to the whims and quirks of providers and the system. Mike was willing to go home from the hospital after it was determined he was unlikely to be having a heart attack – but he was told that if he did, it would be against medical advice. Because it was a weekend, he was forced to stay in the hospital until he could have a stress test on Monday. Then because of an equipment breakdown, he had to stay yet another day. He was billed for all of it, even though he had no control over when the test was scheduled.

Or take the case of “Sticker shock,” a finalist entry in the essay contest that describes how a patient ended up with $10,000 worth of out-of-pocket expenses for a surgery because the anesthesiologist turned out to be out of network. Dr. Grayson Wheatley, the author of the essay, writes that patients rarely are given any say over who their anesthesiologist will be. “Despite the anesthesiologist meeting the patient in the holding area before the procedure, no one informed the patient about his upcoming out-of-network charge related to anesthesia services or gave the patient an option to choose another anesthesiologist who was within his insurance’s network,” he wrote.

– If the patient’s out-of-pocket expenses are relatively small – and by “small” I mean a couple thousand dollars or less – the perception can be that this is no great hardship. But as the two winning essays clearly demonstrate, this is a false assumption. For Edmunds-Jehu’s patient, $1,400 worth of medical bills meant she had to choose between paying the bill and buying food for her family. It took Wright six months of economizing to pay the $478 he owed for an out-of-network blood test.

– There’s often a lack of creativity in developing ways to help reduce the cost to the patient. If you show up at an emergency room with chest pain, your choices are typically the full barrage of treatment or nothing. Whatever happened to a reasonable middle ground for patients whose chest pain is unlikely to be a heart attack? Here in Willmar, Rice Memorial Hospital created a pathway for these lower-risk patients, ensuring they’re appropriately evaluated and monitored but not subjecting them to aggressive, expensive and possibly unnecessary care. More hospitals ought to follow this example.

– The public dialogue about health care costs often focuses on consumers, as if they’re somehow to blame for all of it. The health care system itself has contributed significantly to the problem, however, and providers need to recognize the role they’ve played in the escalation of costs.

The conversation launched by Costs of Care isn’t over yet by a long shot. Starting the first week in January, a new story will be posted on the Costs of Care blog each week for the rest of the year. Information, links and updates also will appear on the organization’s page on Facebook. Is it too much to hope that at some point, “cost” will stop being health care’s unspeakable four-letter word?