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Sunday, September 21, 2014

Lack of price transparency and the normalization of deviance

I am confident that the story is not going away. Again on the front page of the Sunday Times today is yet another story about the lack of transparency in health care billing which is accompanied by a litany of comments from people who reinforce the message. (NYT- Billing surprises)

The story itself is about a young man who had the acute onset of a neck injury; a herniated set of disks which resulted in pain and neurological dysfunction. He thought he had his ducks lined up and had properly researched his options and the costs. However, he was blindsided by a bill from an assistant surgeon who he did not recall actually meeting. The bill for the assistant surgeon...$117K. What did this surgeon do to justify such a fee? That was not so clear and oddly enough the payment to his primary surgeon ended up being less than 1/10th of this amount.

The stories from those who wrote in that followed the Times story showed a consistent theme. Providers who swooped in during a medical stay, delivered some sort of perfunctory service (or not?), and dropped some sort of outrageous a bill. How common is this? Who knows but perhaps this is not such a rare event.

In my opinion, this phenomena can be traced back to two fundamental issues. The first issue is the widespread and apparently expanding gaming of the billing system. There is no question that the current system has opportunities for exploitation. In the earlier part of my career, the relative lack of financial pressures and the anchor of professionalism served as a brake on such activities. As individual actors identified and leveraged opportunities and their financial windfalls became more apparent to the broader medical communities, the brake exerted by professionalism weakened and the outrage previously expressed over outrageous billing practices disappeared. Why be a chump and "leave money on the table?"

We rationalize such beliefs by looking at all the activities we engage in which provide no or insufficient financial compensation and do some balancing math. However, once you have made that transition and are comfortable with accepting payment not commensurate with activity and value you  added, it becomes a slippery slope. There may be no upper limit on what some will ask for, especially when third parties pay the fee and insulate the patient from the bill.

However, the other issue is no one is really in charge. Patients are cared for a "team" of people who operate in different silos and who are not coordinated in their efforts. There is no big picture person who has the incentives to make team roles explicit. One might think that the lead surgeon would be this person but that is generally not the case. Review a chart of a patient hospitalized for a particular intervention and look for specific orders regarding consultations. You are not likely to find them and if you do you are not likely to find anything specific of what the actual deliverables might be. There we have it; no defined team, no defined roles,  no one in charge, and little or no accountability.

Creations of well functioning teams would go a long way to solve this problem. A team leader should be accountable in terms of everything that happened before, during, and after surgery. Before this person would make sure that the patient was aware of  who was on the team, what their roles would be, and what the costs should be. However, this would require a change is how we are paid since at this point in time, there is no financial value associated with this type of activity, even though there might be tremendous value brought to the patients involved.

I believe we either fix this issue or we undermine the trust of patients to a point where it becomes irreparable.