Price-Shopping Patients Raise Concern for Physicians

Gail Silver , MD

Associate Vice President of Ambulatory and Urgent Care Practice

Ellis Weeker , MD, FACEP

Published January 23, 2014

It makes perfect sense to look around for the best deal on a Toyota Prius or a Vegas vacation package. But in October 2013, the Associated Press reported on an emerging consumer trend: price shopping for healthcare services.

Driven by unpredictable bills and rising deductibles, today's consumers want to know the bottom line before booking an appointment. Physicians' offices have been inundated with phone calls requesting "estimates." New websites allow providers to "bid" on procedures. And employers and insurance companies are leveraging pricing variances by sending patients out-of-state (or even abroad) for procedures. Last week, HealthLeaders magazine editor John Commins summed up the trend in his satirical piece, "A Letter to Healthcare Providers from a Consumer."

So can healthcare really be viewed through the same pricing lens as a car or kitchen remodel? Here to offer their perspectives are Dr. Ellis Weeker, Director of Leadership Development at Vituity, and Dr. Gail Silver, Director of Ambulatory and Urgent Care at Vituity.

Perspectives: You're both experienced leaders in different areas of acute care. What were your reactions to the Commins letter?

Dr. Weeker: In some ways, it was hyperbole. But I do think that people are getting fed up with getting a bill in the mail and having to pay it. You have this high deductible, and you never know which charges you'll be hit with. As a consumer, I wouldn't like that.

Dr. Silver: Well, I understand that the consumer wants some control over what they're buying. But they also need to understand what it is they're actually buying. These days, I have people coming in demanding a test or an antibiotic. They think because they're paying the bill, they should get what they want. But what they're purchasing is not the prescription; they're purchasing my expert opinion.

Dr. Weeker: Point taken. I saw a young woman in the ED the other day with cervical radiculopathy. Her MRI showed she definitely needed some surgery. But she kept insisting, "My dad's got heart disease, and I'm sure it's not my neck. I'm sure it's my heart." And she told me which tests she needed, starting with an EKG. When I explained that her insurance wouldn't pay for that, she insisted on talking to my supervisor. I realized I wasn't going to win, so I ordered the tests.

Dr. Silver: The point is that if people are bullying doctors into giving them what they want instead of what they need, that's not good healthcare. And that's a risk of this new consumer-driven market — that doctors will cave in to giving patients what patients want, and not what is medically appropriate.

Perspectives: In addition to rising costs, what other factors have contributed to this mindset?

Dr. Silver: Conversations with patients are different nowadays because everyone's on the Internet. They come in with an idea about what they want. Yesterday, I saw a 20-year-old man with back pain. He'd had the pain for three or four months but hadn't been treated. He'd been on the Internet and talking to his chiropractor, and he really wanted an MRI to rule out disk disease.

I told him, "Even with a positive MRI, we'd still go through the same initial treatment protocol. So why don't we hold off on the $2,500 test and treat you first?"

Perspectives: And do patients listen?

Dr. Silver: With a reasonable person, you can have that conversation, and most of the time they get it. Of course, it takes up a lot of time.

Dr. Weeker: That's a good point, I think. For many of us who are busy with big patient loads, it actually takes longer to tell somebody why they're not getting an MRI than it does to check off the little box to order the procedure.

Perspectives: How is this trend changing the physician-patient relationship?

Dr. Silver: My concern is that if people go into the physician's office with an aggressive, consumerist kind of attitude, it's going to make conversations very difficult and potentially adversarial. Which isn't conducive to good decision-making.

Dr. Weeker: There's also liability. As physicians, we're already looking over our shoulders constantly worrying about malpractice. And an adversarial relationship increases our chances of a lawsuit, regardless of the type of care we provide.

Perspectives: What do consumers need to understand about healthcare pricing?

Dr. Silver: For one, that there are certain practical considerations. Sometimes they'll call my practice and say, "I have a laceration. How much does it cost to get it fixed?" And the real answer is: it depends on a variety of factors, including the size, location and complexity of the wound. We can't estimate the price until we evaluate the wound.

Dr. Weeker: It's kind of like calling up the body shop and saying, "I just had an automobile accident, and my fender and front end are all smashed up. How much will it cost to fix it?" Well, the technician needs you to bring the car in to see what's damaged. He or she can't give you an accurate estimate without a proper inspection.

Perspectives: Dr. Weeker, in a previous post you discussed some possible pitfalls that transparency laws could create in emergency care. What are you seeing in your own practice?

Dr. Weeker: We sometimes have ED patients say, "I don't want a CT scan because I don't have insurance." They don't want to pay $5,000, and that's understandable. But let's say that person's in serious need of an expensive test. Or worse — what if it's a child who's the patient? Do you call the child protective agency because the parent's unwilling to get needed tests? And if you send the child home, are you going to be held responsible for the parent's choice?

Perspectives: What "hidden" healthcare costs should consumers consider?

Dr. Silver: Whenever you're price shopping anything, it's important to understand that a bargain basement price doesn't always mean it's the best deal. Consumers also need to look at quality and outcome data. Because if a physician charges a thousand dollars less than competitors, but his outcomes are significantly worse, do you really want to go there?

Perspectives: The two of you have given us a lot to think about. Any parting words for physicians on the front lines?

Dr. Silver: I think as a first step, docs need to gain an understanding of what their charges are. I've spent two years developing a comprehensive, cash-fee schedule for our ambulatory care division [at Vituity]. It involved looking at every code we've used in the last couple of years, the utilization rates and trying to come up with a fair cash price for each service. That way, we have an answer when patients ask, "How much does this cost?" And when you need to, you can say, "This is why we charge what we do, and this is why it's worth it."

[Image credit: "Mall of the Emirates" by Peter Gronemann licensed under CC BY 2.0.]

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