Originally created 10/29/06

Medical sector lifts the veil on cost, quality data

In today's information-on-demand society, consumers can comparison-shop for nearly every product or service they buy, from homes and appliances to the clothes on their backs.

When spending money on that which is most important - their health - they are essentially blind, though.

The U.S. health care model, in which government and private insurance companies bear most of the $2 trillion in annual costs, has created a system in which consumers don't know, nor seem to care, about the true cost of their colonoscopy or hip-replacement surgery.

Government crash-test ratings for automobiles, for example, are a few mouse clicks away on the Internet, though finding out which hospital near you has the best patient outcomes for a double-bypass surgery can be a daunting task.

The system is changing, however.

Consumers are being asked to foot a greater share of their medical costs through high-deductible health plans, requiring them to act like consumers.

"People want this information," said Christina Pearson, the deputy assistant secretary for the U.S. Department of Health and Human Services. "If you want to check out an airline, you can go online and get ratings and compare prices. But for health care, we don't have standards to judge."

PUBLICLY AVAILABLE PRICE DATA are scant, and quality standards vary, making health care shopping difficult. Health policy officials say that should improve because of the recent movement toward greater disclosure, or "transparency," as it is called.

Under pressure to create a more consumer-driven medical system, doctors, hospitals and other segments of the health care industry are being prodded into lifting the veil on their charges and standardize their reporting practices so "apples to apples" comparisons are more easily made.

The idea is that greater disclosure of costs and quality data will give consumers the tools they need to make wiser, and often less expensive, decisions about their care.

The transparency movement got a boost in August when President Bush, in an effort to improve health care efficiency and put a lid on skyrocketing costs, signed an executive order making transparency a priority in federal health programs such as Medicare and Medicaid.

THOSE TAXPAYER-FUNDED PROGRAMS cover a quarter of all insured Americans and pay for 45 percent of all health care costs, and by their sheer size tend to influence the entire U.S. health care system.

On Oct. 18, Georgia Gov. Sonny Perdue signed a similar order that creates a state body called the Health Information Technology and Transparency Advisory Board. It will be charged with advising the state Department of Community Health on health care transparency issues.

The medical profession has adopted an active but cautious stance to ensure that transparency is uniformly applied and that - because no two surgeries are alike - comparisons are clinically meaningful.

The American Medical Association wants the federal government to use its Physician Consortium for Performance Improvement standards as the basis for quality measures.

To be fair about pricing, the association said health insurers also should give full disclosure to the consumer.

"If we want patients to become more prudent purchasers of health care, they need to be in greater control of their own health insurance choices and decisions, and need price transparency from all insurers - not just the federal government," said Dr. Edward L. Langston, an AMA board member, in a statement issued after Mr. Bush signed the transparency executive order.

In January, the Georgia Hospital Association, which represents every nongovernmental acute care facility in the state, is set to unveil a Web site listing price and care quality data for consumers.

The site, modeled after the Wisconsin Hospital Association's www.wipricepoint.org, will be designed to show consumers which providers give the best care at the lowest cost.

"There's always been a willingness to share this information with the consumer, but the issue has been how do we do it in a way that's accurate and complete," said Kevin Bloye, the spokesman for the Georgia Hospital Association. "It will go a long way toward scratching an itch the public has had for a long time."

EMPLOYERS, WHOSE BENEFITS plans cover nearly 60 percent of all insured Americans, are the driving force behind transparency.

The average yearly cost of the most popular type of insurance plan offered by employers hit $11,765 this year, with the average employee paying $3,226 of that, a Kaiser Family Foundation study shows. Average premiums have risen 87 percent since 2000, while workers' earnings have risen 20 percent.

Companies say they can no longer afford paying for health care costs that have grown, on average, three times faster than the overall rate of inflation in recent years.

General Motors Corp., the ailing automaker that has become the poster child for being crippled by health costs, spends more on medical care for workers - about $5.6 billion in 2005 - than it does advertising its product. Health costs for its auto workers, whose union contract stipulates no-cost family health care coverage, adds more than $1,000 to the price tag for a GM vehicle.

"Employers are looking at (health care) costs and finding it difficult to maintain profitability at the same time," said David Foster, a senior benefits consultant at Atlanta-based Mercer Human Resource Consulting. "Companies now look at health benefits as a shared responsibility."

The corporate response to rising health costs in recent years has been to shift more of the burden to the insured through so-called "consumer driven" health plans that carry higher premiums, deductibles and co-pays and are sometimes linked to employee-funded health savings accounts.

Wal-Mart, for example, this year instituted a health plan for new employees that has very low premiums, as low as $11 a month for an individual. The coverage, however, carries high deductibles in which individuals must pay the first $1,000 in costs - families pay $3,000 - before coverage kicks in. Like many other consumer-driven plans, Wal-Mart's insurance kicks in for catastrophic expenses and emergencies but forces workers to be price-conscious for lower-cost routine care that they have more control over.

HIGH-DEDUCTIBLE, consumer-driven plans are a shift away from the type of coverage that previous generations have known, with which consumers were "artificially separated from the cost of their care," said Walt Cherniak, the spokesman for Aetna Inc., one of the nation's largest insurers.

Aetna made news last year when it created a program that gives plan participants in certain markets online access to its discounted payment rates to individual doctors for common services, such as basic visits, X-rays and lab tests.

UnitedHealth, the nation's No. 2 insurer, offers members access to an online cost estimator that provides average cost for common procedures by geographic area. Unlike Aetna, UnitedHealth doesn't disclose physician charges, or "unit prices," because those charges alone don't give consumers a complete picture of their cost.

"It would be like buying a tire and being told only the cost of the tire, not any of the other charges associated with buying a tire," UnitedHealth spokesman Daryl Richard said.

The private sector's resources complement the data found on the government's Medicare Web site, www.medicare.gov, which posts price and outcome information for the 30 most common health care procedures by geographic region, giving consumers a ballpark figure of what to expect.

NUMEROUS OTHER WEB sites also rank hospitals' quality based on how well patients fare and whether the facilities follow nationally recognized standards for providing care, but there are still a lot of data that are not being reported, and some of the data from health care providers lacks the uniformity to make an apples-to-apples comparison.

Currently, price and patient outcome data are available for only about one-third of the health care industry, said John Friedman, the communications director for the National Committee for Quality Assurance, a Washington-based nonprofit dedicated to improving health care through measurement and accountability.

That percentage is increasing all the time, however, and should accelerate because of the recent Bush transparency mandate, he said.

"The momentum is clearly pointed in that direction," Mr. Friedman said.

How consumers adapt to being in the driver's seat for their health care decisions remains to be seen. Generations of Americans who have historically lacked the information to shop for health care will have to break old habits, such as taking a physician's word as gospel.

"It's OK to challenge a doctor," said Dr. William Hauser, Aetna's Southeast and Southwest regional medical director and a former private practitioner with three decades of experience. "You have to ask the critical questions about your care, like 'Why do you want to do this?' and 'Where is the best place to go to have this done?'"

Reach Damon Cline at (706) 823-3486 or damon.cline@augustachronicle.com.

Cost-cutting tips

Although living a healthful lifestyle is the best way to cut down on medical costs, you can also try these consumer tips:

Brush up on first aid: Proper treatment of various accidents might reduce the number of visits to the doctor. Always keep an updated medical kit in your home or office.

Heal thyself: Don't see a doctor for largely untreatable ailments such as cold, upset stomachs or occasional fatigue. All you'll get is reassurance to do what you're already doing: staying home, resting and taking an over-the-counter medicine.

Use 24-hour "dial-a-nurse" services: Not sure whether you need a doctor or just bed rest? Find out whether your area has a 24-hour nurse line. The call is free and the advice is from a professional. In the Augusta area, call the University Hospital Ask-a-Nurse line at (706) 737-8423 or (800) 476-7378.

Call your insurer: Because your coverage can vary greatly depending on the type of care provider or facility you use, you should call your health insurance company to check on the financial ramifications of any nonemergency health-care decisions you plan to make.

Ask about charges: Before you see a new doctor, including specialists, find out about their fees and billing policies.

Interview your doctor: When seeking a new health professional, you might want to try making an appointment to interview the doctor in person or over the phone before scheduling a medical appointment. If your choices are limited by your insurance plan, start with those professionals recommended by close friends. Because doctors are well-shielded by their support staffers, it takes some effort before the physician actually returns your call. If you don't get a response after three messages, that might be an indication that the doctor might not be the most attentive to his or her patients.

Bring an advocate: If you are uncomfortable with health professionals, bring a friend or family member to help you communicate and provide you with comfort and objectivity.

Write down questions: Most doctor visits are brief, hurried affairs. If you have questions you don't want to forget to ask, write them down before your appointment.

Just say no: If you encounter what you believe is a rapid diagnosis and treatment solution during your appointment, or if you are uncomfortable with the diagnosis or treatment, you have the right to seek a second opinion. If you are afraid of being easily swayed, take a friend to the consultation with you. Remember that you have the right to say "no" and have the a final decision when it comes to your health.

Get a second opinion - out of town: Statistics show that the frequency in which certain medical procedures are performed varies widely from location to location. Certain operations are simply more fashionable in some parts of the U.S. If you plan to get a second opinion before surgery, consider going to a specialist in another city. Get the names of second-opinion doctors in your region using the federal government's toll-free second-opinion hot line at (800) 638-6833.

Don't pay double for tests and x-rays: If you're getting a second opinion or seeing another doctor, ask your primary physician to send copies of your medical records, X-rays, and lab tests to avoid unnecessary retesting. That goes for dentists, too. Remember, your records belong to you.

Go generic: Ask your doctor to prescribe generic drugs. Medicine marketed under its scientific name is usually 50 percent cheaper and just as effective as brand-name versions. In addition, look for generic drugs in the medicine you purchase over the counter.

Take only the drugs you really need: When your doctor prescribes medication for you, understand exactly what it's meant to do and for how long. For example, if you have an earache, you might receive two prescriptions: an antibiotic and a painkiller. If you have little or no pain, you might want to forgo the cost of the painkiller.

Is it covered? If your hospitalization isn't for an emergency, check your insurance policy to find out what it will cover and how much it will pay. Be sure to carefully review the section on "exceptions and exclusions." It will tell you what your plan will not cover. Make sure that everyone who will be treating you - the surgeon, anesthesiologist, radiologist, pathologist, etc. - participates in your insurance plan.

Bring your own: If your treatment involves a hospital stay, find out what room amenities you'll be charged extra for. If tissues, for example, are not included in the room charge, bring your own. Ask whether you can bring your prescriptions from home to avoid paying for medications administered by the hospital.

Check your bill: A large percentage of medical bills, including those from hospitals, contain errors and overcharges. Things to look for include being charged twice for the same service, supplies or medications; incorrect date for admission and discharge; and incorrect room charges (being charged for a private room when you were in a semiprivate room). If you think your operating-room time is inaccurate, check it against the records of your anesthesiologist (who charges by the hour).

Don't be afraid to ask questions: If you're given a bill with confusing codes, ask for it to be translated. Don't accept bills that use terms such as "lab fees," or "miscellaneous fees." Demand an itemization. If you don't get satisfaction from the hospital billing department, appeal in writing to the hospital administrator or patient ombudsman.

Sources include: HealthInsurance.org

Price and quality resources

Public access to medical price and quality data is expected to increase in coming years as the government, health care providers and insurance companies find better ways of gathering and analyzing the information.

Aside from individual health insurance companies, which post market-specific data on their Web sites, consumers can find information at the following sites:

- www.medicare.gov: The federal government's Medicare site shows what the health program pays hospitals within a specific county and state for some of the most common procedures and treatments.

- www.hospitalcompare.hhs.gov/hospital/home2.asp: A Department of Health and Human Services site allowing consumers to compare hospitals in their region based on their patient outcomes for various procedures.

- www.leapfroggroup.org: The Leapfrog Group, an employer-funded organization, offers consumer tips on reducing preventable medical mistakes and provides hospital ratings.

- hprc.ncqa.org: Run by the National Committee for Quality Assurance, the site provides a Health Plan Report Card for insurance companies.

- www.wipricepoint.org: An example of a state-specific site allowing consumers to get basic price information. The site, created by the Wisconsin Hospital Association, is the model for a site being developed by the Georgia Hospital Association.

- www.floridacomparecare.gov: An example of a state government-run site that serves as a portal for research sites giving consumers everything from retail prices for prescription drugs to hospital mortality rates.


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