* * Anonymous Doc

Tuesday, May 25, 2010

I just noticed someone asked in a comment on my blood transfusion post, "How much does the hospital charge for a blood transfusion? How much does it pay? (Is the blood donated? What's the processing fee?)"

The question makes me laugh. How much does the hospital charge? I have no idea. The processing fee of a blood transfusion? Beats me. We order things, they get done, we are completely insulated from whatever the billing process is. And I'm glad. Not just because the last thing I want is more paperwork-- we write tons of notes as it is, we spend a great fraction of our day sitting in front of computers and typing instead of actually doing patient-care-related things-- but the last thing the system should encourage is making decisions centered around things unrelated to patient health.

Yes, I think the system is broken-- I know hospitals charge what seem like insane amounts of money, and if you don't have insurance, any little medical issue can absolutely bankrupt you-- and I think that's bad, and troubling, and frightening. But I don't think the answer would be asking our patients if they'd rather have the $3,000 TEE or the $0 "lie in bed and wait for another heart attack." We do things because they're necessary-- the fact that they cost money is unfortunate but I don't think we want doctors deciding on the balance between cost and health, and I don't think patients are equipped to sensibly make those choices-- is the procedure worth it even if you need to default on the hospital bill and declare personal bankruptcy? Well, if it means the difference between life and death, I think it probably is, and I don't know who wants to argue that it isn't.

What I do know is that the billing doesn't always make sense. Insurance companies have deals with the hospital where they pay a fraction of the "retail" rate that self-pay customers are billed. Patient might get a bill for $500 when an insurance company would have been able to settle that claim for $50. That's clearly unfair to patients who, for whatever reason, aren't covered. And that doesn't just affect the uninsured-- it affects people who are seeing doctors outside of their plan-- which isn't always the patient's fault-- the hospital sends over a specialist for a consult, you have no idea if they take your plan and you're in no position to do anything about it even if they don't. There are tests that aren't covered, there are claims that get rejected. It's a mess.

But the fortunate thing for residents is that we deal with none of it. And, frankly, I can go on and on about how in an ideal world I don't want to be a hospital-based physician, I want to see patients in private practice, I want to see them when they're well and not when they're dying-- but there are huge advantages to being based at a hospital and spending part of your week dealing with inpatients-- the hospital deals with all of that back-end stuff, you don't need to deal with the billing and the insurance, you don't need to deal with finding and maintaining office space, and having a staff and the infrastructure you need to effectively run an office. You get to spend your time seeing patients instead of being an accountant. So there's certainly benefits there.

But, gosh, the last thing I want to do is think about how my patients are paying for their medical care. I just want to worry about getting them healthy enough to leave.


  1. That is pure laziness on the part of doctors. Straight and simple.

    Doctors not wanting to worry about cost is the real reason so many people can't afford health care! Don't blame the insurance companies -- blame yourself.

    Every other profession in the world has to reconcile the services they offer with what people can actually afford, and work with their customer to find a solution that best fits their needs. Health care should be no different, but because we make an exception, the only people that can actually afford health care are the wealthy.

    It is intellectually lazy to assume that only one solution -- the expensive one -- exists for every medical problem. If no MRI guarantees a 95% healthy outcome but the MRI guarantees 99% healthy, does the MRI really need to be done? Yet there is no incentive structure for people to explore these options, and therefore we continue to price out the poor out of the health-care market.

  2. @Jason

    As another resident in another city somewhere out there, I do agree that doctors need to pay attention to the cost of their lab workup and services rendered. I can tell you that we certainly do pay attention in our hospital, and I'll bet you that they do at Anonymous Doc's too. But I do also think you're missing a big part of the picture, and you'll have to pardon me for saying this, but I think you're lacking in insight as to how healthcare works from a practical standpoint.

    Take the MRI that you brought up. MRIs are *expensive*. There's no question that they are over-ordered, and there's no question that they are bloody expensive. But there is definitely a role for MRIs in healthcare:

    Fundamentally, MRI is an imaging modality -- in simple terms, it detects but certainly does not cure illness. If being able to diagnose you with a disease--say, multiple sclerosis--allows me to focus and specifically direct my treatment for you toward what we know is an effective treatment for MS, then running a $3000 MRI/MRA to diagnose you may *save* money in the long run because we can start a more effective, focused treatment *earlier*, and we don't waste money on other studies or treatments which would be completely needless, not to mention ineffective.

    Plus, by appropriately ordering diagnostic tests at the right times, we can avoid needless suffering while you're waiting for us to figure out what exactly is going on (and are meanwhile developing a deep hatred and mistrust of all things related to medicine and doctors).

    I'm oversimplifying the case, obviously. But again the issue is -- does a test or procedure help us save money in the long run by helping us to treat patients more effectively? If I am confronted with the $1000+ cost of an MRI each time I order one, am I less likely to order the test simply because of the up-front cost?

    I should add that hospitals most certainly pay attention to this. Are tests being ordered appropriately? Do they affect patient outcomes? This is only the tip of the iceberg, but I hope this helps you to understand, at least, that it's not just a lazy group of miscreants running around in your local hospital, feeding at the trough and not giving a shit about the oppressed poor.

  3. @ Jason

    The diagnostic procedures and treatments that doctors order are usually based on guidelines that have undergone extensive research. In other words, physicians would not request anything for a particular patient if they did not deem it absolutely necessary. As such, it is the responsibility of the doctor to educate his patients of why a certain procedure/treatment is important.

    Having said that, once a complete and informed consent has been made, whether verbally or in writing, it will still ultimately be the patient who decides whether or not to proceed. Although, arguably, they may not have the capacity to make the best decision for themselves, the final word is still at their hands.

    Most doctors only want what is best for their patients. Sadly, as in all other fields (not just in medicine), money still governs and restricts our practice. In spite of this, however, you cannot ask us to request for something less than what a patient actually needs. These are people we are talking about, every decision can mean the difference between life and death.

    I am very disheartened and frustrated that you think doctors are "lazy". We sacrifice a lot just to be in this profession. I am a doctor in a developing country and I've really seen a lot of people succumb to their diseases out of poverty. Where I have worked, if a patient cannot afford a certain procedure and/or treatment, we step down to something cheaper. For example, if a patient needs an MRI but has funds enough for only a CT-scan, we would have to settle for the latter even though it's not the best and probably has half the detection rate of whatever it is we're trying to look for. What I'm trying to say is that we DO actually take note of the costs of these procedures, at least in a general sense, however, we cannot let our management be governed by it. We still NEED to give what's best and recommended for our patients, and should they not have the means to do so, then we step down from there and make, what you would call, "compromises".

    It is a sad and harsh reality, I agree. Being in a "third" world country, the gravity of this is even more severely felt. A lot of times, we have to get money out of our own pockets just so we can proceed with our management and hope for our patients' well being. I don't intend to force my opinions on you, but I would appreciate it if you just looked at this from our perspective.

  4. Both as a patient and as a health services researcher (and hospital employee), I have to laugh at the idea that costs don't get taken into account in decision making at the point of care. I'm sure that may be the case for you as a resident, but I can guarantee you that it's not the case for most of the attendings you're working with. I know the hospitals I've worked for keep close tabs on which attendings are using more resources than others, and which don't recoup those costs in billing as well (i.e., because they didn't pay attention to whether the patient's insurance would pay for X test without Y diagnosis) -- and I know of more than one outpatient practice where these issues are what decides annual bonuses.

    And both this post and the comments above seem to be oversimplifying here. It's more often not about "should we do an MRI or not, because they're expensive" -- it's about what's the marginal benefit / marginal risks / marginal costs of doing an MRI instead of doing a different test.

    Now, because of my role professionally, I'm guessing that docs often involve me in decision making a little more than they might otherwise. But more than once in the last year alone I've had discussions with docs about exactly this --

    * In one case, it was a question of whether to just go straight to MRI, or to do an ultrasound first and then go on to an MRI if we didn't get definitive answers from the ultrasound. Going straight to the MRI would perhaps save me time, and get me to surgery a few days more quickly -- but it would also cost my insurance company a lot more, plus increase the odds of incidental findings that would require follow-up and perhaps even unneeded intervention. I went for the ultrasound, largely because of the cost issue, even though my out-of-pocket cost was the same either way. But why would it be a better thing for the doctor to have kept himself completely ignorant of the cost differences, or refused to include that in the decision making?

    * Just this morning, I had another doc ask if I wanted a shoulder MRI to check for a tear. He said that the MRI would tell us whether it was torn or not, but wouldn't change how we managed it for the next month -- and that if we did want to go to surgery, I'd need another MRI at that point anyway. So an MRI now would have been purely for information's sake. And again, cost comes into play -- am I willing to have an inexpensive blood test purely for information's sake? Sure! I like data, my doctors like data, the $10 it costs the hospital to draw the sample and run the test seems worth it for that. But why should I or my doctors put a priority on making these decisions cost-blind?

    In neither case am I getting bad care because we're taking costs into account. But we *are* balancing the desire to have all the information right away vs. the desire to constrain costs.

    I have been to private practice docs who pretty much ignored costs when making decisions and recommendations -- and there's a reason I no longer go to those docs. My out-of-pocket costs had gone up *without* a big enough increase in my quality of life for it to be worth it. Yes, going from a $40 a month med to a $2000 a month med meant that my pain went from 6/10 to 5/10 -- but it also meant that I needed to take a 2nd job just to pay for my meds. So I changed docs -- and changed to docs who aren't focused solely on absolute symptom minimization as the only priority, and who are willing to take my priorities into account, too.

    Being cost-blind probably makes decision making simpler for you in a lot of ways, but I wouldn't be so quick to assume that doing so is always going to be in your patients' best interests -- or even in your own.

  5. I don't think the answer would be asking our patients if they'd rather have the $3,000 TEE or the $0 "lie in bed and wait for another heart attack."

    Oh, I do. We make those kind of life-or-death decisions every time we decide whether to spring for airbags, or go work on an oil rig, or stick it out in this cheap apartment for one more year. Just think, the procedures you believe are "necessary" now were impossibly expensive fifty years ago -- all those people who had those conditions and died essentially decided the money was better spent on other things than a few years of life. Now we're much richer and a lot of those decisions are at the tipping point... but there's still no "it's necessary, it doesn't matter what it costs."

    In my factory, I know what's necessary to eliminate all defects, but it's crucial for me to know how much it costs to make scrap while I fix the defect, so I don't make decisions that bankrupt the company. I put the high-cost skids on hold and let my boss decide whether to scrap them. In the case of health care, the patient is the one who could go bankrupt and so he's the one who needs to make those decisions. You need to know the cost of the things you're recommending so that you can know when to kick those decisions upstairs, to the patient.