Between being retired and pandemic limitations on personal contact, I have become blood brothers with my computer. Mostly cyberspace sites that have large access followings, some smaller assemblies of people like my synagoge or Osher Lifelong Learning Institute, though some with just me and what the geniuses of Microsoft enabled without having me connected to the world. While I jot down in a notebook at 7PM each evening with roller ball pen three favorable experiences of the day, there are many good things that do not isolate to specific days. My inquisitive mind did not get fully mashed in the latter days of my medical career by the Electronic Record or a level of oversight that tallied my performance score by measuring how much, often to the neglect of how well. There are daily goals, as there have been for decades, but better completion as the diversions of commuting, committee meetings, or even workday grooming have moved to the background.
One of my more gratifying self-schedulings has been regular viewing of TED talks, to which I was introduced in recent OLLI classes. Experts in more fields than I can name, most with a Wikipedia entry to establish their expert credentials, archived over about ten years by date and by topic category. As an introduction, and to encourage consistency on my part, I assigned myself two talks a day, chosen by subject in sequence by letter of the alphabet. While many stimulate my frontal cortex and my stored knowledge meticulously accumulated over decades, I particularly wanted to explore more after a talk on price transparency in healthcare. It was not really a stump speech that any elected official would offer if elected, but a more thoughtful summary of what an expert thought would happen if that politician really did incorporate price transparency of our medical care to parallel what we pay in a department store or a gas station.
https://www.ted.com/talks/jeanne_pinder_what_if_all_us_health_care_costs_were_transparent?language=en
This presentation took place about two years ago, given by a journalist who post-retirement pivoted to an agency head that collects data on medical pricing. It has had more than two million views, though not with the endorsement of the movers & shakers who can make this happen though a preliminary proposal for this came from the Center for Medicare and Medicaid Services (CMS) at the beginning of the Covid-19 pandemic but has proven less newsworthy than more urgent public health concerns. Indeed, whether it should happen remains an open question. While most of us of my age have a fondness for that great medical icon, Dr. Geraldine, who taught the world from our home TV's that "what you see is what you get" doing that with the GDP fraction of health care expenditures can create a Pandora's Box of immense negative possibilities and without that gem of HOPE nestled at the bottom. The TED speaker's site collects actual prices reported by consumers of medical care for the services they either purchased, shopped for, or had somebody else, usually their insurance, pay an outrageous sum on their behalf. The almost immense spread of reported prices would be viewed by most readers as scandalous, but the insiders who set the prices and the insurers who pay them are well aware of the pricing structure, its extreme variance among providers, and those gentlemen's agreements to pay the final sum total irrespective of the merits or negotiation of the individual items that create the total.
This shielding of itemization, never done in grocery shopping or similar small purchases, had a previous legacy elsewhere in the consumer economy. When my father shopped for a new car, he would take us as a family to several local dealers. At the time, American cars dominated and more people ordered their car to be built at the factory to specification rather than drive one home from the dealer's inventory. The salesman would show us the car. Then he would give us a list of options to make the car "nicely loaded." My father would add a radio and an automatic transmission, consider air conditioning, or some elective safety features, or tinted windows. The salesman would write this down on his carbonized form. The front page where he wrote would have entries for adding what we desired, the total added with an adding machine while shielded from our view, and my father would be handed one of the carbons with the total asking price. The consumer copy had blacked out the itemization prices so you only knew the base price and the total. If you said AM/FM radio, the savings to be had by giving up FM was withheld, keeping the consumers at a disadvantage.
Japanese manufacturers eventually undid this industrywide performance norm by just including the options that their data showed most consumers wanted and give a price. It's a two edged sword, forcing that AM/FM radio because that's the only way their cars were built, even if all you use the radio for is the commuting traffic report or forcing power windows on the customers who really didn't mind rolling their window position manually. The system created more price transparency, virtually eliminating the American car salesman's "bump" that add a $50 item that you didn't know about but he did because you never got the itemized list of what you agreed to purchase.
We have some variants of this today. In the days when men were the hosts at business or personal restaurant outings, there were "women's menus" that lacked prices. Recently a good friend took me to lunch at his snooty city club restricted to alumni of his Ivy alma mater who paid a fee to belong. Nice restroom with university logo paper towels. At lunch, my menu had no prices. I did not see his menu. Maybe it didn't have prices either if the costs of his meals were part of a membership obligation. But there was a menu in their lobby that did. Despite my effort to become literate in Hebrew which is read from right to left, they did not want me reading their menu that way, particularly when somebody else is obligated to pay for what I select.
For a short time, during a wage-price freeze in the pre-computer era, the Nixon Administration included a requirement that the 50 most commonly billed items in medical offices be kept in a loose leaf at the front desk for review by patients.
Even though I did not pay for my family cars and I did not offer to go Dutch at my friend's alumnus haven, I resented having information that might guide my selection withheld from me. There is a reason that those obliterated carbon copies of car dealership price obscurity and "women's menus" are no more. The rebellion of the consumer, either by preferentially buying price transparent Japanese cars or by a female executive shaming her waiter by telling him that as the one with the company credit card, she gets the menu with the prices, led to the demise of these attempts to deprive consumers of pricing knowledge they were entitled to have.
Health care outside the scope of physician care has made some progress. At a dental implant, my periodontist had his front desk offer me a pre-procedure itemization, including surcharges for the CT scan and for harvesting my white cells should those be needed. Unlike a restaurant patron, I did not have the option of declining a portion that he thought needed to be done. As a Medicare beneficiary, I shop for a supplement each Open Season. This includes a Part D prescription plan where the quarterly copay for each of my current prescriptions is itemized, though the portion paid by the insurer is not disclosed to me . However, the monthly premium is. As a Medicare Beneficiary with a good Medigap policy, when I see my doctor a statement is sent with fee submitted by the doctor's office, the amount that Medicare pays, and later from the Medigap carrier telling me what they paid. This is more the illusion of transparent, at least for Evaluation & Management codes of office visits, along with an understanding that the price submitted by the. office to Medicare was essentially fictitious. There is no reason to shop as a different provider will not result in a different final price to either me or to my doctor. It makes no difference if the submitted sum to Medicare far exceeded any fair market value of what the doctor billed, though it might for bills that contain itemization of procedures that Medicare pays for but really could have been safely declined by an informed patient.
As much as this is accepted customary delivery of medical care for a fee, sometimes the consumer is the payer and some consumers, myself among them, regard ourselves as stewards of our insurer. If it is despicable to gouge me, it is just as despicable to gouge them, even though they are run by professionals who would spend more company money screening and challenging charges than they would just paying them. Moreover, many of us now have high deductible plans so are effectively direct consumers for a considerable up-front sum. But ultimately, there is a premium paid by either consumer or employer for the coverage, so that gentleman's agreement of deep pocket insurers to just pay what is requested returns to either the taxpayers for public programs or to employers or patients subsidizing the lack of transparency indirectly for commercial insurers in a competitive marketplace.
Something like imposing price transparency on a national scale amid a tradition of itemized obscurity would generate a fair amount of disruption. It is far from apparent whether mandatory compliance achieves pre-determined goals, assuming we know what the goals are. Enabling individual consumers shop more wisely seems easy to accomplish and very consistent with other consumer initiatives. The impact on institutions may have a more significant down side. Moreover, as quality may be better served by value based payment systems, Geraldine's itemized "what you see is what you get" could reinforce fee for service which has created an incentive to do more medical care when less might be better.
Price shopping for deals means that a purchase is not urgent. Mammograms, lipid testing, doctors visits et al have some leeway but not unlimited flexibility to acquisition. So delaying care in a harmful way could happen. Some decisions, while not urgent, are more complex. They carry a higher price tag with serious consequences to indefinite delay, such as heart surgery or cancer care. Delays to get the best financial deal might be more unwise.
Perhaps the most intriguing provision of the CMS transparency proposal involved providers making available the real cash payment they would accept in lieu of the inflated price given to the self-payer, enforced by collection agencies, later amenable to partial payment. That's the real price. For one time purchases such as a car or a home, there is some variability with sellers offering different prices to different buyers. Parts of the world still have souks. But JC Penney and FW Woolworth made their fortunes by reassuring their customers that all would pay the same stated price for the same item. Medical care should not be modelled after the bazaar or the car dealership.
Bringing transparency to institutions, less vulnerable than individual patients, that have professionals and attorneys galore to protect their financial and competitive interests may expose a bigger downside. Despite their bargaining clout and sophistication, payment for a specified service vary widely between hospitals dealing with the same insurer and between multiple insurers paying itemized or bundled fees from an individual hospital. Confidentiality allows deals to be negotiated on a very large scale. If everyone knows what everyone else charges and receives, some services will inevitably play out as commodities, items sold in bulk at market rates irrespective of variations of quality. As competitive forces restrain the prices of the bulk items, the services provided under conditions of urgency would rise to maintain net financial solvency. Thus ER or services unique to a particular institution would rise. Hospitals in less populated areas or hospitals serving an underinsured population would have less ability to leverage their geographic exclusivity. And as prices that institutions are paid by their insurance contracts are known and squeezed, the source of investment revenue would become less secure as well, jeopardizing acquisition of new expensive technology with uncertain profitability.
Finally, once itemization of real payments, not fictitious charges, becomes public knowledge, it becomes more secure to reaffirm fee for service predictability for a less certain value or outcome based payment system which may have an advantage in nudging optimal medical care. The ability of physicians or our employers to predict individual or cumulative outcomes leave a measure of uncertainty beyond knowing in a predictable way what you will receive for the work you do irrespective of outcome.
What seems to be my expectation is that individual consumers think of their care as a consumer purchase more when they have to present their credit care than their insurance card. Dr. Geraldine's "what you see is what you get" has considerable appeal. Once you get past the consumer to institutional haggling which has to include value as well as price, there may still be some advantages to keeping the verifiable payments confidential. That emptied Pandora's Box may lack the expected gemstone on the bottom.
