How to Manage Your Health Care Costs – Beyond Just Coverage Costs and Gaps

Consumers are rapidly becoming aware that costs for health care coverage extend well beyond premiums, copays, and deductibles—costs such as additional charges for out-of-network physicians and facilities. There is also a growing understanding that different providers charge varying costs for services—and that other hidden variables can increase the final bill for treatment.

But consumer health care costs are not only a price issue. The cost of health care is the final sum of many decisions that are—at least partly—controllable by consumers or providers. Unfortunately, most consumers don’t know all the factors that make up health care costs, and why those costs differ so broadly across treatments and providers. And they often feel that they don’t know enough to question their doctors to get answers or explore alternatives.

That must change, quickly. Unexpected costs have put consumers at risk of bankruptcy and lawsuits. Let’s examine four ways that you can be empowered to lower your health care expenses:

1. Evidence: Question the Evidence and the Case for New or Continued Treatments

The British Medical Journal recently published an analysis of randomized clinical trials—the gold standard in determining clinical value—for more than 3,000 medical treatments and procedures and found, shockingly, that for half of those studies, treatment effectiveness was unknown. Only 11 percent had proven benefit; an additional 24 percent were “likely” to be beneficial. Treatments identified as harmful, unlikely to be beneficial, or where the potential harm equaled the benefit, made up 15 percent of all those examined.

The fact is that medical practice still often relies on theories and preliminary findings based on other known facts. Once treatments get into the mainstream, belief systems of both providers and patients make them hard to break. The effectiveness of aspirin in preventing heart attacks, vitamin D supplements to help bones, joint injections for arthritis—the list goes on of popular treatments that have since been challenged by studies that have identified suspect evidence of benefits at best, and potential harm, at worst.

If our culture promotes quick and technical “fixes” to many problems, including medical issues, the health care system under Fee-for-Service was complicit in promoting interventions with questionable merit. By contrast, Financial Risk will introduce incentives to avoid treatments without clear value. But it will take time.

As a health care consumer, you can and do influence the pace of change, and can become a better steward of your body and wallet. Here’s how:

• Ask your physician to provide published articles of trial results of both benefits and harm, in numbers rather than “improvement percentages” (which inflate the positive effects). These articles are usually not directly available to consumers.
• When reviewing trial information, request how similar the trial population is to you and/or your condition, how large it is, and how the trial results dealt with patients who did not complete the trial. Discuss with your physician how these issues affect the validity of results.
• Discuss how your treatment will vary from the treatment in trials, and the basis for that variance.

2. Excellence: Request Information About Your Providers

Under Valuer-Based Health Care, providers are being tracked. There is data on their volume, costs, quality processes, and outcomes. You don’t need to be satisfied with seeing just education and training credentials. Nor should you automatically accept providers’ self-marketing as centers of excellence, without knowing the facts.

Here’s the reality: How providers practice affects consumer costs. For surgical procedures, volume is highly associated with expertise and better outcomes in many cases. The tests that surgeons order, their decisions about type of anesthesia and location of treatment, the drugs they prescribe—all have both clinical and cost implications for consumers.

But how should consumers find good information about their doctors? Most information is currently private, but Medicare does provide some information on its Physician Compare site, and there are other emerging sites that are beginning to compare costs.

The first rule is to ask the physician or practice. A pushback may signal that the practice is still struggling with empowered consumers, and that alone is important feedback. Consumers must perform due diligence on the provider suggesting treatment. These are questions to ask:

• Request the physician’s history of treating patients like your cohort.
• Ask which quality measures are being tracked in the practice, and where to find information about quality performance.
• Ask questions about how the physician responds off hours, and within working hours, to important health care needs.
• Ask about the physician’s communication practices, including systematic use of the Electronic Health Record portal, telemed, phone calls, and emails. Ask how test results are released to your digital record, and whether it is the physician’s policy to talk them over with you first, prior to release.

3. Experience and Respect: Question What Doesn’t Seem Right

This includes respect for your own time, which costs you money. Health care professionals have the same biases as other people, so you should push back if you feel symptoms are being dismissed or that treatment plans ignore your preferences.

Health care providers have been slow to embrace the consumerism movement in health care, because it is a big change. Value-Based Health Care is pushing providers to be more responsive and accountable for the services they provide to patients. Medicare, health plans, and employers are pushing providers to engage patients in care so that patients can do better.

At highest risk are vulnerable groups like minorities and women, people with behavioral health issues like addiction, and others with socio-economic challenges. Care for people with psychosocial issues—with significant overlaps between depression and other mental health concerns and employment, access to housing and food—is a major concern that is just now being acknowledged.

Consumers must be advocates for themselves and their families. Here’s what to consider:

• It is important for older consumers, in particular to involve and bring family or another support person to appointments. Any patient, however, benefits from the support and extra eyes and ears of a trusted family member or friend. You should note whether the physician is treating that person as an asset and trusted advisor to you, or as someone who doesn’t belong.
• If the physician keeps you waiting for 35 minutes or more, you should question whether the practice is understaffed. Understaffed personnel make errors, including medical ones.
• Minority, female, and patients with psychosocial or economic problems need a physician who is a partner in health. If symptoms are dismissed or there are other barriers to treatment, the conversations about effectiveness, quality, and cost cannot take place. It’s legitimate to question whether this is the correct “fit” of provider.

4. Transparency: Ask for Costs and Validate Coverage of All Services—and Providers.

Broadcast news has recently spotlighted many cases where consumers proceeded with emergency health services, only to discover later that there were problems with costs and coverages. One common root problem is that not all providers in a physician’s referral network may actually be “in network,” generating thousands of dollars in out-of-network costs for unaware consumers. As employers and health plans continue to narrow their networks of providers, consumers who believe they have coverage are being caught, unaware, in serious financial crises.

Imaging, anesthesiology, and specialists are the trouble spots for potential conflicts. So, too, are referrals to specialists by an “in-network” provider to another who is outside the network. Nor is it safe to assume that in a large multi-specialty center within the same walls, that everyone is under the same network. It is virtually guaranteed that they are not.

Nor can you assume that once you purchase coverage in which your provider is in-network, that this is permanent. Continue to validate your provider’s position just as your provider’s office requests insurance validation at every patient visit or service.

In addition to network issues, comparing costs between providers is very difficult. Consumers cannot use providers’ price lists to tabulate their expected costs, counting services and prices. You need to be vocal about demanding the cost of a surgical episode of care, and what is covered before, during, and after services within a time limit for any procedure.

Price transparency is getting a big push from Medicare, which first insisted that hospitals post prices, but later discovered that the price lists were not useful. Hospitals continue to push back on these reforms for competitive reasons, but, ultimately, cost transparency will prevail. In the meantime, however, here is what you should ask:

• Request episode-of-care costs associated with any medical or surgical procedure. You might get them.
• Validate coverage and costs for every referral from the primary care physician.
• Get second opinions whenever feasible, and if appropriate to the situation, seek opinions across specialties—for example, orthopedics and neurosurgery for issues of the spine.
• Ask the health plan for comparable cost information of providers.
• Before deciding on treatment, check for general cost information, like the Fair Health consumer site.

Consumers Can Direct Costs, But Much Is Still Driven by Providers

While managing health care costs begins with wise choices about personal lifestyle like diet, exercise, sleep, we know that “living the healthy lifestyle” is not enough to eliminate health care costs. All of us will face increasing challenges of vulnerability to disease and dysfunction as we age, as well as the impact of underlying genetic and environmental issues. These are mostly out of consumers’ control.

The key is to break down the mystery of health care and learn to control its use. This is a learning process, and not all consumers are yet prepared for the task. If not, they must ask for the support of family or friends to help

The most important advice: research and question, and then verify findings as much as possible. Ultimately, medical decisions are those made by patients under the guidance of physicians. It is a consumer’s job to insist on the facts and assess research, as well as enlist support when too overwhelmed or incapacitated to manage the task.

Founded as ICLOPS in 2002, Roji Health Intelligence guides health care systems, providers and patients on the path to better health through Solutions that help providers improve their value and succeed in Risk. Roji Health Intelligence is a CMS Qualified Clinical Data Registry.

Image: Jeffrey Hamilton