The Cost Conundrum: Healthcare Patterns vs. Personal Decisions

January 30, 2015 in health care costs, health care quality, News

“The Cost Conundrum” by Atul Gawande brings an interesting perspective to health care.   While the original article is from 2009, its relevance is brought forward in time by an opinion piece this past fall in the New York Times, offering a five year followup: Times opinion piece includes the claim that Atul Gawande may have written the most influential magazine article of the past decade.

To me, the Gawande article reinforces the importance to the health care consumer of being acquainted with
health patterns (i.e. epidemiology) as related to health care alternatives. Information on outcomes and statistics from public health practices may be challenging to relate to one’s own personal situation.  However, they can provide the ultimate deciding factor, especially when other elements of decision making do not offer clear cut choices.   Examples where clear cut choices may not exist are many, such as which prescription medicine to give or when to order additional tests.

Atul Gawande’s original article was found at the following link:

and an NPR report on the original article was here:

Atul Gawande is a surgeon at Brigham and Women’s Hospital and a professor at Harvard. He has received many awards for his research and writing including the MacArthur Award in 2006.

Unknowns of medical marijuana delivery

January 21, 2015 in Member Stories

Given the earlier legal prohibition on marijuana and its present changing status, the legal and law enforcement questions are complicated. Until the marijuana dispensaries are open, Massachusetts law enforcement guidelines state: “The law is silent about where the marijuana may be purchased, although once [dispensaries] are operational and open for business, patients will be able to purchase marijuana and marijuana infused products from a [dispensary.] In addition, chapter 369 allows a patient to cultivate a 60-day supply until DPH begins registering patients and awarding (or denying) hardship cultivation registrations.”


In principle, cultivating marijuana could be easy. After all, it is referred to as a weed. However, restrictions and technical requirements appear to make this route difficult except possibly for determined patients and caregivers.

The situation is also unclear as to how cannabis is to be best and effectively used by the patient. It is likely that physicians will eventually be trained on efficacy and best practices. At the present time, the state allows a 60-day supply, which is defined as 10 ounces of cannabis or equivalent. Since methods for human ingestion of cannabis can take many forms such as edibles, vapor, and smoking, this is complicated. The ingestion of marijuana appears relatively innocuous in that patient deaths from overdose are reported to be close to zero, and as such is less likely to be lethal than common over the counter medicines such as aspirin or acetominophen.

The Massachusetts law also defines caregivers, who must register if they are to help patients with the marijuana. The voter approved rules allowed multiple patients per caregiver, while the current state regulations conflict with that. Unlike the concept of good samaritans, each caregiver is limited to assist only one patient. The caregiver can transport the patient, obtain the patients cannabis, grow cannabis under approved hardship conditions, prepare cannabis for consumption and administer cannabis to the patient. Unless the caregiver is a friend or relative, the tasks may seem rather thankless.

The subject of medical marijuana is not complete without noting that there are vociferous opponents of marijuana use and indeed of medical marijuana. Some question opponent’s motives as originating from pharmaceutical companies who could lose major market share and from law enforcement sources who could lose easy means for incarceration, lucrative management of heavily populated jails, and lucrative asset forfeiture. Aside from motives, the argument is made that marijuana can be a gateway drug and lead to more serious drugs for users. This can be balanced against the arguments that marijuana is an exit drug, and that if more readily available could reduce its attractiveness as a gateway. Another argument against marijuana prohibition is that it is not working, just as it did not work for alcohol. Also mentioned is the egregious failure of the war on drugs of which marijuana has been a significant part.

[Final note of caution: The above post is background about non-traditional healthcare resources, with which consumers may wish to be informed for their own benefit. The post contains best efforts information on a nebulous and changing topic, and the poster requests that the post not be relied upon for ultimate accuracy.]

Medical Marijuana Healthcare Quandary

January 21, 2015 in health care quality, Medical Care, News

Media have given prominent attention in recent months to marijuana. The Boston Globe reported a few months ago that marijuana legalization is on the cusp of mass acceptance. The New York Times has called for repeal of marijuana prohibition. Voting residents of the Commonwealth of Massachusetts in 2012 were sufficiently comfortable with the concept of medical marijuana that a ballot initiative for its use was approved..

Consumers may deservedly question how the change can alter personal healthcare advantages or disadvantages. Many residents, and I include myself, started with little knowledge about how marijuana could be medically helpful. To first clarify terminology, marijuana is a plant, a vegetable, that has a traditional name of cannabis. When the plant is used for other purposes such as producing clothing or fuel, etc. it is called hemp. Parts of the plant can be psychoactive. Cannabis can grow naturally out of doors in many parts of the world.

The subject of marijuana is polarized among the populace, with many very negative and many very positive viewpoints, plus people in the middle who lack information. Due to recent opening up of information channels, the claims for medical benefits are becoming better known. These include pain relief allowing a person to function more normally while reducing the use of other medicines such as opioids and non-steroidal anti-inflammatory drugs, which may have serious side effects or be debilitating. In some cases, cannabis is reported to be unique among alternatives to bring about patient relief or cures.

Despite the November 2012 approval, the Commonwealth of Massachusetts has not provided dispensaries that would make cannabis available to its citizens. On the other hand, Massachusetts does have an accredited cannabis lab to which samples can be submitted to test for active ingredients and contaminants. With the testing, supplied cannabis can in principle be checked and tracked better than say, other vegetables such as those going to the dinner table.

In the face of the marijuana healthcare quandary created by change, other states seem to be taking the lead in speedily addressing and redressing issues of cannabis delivery..

[Final note of caution: The above post is background about non-traditional healthcare resources, with which consumers may wish to be informed for their own benefit. The post contains best efforts information on a nebulous and changing topic, and the poster asks that the post not be relied upon for ultimate accuracy.]

Adjusting to pain killers — and medical marijuana

January 10, 2015 in Member Stories

NSAIDs offer pain relief, although I suspect that most people do not want heavy doses of pain killers for long, with their many possible side effects. In my case, two physicians independently advised me to double up on the recommended NSAID doses due to severe pain from osteoarthritis. The NSAIDS helped reduce the pain, but created new issues. First was severe stomach pain. Second were systemic feelings of sluggishness that reduced my activity level as much as the pain did.

I have been willing to consider uncommon alternatives that go beyond NSAIDs. Being adventurous I decided to check out medical marijuana, aka cannabis, based on hearing of so many people who have used it. I am over 70 years old, but had zero experience with it until this past summer, so my journey was long in a short period of time. The bottom line of my efforts is that cannabis has allowed me tosignificantly reduce the NSAIDs without any noticeable uptick in pain and without other apparent side effects, such as behavioral, sensory, or physical. I am told that I am less irritable, as well, which I suppose is a side effect.  What a relief!

I am not alone in pursuing the cannabis route. If some of several recent reports are to be believed, cannabis is an area of fertile development for improving healthcare.

In keeping with the intention of this blog, I am planning to subsequently give comments on cost, on use and on finding best care. In my opinion, the cannabis delivery model is different from others we might think of such as alcohol, most pharmaceuticals, tobacco, or less commonly candy, gluten, nuts, or whatever. I will try to post more on this. The whole subject is rife with pitfalls. I will be interested to see if other related comments, ideas, and opinions are also posted here.


Leveraging Competition in Healthcare to Bring About Price Transparency

July 23, 2014 in health care costs, health care quality, Hospital Bills, Member Stories, Quality of care

by Randy Cox

Executives and administrators in the healthcare industry will tell you that competition in their business is not new. It just looks different. There tend to be few if any TV or internet ads touting 50%-off discounts, or facilities matching the rates of the clinic down the street. But 21st century American healthcare has plenty of positioning on price, expanding of services provided, healthy marketing departments, and reports analyzing trends in patient volume compared to other facilities in the region.

Invisible Competition

No, competition is there. But other than the plastering of quality awards and ER wait times across websites and along freeways, much of the competition in healthcare is not consumer-facing.

You might ask, “Isn’t invisible competition the same as no competition?”

The quick answer is yes. Providers don't typically act like competing businesses on the outside. Their expenses are often unreasonably high, and they don't seem to care if a patient has a 2-hour wait or gets milked for thousands more than necessary. Nor is there any way to properly evaluate the merits of one surgeon or clinic compared to another, causing patients to be more easily taken advantage of, both in their pocketbooks and in poor quality of care.

But the medical industry is not a true monopoly (yet), and so its competitive forces can be leveraged to benefit consumers.

Price Comparisons Can Backfire

How exactly is that to be done? A common but naive view held by many in my industry is that simple, direct price comparisons will bring about the type of competition that will address most of the problems in healthcare affordability. It won’t, and here’s why.

The imaging centers and surgery centers we talk to have experimented with listing some of their prices on a few of our competitors’ sites, sites that use sort-by-price lists or some notion of a “fair price”. At first it seems natural that mimicking an electronics or hardware retailer is a step forward for consumers wanting to “shop” for medical care.

The effect of this type of comparison however is the cheapening of care. Providers are obviously opposed to this. Ironically, so are patients. Though it would seem that quick and easy price comparisons could provide less expensive care, people are strongly against the treatment of their health being trivialized and commoditized, even with routine procedures that have little to no risk, and yes, even if it saves them money.

When it comes to a person’s health, anything that smells like trivialization will be met with distrust. Price transparency accompanied by hype, advertising, and plays at “online shopping” are largely ineffective, and may actually drive people away, rather than attract them.

Medical institutions continue to resist being represented on sites that cheapen care in any way, not primarily because it affects their margins, but because it discredits the quality of their establishment. And, interestingly, we’ve received a number of reports that patient customers who are referred by “sort-by-price” sites are typically described as trashy, unreliable, unserious.

Where Price Transparency Can Add Value

Pricing Healthcare takes a different approach. We certainly believe in publishing prices (hence our name), and we believe that facilities’ prices should be compared. But we do not line prices up in a lowest-at-top sorted list like so many do. We take pains to represent facilities and their services in the best possible way.

Because of competitiveness among facilities, they are willing to promote themselves on our site, and to list prices for many of their procedures. We thus use competition to bring about price transparency, rather than the other way around.

We aren’t opposed to searching by location, by facility type, or by procedure, but we believe that when showing results, there are a number of problems with oversimplifying comparisons on price.

First, in some cases there may be dozens of reasons why services with the same name (and the same medical code) may not in actuality be the same, and may in fact require additional outlays that are difficult to enumerate. This is true even for treatments that have become fairly standardized in terms of what procedures and services are involved.

Knowing beforehand what a procedure will cost is of immense value to individuals and employers, and it of course needs to be visible. An upfront price puts limits on how much a person can be taken for, and increases options for those on a budget. But what is and isn’t included for that price needs to be accurately listed next to the procedure. The proper design of pricing data visibility can thus 1) make price a great resource in the hands of someone trained to use it properly, while 2) preventing the untrained eye from putting too much value on the sticker price alone.

Second, it can be dangerous to detach medical treatment from all other considerations besides affordability. Perverse utilization of care (either too much or too little) can be caused as easily by price transparency as by per-procedure provider reimbursement.

It takes a fair amount of reading and research for a patient to become educated sufficiently to use provider comparison tools wisely. And even with all the information available online today, there is still a need for consultation with a physician.

Third, quality matters. There can be considerable differences even between highly skilled, conscientious, experienced surgeons. Equipment, nursing staff, attention to detail in a myriad of aspects at the facility, can also make a big difference in how well a procedure is performed and a person’s quality of life afterward. How are these to be valued when it comes to one’s health? What kind of price can be given to care quality, not to mention the ability to avoid unnecessary post-treatment expenses? These types of things should be considered carefully, much more than the sticker price.

Physicians’ principled adherence to giving the best care with no consideration of cost has merit. Not that prices shouldn’t be known ahead of time, but that having too much focus on something as quantifiable as cost detracts from things of much greater importance and enormous variability.

A Bright Future

As American healthcare institutions are given the chance to present themselves and their services in the best possible light on price transparency sites, we believe there will be less trepidation about the publishing of rates.

One of the exciting things we’re seeing at Pricing Healthcare is a growing number of hospitals, surgery centers, imaging centers, and in fact healthcare facilities of all types across the country, wanting to publish pricing information. By doing so, they brand themselves as patient-friendly in terms of price and quality transparency. In turn, patients worry less about sticker shock and become more comfortable obtaining proper care. Ridiculously priced outfits will certainly lose volume, but we believe patient volume overall in the U.S. will increase, with more individuals and families able to afford to pay for the care they need.


Randy Cox is the Founder and CEO of Pricing Healthcare, an open, independent, direct-pay marketplace where healthcare facilities present services and prices online. Facility pages, including pricing information, are free for anyone in the world to access.

To see how Pricing Healthcare presents facilities and their prices, go to a page of Utah dentists accepting new patients or a list of California facilities publishing price lists.

It’s Time for Doctors to Consider Medical Costs

April 28, 2014 in Member Stories

TIMOTHY GOWER’s article, “Should doctors consider medical costs?”  (Boston Globe, Ideas, April 13) should serve as a wake-up call about the state of transparency in our health care system.

It should be required reading for everyone touched by our healthcare system whether you’re a   consumer, a business, an insurer or a provider.  Gower takes us through the story of a woman who was on the precipice of a potentially fatal medical emergency and was reticent to receive care until she received a quote for her ultrasound. The reason?  She was still paying off skyrocketing bills from tests ordered at an earlier visit that may or may not have been necessary.  The doctor, growing more concerned by the minute about the health of his patient tried to chase down the figure for this routine test. It took him a day to get it from the hospital. He received the figure and the patient relented and accepted the treatment.

The lack of transparency and information surrounding health care costs has resulted in some consumers making uninformed and sometimes risky decisions.  Gower points out that some patients may forgo treatment because they are uninformed about lower-priced options for medical services, including tests or routine procedures. When a person’s health is at stake, having information readily available about options and costs is very relevant to the decision-making process.

We know that high deductibles and co-insurance are becoming more common in health plans especially for small groups and individuals. Even with healthcare reform, there are large differences in out of pocket costs among various types of policies.  In 2012, Governor Patrick signed legislation that requires both carriers and providers to give price and out-of-pocket information to healthcare consumers within two days of a request. By this October, insurance companies will be required to provide this information in real-time. For more and more consumers this information is very important.

Empowering healthcare consumers through price and quality transparency is the wave of the future and providers must play an integral role in this, particularly given the trust that many patients place in their doctors’ recommendations.

Doctors, hospitals, and other providers have a responsibility to be prepared to talk about healthcare costs with their patients and potential patients.  As consumers, we expect to know price estimates before making a selection for a variety of services and we should be able to expect the same from healthcare providers.

Accepting bids – who’ll do the cheapest colonoscopy?

April 19, 2014 in health care costs

If you can’t compare health care prices in advance of paying for an MRI or some other test, maybe you should ask for bids.

I came across Medibid last year when I needed a colonoscopy, and decided to give it a try. I had to answer some questions about my health, explain what I was looking for, say when I wanted to have the test (within 1-2 months) and how far I was willing to travel (not outside my state).

Over the course of a year (plus), I got back three bids, all were a long way from Boston.

The folks in McMinnville, Oregon pitched their location (3,238 miles from my home) as a plus.

“Sorry I’m not in your state, but at $500 you could take a trip to Oregon wine country and get your colonoscopy and probably still save money. We would be happy to help if we can be of service to you.”

The bidder in Baltimore, at $1500, was clear and succinct.

“Includes anesthesia, facility fee, and physician fee.”

And the facility in Nashville, while the most expensive, made a good case.

“The pricing includes physician, facility, anesthesia and pathology fees. We are a Joint Commission and Medicare certified facility with an emphasis on providing high quality care to our patients. We are located in central Nashville on the St. Thomas Midtown campus (previously Baptist Hospital). It would be our pleasure to care for you/your family member in a warm, friendly atmosphere.”

But I’m not up for becoming a medical tourist for something as routine as a colonoscopy. Would anyone travel for this test? Should I be surprised that no one in my home town, the medical mecca, put in a bid?

For my colonoscopy, I chose quality over cost

December 21, 2013 in health care costs, Quality of care

I finally got that colonoscopy that I started shopping for almost a year ago. I’m really good at proscrastinating when fasting and voluntary diarrhea is involved.

I had a good experience in the end. I probably spent more than I should have, but…

1) I wanted to go someplace close to home. You’re not supposed to drive after this procedure and I didn’t want to drag a designated driver too far out of the way.

2) So I compared a doctor recommended by my PCP, who is at Beth Israel Deaconess Medical Center with a team of docs at Faulkner Hospital. Yes, the Faulkner is owned by Partners, but rates I’ve seen for the Faulkner are more in the community hospital range. I’m pretty sure BIDMC would be more expensive, but I don’t have the exact charges

The problem was, I couldn’t get any quality info from the Faulkner. I called four times and spoke to someone twice. They said they couldn’t answer my questions about: polyp detection rates, complication rates, withdrawl time and how often the doctor reaches the beginning of the colon (the cecum).

So I went to BIDMC, which had offered quality info earlier this year and where I had a frank conversation with my doctor (although not until just before the procedure).

I came away with an interesting, gross to some of you, set of slides of my doc’s work. Dr. Chuttani always, apparently, gets to the cecum and takes a picture. You can click to the next page to see mine (I don’t want to force it on you). Did you doctor show you results of the procedure?
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What would happen if my doctor wore the johnny and I had on a fancy robe?

December 18, 2013 in Member Stories


Screen Shot 2013-12-18 at 11.23.18 PM
There’s something about changing into a johnny, the clothing equivalent of a paper bag, that strips our confidence, intelligence and power as patients.  So what would the office visit feel like if the patient put on a luxurious dressing gown and the doctor wore a johnny?  The wardrobe power swap wouldn’t, alone, re-balance the doctor-patient relationship, but would it help?

Thanks for the ‘toon Tyler!

Massachusetts man dies after losing coverage for two months

December 17, 2013 in Health Insurance, Member Stories

The man I’ll call George died at a hospital in Massachusetts last April.  He had AIDS and Hepatitis C. George was managing both until February when his state subsidized insurance coverage ended.  He’d started earning too much money and no longer qualified.  George, a construction contractor, found an employer who let George sign on to the company plan.  He submitted the paperwork, but there was a delay. This happens. There might be some missing information or the first month’s payment is late.  For George, there was a 10 week gap between when his coverage through Commonwealth Care ended and his new insurance plan kicked in.

In February, while he was uninsured, George stopped taking his medicine.  He didn’t have the roughly $4400 a month to refill his AIDS prescriptions.  George skipped his meds again in March.  That month George got a bad cough.

He went to the hospital.  George had had pneumonia before and was pretty sure he had it again.  A doctor gave him a prescription and sent him home.  By the time George returned to the hospital, a virulent strain of pneumonia had settled into both lungs.  George, with his weakened immune system, couldn’t beat it.  Two months after George lost his coverage and stopped filling his prescriptions, he died. A letter telling George his new insurance was active arrived a few weeks later.

I heard this story from a doctor who treated George and his long term partner.  I don’t have all the details and am not using George’s real name because his family is embarrassed about the fact that he had AIDS.

I’m sharing what I do know of the story because the tragedy of George’s death is especially potent right now.  The state Health Connector website is still having problems.  Connector staff and board members have extended the current coverage for members in an effort to make sure that no one goes without health insurance while the re-enrollment problems continue.  But there are concerns that people will get frustrated and either give up or will put off going through the process of choosing a new plan.  Many of us push letters from our insurance companies aside, thinking they aren’t that important or won’t make sense if we do open them.

A lapse in coverage might not matter for most of us. We aren’t in the same precarious state as was George last February.  But don’t delay. Going without coverage for even a couple of months can be deadly.




Consumer Affairs Issues Report, Holds Second Conference on Transparency

October 18, 2013 in Member Stories

According to a report on healthcare transparency issued by the Office of Consumer Affairs and Business regulation, Massachusetts consumers are more likely to research the cost of a TV than to research the cost of their medical care, however, most consumers would like to be able to compare costs of medical services from different providers.

The report details findings from a daylong conference with health care leaders in May.

Conference attendees were also polled on their attitudes about health care, answering questions at both the beginning and end of the conference about how important it is to know costs ahead of time for healthcare services and whether a comparison of prices would affect choices about where to receive care.

The final findings of the break out groups, which are detailed on page ten of the report, shed some light on how price and quality information affect healthcare consumers’ decision-making:

  • Cost is a factor, but not the most important one;
  • Doctors are important and  influential in the decisions about healthcare;
  • Consumers want more  information about price, quality and options; and
  • Consumers should  understand more about the variables that affect their own health care.

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Breast Cancer Awareness Month: Instilling Confidence in Women through Shared Decision Making

October 11, 2013 in Member Stories

According to the American Cancer Society, an estimated 232,340 new cases of invasive breast cancer will be diagnosed in women in 2013, making it the second leading cause of cancer death in females, exceeded only by lung cancer.  For the 28th consecutive year, the sea of pink can be seen almost everywhere as individuals, charitable organizations and commercial organizations across the country once again joining forces in support of National Breast Cancer Awareness Month and the many women affected by breast cancer.

Being diagnosed with breast cancer can be a scary and overwhelming experience for women and their families.  That’s why it’s important that they have access to resources that will fully inform them about their medical condition, allowing them to make an educated decision about what treatment option is best for them, personally.  And because there are several treatment options – each with differentl risks and benefits – it’s even more important that a patient’s personal preference drive a treatment decision.   This concept of empowering patients and their families to make informed decisions about their condition and treatment—decisions that are aligned with their values, preferences and lifestyles – is called Shared Decision Making.

In honor of National Breast Cancer Awareness Month this October, Health Dialog is making its Shared Decision Making and planning aids on breast cancer publically available throughout the month. The early stage breast cancer and breast reconstruction surgery decision aids help guide patients through all stages of the decision making process, from explaining how to read a pathology report to illustrating what a patient can expect from different types of surgeries. Health Dialog also offers planning aids for patients and families who are having needle or breast biopsies to prepare for what will happen before, during and after the procedures.  All of these aids and resources can be accessed by clicking here.

The Shared Decision Making process aims to give patients the care they want and nothing more. The process involves patient use of shared-decision making aids with constructive discussion between the patient and a healthcare provider. Shared decision aids come in various forms—print, online and video—and are designed using clear and simple language in order to prepare all people to participate in their health care and health care decisions. They provide balanced information about options and outcomes from the patient’s point of view and help the patient clarify their own personal values. Patient decision aids are designed to complement, rather than replace, counseling from a healthcare professional.

So, as we come together for a good cause this month, let’s all remember the patient and the fight they are each individually undertaking. By putting the tools and resources they need at their disposal we help them feel a little more confident.

Peter Goldbach, MD, is the Chief Medical Officer at Health Dialog, a leading provider of healthcare analytics and decision support. He has 15 years of experience in medical administration and 17 years maintaining a primary care and pulmonary disease practice. He received an undergraduate and master’s degree from UCLA and his medical degree from SUNY Downstate Medical Center College of Medicine. 

Out-of-network Medical Costs Affect Everyone

October 5, 2013 in health care costs, Health Insurance, Hospital Bills, Insurance Bills, Medical Debt, Member Stories

According to a survey this year by America’s Health Insurance Plans, 12% of all medical claims received by insurance carriers were out-of-network in 2011. That translates into huge out-of-pocket costs for American consumers, and sometimes uncapped costs. Out-of-network charges can be nearly 100 times (100 times!!) the rate that Medicare allows (typically you will be no more than 2 or 3 times the Medicare rate with insurance).

Don’t think any of that applies to you because you have good insurance? Think again.

Excessive out-of-network fees are typically not covered by your insurance carrier to the full extent, and are often not applied to your deductible. This means you could not only be on the hook for large fees for some services, but those amounts could be uncapped, the equivalent of being uninsured, even while having a very good insurance plan. New Obamacare plans don’t solve this, as they are not required to cap out-of-network charges. And almost all carriers are shrinking their networks further for new exchange plans. How did this slip through the Affordable Care Act?

Health insurance carriers negotiate rates with a number of physicians and hospitals to get lower rates with its plan holders. These providers and facilities form a health plan’s “network”. When patients go to providers “in-network”, the insurance carrier pays significantly less. It is reasonable then that a plan might want to discourage you from going with a provider not in that network. It is also reasonable for a carrier to remove all but the lowest-cost providers from its network over time. The ACA also wants to keep people away from the highest-priced providers, in an effort to reduce healthcare costs overall.

The trouble is, sometimes going out-of-network is the best or only way to ensure critical healthcare. Specialists and key facilities in various parts of the country may not have a relationship with your carrier. There are also many cases when you end up receiving services from an out-of-network provider because of the nature of integrated care by professionals from a number of different companies. For example, even though you know your physician and hospital are in-network, you may not think to ask if the anesthesiologist is.

The 12% figure will surely rise under the ACA. More individuals will find that their preferred doctor is no longer in their plan’s network. Employers are beginning to cut spouses and children from plans, which will add to the confusion about which doctor you should be going to for which family member.

Some of the largest carriers like UnitedHealthcare and Aetna will only cover out-of-network fees up to what they consider a “fair” amount, and then you have to pay the rest yourself, even if you’ve already met your deductible. Good luck finding out what the cost will be beforehand. Doctors and nurses don’t know, and many facilities are known to not provide that information even if you call their billing department.

For more information on out-of-network services and payment, see FairHealth’s website. You can also see the websites of UnitedHealthcare and Aetna on how they deal with out-of-network costs.


Randy Cox
Founder & CEO of Pricing Healthcare

The Increasing Importance of SDM and Patient Choice in Today’s Healthcare

October 4, 2013 in Member Stories

A recent report (September 2013) from the Center for Disease Control and Prevention (CDC) stated that through effective public health measures, necessary screening and medical care, and lifestyle change, at least 200,000 deaths from heart disease and stroke each year are preventable and that more than half of preventable heart disease and stroke deaths happen to people under age 65.

In the study, CDC officials go on to say that the Affordable Care Act (ACA) will be helpful in reducing avoidable death by providing medical treatment and screening facilities to a large number of uninsured Americans.

Providing up to 29 million new people with affordable health insurance by 2019 is a good start. However, the key to success goes beyond simply providing access to health insurance. It will depend on how effectively plans and employers can actively engage people in their healthcare and the decisions about their health. Engagement can be done through unique and compelling online and offline educational methods including web-based information about conditions and treatment options, DVDs, telephonic health coaching, and/or any combination of those. Through this engagement, patients are empowered with the tools, resources, and information they need to have informed conversations with their doctors and make the decisions that are best for them based on their values and preferences. This is Shared Decision Making. And, it has been proven to improve patient and provider satisfaction, reduce hospitalizations and invasive surgeries, and improve patient outcomes while reducing costs.

By incorporating Shared Decision Making into patient education services, health coaching, and wellness programs, plans and employers can drive true behavior change by helping patients make healthy lifestyle choices and address chronic conditions, such as heart disease and stroke.

As the healthcare industry continues to evolve and the ACA takes hold, Shared Decision Making can play an important role in driving an informed patient. And, an informed and engaged patient is critical to a better system.

Peter Goldbach, MD, is the Chief Medical Officer at Health Dialog, a leading provider of healthcare analytics and decision support. He has 15 years of experience in medical administration and 17 years maintaining a primary care and pulmonary disease practice. He received an undergraduate and master’s degree from UCLA and his medical degree from SUNY Downstate Medical Center College of Medicine. 

Just asking “How much will this cost?” makes a difference

October 2, 2013 in Member Stories

I had an awesome hour of squash with some old friends over the weekend.

Three days later I’m gritting my teeth through spasms in my lower back.

So I go see an orthopedist, or actually, his physician assistant.  She orders x-rays.  I assume that means one and ask, “How much will it cost?”  She looks at me with surprise.  Well, she says, if you’re worried about the cost we’ll justrun two.  We usually order a package of five, but you probably don’t need the five anyway.  I’ll look at the two and if I need more, we’ll take them.

How much did I save the system? Probably not more than a couple hundred bucks.  And I won’t get a share of the savings, but then I didn’t get any unnecessary radiation either.  A win all around, sort of.

I’d never met this PA and it didn’t fell right to suggest that she ask herself every time, does my patient really need five x-rays?  But I wonder: how often would asking about the cost make a difference in the treatment we receive.  My guess is, often.




Reframing Healthcare in the Minds of Younger Americans

August 27, 2013 in fitness, health care costs, health care quality, Health Insurance, lifestyle, mental health, nutrition

The clock is ticking towards October 1, 2013 when public insurance exchanges are set to go live and begin offering health plan benefits to an estimated 30 million previously uninsured Americans. And as that day draws closer, all parties involved—plans, providers, employers, and patients—are scrambling to figure out just what it will mean to them from a cost and quality of care perspective. Yet, perhaps one of the biggest conundrums associated with the health insurance marketplace is how to deal with the potential sticker shock facing younger Americans and the ripple effect it could have on everyone. Specifically, with an age band as narrow as 3:1, there is a possibility that premiums for younger people (who tend to be lighter users of service) will be considerably higher in order to compensate for older Americans, who typically utilize more health care services. When combined with a relatively low penalty for not getting coverage, there is a very real fear that many of these ‘young invincibles’ will forgo coverage and simply choose to pay the penalty.

So, the question becomes, ‘how do we articulate the value of health coverage to this younger generation?’ or, in other words, convince them that coverage is relevant (and worth it) to them?

We need to help this younger population understand and believe that healthcare is not solely about supporting the sick – support is also critical for the well. For example: a recent college grad that is just starting out in his/her career and may have issues dealing with the stress of that new job; the twenty-something who runs marathons but wants to improve their nutrition; the new mother who wants to start a workout program to shed some of the baby weight; or the avid skier who suffers a knee injury on the slopes and wants to understand what treatment options are available to them.

These scenarios play out each day across the U.S. and could happen to just about anyone between the ages of 18-35, not solely older people or those with chronic conditions. And there are programs, resources and tools focused on shared decision making and wellness that are critical components of modern healthcare that young people can take advantage of. So at the core, the solution for this current dilemma needs to be about making the younger population aware of these resources because they support behaviors that contribute to better health and wellbeing. Specifically, we need to create a  culture that encourages all people—including the younger population—to think differently about their health, make more informed choices, and understand not only the resources at their disposal but also the value they provide.  If we can do that, we will go a long way in positively impacting the health and wellness of these younger generations and controlling spiraling healthcare costs.

Robert Mandel, MD, MBA, is the CEO of Health Dialog and has more than 15 years’ experience in senior leadership positions in health systems and health plan management. 

Patients Exposing Medical Prices, Taking Matters Into Their Own Hands

August 14, 2013 in health care costs, Hospital Bills, Insurance Bills, News

The medical world is moving toward price transparency — very slowly.  Unfortunately the amount of data available is still relatively sparse, considering the wealth of useful data that could be published. What users are shown is often nothing more than an average or calculated estimate for an area.  When the rare facility-specific data is revealed, it is too often list prices (which almost no one pays) or several years old.

One reason for the crawling pace is the healthcare industry’s reticence to let consumers compare costs, which would surely send a great deal of business to lower-priced facilities and put downward pressure on prices.  It would be disastrous to their revenues.  And don’t think for a minute that the federal government is in a hurry to bring about transparency. The “Affordable” Care Act was carefully crafted to keep hospital revenues in tact, influenced by the billions politicians receive from healthcare lobbyists (more than 4 times greater than the next 3 largest lobbying groups combined). Patients just don’t stand a chance against such powerful forces.

Enter Pricing Healthcare, a relatively new addition to the playing field. They’re asking consumers for a little (anonymous) pricing data from their medical bills in an effort to expose what should be openly and readily available to patients. The company is interested not just in the prices hospitals and physicians charge, but more importantly what real patients are actually paying, in the form of discounted and insurance-negotiated rates. Users can enter data from bills going back nearly 3 years, but as people enter more recent data, it keeps the content current. The website makes the process relatively easy, and patients from all over the U.S. have already started submitting data, many with a great deal of enthusiasm.

Crowd-sourcing isn’t Pricing Healthcare’s only source of price information on the user-friendly site. While consumer data is being collected, the company is also pulling in data from other sources (as can be seen from the large amount of San Francisco data they have published). For the first time the company says, consumers can compare cash prices for scores of hospitals in a large metro area. They company is asking patients in the San Francisco area to help them discover insured rates (the hardest prices to come by) by supplementing the data already on the site from their own medical bills.

Grass roots efforts have done a great deal to influence the course of American history. The internet age certainly makes it easy for individuals to band together and force change. Pricing Healthcare hopes citizens will be concerned enough about the high cost of healthcare to lend their voices and make a difference. Time may be running out.

For more information, visit, or send the company a message at
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by HCSavvy

Valiant effort to persuade the young invicibles…you need health insurance

August 14, 2013 in Health Insurance

Picture 11This guy is definitely going do some damage to his back – hard to say how much and where.  The MRI alone could cost more the penalty he’d pay next year for not having insurance.  But will the young invicibles sign up?  It’s going to be tough sell.

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by HCSavvy

Is caffeine withdrawal a mental health issue?

August 11, 2013 in lifestyle, mental health

Brietta’s graphic begs the question, are the effects of too much caffeine and the withdrawal messing with our mental health?

The American Psychiatric Association says it’s time for some rigorous research and has included caffeine withdrawal in its latest Bible, the DSM-5.  Here’s why:

Picture 10 Click here to play the video

Is America a Nation of Java Junkies?

August 10, 2013 in Member Stories

Is America a Nation of Java Junkies?
Source: Top Counseling Schools