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Keeping the “Affordable” in the Affordable Care Act

By Dr Pramita Kuruvilla

Early last week, the New York Times published Elisabeth Rosenthal’s article: “The $2.7 Trillion Medical Bill: Colonoscopies Explain Why U.S. Leads the World in Health Expenditures”.  In her article, Ms Rosenthal does not actually dispute the benefit of appropriate colon cancer screening for the US population, but she draws attention to a preposterous medical expense structure which permits absurdly variant costs for the very same procedure (and all at a much-inflated rate when compared to other countries).   

Whether directly from their wallets or through insurance policies, Americans pay more for almost every interaction with the medical system. They are typically prescribed more expensive procedures and tests than people in other countries, no matter if those nations operate a private or national health system. A list of drug, scan and procedure prices compiled by the International Federation of Health Plans, a global network of health insurers, found that the United States came out the most costly in all 21 categories — and often by a huge margin.

Why on earth should a colonoscopy in NY cost $8577 while in Baltimore the same procedure has a bargain-basement price of $1908?  And for that matter, how can Switzerland provide the same procedure for under $700?  Ms Rosenthal explores the possible answers to her questions, finding that costs were influenced by the site of the procedure (clinic vs outpatient surgical center vs hospital), the frequently-unindicated use of anesthesiologists for sedation administration, the unclear benefit of having repeat procedures at shorter-than-recommended intervals, and more.  Patients, regardless of insurance status, faced negative consequences of these high costs, both directly (out-of-pocket expense) and indirectly (higher insurance costs). 

The other seemingly-outlandish-and-yet-far-too-common finding was that patients were not provided with the costs of the procedure up-front but only afterwards, and due to the opaque matrix of the medical billing world, the performing physicians often were unaware of the total procedural cost to the patient (or the insurance).  A follow-up editorial this past weekend had the following statement:

Under the reform law, insurers have to pay for preventive services like colonoscopies without cost-sharing. But, in most cases, giving patients more information could help. They need to know what the total costs will be on a procedure, what their share will be and how well various doctors perform.

Though not directly referenced, Steven Brill’s “Chargemaster” comes to mind.  If you dear readers have not yet experienced Mr Brill’s thirty six page tome published earlier this year in Time Magazine, please consider this your upcoming Father’s Day weekend beach read.  (Please be advised to keep an aspirin near you as your blood pressure may climb extraordinarily high learning about the costly shenanigans of our medical expense infrastructures)  An excerpt from his conclusion:

The health care market is not a market at all. It’s a crapshoot. Everyone fares differently based on circumstances they can neither control nor predict. They may have no insurance. They may have insurance, but their employer chooses their insurance plan and it may have a payout limit or not cover a drug or treatment they need. They may or may not be old enough to be on Medicare or, given the different standards of the 50 states, be poor enough to be on Medicaid. If they’re not protected by Medicare or protected only partially by private insurance with high co-pays, they have little visibility into pricing, let alone control of it. They have little choice of hospitals or the services they are billed for, even if they somehow knew the prices before they got billed for the services. They have no idea what their bills mean, and those who maintain the chargemasters couldn’t explain them if they wanted to. How much of the bills they end up paying may depend on the generosity of the hospital or on whether they happen to get the help of a billing advocate. They have no choice of the drugs that they have to buy or the lab tests or CT scans that they have to get, and they would not know what to do if they did have a choice. They are powerless buyers in a sellers’ market where the only consistent fact is the profit of the sellers.

The theme of these three articles is to inform us that we are woefully uninformed, and the American public needs to demand more information and transparency when it comes to our medical costs.  It doesn’t matter if the government is paying or whether we are.  Regardless, we are all being pauperized by an unethical and unjust payment system which makes absolutely no sense for anyone apart from the medical industrial complex whose profits are skyrocketing.  If the ACA is to have a chance of succeeding, our medical costs need to be affordable, and not just looking to “fix” the excess costs at the end of life, but more so to contain costs for the everyday routine procedures that seem to be currently bankrupting our finances (or those of our insurance companies).  We need to look long and hard at what our patients (and ourselves) are being charged, and bargain nationally for reasonable costs.  As the editorial board of the NYTimes wrote last weekend: “High costs are no guarantee of high quality.”

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