Tuesday, April 05, 2005

The Medical Marketplace....
From The Wall Street Journal($$):Childbirth for Bargain-Hunters:
Expecting her third child this winter, Sandra Hughes became an unexpected pioneer in the new world of health care -- a world in which consumers have a direct stake in limiting their spending on treatment and tests.

Mrs. Hughes and her self-employed husband had health insurance, but couldn't get maternity coverage because of two previous Caesareans. So in nine months, Mrs. Hughes went from novice health-care consumer to hard-knuckled haggler. She negotiated discounts with doctors, convinced her obstetrician to match another's offer and wrote to the chief executive of a local hospital demanding a reason for refusing to meet her price.

"In the beginning, you think, wait, this is my health care: I don't want to make these people mad or insult them by talking money," says the 31-year-old former special-education teacher. "But after a while, it felt like I was buying a car."

Pregnant women are by necessity and ingenuity paving the way in what is called "consumer driven" health care. As companies boost premiums for family coverage -- and in some cases drop dependents altogether -- a growing group of women lack health coverage for pregnancy, one of the biggest medical costs they face. Others are in some type of consumer-driven high-deductible plan, with a Health Savings Account, that gives patients incentives to shop around.
And shop around they will:
Ronna Alexander, a self-employed design consultant in Douglas, Mich., had a medical savings account and catastrophic-care policy, so she and her husband were used to paying upfront for much of their health care.

When she called hospitals for maternity-related prices, they were reluctant to break down specific charges, arguing that every delivery is different. By her 20th week, she says she already had paid out about $800 in prenatal care, but felt that most of the tests were done to protect her doctors against liability and that they had little time for counseling -- a sense all the more acute because she was paying the bills. So she made an appointment with a midwife who does only home births, even though "I am the last person who would do a home birth."

She liked the midwife's more-attentive approach, and the price: only $1,800. Yolanda Visser of Grand Rapids, the certified professional midwife, says that for about half of the mothers she works with, price is at least one factor in having a home birth. She now charges $2,200 for full prenatal care and delivery.
What if the home birth goes wrong? Does the "break glass in case of emergency" OB/GYN get a cut of the $2200?
The new focus on limiting costs is putting added pressure on expectant parents. When Deborah Elissagaray and her husband shopped for a family policy a couple of years ago, they felt they couldn't afford an extra $200 to $300 for maternity coverage on top of the $700 a month for regular medical insurance. The couple was just starting up a winery in Placerville, Calif. Their broker assured that if they did have a child, they would spend less money by paying for it themselves.

When Mrs. Elissagaray became pregnant about six months later, she and her husband thought they would have to rely on money from their 401(k)s and part of a business loan. Worse, she says, was having to decide whether to forgo some prenatal tests, including a $3,000 amniocentesis test for genetic diseases. At age 38, she was at higher risk for having a baby with problems such as Down syndrome. She went ahead with the test.

In the end, Mrs. Elissagaray wound up qualifying for a maternity-assistance program in California called AIM, targeted at people who aren't poor enough to qualify for Medicaid. "When I found out, I cried right there in the office," she says. Her baby, Olivia, was born in February.
When Sandra Hughes in Florida reviewed a breakdown of what her previous insurer paid for her last pregnancy it showed her the rates were much lower than what the doctors and hospital charged so-called cash patients who pay out of pocket. When she asked for the same deal on her current pregnancy, one obstetrician complied. When she asked another doctor's practice to match it they did, cutting the usual $3,000 fee to $1,900.

When she tried the same with the hospital, she met resistance. Although her old insurer had paid $3,200 for her last Caesarean section there, Mease Dunedin Hospital in Dunedin, Fla., said its best price for a cash patient was $5,000. She says she wrote Jim Pfeiffer, president and chief executive of Mease Hospitals, demanding he justify the discrepancy. "By then, I was almost nine months pregnant, and I was angry!" she says.

Mr. Pfeiffer says he didn't receive the letter, but says the hospital's average cost for a Caesarean is actually $5,100, with a list price of about $10,200.

Since she already had negotiated deals with an anesthesiologist at Mease Dunedin and liked the care there before, she choose to remain at the hospital. But she says, "If more people asked about prices, it would all be far more transparent."

So when patients treat the payment for medical services like buying a car they are praised for their spunk and inventiveness. But when hospitals and physicians bring up the economic angle they are denounced as scoundrels.
What a system like the one above will do may not necessarily lower costs, but would certainly allow you to get your money's worth. If I have less complications and better outcomes from a procedure than the surgeon down the street you better believe that I will charge more. Of course feel free to face a wound infection rate twice as high as mine or a one in ten chance of a common bile duct injury and pay 75% of my fee, but remember caveat emptor.
This could also lead to cost shifting according to patient risk. Right now I am paid the same for a cholecsytectomy performed on a healthy 25 year-old as well as a diabetic 70 year-old who smokes and has had three AMI's. In the open air medical flea market I could offer a sliding scale with a "smoking surcharge", "diabetic surcharge", "non-compliance surcharge",ect.....Sound fair to you? Depends on where you would fit on the fee schedule most likely.
To be fair the marketplace would have to work in both directions. Given what I have seen so far, I don't think it would.
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