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Should costs matter in healthcare decision making?- 2015 Policy Prescriptions® Symposium
1. Should Costs Matter in
Your Decision-Making?
Laura Medford-Davis, MD
Robert Wood Johnson Clinical Scholar
University of Pennsylvania Emergency Medicine
5. Do You Know How Much We Charge?
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
45.0%
$1000-2000 $2000-3000 $3000-4000 $>4000
CT Abdomen and Pelvis with Contrast
6. Do You Know How Much We Charge?
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
45.0%
$1000-2000 $2000-3000 $3000-4000 $>4000
$5,620
CT Abd $2,876
CT Pelvis $2,317
IV Contrast $178
Gastroview $29.80
Physician Fee $219
Total $5,620
CT Abdomen and Pelvis with Contrast
7. Do You Know How Much We Charge?
• Median Charge for ED Visit: $1,233
– Kidney Stone $3,437
(Range $128 - $39,408)
– Cold/URI $740
(Range $19 - 17,421)
Hsia et al. PLoS ONE 2013.
9. Typical ER Bill-Facility Charges
Service Quantity Total Charge
Level 4 ER Visit 1 $954
Conscious Sedation 1 $22
Ankle XR 2 $586
BMP 1 $199
CBC 1 $133
Coags PT 1 $15
Coags PTT 1 $108
Dilaudid 1mg/ml 4 $12.16
Propofol 10mg/ml 2 $19.20
IV Push 2 $136
TOTAL $2,184.36
10. Typical ER Bill-Professional Charges
Service Quantity Total
Level 4 ER Visit 1 $329
Conscious Sedation 1 $200
Ankle XR 2 $116
Lower Leg Splint 1 $475
TOTAL $1,120
11. Typical ER Bill-Costs
TOTAL $2,184.36
Medicare -$424.85
Insurance Adjustment -$1,657.12
Patient Responsibility $102.39
22. Healthcare Spending for a Family with
Average Income $66,570
Premium Contribution $3,100
Out-of-Pocket Costs $1,952
Tax contributions to government health
programs $4,664
Foregone Wages $6,482
TOTAL $16,198
Polsky D, Grande D. N Engl J Med 2009;361:437-439.
26. Effects on Patients
• 41% have trouble paying medical bills
• Medical bills are the #1 cause of bankruptcy
– 3 in 5 bankruptcies
Commonwealth Fund Health Insurance Survey 2012
27.
28. Outline
1. How much does it cost?
2. Cost Trends
3. Impact on your patients
4. Value
31. Choosing Wisely
1. CT Head for low-risk head injury
2. CT Head for Syncope and normal neuro exam
3. CT A/P for kidney stones
4. Foley Catheters
5. Wound cultures for I&Ds
6. IVF for kids without PO challenge
7. CT PE if PERC Negative
8. Spine imaging for low back pain
9. Antibiotics for sinusitis
10.Futile end-of-life care in the ED
32. The Future
• Increased Price Transparency
• CMS Paying for Value
• ACA Exchange Plans
– Narrow Networks
– Higher deductibles
33. Key Takeaways
1. We spend A LOT on healthcare
2. Costs affect our patients
3. The future is moving toward Value
Patient scenario (here or on the do you talk to your patients slide)
Raise your hand if … and keep it up there…Has a patient ever asked you? Has a patient ever refused services due to cost?
78% responses were underestimates; Best score was 53%. Correct answer $5,620
Maybe?
Charges vs Costs (Costs to provider, payer, and patient) Ankle Fracture Visit Level 4
It’s complicated (depending on their insurance)
Charges vs Costs (Costs to provider, payer, and patient)
It’s complicated (depending on their insurance)
Charges vs Costs (Costs to provider, payer, and patient)
It’s complicated (depending on their insurance) ~18% uninsured; ~60% privately insured; ~22% public
Hospitals: cross-subsidizing
Annual US healthcare spending 2011; per capita 2011; % of GDP; % spent by top 1% of patients (97.1% by top 50%)
Annual US healthcare spending 2011; per capita 2011; % of GDP; % spent by top 1% of patients (97.1% by top 50%)
Compared to 1945
Who’s Paying?
Increasing % of payroll (median 8.2% to 12.8% 1999 to 2010)
Median income is only $48,201. This was 2006. 24%
Out of pocket AFTER premium cost up 73% 1996 to 2009
High Deductible Health Plan (>$1000) enrollment tripled from 2006 to 2012 (10% to 34%)
Average for employer-sponsored deductible plans is now $1,217 in 2014 (“high” deductible=>$1000)
Average for Bronze Marketplace plans $5,200
More patients will be asking questions about quality and cost where previously they were insulated from the information or from caring
More patients will be asking questions about costs
Anecdote about patients not filling scripts (45y/oF with hemorrhagic stroke; 47y/oM died of pneumonia didn’t fill insulin or levoflox)
Value: A PATIENT-CENTERED concept. Who’s heard of PCORI? Finding grandma a nursing home rather than a hospital bed, avoiding that CT in a kid, seeing the result of the CT at the ER down the road yesterday. Care coordination. We’re not there yet, and we don’t have all the tools and incentives we need yet, but it’s coming.
If it’s really high value, it may be OK that it costs a lot
Raise your hand if you’ve heard of Choosing Wisely. Who can tell me what’s on the list?
Free standings have cost sheets; CMS releasing hospital and physician payment data; Massachusetts has a price transparency law
