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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
- 2. Key Takeaways 1. We spend A LOT on healthcare 2. Costs affect our patients
- 3. Outline 1. How much does it cost? 2. Cost Trends 3. Impact on your patients 4. Value
- 4. MedScape Emergency Medicine Physician Compensation Report 2012.
- 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
- 12. Profit Margins by Payer -60 -40 -20 0 20 40 60 Private Medicare Medicaid Uninsured Percent
- 13. Outline 1. How much does it cost? 2. Cost Trends 3. Impact on your patients 4. Value
- 14. We Spend…A Lot • $2.7 Trillion • $8,680 • 17.9% • 21.8%
- 15. We Spend…A Lot • $2.7 Trillion – spent in the US in 2011 • $8,680 – per American • 17.9% - Percent of GDP • 21.8% - Spent on top 1% of patients
- 18. Centers for Medicare and Medicaid Services 2013.
- 19. Centers for Medicare and Medicaid Services 2013. What Are We Paying For?
- 20. Outline 1. How much does it cost? 2. Cost Trends 3. Impact on your patients 4. Value
- 21. Insurance Premium Prices are Rising Kaiser/HRET Survey of Employer-Sponsored Health Benefits
- 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.
- 23. Kaiser Family Foundation from AHRQ-MEPS Table 1.1 Out-of-Pocket Spending up 73%
- 24. Increase in High-Deductible Plans Kaiser/HRET Survey of Employer-Sponsored Health Benefits 2012
- 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
- 28. Outline 1. How much does it cost? 2. Cost Trends 3. Impact on your patients 4. Value
- 29. Quality x Access VALUE = ------------------------ Cost
- 30. ↑Health ↑Patient Experience ↓Costs Triple Aim for Healthcare Improvement
- 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
- 34. Questions
Editor's Notes
- 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