LIMA — When medical help is needed, can you be 100% sure you’re receiving the best health care at the best price?
Five out of five local doctors agree: Not really. No. Also, it depends.
Like many aspects of the health care industry, what should be a simple answer requires a much more complicated explanation. But as health care costs continue to increase at rates higher than inflation, it’s still worth asking.
In a post-Obamacare world, how does one find the most bang for a buck? Why does everything cost so much? And will the American healthcare system ever find a way to deliver better outcomes at a cheaper price?
Pricing and outcomes
The national gym franchise 24 Hour Fitness reported $1.44 billion in revenue in 2017. Meanwhile obesity rates continue to go up.
There are good reasons for the discrepancy; you can’t just pay for a healthy weight. The exchange of dollars is a payment for a service that relies on other outside factors. Mainly, a gym-goer needs to go to the gym for the service to work.
In the same way, the outcomes of the health industry rely on many other outside factors. A patient seeing their doctor on a regular basis, however, is just a single factor among many others.
Outside the doctor’s office, healthcare insurers negotiate prices for in-network resources, which can result in sometimes exorbitant surprise out-of-network charges for patients. Pharmaceutical companies increase pricing at what seems to be a rapid rate. Sometimes, digital records have complicated already complex bureaucratic record-keeping practices.
While fixes to such issues have varying levels of bipartisan support, health care remains a heavy burden for most Americans. With all that said, many still want an answer to what is a relatively easy question: how do I get the best healthcare at the best cost?
Asking the experts
Eric Seiber, a professor of health services, management and policy at The Ohio State University, explained how many of issues affecting health care hinge on price.
“In health care, we say we have a pricing problem,” Seiber said. “In all health economics and policy, the concession breaks down on the solution.”
In economics, if someone wants to pay for something at a certain price, they’ll find the price and decide if they want to buy it. But when it comes to healthcare, that option of finding a price isn’t often available due to how the system works. Seiber said he’ll often task his students with finding prices for certain procedures just to show how impossible it can be.
“I can’t even tell what it’s going to be,” Seiber said. “We got primacy care, and I can’t tell you what I’m going to pay for a vist, and this is something that I’m interested in. You think of the average person, they just don’t use those tools.”
Health care insurance partially obfuscates the pricing system. Insurance companies negotiate health care pricing with providers, and the final costs can vary widely depending on the insurance policy. In fact, finding the cheapest price on a procedure is almost impossible due to the privacy of such negotiations.
A second difficulty for accurate pricing lies in how health care solutions are based on probabilities of success. A surgery may find a complication, which creates a more expensive procedure. A misdiagnosis may create more problems than solve. Medicines don’t always work the way they were designed due to biological differences, and more expensive alternatives may be necessary.
“The problem is, I know if I got a car fixed, my guy would call me, but when you’re in the (operating room), you can’t really say ‘yes’ or ‘no,’” Dr. Bill Kose, chief medical officer at Blanchard Valley Health System, said.
Instead, price transparency may play a factor in more repeatable instances. While major surgeries and treatment plans may be more of a one-time occurrence, those dealing with reoccurring issues, such as chronic pain, can find ways to shop around by calling their insurers or using online chargemasters required by the federal government. Local doctors across the board said they have seen some patients use the local pricing information primarily for certain specific procedures, such as imaging, testing, cosmetic surgeries and pharmaceutical services.
“I think there’s fairly few things that are shoppable, which means that in health care even though we may sit in a town for provider health care services, people aren’t judging where they go necessarily based on price,” Dr. Ronda Lehman, Mercy Health-St. Rita’s Medical Center president, said.
Federal policy has been floated to increase price transparency by forcing hospitals to publish prices negotiated with insurance companies, but health care professionals have been hesitant about going down that road. The recent change under the Trump administration has since been challenged in court just this past week by a number of industry associations.
Quality of care
While price is one side of the health care cost equation, the other is value, and that can be an even more difficult variable to track down as the quality of health care is often dependent on ancillary services and how well a doctor can utilize them.
“So the primary care doctor has to be the gatekeeper, has to be the quarterback,” Dr. Suman Kumar Mishr, president of the Lima and Allen County Academy of Medicine, said. “Patients will say when something is recommended: ‘Okay. Let me check with my primary care physician.’ Because the primary care will know.”
Blanchard Valley’s Kose gave an example of how a doctor’s use of outside services can shift costs and outcomes. Currently, magnetic resonance imaging, or MRI, tests are often used as diagnosis tools, but they aren’t always necessary, Kose said.
Sometimes, cheaper tests can be found that will often prove the same thing. MRIs also often require pre-authorization from an insurance company, which racks up administrative costs, but physicians may still pressure a patient anyway toward using an MRI because it protects doctors from malpractice lawsuits. Vice versa, the patient may pressure a physician to get an MRI due to health worries.
At the end of the day, the patient will most likely get an MRI, and as a result, the cost has gone up and the quality may actually be lower depending on the testing alternative.
To head off costly and sometimes unnecessary care, Kose said Blanchard Valley is trying to move toward “lean” management systems, especially for those who deal with patients on a daily basis. The idea is to institute systems that provide both cost-savings and value to the consumer by encouraging systemic fixes, such as re-categorizing incentives to ensure the right outcomes.
Lehman with Mercy Health said they’ve also seen some pressure for better outcomes from the federal government through its Medicare program. As one of the largest insurance providers, the program has been able to encourage outcome-based metrics in the interest of saving dollars.
“Commercial payers are now following suit,” Lehman said. “They appreciate Medicare getting into this space, and then they go, oh yeah, we want that too. We don’t want we don’t want bad things to happen to our patients. We want to make sure you’re producing a wonderful service for us for our money.”
Many area hospitals are also trying to improve accessibility and quality of healthcare by creating networks of “walk-in clinics.”
Because not everyone uses a primary care physician or family doctor, organizations such as Lima Memorial Health System have expanded such locations and hours “in an effort to provide convenient access to quality and affordable care for patients.”
Mercy Health and Blanchard Valley are making moves along much of the same lines.
“The more accessible we are, the greater chance that patients are going to use the more affordable type of care. So it’s been we’re trying to use existing locations and providers to change the model as an asset so that when people walk in we have that flexibility,” Lehman said.
“I think one thing is to have a family doctor, because they can guide you through a lot. And it’s just not expensive to see a family doctor for a regular visit,” Dr. Susan Hubbell, president of the Ohio State Medical Association said.
In a similar vein, hospitals have been reducing costs of visits by encouraging digital check-ins. E-visits, or visits by teleconferencing, have increased in popularity, Mercy Health’s Chief Medical Officer Dr. Matt Owens said.
“So I’m trying to reduce admissions for things like heart failures and pulmonary disease, where we are touching base with them more often, even if that’s remotely, to be able to kind of gauge their symptoms before they get into a very costly admission,” Owens said.
The other member of the two-person team responsible for low-priced high-quality health outcomes is the one suffering the health issue — the patient.
“One of the main initiatives to lower health care costs should be more education for consumers, so they can make well-informed decisions and take ownership of their health and wellness,” Lima Memorial President/CEO Mike Swick said. “We are active in the community promoting wellness.”
“We have clean water. We have clean air,” Mishr said. “We have the best of these. And so many laws regulating the food, but because our lifestyle is not healthy, we get so much sickness.”
“You can walk. It doesn’t cost anything. Everybody can do that to try and get yourself in as good shape as possible to start with and that decreases problems. People that are active as they get older are healthier,” Hubbell said.
“Wellness is really where the future is,” Lehman said. “A lot of other industrialized nations are doing this better than us. They focus a whole lot more on preventative and wellness care than just taking care of the disease process once it’s already reared its ugly head.”
“As a consumer, we make the decision to step onto the healthcare treadmill. Am I going to seek care? Once you make that decision, it’s the physician that decides on the spending,” Seiber said.
Multiple health systems in the region spend extra dollars toward public health initiatives meant to encourage healthy lifestyles and overall wellness. Ultimately, prevention of chronic illness decreases healthcare costs overall.
“If you take someone that has a problem, the medical profession can do something about 25% (of the problem). Most of these things are social dependents, what the person is like at home. We can’t do a lot about the genetic component,” Kose said.
So how do you have the best healthcare at the best price? It’s a four-step process.
First, don’t get sick. Second, get a good family physician. Third, shop around to find the best healthcare pricing, provider and insurance for your own needs.
And finally — the fourth step — wait for a future policy change.
“Our nation’s current healthcare model is not sustainable. We are proactively making intentional strategic investments to be well-positioned for changes on the horizon,” Swick said.
“There’s very little price negotiating for healthcare, and the policy question is where do we negotiate price?” Seiber said.
Reach Josh Ellerbrock at 567-242-0398.