The American Healthcare System is complex. That is not an accident, it is made complex by the health care entities vying for your health care dollars. They would prefer that you don’t know exactly what your prescriptions or procedures will cost you. Instead, you are lulled into the “trust your pharmacy, physician, or insurance company” to deal with the costs. “You don’t need to worry about it” is how they would like us to think. Price transparency in healthcare is almost non-existent. In fact, a price transparency executive order which took effect January 1, 2021, calling for hospital systems to list common procedures in a ‘customer friendly format’ has been virtually ignored by our nation's healthcare system. Even after an increase in fines for non-compliance was instituted in January of 2022, 85% of our nation's hospital systems are still non-compliant, and not one dollar of fine money has been collected. What is a baby boomer, or anyone, to do if they want to understand the cost structure for an upcoming elective procedure? Enter Healthcare Bluebook, a website that can show you the approximate costs for a procedure in your area. It begs the question that if a third party can access this information why are healthcare entities not forthcoming with costs associated with health care? The answer is they don’t want you shopping around for your next procedure. For instance, if you have total knee surgery in my area it will cost you $12,000 at a hospital but only $8,000 at an ambulatory surgical center. That’s a whopping one-third off and ambulatory surgical centers often have better quality outcomes! With healthcare expenses responsible for 58.5% of personal bankruptcies, we need to pay more attention to health care costs. We price shop for cars and houses while health care is one of the costliest items we purchase, we do not shop around to ensure we are getting the best quality and lowest cost.
If you do your research you can arrive at an approximate cost for your procedure but how do you know if the hospital or the physician actually deliver quality care? You will need to do additional research to understand the quality of care delivered by both the hospital and your chosen surgeon/physician. CMS.gov is the website for the Centers of Medicare and Medicaid Services. Included on the site are star ratings for your local hospital based on a five star system with five stars being the top rating and one star being the lowest. These star ratings are derived from surveys that patients do after they have been an inpatient at your local hospital. The star levels also affect the hospitals reimbursement which is why you have seen many more hospitals start to center on the ‘patient experience’. A hospital system with ratings of anything less than four stars should be avoided. I often wondered why people were flying to MD Anderson for their cancer treatments when they could simply get them at their local hospital, but when I did the research on star ratings it became evident to me what their rationale was. They wanted to spend their money on quality health care and be taken care of by the best of the best.
OK, so now you know the approximate costs for your procedure and the star ratings for the hospital or ambulatory surgical center that you will be having your procedure at, but what about the surgeon that will be performing the procedure? In my book How to Avoid Being a Victim of the American Healthcare System: A Patient’s Handbook for Survival, available on Amazon, I discuss the questions you should be asking your surgeon. For instance, in a teaching hospital do you know that your surgeon may not be the one doing the actual surgery? An Intern or Resident may be performing the surgery with your surgeon supervising. I don’t know about you, but I prefer my surgeon bring their A game when I am being operated on. Another piece of information from the book encourages you to attempt to be the surgeon’s first case of the day, as the data shows the first case of the day does significantly better in quality areas such as decreased infection rates and better patient outcomes. Plus, you will not be able to eat or drink after midnight so being the first case lessens the lousy experience of not being able to eat or drink all day. But the most important thing you can do to ensure you have a decent outcome from surgery is to research your surgeon and anesthesiologist on Healthgrades.com. They use actual patient ratings using the five star rating system that the Centers for Medicare and Medicaid services uses. In my book, I discuss hearing a woman in a grocery store discuss her upcoming procedure at a local hospital that I was working at. Her procedure was being done by a surgeon whose patients I had taken care of in the past. These patients did not have the best quality outcomes and did much worse than the other surgeons’ patients who performed the same procedure. I was able to intervene because we were in a community setting, but if I was prepping the patient for surgery that would have been inappropriate and I could have lost my job! If the patient had researched this surgeon she would have been able to see what previous patients had rated this particular physician, so do your research!
After surgery, your surgeon may prescribe you some medications such as antibiotics or pain medications. With the plethora of insurance restrictions around prescription medications, you never know what you will pay at the pharmacy counter. At one pharmacy your prescription may cost you $50 while at another it may cost $500. Why does this occur and what can the average health care consumer do about it? While I could write a whole article about this, at a high level once a prescription is written and before it is filled it must pass through a pharmacy benefit manager. Pharmacy benefit managers use rebates and coupons to land at the approximate costs that the insurance company or you will pay out of pocket, often pocketing the savings for themselves. In the book, I share a story of my sixteen year-old dog who was having some mild heart failure. This was a dog which we had no insurance coverage on. The vet prescribed Viagra which is a drug that originally was developed as a pulmonary anti-hypertensive medication designed to draw fluid off the lungs. Once the side effect of improving erectile dysfunction was discovered the drug shot up in price. My wife went to fill our dogs prescription at a local pharmacy and the price was over $700 for a month’s supply. It's interesting to note that in most states pharmacists are not allowed to provide you with lower cost options for medications, you have to do your own research to find that information. She left the pharmacy and downloaded the GoodRx app which was able to find the drug across town for $63 for a month’s supply. If she hadn’t done her research we could have paid over $600 more for the drug. In fact, sometimes the GoodRx price is less than using your insurance and a co-pay but you will need to do your research to compare the two.
With prescription drug prices being so high and so volatile, it’s welcoming to see disruptors such as GoodRx and Mark Cuban’s mail order generic online pharmacy appear. The latter’s model is to remove the pharmacy benefit manager from the equation and deal directly with the drug manufacturers lowering cost significantly for generic medications while selling them to the healthcare consumer for at cost plus 15% to run the business. Generic practices such as ‘pay to delay’ are common. A pharmaceutical company pays a generic manufacturer to wait on releasing the generic form of the drug, which usually costs less but not always. This allows the original drug manufacturer to continue to charge inflated prices for the drug. Given practices like this, disruption in the prescription drug world is welcome.
For the baby boomers on Medicare, do you know that for years the Secretary of the Department of Health and Human Services was not allowed to negotiate drug prices with the pharmaceutical companies? The largest payer in America was forbidden to negotiate drug prices which is estimated to cost Americans over 11 billion dollars a year! It’s called the ‘noninterference clause.’ Recently legislation was introduced allowing Medicare to negotiate the price for up to 50 drugs by 2025 but it still hasn’t passed either the house or the senate at press time. Given Washingtons history of delayed action on high medical costs, I wouldn’t hold my breath.
The best way to decrease health care costs and ensure you have quality outcomes is to do your research and be a partner in your health care. Informed healthcare consumers ask questions and proactively manage their health care in conjunction with their healthcare team. This is why I wrote the book How to Avoid Being a Victim of the American Healthcare System: A Patient’s Handbook for Survival, available on Amazon.
About the Author
Dr. Wilcox is a Doctorate prepared nurse who also holds a Masters in Health Administration and is Board Certified in Nursing Informatics. Dr. Wilcox has 28 years of healthcare experience in which he worked as a bedside nurse, hospital administrator, and in healthcare information technology which has helped him to develop his unique perspective on the American Healthcare System.
Dr. Wilcox is the author of the book How to Avoid Being a Victim of the American Healthcare System: A Patient’s Handbook for Survival (2021).
Dr. Wilcox currently resides in North Carolina with his wife and their three dogs.
Dr. Wilcox’s website: Dr. David Wilcox - Healthcare, American Healthcare System (https://drdavidwilcox.com)