Top Docs '14: The Patient is In

In the brave new world of health care, patients need to step up

This spring, a 45-year-old poet living in Madrona experienced what she described as a fluttering heart. During a checkup, her general practitioner prescribed a 48-hour EKG device. She dutifully wore the portable monitor, and a week later, learned that her heart was perfectly healthy. That was good news—until the bills came, four of them adding up to $39,000, of which only $6,000 was covered by insurance.

Her mind swarmed with questions: Why was it so expensive? Did she really need the test in the first place? When she called her insurance company, she was told, “It is always the responsibility of the patient to ask how much any procedure costs before agreeing to it,” something she’d never thought to do before. She wondered if her doctor would have known what the procedure cost. After stress-filled follow-up calls, she learned her bill had been keyed in with the wrong code. The procedure was only $400, almost all of which was covered under her insurance plan. She was relieved, but a queasy feeling and questions—about costs, communication, transparency and responsibility—remained.

Most of the public attention on the Affordable Care Act (ACA) over the past year has been focused on the expansion of insurance coverage and health care exchanges, but as hundreds of thousands of Washingtonians experience coverage for the first time, other aspects of the legislation are moving into the foreground—in particular, a focus on all of the poet’s questions.

The high cost of health care and the inconsistency of procedure costs among different hospitals have been important pieces of the puzzle. Efforts to control and reduce costs gained new urgency in late April, when the U.S. Bureau of Economic Analysis reported that health care spending had increased over the previous quarter at the fastest pace since 1980.

The nearly universal response to the expense challenge has been to target unnecessary hospitalizations, tests and unproven treatments, which according to a frequently cited 2007 Dartmouth study, accounted for up to one-third of health care costs (currently running more than $2 trillion annually). Seattle-area physicians are taking a closer look at costly screenings and procedures, and questioning which ones are truly necessary and beneficial.

“We won’t be recommending so many interventions,” says Rick Clarfeld, M.D., medical director of Overlake Medical Clinics. “We find they don’t really help the patients. It’s not about what helps the providers. It’s about what will improve the patient’s quality of life.”

Instead of the traditional—and expensive—fee-for-service model that rewards the number of tests your doctor orders and the number of patients she sees, new reimbursement plans will reward lower costs and better results. Health care, in other words, is moving toward value, not volume.

Marc Mora, M.D., an internist and medical director of the consultative specialty service at Group Health in Seattle, calls this a “fundamental restructuring” of care. “It’s necessary,” Mora says. “We have an ethical and moral imperative to do it.” At the core of this restructuring is a movement toward standardizing health care in a way that emphasizes outcomes (how well the patient does) and quality. For example this might mean eliminating pricey tests, such as EKGs, which were once de rigueur at annual physicals.

Choosing Wisely, an initiative of the American Board of Internal Medicine, has been leading the national conversation about looking more critically at medical interventions. Aimed at both patients and physicians, it lists tests and procedures that providers and consumers should question when making treatment decisions. Many health organizations, including Group Health, are looking toward Choosing Wisely for evidence-based recommendations.

Other local hospitals are adjusting their systems to support patients and physicians in this new approach as well. Swedish Medical Center is in the midst of developing a standards and payment system that includes a new incentive pay structure for doctors, to be phased in by 2015, that makes 25 percent of a physician’s pay dependent upon performance and results, rather than traditional fee-for-service.

“The goal is for providers and patients to work together to manage their care,” says Swedish spokesperson Clay Holtzman.
It’s this “shared decision-making”—a cooperative relationship between a physician and an informed and engaged patient—that is at the heart of reducing costs and improving outcomes. “It represents a big shift for doctors to give up a role they have traditionally enjoyed,” said Arnold Milstein, M.D., professor of medicine and director of Stanford University’s Clinical Excellence
Research Center, during a panel discussion about affordable care in Seattle in May. He cited research that found that patients usually opt for more conservative interventions when their doctors take the time to communicate the full range of information, including side effects and long-term outcomes, resulting in a 20 to 30 percent reduction in interventions.

The unprecedented amount of information available to patients today is also pushing the relationship in a new (and reformers believe, better) direction. By consulting websites such as WebMD and MayoClinic.com, and using some 43,000 DIY health care apps available on iTunes, from trackers for blood pressure and sleep patterns to hearing tests and more, patients are taking control of their information—whether doctors like it or not.

“People don’t believe us as much as they used to…everyone carries a medical library in their pocket. Our job is to help people curate that information,” says Mark D. Smith, M.D., founding president of the California HealthCare Foundation, a philanthropy that supports quality, efficiency and affordability in health care.

And that includes the information your doctors are writing down about you. Today, with a few clicks, patients can access their medical records and test results. Group Health’s Mora views this as a big win for patients. “The medical record is not mine, it’s theirs,” he says. “Patients are pulling information out. It gets them to own and manage their clinical conditions.” In addition to information about medical conditions, patients are also demanding more cost information, wanting to reduce costs and make price comparisons the same way they do for other, nonmedical services. As more of us pay a larger share of our care—in the form of higher deductibles and co-insurance—the more we will be shopping for high-quality, lower-cost options.

Last April, Governor Jay Inslee signed legislation (Senate Bill 6228) requiring insurance companies to offer online information to enrollees that includes costs for common treatments and prescription medications in Washington state. Consumers will also have the ability to rate and offer feedback about their medical providers. These new requirements will be in place by 2016.

In a similar move toward transparency, the Centers for Medicare and Medicaid Services (CMS) released data to the public that included 2012 Medicare payments made to individual health care professionals. The information—not available to the public since the late 1980s—lets patients compare the way physicians practice and are paid in the Medicare program, helping patients make more informed choices about their care.

Gone are the days when we blindly followed a doctor’s directives, no questions asked. We now have more access than ever to information about our health and care. In an effort to help us navigate that influx of information, doctors and hospitals are embracing new roles, making moves toward increasingly transparent records and costs, and taking a critical look at procedures we used to take for granted. The goal: care that is less expensive and better.

Additional reporting by Lisa Wogan


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