Contributor’s Corner: It’s All About the Money!

“An educated consumer is our best customer.”  That was the commercial tag line used by famed clothing retailer, Sy Syms.  However, for healthcare customers (aka: patients), knowledgeable consumers will find these two real-life scenarios over-the-top.

In Scenario #1, the patient has an approved PET/CT scan scheduled.  The day before the procedure, the patient receives a call from their insurance carrier advising them that they may want to consider having the procedure done at a different provider facility than the one where the test is to be performed.  The reason for changing facilities is summed up as follows:  “Did you know that the other facility is less expensive?”  That might have been okay as a public service announcement, but when the insurance company representative continued to press the patient to make the change, even offering to help have it rescheduled, the line between reason (okay maybe I should consider less expensive) and rights (don’t I have a right to choose my provider—especially since it was an in-network provider) seems to have been crossed.

This representative while arguing the virtue (and I mean arguing) of less costly really meant the insurance company would pay less to the second provider.  However, when asked about the out-of-pocket expense difference to the patient by choosing the alternate provider—the representative exclaimed they didn’t know.  In fact, the out-of-pocket expense would have been the same for either provider (in this particular case).  And if an out-of-network provider was chosen, it would have been in fact a larger patient expense; although one provided for as part of the coverage selection afforded by the choice of the plan.  What was missing from the representative’s telephone script was the fact that by choosing the original provider, the patient had selected the same provider where previous tests were already on file, and readily available to the ordering physician (who also was affiliated with the initial facility).  Perhaps not having that information was a HIPAA protection; but the entire episode lacked any concern for continuity of care, patient choice, or care management.

In Scenario #2, the patient was scheduled to have a second knee replacement procedure.  While listening to a commercial (Sy Syms would have been proud), the patient learns that the company was now advertising its new “30-year knee.”  The patient asks the orthopedist if the “30-year knee is being used,” and learns that a “15-20 year knee” was instead being used.   When asked about getting the “30-year knee,” the patient learns that the hospital refused to approve the more costly 30-year knee.  Which raises these questions: “So who’s getting the 30-year knee?  Was the decision based on the patient being too old—although not too old to be gladly admitted for surgery?  The patient is outraged, postpones the surgery, and writes a letter to the hospital’s Board chairman.  Even at age 65 (and still working and covered by a company insurance plan), why should the patient settle for a knee that might have to again be replaced at age 85, when the likelihood that they could well live beyond that and not have needed one until age 95 (perhaps less likely—but certainly sets the stage for a 85-95 year possibility)?

These two cases have a lot in common, and makes you wonder how many different assaults on an individual’s choice there will be.  I’m okay with an insurance carrier letting its patients know there are less expensive alternatives.  What the representative didn’t tell the patient is that their payment to the providers for the PET/CT scans noted above actually differed by only about $50.00, and of course was not even aware that the patient’s out-of-pocket cost was unaffected by the choice in provider (although if there was a coinsurance provision—the approved payment level would have mattered).  So who actually would have saved money in this case?  The answer:  the insurance carrier.

With regard to the knee, the patient really needed to know what type of knee the doctor was going to use in the first place (try thinking about putting a less expensive tire on your car).  It’s too bad the patient needed to learn of the difference from a commercial, but it’s been said that Gen X, Gen Y, etc., often get their news through social media.  In this case, it helped a senior know beforehand that another option was available.  The bottom line—is the bottom line.  And in both cases, it wasn’t so much the cost—but the profit margin associated with the procedure.  It gives new meaning to: Caveat emptor—let the buyer beware!

Allan DeKaye is the author/editor of The Patient Accounts Management Handbook (Aspen, 1997), and is presently developing a new book entitled: My Medical Bills are Killing Me©.  He is also a member of the WKLB Healthcare Editorial Advisory Board.