Ever since taking a spill two weeks ago, Mr. Grant has experienced lower back pain. Worried about the lingering aches he’s feeling, he sets up an appointment with his primary care physician (PCP). After an evaluation, his PCP recommends that he get imaging work done at an outpatient imaging center affiliated with the hospital.
One of the radiologists at the clinic, Dr. Oliver, is an MSK-trained radiologist. Mr. Grant calls the outpatient facility’s billing department in advance of his appointment with Dr. Oliver, and, after checking his insurance, the department quotes Mr. Grant an out-of-pocket cost that he considers a bit high. But since he’s used to paying a premium for great products and services in general, the high cost doesn’t initially bother him.
This is where patients will often stop weighing their options and decide to simply go with their PCP’s recommendation. But being a conscientious consumer of health care, the next day Mr. Grant calls his insurance company himself to double-check how much they will cover. He’s surprised when, contrary to his PCP’s recommendation, the agent advises that he seek out the services of a practice across town whose radiologists, who are in-network, charge far less for imaging work.
What to do? The insurance company is appealing to his wallet, but Mr. Grant feels that he should spare no expense — this is his health, after all. At the same time, unlike many people in his position, it doesn’t sit well with him that, although he’s known his PCP for a long time, he’s taking it on faith that his PCP has referred him to a quality radiologist. It’s not beyond the bounds of reason that his PCP has recommended Dr. Oliver simply because she’s affiliated with the hospital at which the PCP practices.
Not only that, but although Dr. Oliver may be an eminently qualified radiologist, how does Mr. Grant know, for instance, how many times she has missed an abnormality on a scan? Is there any way to objectively judge the quality of the service she provides? Or does shopping around for quality imaging work like buying a car, where the more expensive option is often the best?
And there’s still another factor Mr. Grant doesn’t even know to consider: in some cases, and depending on the symptoms, the consensus among imaging experts is that no imaging tests for back pain can be the best prescription of all. But if Mr. Grant is already circumspect about paying less for his imaging, the thought of skipping it completely isn’t likely to enter his thoughts.
The above example represents a conundrum faced by patients every day: how to get the highest-quality scan without breaking the bank. Even for Mr. Grant — a highly-informed, curious patient — the quality landscape is nearly impossible to navigate successfully. Since the typical patient does not share Mr. Grant’s determined nature when it comes to understanding how the cost of imaging works, gauging quality imaging care is far beyond their reach.
Complicating matters still further is the term “price transparency,” a label meant to evoke the notion of openness in pricing, but which often means different things to different entities. A patient might define it as gaining an understanding of the out-of-pocket costs they’ll incur as a result of a medical procedure; on the other hand, a medical practice may consider itself transparent if it is forthcoming about the total cost billed.
This lack of an easy definition presents a hurdle to open discussions between patients and health care providers. Mr. Grant has done his due diligence and understands what his out-of-pocket costs are, which, to him, meets his qualification for transparency. However, as we’ve already seen, costs don’t always correlate with quality. Further, there is a lack of consensus on what the term “quality” in medicine even means.
Although there may be wide disagreement about the terms involved, research performed in recent years goes a long way toward explaining why patient demand for price transparency has gained purchase in the health care marketplace. One poll found that 42 percent of respondents claimed it was difficult for them to afford health care, and that the percentage “reporting a difficult time affording health care increases greatly among the uninsured and those with lower incomes.”
A separate report published in 2016 observed that in that year, 29 percent of all workers were enrolled in either Health Savings Accounts (HSAs) or Health Reimbursement Arrangements (HRAs), which was up from 20 percent in 2014. HSAs and HRAs are employer-provided health spending accounts that allow employees to pay lower premiums in exchange for taking on higher deductibles.
At a time when many patients find it challenging to pay out of pocket for health care expenses, it stands to reason that they would demand more information to make better decisions for their care — and their bottom line. However, according to the authors of a recent article in the American Journal of Roentgenology, “health care pricing discussions happen in less than half of patient-physician encounters.”
In the absence of constructive conversations about pricing in medical settings — let alone quality — many patients turn to online pricing tools. But, according to the article, these platforms “may not give them an accurate picture of the cost-to-benefit ratio of an exam.”
So where does radiology fit into this equation? In a series of blog posts, we will explore the role radiology can play in helping patients understand costs as they relate to quality imaging.