A Health Care Plea from Bended Knee

Wincing as I sit down to blog today on quality improvement and the patient experience, my left knee compels me to share its humble story:  the cautionary tale about a systemic problem that if left untreated could have staggering consequences for you and me.

On Memorial Day, I injured my knee and was treated at an urgent care clinic within my insurance network. I left on crutches, wearing a knee brace; and carrying a prescription for pain medication and an order to see an orthopedic surgeon -- all provided to me by the the clinic.  Several weeks later, I received my insurance company's Explanation of Benefits telling me that the clinic's invoice was paid.  Now, let's fast forward to September, when an unexplained bill for $500 from a company I never heard of arrived in my mailbox.  My insurer explained that the bill was for “medical equipment” -- the crutches and knee brace -- provided to me because the urgent care clinic's medical equipment supplier is not in my insurance network.

How is the consumer able to make an informed decision under circumstances like these?
With all the talk about waste in medicine, all the hoopla about reform, all the uncertainty and staggering costs, how can the consumer ever make informed decisions under circumstances like these?  Here I am in pain, doing my best to make sure my visit is covered, following my insurance company’s rules, and still I end up paying $500  for crutches and a brace that I could have purchased from a network vendor for a fraction of that had anyone bothered to inform me that the equipment would be billed separately and that the clinic’s vendor was not in my insurance network. As a consumer, could I possibly have known this information?

It’s a buyer-beware health care environment, but every effort is made to make costs, insurance payments, and all other financial aspects of receiving health care services as confusing and obscure as possible for patients.

It's not just that I’m out of pocket $500 in addition to my $1,000/month health insurance premium.  It's about wasted dollars due to lack of transparency. 
It's the fact that an injured patient in pain was charged $500 because she was not informed that the medical equipment was not covered by her insurance.  It's the fact that she could have been given a choice to purchase it for $500 at the clinic, or for $100 at a local drugstore.  The system provided no transparency or choice to the patient, who then had no choice except to pay $400 for the system's lack of transparency.

Multiply this type of experience by each of us several times a year, plus all the other ways this same scenario plays out, and it's easy to see billions of wasted dollars paid to health care providers who take no responsibility for providing information that helps consumers make informed choices.

I think it's highway robbery, no different from Medicare fraud or any other rip-off of a government program, except that it is happening to individual consumers like you and me. If I can be given an estimate of costs by other professionals, why can’t medical providers do the same?  That way, we could all participate in helping to control and bring down the costs of health care.