Healthcare Decisions: The Importance of Closing the Knowledge Gap
By Alison Laevey
It’s no secret that making healthcare decisions can be complicated. Even those who should know, struggle to make good decisions about where to go and what treatments to have. Whether it’s a lack of transparency in price or quality, or simply being at our most vulnerable, there are real and significant barriers to getting the right care at the right price.
Earlier this year, when I broke my wrist and had to decide how to treat it urgently, I was faced with decisions about where to go. Recently, I’ve found my experience and confusion is shared by other experts in healthcare purchasing. As professionals, we understand value-based healthcare and variation in quality but found doing can be much more complicated for different reasons.
Avoiding Unnecessary Care
I broke my right wrist playing racquetball just a few weeks after spraining my left wrist on the same court. For the sprain, RICE — rest, ice, compression and elevation — did the trick. However, it only took a few hours of a very different kind of pain for me to realize that this second injury would need different treatment. I am fortunate to have decent coverage for emergency care at a nearby hospital with a trauma center. Insurance, as it often does, informed my first good decision, to forgo an urgent care center that wasn’t covered and head to the emergency room. I was lucky that it was a level-one trauma center with a cadre of on-site specialists. That was not a factor in my decision to go there but certainly became my good fortune. An urgent care center would not have been able to provide the early treatment that ensured a good outcome for me, nor would a hospital emergency room without specialists.
After x-rays revealed a complex fracture from falling on my flexed wrist and compressing my distal radius, an orthopedic resident advised that I would likely need (expensive) surgery and pins placed in my wrist. A follow-up consultation with an orthopedic surgeon in a week or so would decide. In the meantime, I needed a cast.
Here’s where my good fortune comes in: because I was at a trauma center, two orthopedic specialists were on-site to manipulate my wrist before casting. First they weighted and hung my arm from an IV pole to let gravity help pull the compressed bone apart. Next, they double teamed to extend my wrist — one holding my elbow and the other pulling my hand — periodically taking images from a portable x-ray. (It hurt. A lot.) When they were satisfied they set my wrist in a cast. I was on my way within a few hours, contemplating the upcoming surgery.
My insurance network is closed so my specialist options were limited, including for second opinions. Having worked in fee-for-service health systems, my experience is that surgeons most often lean towards surgical procedures when the opportunity (read “any patient”) presents. Nothing for me to know or do at this point, I was in the system. In the days leading up to the consultation, my wrist started feeling better. It felt so much better that I was optimistic that I might not need surgery. But because of my experience, I was skeptical that a surgeon would agree. I was stunned when the surgeon reviewed the new x-rays and indicated that surgery may not be necessary. After several follow-up visits, she recommended only physical therapy for recovery after removing the cast. The excruciating manipulations by the ortho residents in the emergency room effectively set my bones to heal properly without the need for subsequent surgery or pins, or an expensive co-pay. Since it was a closed system where doctors are paid a salary, there was no financial incentive to perform surgeries either.
Many months later, my wrist is fine with full mobility and I’m back on the court. I wish I could report that my outcome was due to my inside knowledge of the healthcare market and expert choice of a conservative surgeon. It wasn’t. It was good fortune during a vulnerable time when I was in a lot of pain and in need of urgent treatment. Getting good outcomes shouldn’t rely on good fortune. We should all have the information to know better so we can do better and get the right care for ourselves and our families.
Unnecessary high prices
Many of us who know healthcare face obstacles of getting access to high-value care. Chris Skisak, Executive Director of the Houston Business Coalition on Health (known as HBCH), writes about his frustration and confusion with cataract surgery. After decades of knowing how the healthcare market works, he was unable to get satisfactory answers to some basic questions about his procedure, such as why can’t you do two eyes at the same time, like in Europe, instead of charging for two separate procedures? With so much experience in healthcare pricing, Chris was still surprised at the chasm between billed charges and Medicare reimbursement. His experience is worth reading.
Price transparency informs imaging decision
As my partner and former executive director of the Colorado Business Group on Health, Donna Marshall writes about the tools available to help make informed decisions. It’s always best to be aware of those tools before an emergency occurs. But even the people working on those tools face challenges trying to use them. Rachel Linn tells her story of finding the best imaging center for her husband in an emergency situation. Rachel works for the Colorado All-Payer Claims Database (APCD), and understands her insurance plan and the hospitals in her network, but not her husband’s. First, they had to do a bit of self-diagnosing to choose the right type of facility, in this case, an emergency room. There were two choices of hospitals in her husband’s plan. Since both have good reputations for care, and her husband had a high-deductible plan that required them to pay a significant amount of the costs, price would be a deciding factor. Rachel accessed CIVHC’s imaging facility price report (see example below showing prices for an MRI of your arm) and discovered that one hospital had significantly lower prices. Rachel knew about the price transparency tool and acted on that knowledge. Check out the APCD Council to know what is available in your state.
The healthcare system can do better to close the gap between knowledge and access to care. Health outcomes should not be based on knowing about high-quality providers or lowest cost. We’d like to think that our trusted providers do right by patients, but with the possibility of unnecessary care, price variation, and high prices, we all must do more to be knowledgeable. By sharing our stories, HBCH, CIVHC and Knowledge Benefits hope to encourage others to question providers and demand transparency. If you’re interested in learning more about closing the healthcare knowledge gap, contact the team at Knowledge Benefits.