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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.

wrist fracture xray

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.

MRI prices in colorado

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.