Counting Costs: A New Medical Price List For Doctors

Dr. Richard Parker reviews a medical price list created for doctors at Beth Israel Deaconess Medical Center

WBUR’s Martha Bebinger reports:

A one-page list of 56 common medical tests and procedures could shake up the way doctors deliver care at Beth Israel Deaconess Medical Center. Why? Because there’s a price next to each item.

Such lists are very unusual. Most doctors have no idea what they are spending when they order care for patients — and finding out is an eye-opening experience.

“I didn’t realize that the prices were as high as they actually were, although I knew that there were some pretty extreme examples,” said David Ives, a primary care doctor and the medical director of Affiliated Physicians Group, the largest group of private doctors that admits patients to Beth Israel.

“One [price] that really pissed me off,” Ives said, “was that when you send someone to an ear, nose and throat [specialist], something like 80 to 90 percent of the time they get a flexible scope of their sinuses.”

Ives says using this flexible cord with chip camera is rarely better than having the doctor look up a patient’s nose or down their throat, but it costs 10 times more than the physical exam.

“It’s just done because the technology is there,” Ives continued, throwing up his hands. “Is there value added for that? And I thought, probably not. And that might someday dissuade me from referring to someone who does a lot of those.”

Ives acknowledges that some ear, nose and throat specialists would disagree and argue that the scope is a valuable test. But raising that disagreement is part of the point of the price list. Phil Triffletti, another primary care doctor at Beth Israel, says that as health care costs continue to rise, physicians need to talk to each other about which tests or procedures are worth the money.

“Really the increases are unsustainable,” Triffletti said. “We have a responsibility as health care providers to make sure we get the best health care we can out of the money that’s available.”

But considering costs and deciding what’s worth the money is not part of most medical school programs, says Neel Shah, who directs a website, costsofcare.org, that tries to help doctors understand how their decisions affect what patients pay for care.

“In medical school, forever, you’re taught: do no harm,” Shah explained. “If it’s safe and it has a reasonable chance of working, you do it and that’s it.”

Some doctors say considering costs as they care for patients is unethical. Shah mentioned the slogan that guides physicians at the hospital where he practices.

“The slogan at Brigham and Women’s is: ‘everything possible.’ So the question is: how do you reframe cost conversations within the doctor-patient relationship. That’s a challenge because traditionally, it’s considered to be taboo.”

“We have a responsibility as health care providers to make sure we get the best health care we can out of the money that’s available.”

The taboo is lifting, Shah says, as more doctors realize that medical bills are the leading cause of personal bankruptcy; so, ordering care that isn’t clearly necessary can cause harm. The taboo may be pulled away as more and more doctors are responsible for managing patient medical budgets.

“I want doctors to think about the costs of the things they are doing,” said Richard Parker, medical director for the Beth Israel Deaconess physicians group. “It’s important to think about what something costs to understand its value.”

The price list is Parker’s idea. He says he hopes that using the list will help doctors lower health care spending while making sure patients get everything they need.

“We’re not saying don’t give patients what they need,” Parker said, his voice rising. “We’ll fight hard to get them what they need, but please don’t give them what they don’t need — we just can’t afford that anymore.”

You might be wondering where you can see the price list doctors at Beth Israel are using. You can’t — unless a doctor there shows it to you. Physicians, hospitals and most insurance companies don’t make prices they agree to in a contract public.

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  • Jdhingra

    The idea of putting the cost list, while a novel one, does very little to really educate the people about, what is a very complex and difficult problem.
    It simply results in exchanges such as these, with eveyone passing the blame onto some else. If ENT surgeons not doing a comprehensive assessment of their patients resulted in solving the Healthcare costs issue, I would happily do my bit and retire.
    Issue of pay for procedures is definitely a contributing factor along with myriad other issues; pointing the finger at one speciality or procedure does very little to move this debate forward, and is counterproductive.
    Jag Dhingra, MD
    ENT specialists

  • Dr. Shao

    Dr. Ives, as a physician in a leadership position, you should be ashamed of your ignorant comment. If you don’t like the technology of nasal endoscopy or flexible laryngoscopy, don’t send your patients to ENT. But be prepared to get good malpractice coverage as sooner or later, your patients will sue you for delayed serious diagnoses. On the other hand, if you don’t like the prices of the procedures, design a global payment plan so that physicians are not incentivized by individual procedures.

    ENT physicians are conscientious people too. We know how expensive health care is today. We don’t want to bankrupt our nation. However, we often have to do endoscopies for defensive practice.

    BTW, do you have any clue how expensive these scopes are and how labor intensive it is to clean them up to the newest national standard? For every dollar an ENT gets from a scope procedure, not much is left after cost, not to mention some insurances don’t pay for it at all or severely under pay it.

  • Docbruce

    Your reporter should have checked the other side of the story before publishing this article.

    Medical care costs are rising, and a lot is due to technology, no question.  And, overuse of technology is common as well.  But singling out nasal endoscopy for criticism is a very poor example, because this is an extremely useful technology and when used correctly, it vastly improves the possibility for making accurate diagnoses of a host of ENT problems.   I was in training when this technology was introduced into the US, and the difference between pre and post introduction of endoscopy is like the difference between pre and post CT scans.  Both technologies are expensive, both can be abused, but both are a quantum leap over old ways of diagnosing illness.  Dr. Ives can decide not to send his patients for endoscopy if he wishes, but those patients will be getting decidedly substandard, 1970′s style medicine.  

    The way to restrain rising medical costs is not to assail technology, but to change the reward structure that pays health care providers to do procedures (and useless office visits), to instead pay for curing patients.  

    Bruce R. Gordon, MD, FACS

  • Robyn

         Though well-intentioned, I think it is misguided to use this price list as a tool to contain costs.  Does this simply have the test and the price listed?  Or does it have evidence-based indications for using them and situations when they are not appropriate?  Having a list of comparative prices between different providers may be somewhat more useful, though so long as patients decide on where they go based on parking, convenience, and brand, rather than any real sensitivity to prices, I think it too would have only a minor impact.  

          I think the cost-containment tools that are now part of the public dialogue on containing costs are being conflated and getting confused.   There seems to be a lack of understanding about how each of those tools work and in whose hands they need to be placed.   

         It is employers and consumers who need to demonstrate sensitivity to prices and demand a more rational and transparent pricing system.  Doctors need education about indications and evidence-based appropriateness;  much better, scientific, more reliable information about efficacy and appropriate use of tests, treatment alternatives, therapies, drugs, etc.  

        As the exchange in the other comments below shows, what good is it to see the cost of a scope if there is no reliable evidence and consensus regarding the utility of that diagnostic tool?  Do you want YOUR doctor making a decision about a test based on a price list and poor or non-existent evidence-based guidelines?  I sure don’t.  I want the right tool in my doctor’s hands, and a price-list isn’t it.

  • Joseph H. Oyer md

    I appreciate the opportunity to respond to Dr Ives comments about fiberoptic nasal exams. This technology allows visualization of the mid nostril, posterior nostril and the nasopharynx. As an E.N.T. physician I am convinced that my diagnostic ability is significantly improved with this technology. It is often difficult to impossible to view the nasopharynx in an office setting without a fiberoptic scope. With respect to Dr Ive`s comments about the standard nasal exam, it would be sort of like opening the door to someones home, taking a step inside, seeing no one, and saying “nobody is at home” vs doing a room by room search. With fiberoptic endoscopy I find many lesions, polyps or other tumors both benign and malignant. in the posterior nostrils and  in the nasopharynx ( the space behind the nose and above the soft palate). I frequently CAN NOT SEE THESE AREAS without fiberoptics!! These are hiding places for tumors and disease. Dr Ives comments are shockingly ignorant and from a medical perspective, truly dangerous. The argument is not is the technology helpful. It is most definitely very useful!! The issue is what the sytem will pay for it. This is a discussion that should take place between the medical community and insurance carriers including governmental payors. WBUR might want to obtain an opinion from the  specialty under their scope before it publishes such poor information. I would advise WBUR to obtain a comment from the Mass. Society of Otolaryngology, a division of the MA Medical Society. Respectfully submitted
    Joseph H. Oyer md

  • EyeOnBI

    The ENT consult service at Beth Israel has been notified and, as per Dr. Ives’ request, will henceforth refrain from performing full comprehensive evaluations of his patients.
    Just another reason to “keep an eye on the BI”.

    • Dr. Shao

      It would be spineless, selfish, and self-incriminating for the BI ENT to provide substandard and potentially dangerous medical services to Dr. Ives’ patients simply to please his ignorant sense of medical stinginess.

    • Rfranken

      As Chief of Otolaryngology at the BIDMC I can respond to this comment as being untrue and simply made to damage the reputation of hard working, competent, Otolaryngologists and Head and Neck Surgeons.  Why would you ever do this except to further your own agenda based on lies.

  • Michael A. Stamm, MD

    Dr. Ives, you have got to be kidding.  As an ENT physician, I probably use the fiberoptic scope on 10% of my patients.  I only use the scope when I don’t have an adequate view of the nasopharynx or endolarynx using mirrors.  It also allows visualization of the middle meatuses which is impossible without the scope.  In addition, we usually are not reimbursed for the use of the scope if we also submit an e/m code.  The reimbursement is equivalent to a level III new patient code.  I don’t know where you got the idea that it pays “10 times more than a physical exam.”   This technology routinely allows the early diagnosis of cancers that would be otherwise missed on a routine exam.   You should research these issues prior to disseminating such inaccurate and potentially damaging information.

  • Josh Archambault

    Would love to see a story that follows up on this about giving patients better cost information. I am not sure just having doctors look at prices will solve the “cost” problem, but I hope it helps. Dr. Shah deserves a lot of credit for pushing this issue.
    The natural issue becomes insurance design for employees, and making patients better consumers in that process. In my mind, MA has largely ignored this factor. As a result regulations put in place, such as capped deductibles, MLR ratios, and first dollar coverage has removed the incentive for patients to ask about price.