Teaching Residents about Costs: The Price is Right

It all started while out to dinner with a couple of my fellow Brigham/Massachusetts General Hospital OB/Gyn residents. We were discussing our favorite old TV shows and one fellow resident’s love of The Price Is Right with Bob Barker. After talking about the game show, a light bulb went off in my head and I thought, “Why can’t we play The Price is Right with hospital charges to our patients?”

With further discussion we realized that none of us knew the hospital charge, or the cost to our patients for routine workups we routinely order in our gynecology clinic. We really had no idea.

After asking around, I realized that I was not alone in my lack of knowledge, or the idea to play The Price is Right with hospital charges. A couple of years prior the Massachusetts General Hospital Internal Medicine residents had played a similar game with the goal to create awareness of the costs associated with routine workups.

There is very little data on how much residents (and attending) physicians know about the costs of what they prescribe, of what changes practice patterns. I had an upcoming conference for the gynecology residents and faculty around the Christmas Holiday and figured that this might be a good venue.

In first thinking about what costs to use, I consulted my esteemed colleague, Neel Shah. He directed me to use hospital charges which are standardized across patients and not specific to the insurance company or patient. I wanted to use Brigham and Women’s specific charges, with local comparisons. Because I wanted it to be pertinent to every day care, I decided to use case based scenarios with 3 of my clinic patients, a hybrid with Choose Your Own Adventure.

I started with our gynecology clinic practice manager (after she overheard me discussing where to find these numbers). She had some information on the visits to our gynecology clinic and hospital charges for the technical end for procedures. But, I soon realized that no one really knows how the hospital charge value is arrived upon, or if and how it changes year to year. And while she could tell me the charge for a RN intramuscular injection fee, she told me to contact the pharmacy for the drug charge. After asking around, I resorted to calling the individual labs/departments to find the appropriate costs. People were often willing to tell me as few people even ask. I called the pharmacy, hematology lab, microbiology lab, emergency room billing, hospital billing, the nurse practice manager for the family planning clinic who coordinates with the nurse in charge on labor and delivery, and a separate operating room billing manager. Because OR costs are determined in increments of 15 min, they are provider and case specific.

We choose a recent hysteroscopy that I had done with an attending who does many hysteroscopies on an average case, and she gave the line item hospital charge breakdown. The microbiology manger prefaced her costs with, “Do you have a pencil and are you sitting down, because you will be blown away!”

The ambiguity of the hospital charge was most apparent when discussing abortion. This is one of the few procedures that many insurances do not cover, so the hospital charge is paramount to self pay patients. The hospital based family planning clinic uses charges from 2004 that are currently being debated. It is unclear if there are separate anesthesia charges, or if they are included in the hospital charge. And because the quotes are outdated, it was difficult to tell what the hospital charge in 2011 is. There is also significant variance in performing the same procedure – dilation and evacuation (or curettage) in the hospital based clinic, the main operating room, in a procedure room on labor and delivery, or in an affiliated private outpatient facility. All of these charges affect our counseling and referral of self-pay patients, and the affordability of these procedures.

The game went over very well with participation and wild guessing from attendings and residents alike. I am not sure if and how practice patterns will or should change, but perhaps knowledge of the systemic charges will better inform our counseling of patients, and consideration of their resources. And, I did pause before obtaining an unneeded gonorrhea/ Chlamydia culture the day afterwards with my newfound knowledge…

Costs of Care (Twitter: @CostsOfCare), where this post was originally published, is a Boston-based nonprofit organization that collects anecdotes from doctors and patients. We feel these stories are poignant because they put a face on some of the known shortcomings of our system, and also because they unveil how commonplace and pervasive these types of stories happen.

8 replies »

  1. I am a Bangladeshi trained medical doctor. Recently I became successful at finding an Internal Medicine residency position in America. I am curious to know, Is America prospective for trained physicians.

  2. This has long been a sore spot with me as well. As I chiropractor in St George UT, I treat a lot of elderly folks who are on restricted incomes. Pain medications are horribly expensive, as is the work-up (Lab, x-ray, MRI). I think if the doctors treating the patients had a better understanding of the costs, there would be a shift in treatment plans.

    I am not opposed to MRI, I order them when needed. The problem I see is when young doctors order an MRI just to cover a malpractice risk, or even worse, as a fishing expedition. We all know that MRI are too expensive and way to sensitive. If one is looking for a disc herniation or other source of lumbar pain, the information provided on a MRI is not as reliable as we have been taught. I made a blog post on this last year. The basics are: To save money, hold off on the MRI for a few weeks, refer out for conservative treatment (chiropractor, PT, massage), don’t be so quick to give them hydrocodone.

  3. As a senior psychiatry resident in Virginia, a colleague and I set up a version of The Price is Right at our annual resident retreat, using the costs of prescription psychiatric medications without insurance coverage. It was shocking to some of us (but not all) that a year’s worth of some medications costs more than a brand-new car. I think versions of these classic games are a great way to bring awareness to our colleagues about what kinds of expenses our uninsure patients face when we write them prescriptions or order tests. It certainly makes me think twice about writing prescriptions for drugs that are brand-name only.

  4. While it doesn’t apply to OBGYN, it’s not hard to find out what Medicare actually pays for various services, tests and procedures which is always far less that the hospital chargemaster rate or full list price. Commercial insurers generally reimburse at higher rates than Medicare for the under 65 population.

    The biggest problem, I think, is that doctors never considered it part of their job to know or care about what anything costs and they have generally supported confidentiality agreements that preclude regulators or anyone else from disclosing contract reimbursement rates. They see their job as diagnosis and treatment along with counseling. There is a lot that needs to change regarding the financial aspects of the healthcare system. The same goes for patient expectations and the medical tort system, both of which also play a significant role in driving physician behavior and practice patterns.

  5. Residents feel empowered to order tests to cover for their incompetence at the art of physical exam. It is easier to click a mouse than it is to auscultate for rubs. Why examine a patient. Order a CT scan instead. I agree with Dr. Harrison. Hospitals have failed to disclose the costs of EHR and yearly maintenance and training, not to mention the never events associated with the EHR deployments.

  6. One of exorbitant costs is that of HIT systems of devices. They have not provided improved outcomes and they have not reduced costs of care. ,The costs of these devices are not factored in to the equations.

    The infrastructure costs have skyrocketed. In some cases, length of hospital stay has increased, and, hospitals and their purchased doctors can now cut and paste upcode to pay for these modern but flawed infrastructures.

    the cost of deaths of patients from HIT? No one is talking.