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A Long Time Coming: Consumer-Directed Health Care

If you believe the hype, the power of consumers taking control of their own care is going to revolutionize our health care system in the years ahead. Based on my own recent experience, it could be a long time coming.

First, the good news. I had a surgical procedure, and everything went smoothly. I was in and out of the hospital in a day, and the doctors and nurses were completely on top of their game. They explained everything, answered all my questions, made me feel comfortable and followed through after I was discharged. Top-flight professional care, all the way.

Then the fun started. The week following surgery, I received a non-itemized bill from the hospital listing charges of $3,617, billing submitted to my insurance company of $3,367, and the $250 difference due from me.

This is weird, I thought. I paid my $250 deductible on the day of the surgery. Where was that noted on the bill? Perhaps they had forgotten to credit it. There was no way to tell, since nothing was itemized.

Being the savvy consumer I am, I decided to ignore the bill. Pay nothing until you have all the information. That seemed like a prudent course to me.

A week later I had a post-op visit with the surgeon. Chatting with one of the office staff afterwards, I happened to glance down at my patient record on her desk, where I zeroed in on the figure of $1,140.

"Is that the charge for my surgery?" I asked.

She shrugged her shoulders. "That's the listed charge," she said. "Everybody pays something different. It's hard to figure out."

No fooling. I filed the number in the back of my mind and dredged it out again when I received the first of what I knew would be many "explanation of benefits" from my health plan. There I saw a billed amount from the surgeon for $1,190, an allowed amount of $596 from the health plan, a paid amount of $277 and $319 that was my responsibility, including the $250 deductible I had already paid - but to the hospital.

There was also another $280 billed by the surgeon for what the health plan called a "procedure incidental to another procedure performed on this date of service." The health plan said I could get a "free copy upon request" of the "internal rule, guideline or protocol" that was used in classifying this as "incidental."

I'm going to look into this, I said to myself. I thought I had just one procedure. Now I find out that I had at least two. So I called up my health plan, where I spent several minutes trying to navigate the phone menu and another five minutes on hold before I hung up in frustration.

I realize I have a low threshold for patience in dealing with large service companies like banks and health plans. But the consumer is king, right? Shouldn't I be able to see all the numbers up front before I buy, get all my questions answered in a timely fashion, see all the charges itemized and be able to talk to my "broker" in the exchange for a completely transparent account of what's going on in any given moment?

My experience was fairly typical and uneventful as these things go. Imagine what it's like for complicated procedures, with multiple providers, payers and brokers.

Imagine what it's like for someone who's uninsured, with little knowledge of the system, few friends and even fewer sources of support.

People who think consumers will actually want to engage this Kafkaesque labyrinth of administrative horror, let alone be able to discern where their best opportunities for access, quality and cost lie, need to have their heads examined. Under the current set up, it's simply not going to happen.

Will it be different in a future where we all use vouchers and more of our own money to directly engage health providers in pursuit of quality care? Will consumer pressure force physicians, hospitals and health plans to live harmoniously together in some kind of electronic infosphere where billing and medical records will be transparent to consumers, providers and payers alike?

I'd like to think so, but at the end of the day what most consumers are looking for is a hassle-free experience where mutual trust and respect govern the transaction. I felt that trust in dealing directly with my surgeon and the hospital staff, but there's a yawning gap between the immediacy of the patient-provider experience and the administrative apparatus that now threatens to strangle the humanity out of it.

Until we figure out a way to bridge that chasm, I don't think we're going to see a wave of consumer-directed health care anytime soon.