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The Journal Gazette

Sunday, June 30, 2019 1:00 am

Transparency's not synonymous with truth

Directive will require more of health care system

Drs. William Cast, Matthew Sprunger and J. Philip Tyndall

The word “transparency” has leaped into common use. We hear it everywhere in politics, in marriage counseling and now in health care.

The concept has been useful since “transparency” first appeared in the English language in 1413, when William Caxton published “The Journey of the Soul.” It is the story of a sinful monk seeking justice at the gates of heaven; his private sins of gluttony and lechery were “transparent ... that I might see what was within.” By Shakespeare's time, 1592 (”Romeo and Juliet”), the word meant open, easily seen through, obvious: “Transparent heretics, be burnt for liars.”

Today, social media demands that “we want to know it all right now!” Any delay suggests that “they're hiding something.”

Recall reports of an airliner crash. We are flooded with instant but incomplete reports. Pilot error maybe. We expect details to make sense – a troubling problem. Understanding requires expertise, and time. In aviation, we are told that the pilot couldn't raise the horizontal stabilizer. What does that mean? The plane was certified by the Federal Aviation Administration. What does certification guarantee?

Health care offers those problems and more.

President Donald Trump has issued an executive order for the Department of Health and Human Services to develop rules requiring hospitals to publish charges “that reflect what people actually pay for services in a way that's clear, straightforward and accessible to all.” Transparency, not after a tragedy but provided in advance.

What if, in attempting to predict your costs for a confusing surgical procedure, you read: “horizontal stabilizer: $600.” “G-Arm Fluoroscope: $300.” “Paracetamol: $4.” In Shakespeare's time or ours, that information is transparent gibberish – clear and open, but not helpful.

You could ask your physicians. But, not so fast. They don't reliably know hospital charges or what your insurance covers. They cannot be certain what tools may be needed in surgery.

Will your insurer know? Certainly they know whether your hospital and physician are “in network,” but not what procedure will be done. And the surgical assistant may be out of network” and supply you with a surprise bill not covered by your insurance.

Your hospital likely provides a consulting service to help you predict the cost, but it's no better than an estimate. Maine and New Hampshire provide that median charges for more than 100 services be posted for insurers, hospitals, medical groups and surgical centers. Both states report modest savings (about 3%) but with only low patient use. Patients have been surprised by the great variation in charges.

Bottom line? It seems as if you need helpful information from several experts, including details of your insurance.

If real transparency is on the way, where are we now? Today, hospitals are required to supply a public display of charges, called Chargemaster. But, here is a disclaimer from a local facility: “The government requires hospitals to maintain a fee schedule, the chargemaster ... published on their websites. These charges do not reflect what patients generally pay for the services they receive or represent what the hospital is actually paid in most circumstances. The chargemaster should not be used to estimate a patient's actual cost of care or as a meaningful comparison about what hospitals are paid for their services.”

An a la carte cafe menu that doesn't reveal the cost of your meal. Again, not helpful.

It should be obvious by now that much more than price needs to be made transparent, and hospitals, physicians, insurers and perhaps even patients may not enjoy the process. Government's first required steps, in January, to post procedure prices were called a “fiasco” when a major medical center posted a charge of $42,569 for a heart procedure described as “HC PTC CLOS PAT DUCT ART.”

Hospitals and insurers have not seemed eager to create informed consumers. It is not a lack of honesty: A hospital can be honest while factually telling patients what the hospital believes needs to be known. Transparency allows patients to see for themselves what patients believe they need. Marketing, however, merely showcases a chosen feature in a positive light and does not feature poor outcomes.

For example, certification for excellence in robotic surgery is paid for (well over $12,000 plus expenses for a single-day inspection) and a facility may then advertise after the inspection is complete. Such cooperation between physicians and administration to set minimum standards is laudable. But marketing any certification may be misleading in that competing facilities may have even more experienced surgeons and as good or better outcomes.

Additionally, it is widely reported that charges for an hours-long robotic procedure are $2,000 more than a (similarly minimally invasive) laparoscopic procedure of shorter operating time with quite similar outcomes. It would seem that transparency would require that informed patients know these details when charges are posted and benefits are marketed.

This is not to deny the great advances in robotic surgery, instead to promote creation of informed patients. Posting charges is but a tiny first step. Creating informed patients requires physicians to tie charges to procedure outcomes and outcomes to standards of care. That path to quality will bring value and lower prices.

Drs. William Cast, Matthew Sprunger andJ. Philip Tyndall are the founders of Northeast Indiana Citizens for Healthcare Excellence.