"How to Haggle With Your Doctor” was the title of a recent Business section column in The New York Times. This is one of many similar directives to the public (as seen here, here, here and here)urging us to lower the high price of our health care by going mano a mano with our physicians about the price of tests they recommend and the drugs they prescribe. Such articles provide simple, common-sense recommendations about how to respond to the urgency many of us feel — insured or uninsured — to reduce our health care expenses.
With unemployment at 9.4 percent and more than 50 million Americans lacking any or adequate health insurance, I understand the impulse of editors to assign this story. Plus, “of all the providers of medical care, physicians are most important in determining how much will be spent,” notes Arnold Relman in the New York Review of Books, since they make all the allocation decisions that “call on the facilities and services of all the other providers of care — hospitals, imaging centers, diagnostic laboratories, manufacturers of drugs and equipment.” The prices charged by these institutions vary widely, and therein lies the opportunity to find some savings.
But coming off a wave of big-buck spending related to my recent diagnosis of stomach cancer, I am acutely aware that haggling with my doctor about the costs of my care is neither simple nor is it a matter of common sense. Rather, it is a matter of 1) understanding in detail both the opportunities and limitations related to my health insurance; 2) being persistent in seeking information, since price lists are often difficult to track down and comparisons of quality (accuracy) of laboratories and testing facilities are nonexistent; 3) using available information and my judgment to weigh options; 4) the willingness to risk the rejection of my request by my provider and perhaps antagonize her; and 5) overcoming my pride and asking to be treated well while seeking the best value for my money.
The fact that health care is not a real “market” for patients is old news, although perhaps not to those journalists who blithely recommend that we set off to haggle our way to cheaper care. And it is irrelevant news to the vast majority of the public for whom discussing cost with their doctor is anathema. Many people would not consider doing so, first, because they may not know that the prices of drugs and tests vary so much by provider/source; second, because they may feel uncomfortable mentioning money concerns; and third, because the public has long held the view that more expensive care is better care and in seeking to pay less, one may be tacitly agreeing to accept less effective care.
Objectively, none of these factors should influence a person’s ability to ask straightforwardly: “I wonder if there is a way you could help me reduce the price of my care?” But our relationship with our providers is rarely objective. We come to them when we are sick and vulnerable. We put our lives in their hands. We trust them to do the best for us. And we value deeply their efforts. Haggle about the price of this commitment? Many of us will not, even if the alternatives are bankruptcy or going without care.
So what should we make of this rash of recommendations to enlist our providers in reducing the price of care?
I, for one, want to know whether similar imprecations are aimed at doctors and other providers so that if we must ask for help to pay less, they are able to respond with useful strategies and without hostility. All health plans remind doctors of policies that aim to constrain costs by providing incentives to physicians who deliver care that is evidence-based, for example, or dictating the priorities of drugs prescribed for certain treatments. But our requests are not policy-based. They relate to the use of specific facilities, dosages and frequencies. Other than providers in federally qualified health centers, many of whom have well-honed skills in squeezing the most care for from each dollar, most providers are largely unfamiliar with the prices of the services, tests and drugs they recommend.
Will this advice to ask for a break on the price of care exert demand that results in more transparency about cost and quality? Perhaps, but only if many more people cast off their traditional passivity with regard to their care, overcome their reluctance to discuss money, and invest the time required to tracking down the elusive price and quality information that is required.
The frequency of the recommendation to haggle with one’s doctor may reassure the public that discussing the price of care will apply pressure to meaningfully reduce what we pay. But saying, “This drug/that test is too expensive for me. Can you do me a favor and spend time with me to find lower-price solutions without compromising quality?” is not an approach that will lead to a widespread and enduring solution.
While we are waiting for the enactment of federal and state policies that would ensure that each of us can afford the care we need, what private policies and public regulations about transparency and price would help us out here? What would ensure that those of us who are willing to take on the tasks of trying to cut a better deal for our care with our providers have the information and guidance to do so?