Why Bundled Payment Is Easier

November 8, 2013
Rebecca Bechhold, MD

If payments were bundled, we would be accountable to evaluate our treatment plans, follow-up visits, tests, and imaging. We need a system that rewards us for excellent care and allows the costs to be presented to our patients.

Fortunately for us, my extended family has been relatively unscathed by disease, injury, or chronic health condition. So call me ignorant of what the rest of the world has been dealing with, particularly those with serious or chronic illness.

I have seen a few medical bills, and I am astonished at both the itemization and errors. For example, my husband had a hip replacement. He was in the hospital for 36 hours, and I was with him virtually the entire time. Imagine our surprise when the bill included a hefty fee for a hospitalist whom neither of us ever saw. Maybe I missed the visit, and maybe my husband's memory was impaired by drugs. I did not dispute the charge, but it made me wary of all further bills, and I tell everyone to check theirs line by line. Follow-up with the surgeon was part of the surgical fee. There were charges I thought a tad inflated, but no real surprises. Surgical charges seem to be defined for each procedure, even if the actual charges are not exactly consistent from one patient (insurance payer) to the next. The outcome of my husband's surgery was outstanding-he had a very talented surgeon, and the staff at the hospital was excellent-and life went on.

Then it was my turn for an outpatient procedure. It was straightforward, the doctor told me all about it, and my insurance agreed it was appropriate. It was a great success-I even referred a friend-but after the procedure, every time I went into the office, as requested, it was one charge after another. The initial evaluation had its own charge-OK, I’m good with that-and the procedure itself was done and paid for, but the follow-up visit that included a scan became another charge (previously unmentioned), and then a visit on top of that was scheduled for a “clean up” procedure and again another scan. I will tell you that after being nitpicked with bills, when I came in for what I thought was just a checkup and yet another scan was ordered, I very firmly asked the doctor what it was for and how he was going to use the information. I said I didn’t want another $500 scan. He claimed no knowledge of the price of the scan. I proceeded with the scan and a small follow-up procedure, but then the doctor said, “I am sure you can watch this yourself and will call if you need to return. You will probably get a call or email to schedule another scan, but I am comfortable that you have had an excellent result and can self-monitor.” I am fairly certain that if I had not gotten a bit huffy, I would have been getting more scans and more “suggested” procedures.

I cannot fathom how oncology patients or patients with lifelong complicated illnesses follow all of the charges we submit. How in the world do you know what you are paying for or if the charges are legitimate! I am ashamed to admit that I do not know what everything costs my patients. I have noticed the co-pays go up significantly in recent years. I am more discerning when it comes to asking patients to come back to the office. I only have them come in if it is truly necessary. I avoid churning patients through the office like some smarmy stockbroker cranking out stock transactions.

Why don’t we know how much it costs to give adjuvant FOLFOX or to treat node-negative, triple-negative stage I breast cancer? No other trade conducts itself as the medical system does. It’s like the lawyer joke where the client says, “I want justice!” and the attorney responds, “Sure. How much justice can you afford?”

I don’t care what they call reform-Obamacare, Romneycare, Bozocare-and I don’t care who takes credit for it. But someone in Washington, DC better get their act together. Could someone please read the current law and make some sane suggestions to make it work? Surely, no one who has had interaction with our current system thinks it is sustainable or fair. And it is certainly not transparent.

If payments were bundled, we would be accountable to evaluate our treatment plans, follow-up visits, tests, and imaging. We need to find a payment system that rewards us for excellent care, values our skills, and can be presented to patients in a manner that allows them to have some expectation of how much it is all going to cost.

We can no longer shy away from the dirty business of cost. We may be part of the problem, but I am certain we can be the driving force for the solution.