Getting Patients to Think About Cost

Harvard Pilgrim Health Care (HPHC), the not-for-profit regional health plan (Massachusetts, New Hampshire and Maine) where I direct the ethics program, is introducing a rewards program - "SaveOn" - to encourage patients to have procedures like colonoscopy, mammogram, and MRI at facilities that provide the service at lower cost. Patients who use lower cost facilities will receive a check for 10$ to $75. Here's how HPHC CEO Eric Schultz explains the rationale:

"It’s the kind of decision patients aren’t making today because they don’t have the information. Doctors are still referring patients for diagnostics based on the way they’ve always done it, without regard for the cost. But we can’t sit around and accept behavior that drives costs up with little or no impact on quality."

I respect and admire Eric Schultz, and think of him as a friend. But here's what Dr. Rick Lopez, chief medical officer for the group I practiced with for 35 years, and who I also respect and admire, and think of as a friend, has to say about SaveOn:

"I do have concerns about this. When I refer a patient for a test or an imaging, I’m taking into account what the patient needs and I’m referring the patient to a place where there’s quality. And I know that from experience. And, [if something goes wrong with a patient’s care] the doctors are liable."

I understand where Rick is coming from. SaveOn is a disruptive innovation. Rick knows and trusts the radiologists who do imaging studies for his patients and the gastroenterologists who do the colonoscopies. Of course he prefers to use them.

If I'm a lower cost radiologist I'm motivated to do a good job with Rick's patients and to communicate with him. If I succeed everyone wins. I build my practice, the patient gets a direct financial reward, and the referring physicians are happy with my services. And if the specialists Rick prefers are losing referrals on the basis of cost, they may decide to lower their fees.

But who benefits from the savings? Here's what Richard C. Lord, president of Associated Industries of Massachusetts, a trade group representing 6,000 businesses, has to say about SaveOn and the savings it may produce:

"Conceptually, it’s a move in the right direction. We’ve been talking about getting consumers more engaged in making their own health care decisions. Up until now, there’s been no incentive to a consumer to shop around. [But] ultimately the savings should be reflected in premiums employers pay."

For the past 25 years I've thought, talked, and written about the ethical imperative to contain health care costs. Unlike health care, words are cheap, and reams of articles and exhortations have not slowed down the cost curve. Innovations like SaveOn have the potential to be more educative than learned articles. If I see that the MRI I'm referred for may cost $1,000 at facility A and $3,000 at facility B, I'll be prodded to think about value. Perhaps B offers $2,000 worth of additional value, but perhaps not. The crucial thing is for the U.S. population to see questioning health care costs as an ethically appropriate activity, not a moral crime!

(The quotations come from a Boston Globe article. To learn more about how the SaveOn program works, see the website of Tandem Care, the subcontractor who provides the service.)