Inside Medicine: Doctors are often in the dark about costs

Commercial Internet sites have some important lessons to offer for the practice of medicine.

When shopping online, each time you select an item for purchase – say from Amazon or Lands' End – you place the item in an electronic shopping cart. As you go along, you can monitor the total for your purchase. If the cost is too high, you can eliminate an item or two. You are informed of your cost as you shop.

Robert Brook, a scholar at RAND and one of the nation's great health policy thinkers, wrote recently that a major problem with American medicine is that there are no real attempts to reduce health care costs or even make doctors aware of costs. There is no "shopping cart total."

Brook points out that increasing numbers of doctors are using computers to write their notes, order lab tests and prescribe medications. Yet they are provided absolutely no information on the charge of the items. In fact, it is nearly impossible for doctors to find the charges for items we order every day.

Car makers, computer companies and construction firms use the power of computers to cut costs and improve value. Doctors do none of this.

In factory purchasing departments and in private homes, people regularly compare similar products by cost and quality across different websites. Why can't doctors look at antidepressants or pain relievers and compare the cost, the quality or the side effects in a side-by-side comparison?

We can look at what other people's experiences are with a hotel, a restaurant or even a doctor. Why can't we look at doctors' or patients' reviews of different drugs, lab tests or X-rays?

Would knowing the price or quality make a difference to doctors?

Based on some studies, it probably would. Brook points to one study where doctors merely were provided with documentation of their weekly costs of laboratory services. Over the 11-week study, lab orders decreased, saving tens of thousands of dollars. Providing costs to doctors would also allow us to compare ourselves with similar doctors to see how expensive our care is. Knowing costs, our computers could suggest other treatment or testing options that are effective but less costly.

As an example, doctors could get running totals (in their shopping cart) that would reveal how much it costs when they order a temperature or blood pressure every hour compared with every four hours.

Brook believes price awareness will make a difference to both doctors and patients.

Many private practitioners who accept only cash – what we often call docs in a box – already post prices for lab tests and procedures, thus allowing patients to decide how much they are willing to pay – a bit like the Web shopping cart.

Hospitals and clinics clearly know the costs of these tests, yet they shield doctors from this information. One can't help wondering why such information is not available in the electronic medical record.

Perhaps if doctors knew the prices, test ordering would decrease and hospital profits would also drop. Is there any other explanation?

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