If I may be honest, no, I do not feel comfortable asking my doctor about specific cost information mainly for two reasons: 1) I fear that I may come across as more concerned about my wallet than my health. It's always been "no price is too high for the safety and well being of my family and me". I think some in the healthcare industry play off this fear and use it to their advantage. 2) I've always thought "Hey, I've got insurance. They'll pay for it". As I'm learning more about the healthcare process, I'm finding that my thinking is way off because I'm doing nothing but shifting my cost to others via higher premiums that we all pay.

As a physician, I do not generally like to discuss costs with a patient, particularly if they don't bring it up first. When the patient brings it up, I used to try to find out, but the experience has generally been poor. I occasionally got forced into the position of having to "defend" the cost, and that negatively affected the delicate rapport I worked to build.

Frankly, most physicians don't even have the faintest idea of that the costs for a particular service/treatment/procedure is. Often the total cost is made up of a physician charge, a "facility" charge, and possible additional "modifier" codes.

In a health-care industry where you can actually get a certification as a "medical coder", it is unrealistic to expect that most physicians will have an accurate idea of costs. I know the costs for a limited number of procedures I do, but that may be different than what is actually charged to patients due to the contract between the practice and the patient's insurance, the "site of service", and several other factors.

That's a really good question. I'm sorry to say that I don't have any single great ideas that work within the current system. However I have some suggestions:

1. It must be easier for patients to somehow make sure that services they receive are from "in network" providers, if that is what they want. Using in-network providers (the merits of such a system of in-network and out-of-network providers is a debate for another thread) allows most patients to both control costs and to be able to somewhat predict what individual services will cost. My family and I have personally experienced instances of going to an in-network primary provider only to have labs sent to an out-of-network lab. There must be some sort of mechanism to either prevent this or at least inform patients and allow them to choose another option.

2. Patients should be advised, at the earliest time it becomes clear but certainly not later than at the time of treatment, what the likely cost of a service/treatment will be if covered by their insurance and also the cost if the service/treatment is NOT covered (out-of-pocket expense). Because this cost is determined both by the individual policy of the patient and the specific set of services/treatments given by the provider, it is a shared responsibility. Perhaps the provider's office can send a list of codes to the carrier and receive back a breakdown of each code's cost and the patient's out-of-pocket portion in both the covered/non-covered scenarios. This could be presented as a form for the patient to sign thus acknowledging what the range of costs will be. Granted that this could result in some very large cost ranges, but unless providers and insurance companies can come up with a way to agree on what services will be covered at what cost, I don't know how else to narrow it.

3. There has to be a way to motivate patients to actually try and learn about the costs and actively shop for the best treatment at the best price. One (somewhat radical) option is for insurance to say "We will pay X for such-and-such service". If the patient can get it cheaper, a portion of the difference is returned as a break on their premium (but not "cash back" otherwise the risk of fraud becomes much more likely). If it costs more than X, they pay out of pocket. A great example is MRI. I've seen insurance have to pay thousands for one, while some self-pay patients have been able to negotiate to get one for as little as $500 if they are willing to come in at an odd-hour or short-notice when the scanner is idle.

4. As a corollary to #3, I realize that there is some negotiation that goes on between certain practices/hospitals and insurance carriers with regard to how much will be paid to the practice for services. Larger practices and hospital systems have leverage to get better rates from insurance. This does not always translate into better service for their patients. If these rates can't be equal between larger and smaller practices, then perhaps patients need to know that it costs their carrier more to go to one practice than another. If there is any quality data to use as a comparison, the patient can then choose to go to the cheaper practice if there is no significant difference in quality of care.

I'm fresh out of ideas for now. If I can come up with others, I'd be happy to share.

Heath: As much as you are concerned that you may come off concerned about your wallet, your provider is concerned about what you may think of them. What if the treatment your doctor feels is better for you also just happens to be the more costly one? Will you think the doctor is trying to fleece you? As well, the doctor will be concerned that you may pick the less effective treatment due to cost, and failure to respond to treatment may in some way expose the doctor to liability since you didn't get the "best" treatment.

Also, I am encouraged by your second point. All to often patients choose a more expensive or even unnecessary treatment, even if there is little evidence to suggest that it is any more effective than cheaper alternatives or than doing nothing. An example of this is the use of once-a-day formulations of certain drugs that are no more effective (but more convenient to take) than their twice-a-day or thrice-a-day alternatives. A related example is the drug industry's practice of taking two generic drugs and packaging them in the same capsule/tablet/liquid and charging a premium price. The patient gains some convenience, but the trade off is a huge cost increase. Drug companies get around this with the use of "co-pay coupons". I was for this practice once, but now realize that in some circumstances it unnecessarily increases the cost to the insurance which ultimately results in increased premiums for all of us. There is an argument about increasing patient compliance with more convenient treatments. But most patients, I hope, would take the cheaper alternative if they knew what the "real and total" cost was.