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Dr. David Wilcox DNP, MHA, BSN, RN-BC, LSSBB

The American healthcare system is complex. It’s no accident, it’s made complex by healthcare entities competing for your healthcare dollars. They would rather you not know exactly what your prescriptions or procedures will cost you. Instead, you’re lulled into “trust your pharmacy, doctor, or insurance company” to meet the costs. “You don’t have to worry about that” is how they would like us to think. Price transparency in health care is almost non-existent. In fact, an executive order on price transparency that went into effect January 1, 2021, calling on hospital systems to list common procedures in a “user-friendly format” has been virtually ignored by our nation’s healthcare system. Even after instituting increased fines for non-compliance in January 2022, 85% of our country’s hospital systems are still non-compliant, and not a single dollar in fines has been collected. What does a baby boomer, or anyone else, have to do if they want to understand the cost structure of an upcoming elective procedure? Enter Healthcare Bluebook, a website that can show you the approximate costs of a procedure in your area. This begs the question: if a third party can access this information, why are healthcare entities not open to the costs associated with healthcare? The answer is that they don’t want you shopping around for your next procedure. For example, if you have total knee surgery in my area, it will cost you $12,000 at a hospital, but only $8,000 at an outpatient surgery center. That’s a whopping third and outpatient surgical centers often have better quality results! With healthcare spending being responsible for 58.5% of personal bankruptcies, we need to pay more attention to healthcare spending. We buy prizes for cars and homes while health care is one of the most expensive items we buy, we don’t shop around to make sure we’re getting the best quality and lowest cost.

If you do your research, you can come up with an approximate cost for your procedure, but how do you know if the hospital or doctor is actually providing quality care? You will need to do additional research to understand the quality of care provided by both the hospital and the surgeon/doctor you have chosen. CMS.gov is the website for the Centers for Medicare and Medicaid Services. The site includes star ratings for your local hospital based on a five-star system, with five stars being the highest rating and one star the lowest. These star ratings are derived from surveys patients take after being hospitalized at your local hospital. Star levels also affect hospital reimbursement, which is why you’ve seen a lot more hospitals start focusing on “patient experience.” A hospital system with ratings below four stars should be avoided. I’ve often wondered why people fly to MD Anderson for their cancer treatments when they could just get them at their local hospital, but when I researched the star rating, it m It became clear what their justification was. They wanted to spend their money on quality health care and be cared for by the best of the best.

OK, you now know the approximate costs of your procedure and the star rating of the hospital or outpatient surgery center where you will have your procedure, but what about the surgeon who will perform the procedure? In my book How? ‘Or’ What Avoid becoming a victim of the US healthcare system: Patient’s Handbook for Survival, available on Amazon, I discuss the questions you should ask your surgeon. For example, in a university hospital, do you know that your surgeon may not be the one performing the actual operation? An intern or resident can perform the surgery under the supervision of your surgeon. I don’t know about you, but I prefer my surgeon to bring his A game when I have surgery. Other information from the book encourages you to try to be the surgeon’s first case of the day, as data shows that the first case of the day does significantly better in quality areas such as lower infection rates and better patient outcomes. Also, you won’t be able to eat or drink after midnight, so being the first case lessens the bad experience of not being able to eat or drink all day. But the most important thing you can do to ensure you get a decent outcome from surgery is to research your surgeon and anesthesiologist on Healthgrades.com. They use actual patient ratings using the five-star rating system used by Medicare and Medicaid Service Centers. In my book, I talk about hearing a woman in a grocery store talk about her upcoming procedure at a local hospital where I worked. His procedure was performed by a surgeon whose patients I had treated in the past. These patients did not have the best quality results and fared significantly worse than patients of other surgeons who performed the same procedure. I was able to intervene because we were in a community setting, but if I was preparing the patient for surgery, it would have been inappropriate and I could have lost my job! If the patient had researched this surgeon, she could have seen what previous patients had reviewed for this particular doctor, so do your research!

After surgery, your surgeon may prescribe medications such as antibiotics or painkillers. With the plethora of prescription drug insurance restrictions, you never know what you’ll be paying for at the pharmacy counter. In one pharmacy, your prescription may cost you $50 while in another, it may cost $500. Why is this happening and what can the average healthcare consumer do about it? Although I could write an entire article on this, at a high level, once a prescription is written and before it is filled, it must go through a pharmacy benefits manager. Pharmacy benefit managers use discounts and coupons to land the approximate costs that the insurance company or you will pay out of pocket, often pocketing the savings for themselves. In the book, I share the story of my sixteen-year-old dog who suffered from mild heart failure. It was a dog that we had no insurance coverage for. The vet prescribed Viagra, a drug that was originally developed as a pulmonary anti-hypertensive drug designed to draw fluid from the lungs. Once the side effect of improving erectile dysfunction was discovered, the price of the drug skyrocketed. My wife went to fill our dog’s prescription at a local pharmacy and the price was over $700 for a month’s supply. It is worth noting that in most states pharmacists are not allowed to offer you lower cost options for medications, you must do your own research to find this information. She left the pharmacy and downloaded the GoodRx app which was able to find the drug across town for $63 for a month’s supply. If she hadn’t done her research, we could have paid over $600 more for the drug. In fact, sometimes the GoodRx price is lower than using your insurance and a co-pay, but you’ll have to do your research to compare the two.

With prescription drug prices so high and volatile, it’s encouraging to see disruptors such as GoodRx and Mark Cuban’s generic online mail-order pharmacy emerging. The latter’s model is to remove the pharmacy benefit manager from the equation and deal directly with drug manufacturers by dramatically reducing the cost of generic drugs while selling them to the healthcare consumer at cost plus 15% to run the business. Generic practices such as “pay to delay” are common. A pharmaceutical company pays a generic manufacturer to wait for the release of the generic form of the drug, which usually costs less, but not always. This allows the original manufacturer of the drug to continue charging inflated prices for the drug. Given practices like this, a disruption in the world of prescription drugs is welcome.

For baby boomers on Medicare, do you know that for years the Secretary of the Department of Health and Human Services was not allowed to negotiate drug prices with pharmaceutical companies? America’s biggest payer has been barred from negotiating drug prices, costing Americans more than $11 billion a year! This is called the “non-interference clause”. Recently, legislation was introduced allowing Medicare to negotiate the price of up to 50 drugs by 2025, but it has yet to pass the House or Senate as of press time. Given Washington’s history of delayed action on high medical costs, I wouldn’t hold my breath.

The best way to reduce healthcare costs and ensure you get quality results is to do your research and be a partner in your healthcare. Informed healthcare consumers ask questions and proactively manage their healthcare in collaboration with their healthcare team. That’s why I wrote the book How to Avoid Being a Victim of the American Healthcare System: A Patient Survival Handbook, available on Amazon.

About the Author

Dr. Wilcox is a doctoral nurse who also holds a master’s degree in health administration and is board certified in nursing informatics. Dr. Wilcox has 28 years of healthcare experience during which he has worked as a staff nurse, hospital administrator and in healthcare information technology which has helped him to develop his unique perspective on the American healthcare system.

Dr. Wilcox is the author of the book How to Avoid Being a Victim of the US Healthcare System: A Patient Survival Handbook (2021).

Dr. Wilcox currently resides in North Carolina with his wife and their three dogs.

Dr. Wilcox website: Dr. David Wilcox – Healthcare, American Healthcare System (https://drdavidwilcox.com)

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