The leadership of the Hawaii Medical Association (HMA) and the Honolulu Star-Advertiser editorial board oppose recent language in HMSA’s provider contract that requires doctors to discuss cost implications with patients who are going to be referred to an out-of-network physician.
Both the HMA leaders and the Star-Advertiser got this one wrong.
First, full disclosure. I’m a medical director at HMSA (Hawaii Medical Service Association). I’m also a practicing surgeon in the community and a faculty member at the University of Hawaii John A. Burns School of Medicine. I have the privilege and responsibility to see the issue from both perspectives.
In every other consumer decision, we base our choices on getting a good value. The value varies from decision to decision, but ultimately it comes down to balancing quality and cost.
One could argue that for health decisions, quality should play a much more important role than cost. But it would be naīve to think that cost plays no role in most patients’ minds.
The problem is that in our complicated and frustratingly non-transparent health care delivery system, figuring out a good value is difficult, if not impossible, for the average patient or consumer.
A health care decision could be one of the most important and significant decisions in a patient’s life.
Who would patients turn to understand the implications of their decision?
Many of my patients turn to me because they trust me to give them accurate information and they believe I have their best interests at heart. I do. My obligation is to give my patients the full picture to the best of my ability.
In the case of referring a patient to an out-of-network doctor, the cost could be astronomically more. And this additional cost is not borne by the insurance company. In fact, HMSA actually pays less for an out-of-network service than it does for one performed in network. And, it is the patient seeing a doctor outside the HMSA network who must pay the difference in what the out-of-network provider charges and what HMSA will pay.
Patients who are not informed of this are often surprised — even shocked — to see they owe hundreds or thousands and occasionally even hundreds of thousands of dollars.
The Star-Advertiser editorial ("HMSA should revise new rule," Our View, April 20) makes the point that a physician has an obligation to the patient. I completely agree.
But I contend that making a patient aware of the cost implications of a decision is an essential part of a physician’s obligation.
Most important, I cannot imagine that consumers or patients would disagree that they want this important information.
In my mind, we as physicians are healers for our individual patients, but must also be stewards of our health care system. Understanding all dimensions of the value proposition helps us keep our autonomy in the management of patients as well as the health care system as a whole.
If not us, then who?
