The Price of a Scar

CHW LogoIf we needed any more evidence that yes, cost matters to patients and families, a new study from Annals of Surgery should be a wake-up call.  Researchers from Primary Children’s Hospital in Utah approached the families of 100 children about to undergo surgery for acute appendicitis.  They were offered 2 options: the open procedure, or laparoscopic surgery.  Based on published evidence, they were told that the complication rates were similar, but that open appendectomy would result in a larger scar.  One half of the families were only given this clinical outcome information.  But the other half were also given information on the charges of the two different procedures: $2172 less for the open procedure.

We pediatric providers have long assumed that, when it comes to their children particularly for something serious or with potential lasting consequences, parents would always pick what was best.  Cost would be no object.  Well guess again.  In this study, among families not shown the charge information 35% of the time, while those who were aware of the charges chose the less expensive, bigger scar option 63% of the time.  Interestingly, this difference was independent of insurance type, deductible, or income.

I’m not suggesting that parents will take their kids to Walgreens for a heart transplant, or that many parents wouldn’t make extraordinary efforts to get what they think is best for their child.  But this study demonstrates that cost is a major factor.  When told the cost, they are willing to trade off some significant possible negatives – in this case, a larger permanent scar.  As one familiar member said, “Cost saving measures are a priority for me when it does not impact the safety of the patient.”  And this is an acute, potentially life-threatening condition, where the parents may weigh cost less due to the pressure of making a decision without time to really consider the alternatives or “comparison shop.”  Imagine how this might look for something completely elective like ear tubes.

A few important caveats.  First, the surgeons in this study could convincingly claim the complications would be expected to be similar because it would be the same team – surgeons, anesthesiologists, nurses, etc. – doing either procedure.  In the real world, parents need to choose between more dissimilar alternatives, such as a specialized children’s center with a full complement of sub-specialists vs. a lower volume community hospital with non-pediatric providers.  Second, parents were provided with the full cost of having the appendectomy: a bundled price for everything.  In reality, most people have a hard enough time finding out the price of each item or service used.  The move to price transparency can only work if hospitals and providers can show what the total cost to the family will be.  For example, our hospital has a reputation for being expensive, based on the price of some of our services.  But analyzing data reported to the state of Wisconsin, I was able to show that for children in the Milwaukee area, the least expensive average charge for an emergency department visit was at Children’s Hospital of Wisconsin!  I didn’t have the data to figure out why, but a very reasonable hypothesis based on other research on differences between general and pediatric EDs is that we do less testing and treatment than at other hospitals because of our greater expertise in dealing with children.  (I have long held that the key to being an excellent pediatric emergency physician is as much in knowing what not to do as what to do.)  Even if Children’s charges more (and I don’t know if this is actually true) for a CT scan of the head, a parent wanting to know the cost needs to understand that their child is far less likely to get one unnecessarily in our ED.

It’s all back to the value proposition.  People paying for health care – and increasingly that is families themselves – want a good outcome and good experience at a reasonable cost.  If we want to attract children to our hospital – and kids do deserve the best – we need to be able to demonstrate all parts of that value equation.  And what this Annals of Surgery study shows is that we can’t assume we know what parents will value.  Many of us would pay more for the smaller scar.  But what matters isn’t what we would do.  We can provide information, we can provide guidance; only the family can decide.

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