The $1,500 Bottle of Ibuprofen
Perhaps the most educational experience I had as a medical student did not come in the classroom or while shadowing physicians; it came after my wife’s Caesarean section for our first daughter. For kicks, we asked for an itemized bill from the hospital and when it finally came in the mail we read through it, and thought it was a joke. To be in a birthing room was $242/hour ($471 for just the first hour). There was an additional charge of $1,460 daily for the use of a “private” room (I have yet to see a shared birthing room in America). A single tab of ibuprofen was $1.06. A liter of sterilized water used for cleaning was $69.63, roughly the same as a liter of normal saline given to my wife via IV ($65.90), which strangely was only $0.38 more than just one half of a liter of normal saline ($65.52). Donor breast milk following delivery was $16 per ounce (before you ask, the donors don’t receive any money).
Those charges would not come as a surprise to these parents you may have read about. They asked for a similar bill and were shocked to discover a $40 charge for “skin-to-skin” contact, which is what the process is called where the newly-born child is placed on top of the mom immediately after delivery. So, $40 to just hold their baby!
Now these costs are not what these hospital actually got paid or what we ended up paying; these costs are what the hospitals billed insurance companies. As a medical trainee, however, I find these costs fascinating. There, in black and white, is a theoretical list of how much care costs. For all of our medical education, physicians and other health care providers are generally as clueless as anyone else about how much health care really costs thanks to this financial cloud of war that obscures the system. One of the most commonly ordered lab tests, one I have ordered hundreds if not thousands of times in the inpatient and outpatient setting, is called a complete blood count (CBC). It is a panel of blood tests that measures how many white and red blood cells somebody has, which can tell you if they’re fighting an infection or anemic. Despite the fact that I have ordered this test countless times, I have no idea how much it costs our system. If someone from Duke told me that lab costs our system 10 cents, I would believe them, given how common that lab is. If that same person told me that the lab is actually more complicated to run and it actually costs 100 dollars every time I order it, I would believe it. So I really cannot even give you an estimate of what it could actually be! The same goes for imaging. If a patient really wants an MRI of a joint that is not medically warranted, I need to warn them that if we did the test anyway their insurance might not cover it. But I have no idea if the actual cost of that MRI is closer to $50 or $5,000 (and even if I did, how much their insurance would ultimately bill them).
We as providers are increasingly being asked to be better stewards of our health care system’s resources. As a country we spend more than $3 trillion on health care and roughly 30% of that is waste, according to the Institutes of Medicine. It turns out, these little orders can really add up. Let’s say, for example, I have a patient who I’m worried might be anemic. Should I order a CBC or just the part of the panel that looks at anemia? Does it make a difference in terms of cost? I asked my father-in-law this question (he’s been a practicing primary care doctor for almost 30 years.) He told me he was always taught that ordering a whole panel is cheaper than individual lab tests. I told him I would have guessed the opposite. Re-looking at my wife’s delivery bill, it would appear that my guess is correct. A CBC apparently got billed close to $70 while just a hematocrit (part of the panel) was a more reasonable $17.
There is a way to increase price transparency among medical providers with our electronic health record. EPIC, the system Duke, UNC and many other large hospitals have spent billions adopting, has a feature baked into the program that can display a price alongside the names of the tests we want to order - like a menu. There have been some small studies that looked at what affect turning this feature on has in outpatient primary care clinics. When physicians are shown prices for what they order - even if they’re essentially made up numbers - they tend to order a little less.
I am attempting to study what effect turning this electronic health record pricing feature on in the hospital has on how much providers order, if any. If my research matches what has previously been seen, price transparency would likely result in at least a modest cost savings to the system. However, it would not be advanced enough to be able to give a patient a head’s up of what their medical bill would be - wouldn’t that be nice? If you look at the statistics, we spend way more on health care, and have poorer outcomes, in America than anywhere else. Maybe it’s time we physicians become savvier shoppers on behalf of our patients.
Update
Since writing the blog post above, my wife and I have received an itemized bill for the birth of our second daughter, born 2 ½ years after our first. Both were born at the same institution and it is remarkable how the prices have changed in such little time. The labor room hourly rate is up 16%. The price of a hematocrit lab is up to $22, an increase of 29%. But the biggest change? A single tab of ibuprofen went from $1.06 to $16.25! That would be more than $1,500 for a whole bottle of over the counter medicine you can probably find at a drug store for less than $5. Discussion: so what do you think? Do those prices make sense to you?
Brian Blank is a second-year resident with the Duke Family Medicine Residency Program. Email brian.blank@duke.edu with questions.
Editor’s note: Duke Family Medicine residents guest blog every month. Blogs represent the opinion of the author, not the Duke Family Medicine Residency Program, the Department of Community and Family Medicine, the Duke University School of Medicine or Duke University.