Transparency: A Vital Link to Quality Healthcare


Transparency requires trustworthy communication and accountability to ensure healthcare services are patient-centered, safe and cost effective. However, our fee-for-service healthcare system, and the fear of law suits from HIPAA violations, have created obstacles to transparency in costs, medical outcomes and quality of care.   Currently there is a trend changing to value-based care, where payment will be based on good quality and cost-effective care through the proper use of resources and improved clinical outcomes. Information sharing rules are in the process of change to provide pertinent information for doctors and patients without fear of reprisal.

Cost of Health Care

Healthcare costs are higher due to advances in medical technology, products and services. The price for diagnostic tests and medical procedures is based on well-defined pricing contracts between health insurers and hospitals.  Allegedly, their mutual goal is to ensure patient care services meet the needs of the individuals.  Some patients require less services while others require more, sometimes due to unexpected care outcomes.  In addition, payment for physician services is usually not included within the cost appraisal process.  Thus, it is difficult for hospitals to list prices in advance.  There is also currently NO cost regulation mandating the equivalent pricing across the board.  In 2006, the American Hospital Association (AHA) Board of Trustees put in place a policy for pricing transparencies.  That policy states that pricing should:

  • be easy to access, understand and use;
  • create common definitions and language describing hospital pricing information for consumers;
  • explain how and why the price of patient care can vary;
  • encourage patients to include price information as just one factor to consider when making decisions about hospitals and health plans; and
  • direct patients to more information about financial assistance with their hospital care.

Additionally, the AHA identified four key components to better price transparency.

The goal of cost-transparency is to ensure your right to know what your out-of- pocket expenses will be before a medical test or procedure is performed to make sure it’s affordable, as reported by Public Agenda, a non-partisan, non-profit research company supported by the Robert Wood Johnson Foundation.

The majority of adults do try to find this information before getting medical care.  At present, information isn’t easy to access or understand, as stated by the New England Journal of Medicine. 

Insurers may be prevented from listing provider prices on their websites (Defining Healthcare Price Transparency).  Prices are discounted based on income to accommodate the uninsured, at times.  Doctors tend to be uninformed about pricing issues, so medical testing and procedures can cost more at one hospital and less at another (NY Times). Price comparison shopping is one of the keys to keeping health costs down.

At present, any of this information isn’t easy to access or understand.

Health Insurers: Costs and Outcomes

There are varied types of health insurance plans to choose from. Some people use employer health insurance benefits only, while others add personal health Insurance plans to lessen out of pocket expenses. You must keep informed about your deductible, co-payments, and out-of-network costs.

Case in point: A Prism client received bills in the thousands because he didn’t know that the anesthesiologist who provided care was out of his network and his insurance claim was denied.  If your claim is denied, was it due to lack of information, incorrect information or a billing error? You must check all bills for errors and omissions yourself. If you find any problems, contact your provider and/or facility and request that the errors be corrected, and the claim(s) resubmitted to your insurance company. If the situation requires an appeal, ask your company representative to review the appeal process with you.

It is important to note that most bills can be negotiated.

Doctor Visits

Time allotted by healthcare insurers for primary care visits is between 15 to 16 minutes, and patients tend to be unprepared to talk with their doctors.   Prior to your visit, outline goals to ensure you understand the basics about your health condition and care plan.  Make a list of your concerns and document, if possible, times and dates. Reconfirm all your medication with your doctor and why you are taking them.   Should you not understand what your doctor is saying, ask for clarification presented in non-medical terms. If you still don’t understand, ask again.  It’s imperative that all health care providers ensure verbal messages are received, processed and understood. (National Institute on Aging)

Patient Portals and Accountability

Patient portals are available in nearly 50 percent of U.S. hospitals and 40 percent of doctors’ offices. So, its probable providers will ensure patient data is accurate and complete as patients can identify inaccuracies in their health records. Portals provide patients with 24-hour access to review personal medical data, like hospital discharge plans, lab or other type test results, prescription refills and messages for staff, like the need for a new appointment.

As our healthcare system transitions from fee-for-service to value-based care, cultural and organizational changes that support transparency are in progress. According to the Institute for Healthcare Improvement, the goal of healthcare services is to honor individuals by being patient centered, safe, science based and effective.

Health Advocates are prepared to deal with the challenges of transparency in patient centered care as they navigate through the complexities of our health care system.

Joan Fox Rose, MA, RN

Post by Victoria

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