Dennis Y. Fong, M.D.

Thought experiment: every service —whether cognitive or procedural, inpatient or outpatient-carries the same percentage copay of cost.

Patients could finally see and feel the bite of true cost relative to utility-and become both quicker to seek care early, and more selective about from whom to seek care.

Copays for cognitive work office visits are usually a much greater percentage of their cost than copays for much more expensive tests, procedures and even hospitalizations—sometimes none—yet those downstream costs often depend on the quality of the office cognitive work. And proper valuation of cognitive work is key. Who would dream of not critically valuating architectural work when, even though it comprises only a small portion of a skyscraper's total cost, it determines that building's cost, utility and ultimate value?

But the problem with valuating clinician cognitive work is informational. Third-party payors can't observe or price each instance of cognitive work (only in aggregate by linking it to outcomes). But patients can when they pay a percentage of its cost-and then the same percentage of downstream costs. In such a true cost transparency model, the patient's payment becomes a real-time valuation signal on behalf of the payor.

This critical valuation on the part of the patient will force clinicians to be much more mindful of cost-effectiveness. First line clinicians-PCPs-will face pressure, especially from complex patients, to detect problems early and nip things in the bud.

Here's one way commercial insurance could offer this-and I suspect the improved cognitive work and lower downstream costs could make it quite profitable:

• Deductible: none, so cost visibility starts with the first dollar.
• OOP max: High enough that hospitalization still "bites."
• Premium: Lower, competitive with other PPO plans.
• Preventive services-vaccines, pregnancy and childhood checks-remain free.

Here the clinician who delivers better outcomes and thus less total costs, earns more because patients see it clearly —especially complex patients.
Even better, payors could add outcome-linked retainers or bonuses.

Can patients judge value in health care? Yes, judgment improves with repetition. Especially if, thanks to tech, we can provide patients in real time with models of downstream consequences-different timing, different choices, different outcomes, different total costs-patients learn to see value. Patients will choose early, well-reasoned care to prevent catastrophic costs.

Health care insurance doesn't merely pool calamity. Health care is partly inevitable,and its magnitude partly controllable.

This will reshape both patient and provider behavior.
True cost transparency could be the most powerful reform of all—because it makes value visible.