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When advance directives are not honored, and how to get data on medical prices

June 13, 2011|By Lisa Zamosky, Special to the Los Angeles Times
  • If something goes wrong ? say you have an adverse reaction to the anesthesia ? it's useful for the doctors to have a certain degree of flexibility to correct the error.
If something goes wrong ? say you have an adverse reaction to the anesthesia… (Joseph Daniel Fiedler /…)

When I checked into a surgical center recently for a procedure that required general anesthesia, I presented my advance healthcare directive. But as I read over the consent form for the surgery, I noticed one of the provisions advised me that the surgical center had chosen "not to honor" these directives.

Can a healthcare provider choose to ignore an advance directive? If so, what use are the directives?

A healthcare provider can decline to honor an advance directive, and during surgery it's common for hospitals and surgery centers to do so as a matter of policy, says Doris E. Hawks, an attorney who chairs the bioethics committee of the Santa Clara County Medical Assn. When it comes to advance directives, laws in every state allow for "conscientious objection," which can be based on religious or ethical beliefs or medical standards.

Practically speaking, why would doctors refuse to comply with your directive during surgery? If something goes wrong — say you have an adverse reaction to the anesthesia — it's useful for the doctors to have a certain degree of flexibility to correct the error.

"Providers want to do everything possible to make sure the surgery is successful," says Charles Sabatino, director of the American Bar Assn.'s Commission on Law and Aging.

That doesn't mean the directives are a waste of time, however. Quite the contrary: Suspension of your advance directive should be time-limited. "You would go into surgery and the advance directive would be suspended," Hawks explains. "But once out of surgery, it would immediately be back in effect." Consumers should inquire about the exact time frame of the suspension.

Once the suspension is over, it's critical that your medical wishes are documented and known by your doctors. It's also critical that you've named someone close to you who will act as your "agent" (the term used in California) or "proxy" to make healthcare decisions for you if you're unable to do so for yourself.

If a provider refuses to honor your advance directive, most states require that it make a reasonable effort to transfer you to another provider that's willing to honor your wishes. "If you don't like their policy, call around," Hawks says. She adds, however, that most providers won't be willing to comply with an advance directive during surgery, especially for a generally healthy individual.

For more information about advance directives, visit the American Bar Assn. at

I've tried to get copies of the fee schedules that health insurance companies and Medicare pay to providers, but the physicians' offices always say they cannot release that information. It would be great if all those fees were made available online so people without insurance would have a starting point for negotiation. It would be like having the dealer invoice price for an automobile.

You're not the only one who thinks so — new websites and public databases are being created to make prices more available to consumers. But unless your employer or insurance company offers a comparison pricing tool, the best you can hope for is a ballpark figure to use as a starting point for negotiation with your healthcare provider, experts say.

In more than 30 states, hospitals are required to report common charges and reimbursement rates online. Check with your state's hospital association at (look for the "Health Leader Links" under the "Resource Center" tab, then click on "State Associations"). To find links to state sites offering cost information, also check (click on the "Cost, Prices, Health Insurance and Medicare Coverage" link).

In California, you can find average hospital prices for inpatient care as well as average charges for the 25 most common outpatient procedures at the website for the Office of Statewide Health Planning and Development, To get prices for common surgeries, go to Hospitals are required to submit these prices to the state each year. Just be aware that this information has its limits.

It's well known that the prices hospitals submit to regulators have no real connection to the actual costs of care, says Laurie Sobel, senior attorney at Consumers Union, the nonprofit publisher of Consumer Reports magazine. "It's like the sticker price of a car. Nobody pays that."

Jan Emerson-Shea, vice president of external affairs for the California Hospital Assn., agrees with Sobel's assessment of the hospital charges listed online but says that using the state's website to get a price range for the 25 top outpatient procedures and surgeries may be useful.

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