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

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.

The federal government website offers a tool that lists a range of data about hospitals, including what Medicare pays for a number of common procedures. Experts say that non-Medicare consumers can use those prices as a guide for negotiating a fair price, but expect to pay anywhere from 25% to 50% above the Medicare rate.

Free independent pricing sites, such as and, allow consumers to search for the average cost insurance companies pay for many inpatient and outpatient procedures in their area.

Insurers have gotten into the game as well. UnitedHealth, Aetna, Anthem, Cigna and others are offering online pricing tools for their members so that they can shop around for their care.

Consumers should keep in mind that venue makes a difference to your wallet, says Christopher Parks, founder of change:healthcare, a company that is working to make prices more transparent to consumers. A few rules of thumb: Surgery, imaging and lab tests are generally less expensive at freestanding centers than in the hospital. Sport and camp physicals at walk-in medical clinics are much cheaper than in the doctor’s office.

But sometimes going old-school is most effective, says Sandy Ageloff, health and group benefits leader with the consulting firm Towers Watson.

“The best thing to do is actually call providers and hospitals and ask about the price of a recommended procedure,” she says. “That’s often more effective and accurate than Internet resources might be.”

Zamosky has been writing about how to access and pay for healthcare for more than 10 years.

Got a healthcare dilemma? Email or write to Health 411, Los Angeles Times Health, 202 W. 1st St., Los Angeles, CA 90012.