Here's the sad truth: When Al was my patient in 1989, I had no idea what the medications I prescribed cost.

We never talked about money in medical school or during my five years as a surgical apprentice. If I were Donald Trump's apprentice, he would announce, "You're fired."

Medical costs are generated in the privacy of a doctor's office, yet neither doctor nor patient feels comfortable talking about money. Further, your employees don't have much reason to care, as they're spending someone else's money. Maybe even yours.

The health saving account (HSA), President Bush's proposed solution to rising health-care costs, offers your employees a reason to care. In broad strokes, employers fund an account from which employees pay for their medical costs -- the real medical costs instead of the co-pays and deductibles.

I'm optimistic about the power of HSAs to lower business health-care costs. The reason is simple. When your employees experience the consequences of their choices, they can and will make good decisions.

If my patient, Al, has a prescription drug plan, he exchanges a $15 co-pay for the medication, whether it's generic or the name brand. He has no reason to ask about cost, much less compare highly variable medication price tags from pharmacy to pharmacy.

If Al has an HSA, the account value is reduced by the amount he pays for the medication, and he has more money in the account when he purchases generic drugs at a pharmacy that offers low prices. Unused funds can be rolled over for the following years. This is a strong incentive to ask the doctor to prescribe generic medication and shop for the best price, with resultant reductions in health-care spending.

We need to make core systems changes to support the success of HSAs. As one student of the health-insurance industry said, "Asking consumers to 'drive their health plans' is like asking blind people to become NASCAR drivers."

It's virtually impossible to compare health-care costs. There are some legitimate reasons. Asking, "What will it cost to get my hernia repaired?" is like asking, "What will a two-week trip to France cost?" It depends on what kind of journey you make.

However, you can easily compare the costs for a 10-day cruise to Alaska on three different cruise lines. It's almost impossible to do the same with a medical procedure, and here's why. Health care, like any other business, is subject to antitrust regulation to avoid monopolies. This has created a veil of secrecy about professional medical fees.

When I set up my surgical practice in the pre-managed care era, I could not just go to a colleague and ask, "What do you charge to remove a gallbladder?" You can see the potential for this discussion to lead to price-fixing.

When I became a provider in a managed-care plan, my patients and I knew what my fee was and what their out-of-pocket expenses would be for a procedure like an appendectomy. If you called my office and asked, "How much is an appendectomy?", the answer would still be, "It depends," as my surgical fee varied by a factor of six, depending on the patient's insurance coverage.

We must shape policy so your employees and their doctors can talk about costs. We must also change the culture so your employees and their doctors will talk about costs. A recent study, published by The Journal of the American Medical Association, reports that most doctors and patients want to talk about costs, and very few engage in the discussion.

Quality is a critical consideration for the informed health-care consumer. The potential cost of poor medical care includes pain and disability, and even the premature loss of life. An employee with an HSA also experiences the financial consequences of poor quality care, as funds from the HSA pay for medical services that fix the problems created by sub-optimal care. Our crude tools to identify the doctors and hospitals with the best clinical outcomes and the most satisfied patients are rapidly evolving.

The early adapters of HSAs report business-cost savings. In a bigger picture, the systems changes that support the success of HSAs, including transparency of medical costs and availability of information about quality of care will in itself improve our health-care system. "Measure it and it improves" is a business truism.

Here's the best news about HSAs. It places responsibility for health-related choices firmly on the shoulders of your employees. It gives them a reason to care. They can and will make smart choices about health-care spending -- because they're spending their own money.

Who knows, maybe this will even be the driving force to make choices that promote health. The ounce of prevention may finally make sense -- and cents.

DR. VICKI RACKNER is president of Medical Bridges. She is a surgeon who left the operating room to help employees become active participants in their health care.