Peter Glickman, MD, Do No Harm Productions, LLC. Follow us on Facebook at The Open Healthcare Project!
Continuing from Part 1…
WHACKED FACT #6: HEALTH CARE IS DIFFERENT from other businesses. This is because unlike just about any other business, the consumer in healthcare cannot possibly have complete information, or even anything close to complete information, before making a purchase. When you buy a car or a computer, you research the car and similar models, and you may even price-shop at different dealers. Eventually you get to a point where you feel like you have enough information to make an intelligent choice, and you go to a seller and buy what you’ve decided is a good deal. Moreover, if problems develop with the car, you often have a warrantee to cover any defects, and if problems still persist, you’ll tell all your friends not to buy that car, or maybe write a bad online review, and eventually the car will go off the market if it’s bad enough.
Now contrast this with health care. Say you come down with horrible belly pain, and you go to a doctor who performs an exam and some tests, and determines you have acute appendicitis. You need an operation ASAP or you can die. Do you have any opportunity to review the surgeons or hospitals where you might go before making a choice? Of course not. You’ll go where your doctor tells you to go. Hopefully your doctor really knows where to send you. Even so, every hospital has many surgeons, some of whom are going to be better than others, and you have no control over which surgeon is on call when your case comes in. Now, in truth, an appendectomy (the procedure to take out your appendix) is a relatively simple operation, and any general surgeon working at a hospital should be competent to perform one. But even in this simple case, it’s more complicated than just which surgeon you get. Some hospitals have higher rates of infections acquired in the hospital than others. Some infection rates are published by the government based on Medicare data, but no patient or doctor in their right mind is going to hesitate long about sending you one hospital over another if your appendix is about to burst.
Now imagine if the disease you have is not something familiar like appendicitis, but something you’ve probably never heard of, like cholangiocarcinoma. It’s simply impossible for a consumer to have anywhere near the amount of information they’d need to make an informed choice. There are many differences in surgeons, centers, chemotherapies, nursing care, home care support etc., some of which are unimportant but some of which are critical. It’s even hard for doctors and researchers to figure out the best place to send you for a particular serious condition sometimes. For these reasons, i.e. what economists call the “inelasticity of demand” and the lack of transparent information, comparison shopping is practically impossible. Prices are therefore allowed to persist at very high levels in some places, even without any demonstrated added value. The cost of procedures therefore become arbitrary, and you’re just gonna end up getting charged whatever the rate the place you end up charges. This is not even taking account how whacked the insurance side of how we pay for health care gets. This leads us right to our next whacked fact…
WHACKED FACT #7: NOBODY can tell you how much a medical or surgical treatment is going to cost you before you get it. That’s right, NOBODY. Not the doctor, not the hospital, not even your insurance company. You might be tempted to assume this is because the system is set up just to rack up profits, but there is a more innocent explanation. It’s because the system is set up to DELIVER CARE, sometimes urgently, not predict costs to patients. That’s one thing our system gets right, and something not always available in countries with fewer resources. More often than not, NOBODY CAN PREDICT exactly what a particular patient will need before care is commenced, even if all of the cost information was easily available. You may go in for a simple gallbladder removal operation, and the surgeon may find something unexpected like a tumor or an infection, and need to do a much bigger procedure than anyone thought. Now unlike the auto mechanic, who can stop and call you to tell you the job is bigger than the original estimate, you’re obviously unconscious in the operating room, and of course there’s no time to stop and let someone know. Moreover it would be malpractice for the surgeon not to treat a serious problem right there and then. In this case, you’re gonna end up with a much bigger bill than you might have anticipated. Now if you’ve got decent insurance, that shouldn’t be a huge issue…BUT, stay tuned for the next whacked fact…
WHACKED FACT #8: DIFFERENT INSURANCE PLANS ARE VERY DIFFERENT in terms of the important details of coverage and cost. This is not exactly a revelation to most people nowadays, although there was a time not to long ago when not many people were aware of this. Even now, people are mostly aware only of the vaguest of generalities about insurance plans, such as the amount of the deductible, whether or not you need a referral for specialty care, etc. There are important details that you’ll only discover if you’re unlucky enough to need to, such as that your plan only covers 10 outpatient mental health visits and only after you’ve paid for 20 out of pocket, whereas another insurance plan with the same premium might cover the first 10 only. Or your out of pocket per hospital day is in the thousands. Depending on how much care you need, these details might mean the difference between affording it and bankruptcy. Again, comparison shopping, in this case for health insurance, is truly impossible in any meaningful sense for the consumer. Now, there are health care navigators for programs like Medicare or the ACA, who are employed by the government to help beneficiaries choose, and they often do a very good job. But even they cannot keep track of all the details, and patients are surprised by their out of pocket bills far more often than not. And if you get your insurance through your employer, good luck even having much of a choice about any of the important details in the policy or policies offered. Employers however, DO have access to high priced reports from consultants that can provide estimates of the value of different plans (another cottage industry spawned by our profit-driven system). But these reports are out of reach for the typical consumer.
Please continue to Part 3 for the conclusion of this list…https://medium.com/@donoharmushealthcare/whacked-facts-about-health-care-part-3-4142864dcf04
5. Mahar, Maggie. Money Driven Medicine, Harper Collins ebooks, 2006.
6. Potter, Wendell. Deadly Spin: An Insurance Company Insider Speaks Out on How Corporate PR is Killing Health Care and Deceiving Americans, Bloomsbury Press, 2009.