Health Costs Part I: What No One Will Say in Washington This Week

I think a lot about costs in health care. Some might say an unhealthy amount.

I write about it some, too, though I tend to delete my posts after just a few days. How do you describe a complex set of competing interests, markets, and needs based on both cold, hard economics and the sticky warmth of life and death and do it in fewer than a 1000 words without offending uncles on Facebook? Besides oversimplification. Anyone? Anyone?

Ok, then. So today, like a good writer, I’m going to lead with a compelling story about a flawed individual that will hook you with his humanity while his actions point to compelling universal themes. Strap in.

Let me tell you about my kidney stones. Well, stone. If I start pluralizing my calcified torture rocks, the drama level won’t be sustainable.

Late last year, a few hours before I had to get on a plane for a work trip, I was woken by abdominal pain that quickly localized to my right side. A WebMD/Google search explosion followed, and I had soon diagnosed myself with having either:

1. Appendicitis (25% chance based on the radiation of my pain)
2. Kidney Stones, or Nephrolithiasis (40% chance for the same reason)
3. Flesh-Eating, Antibiotic Resistant Bacteria (35% chance because Google wouldn’t lead me to something like that if there weren’t a chance!)

Thanks to some great neighbors, my wife packed me up in the 2:30am chill and drove me away from my children, perhaps for the last time.

Ok, I was actually fine-ish. In fact, as we approached the Emergency Department (ED) and the pain began to diminish, I begin to brood in self-doubt. Was I blowing this out of proportion? Should I wait until the morning to go to a less-expensive Urgent Care or maybe even get around to finding that Primary Care provider my insurance kept prompting me to get? I even had my wife stop the car in a nearby parking lot so I could walk around and second guess myself. But after 5 minutes and no change in my pain, I got back in the car, and we checked in at the ED.

Which path would you have taken? — Photo cred

Why? Why did I choose the expensive care provided by an ED instead of waiting for a less expensive care option?

There are 3 reasons. And they can teach us a lot about why we spend so much on healthcare.

1. Fear. Even with diminishing pain, I had experienced a kind of pain that was wholly new and debilitating. I had no words for it, and I couldn’t explain it. My health, perhaps the most precious of my possessions, was under unknown threat. It could be nothing. It could be cancer. A possible threat to my existence was a perfectly natural catalyst towards the triage desk.
2. Moral Hazard. This means that I knew I wouldn’t be paying the full cost for my action and, as a result, I had much less of a constraint on my behavior. To be honest, I didn’t even know what my ED copay was when I checked in (trust me, it did turn out to be substantial), but the mere fact that I knew I wouldn’t be paying full price meant that my fear for life and bowels had a much wider-ranging canvas to play with.
3. Convenience. Closely linked to fear and moral hazard, I wanted care and answers now, not in 7 hours. My immediate gratification was possible, so why wait? I also knew (having worked with many EDs in my career), that my wait time at 2:30am would be negligible. There was even the possibility, if it wasn’t serious, that I could receive treatment and still be on my plane later that morning.

Fear, moral hazard, and convenience. I had the means provided me to make an economically selfish decision, and I made it. I gleefully accepted overpriced pain meds and Zofran. I lay back Zen-like and refreshed by $100 saline as the nurse making $45/hr (good for her!) wheeled me to the CT scanner where I had an absurdly expensive test performed so that the attending physician who shook my hand once (and charged my insurance a healthy premium for the privilege) could rule out worst-case scenarios and ensure that my distraught relatives wouldn’t sue him, the hospital, and one of his team of 3 residents in the event of my untimely demise.

I knew every detail of this before I checked in. I study this stuff every day! I work for health care systems. I knew the order of magnitude of these expenses. I did it anyway.

And so did (or will) you. It may be for yourself, your spouse, or your kids. But you will be faced with a situation in which you could choose an economically logical choice and an expensive long-shot or a costly convenience. I’m putting my money on you choosing the long-shot because, like me, you don’t want to die and (other people’s) money is no object when your little girl is limp and feverish or when you need care now so you can get back to closing that business deal or watching that soccer match.

We have a really easy time discussing health care in the abstract. Those other people need to stop abusing the system, especially the poor, black, or immigrant ones. Now turn down the TV a second so I can phone in my order for the brand-name prescription drug I demanded my physician prescribe instead of a generic because the brand’s TV commercial had happy people on it who were flirting with each other and playing with their dogs and NOT EVEN SWEATING!!

Fundamentally speaking, we are at the core of the problem with health care spending. We want the best for ourselves and our loved ones, and we want everyone else to get a referral first so we can get an appointment next week instead of next year. We want convenient and expensive care without having to pay the full bill. We want the faceless masses to shoulder the cost of our advantage. We want to be the ones who beat the system.

Problem is, we can’t all win if this is the game we’re playing. If we really care about health care costs as much as we say we do, we need to look in the mirror long and hard. Only then can we suit up and go lynch some pharma execs. So hurry up and look!

What I think you’ll find is that our behaviors and preferences are at the root of so many other costs that the politicians and press excoriate. Physicians order more tests because they know we think more is better. Pharma plays on our fears and need for the newest and best. EDs build more and more capacity to handle the influx of impatient patients. But blaming constituents for their own woes is bad politics. So don’t expect Bernie Sanders or Tom Price to come looking for you. Washington is content to rail at the boogeyman smokescreens instead of calling out potential voters.

The truth is that any new plan that seeks to fill the gaping void of where (likely) the Affordable Care Act aka Obamacare used to be has to wrestle with this difficulty. Obamacare opened the doors for everyone to do what I did last year. Some people call that an improvement. I’m inclined to agree with them most days. Speaker Paul Ryan’s love affair with Health Savings Accounts (HSAs) reserves that selfishness for the rich. Other people would say that’s the improvement we need.

So it’s time to ask yourselves: What does it mean when we say “health care is a right”? How far does that right extend? Where are you willing to make the trade-off between the cost and quality of your care? The care others receive? Is cost even the question we should be asking?

I’ll keep thinking and wrestling with this. I hope you will too. Now go call your congressperson.