M y patient asked. “I don’t have insurance and will have to pay out of pocket, is the CT scan absolutely necessary?” Several different thoughts go through my head. Is it necessary? There’s no way of knowing until the CT is read. Old school doctors used to make due with far less technology, using their powers of observation to diagnose complex illnesses, but they also used to taste urine and all too often found the cause of a malady on the dissection table. But these are my people.
I grew up without health insurance. I went to a doctor just a few times while growing up. Most of those times were when my parents worked for a company that had offered health insurance. The rest of the time, unless I was coughing up blood or had some other worrisome sign, I could stay home and sleep it off. Vomiting all day? My prescription was a trash can, saltine crackers, Gatorade and maybe some Sprite…or likely some off brand. Some people would be horrified by this, but they aren’t the type of people that live close to the poverty line and avoid government assistance like the plague.
T ruly I want to answer my patients when they ask. I know they may go into debt any time they visit the ER. People have died because they felt they couldn’t afford their healthcare. Many others have been put in financial jeopardy by medical bills. We push the idea of informed consent, even allowing people to leave AMA when they should receive life-saving treatment, because when push comes to shove, the patient has the right of autonomy. But this goes out the window when it comes to patient finances.
W e’ve all heard the adage about price, “If you have to ask, you can’t afford it.” Imagine going to a restaurant and being given a menu. You’re hungry and you have several options to be satiated, but you would like to get the most bang for your buck. Sadly, there are no prices on the menu. You ask the waiter, but he replies “You’ll have to wait for the bill.” You figure you’ll stick with something basic, because something basic couldn’t cost that much. After ordering a baked potato and some ice water, you still are hungry, but are worried about the bill. You hurry to the register, hoping to get it over with and see some guy with a stack of take-out boxes so loaded with lobster that the lids won’t close. Curious, you listen for the total. “That will be on the house. Thanks for visiting, come again!” The cashier says and then starts ringing up your total. “That’ll be $97.53.” “Maybe I should have had the lobster.” You mutter, as you stare at your wallet. “Oh, yeah, that could have cost $10,000, but we also give it away. It all depends on a host of factors that we can’t disclose.”
I was looking over a medical bill recently, after deciding to write on this subject and found some curious things. Now that I work at a hospital with good insurance, my cost of healthcare is minuscule. From being the guy with the baked potato, I am basically the guy with lobster. My insurance company paid only 57% of the bill. Sounds like I would have been in a bit of a pickle, but my insurance company received a discount that covered 42% of the bill. I only paid around 1%. In fact, the larger the bill, the smaller my share would be. Understandably there are limits, but they are far beyond what the cash paying patient could afford, unless they are independently wealthy. Patient billing is, sadly, a complex system. Government is willing to pay a certain amount and no more. Insurance companies sell insurance, so they actually work to keep prices high, but negotiate a lower actual price for their customers.
A s a patient advocate, I could use the basic numbers from my bill or hearsay from others to give ballpark prices for care. “Yeah, so each injection will likely cost you a couple hundred and if you can avoid a drip, you’re probably going to save a few hundred and that CT is going to cost you like 400 ounces of silver.” But, those numbers are pretty much meaningless. On the one hand, there is a cash discount, if my patient can pay in cash. On the other hand, if they go into debt, they are likely going to pay far more; in interest, late fees, and other intangibles.
I ’ve worked at several hospitals in the U.S. and none of them offered a price list to customers. On the other hand, I volunteered in Tanzania and was shocked that they had price lists up for patients coming to the hospital to see, right there at the entrance! Because of the nature of our system, we can’t exactly post actual numbers, because of the plethora of different levels of coverage, but it seems like we could make it easier for our patients to know the cost of their care and be able to make fully informed decisions.
C ustomers drive the market, in most markets. Healthcare is a seller’s market and patients often feel like they have no choices except to receive, delay, or decline care. A more transparent system with cheaper alternatives being offered as part of expected care would drive the market in the patient’s favor. Isn’t that our ethical responsibility? Aren’t we expected to advocate for our patients?
* Dr. Tom McDonald in his blog “Hey Doc” entitled Hungry Patient
*Here is a great video where a guy tries to figure out how much it will cost for his wife to give birth.
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