If you have to ask, you can't afford it

A couple of months ago, I appeared at the capitol in support of a bill to create a "patient bill of rights" for people in Maine. (Its primary sponsor is my representative, who also happens to live down the street from me. One of the nice things about living in a small state like Maine is that you can get to know the people who make your laws.) Much of the bill pertains to insurance carriers, and to increasing transparency in what different plans will cover and what they won't. An addition provision in the bill, if I recall correctly, would mandate that patients be informed of the cost of procedures and tests before they are provided so as to allow them to make better decisions about what they can afford. (Rep. Treat's statement when she introduced the bill did not make mention of this provision, but I recall it from the press materials that were distributed at the time.)

While I was standing on the big staircase in the Hall of Flags listening to people holding forth on their experiences of being hornswoggled by the insurance industry, I mused about how ignorant I am about the costs of healthcare. Every so often I will get a call from a parent saying that some medication is not covered by their health insurance, and I am staggered by how much the price is. (In those situations, we try to find a less expensive option.) And, when it comes to the price of blood tests or x-rays, I am wholly ignorant.

All of this came back to mind when I read this article (via Washington Monthly)
about the uninsured leaving emergency rooms because they fear the costs of tests and other interventions, often deferring recommended care at significant risk.
In hindsight, maybe Jesse Ashlock shouldn’t have walked out of the New York emergency room last summer, only a couple hours after being knocked unconscious in a Brooklyn bicycle crash.

Medical crews told him he needed a blood test, chest X-rays and probably a CT scan to check for head injuries. And he certainly should have had treatment for major road rash, including raw scrapes on his face, neck and hands.

But the 31-year-old editor for a design magazine was between jobs, briefly without health insurance and afraid of being stuck with a sky-high hospital bill. The doctor on duty dismissed Ashlock’s questions about cost, telling him she was “a physician, not an accountant,” he said.

I don't know that I would have used that particular turn of phrase. (Bad bedside manner, random ER doc! No biscuit!) But the truth is, I would have been in no better a position to discuss the costs of the recommended tests than she was. Perhaps I am egregiously ignorant by comparison to other doctors, but I really don't think so. We're not taught this kind of thing in medical school (at least I wasn't), and we don't see the price when we order a lab test or x-ray. I have an innate antipathy toward ordering unnecessary tests on principle, but this has as much to do with not wasting time gleaning useless information as it does with cost.

I was also reminded of a study published recently that was authored by a good friend of mine, in which she found that the uninsured are not responsible for the shared costs of emergency care. From a Newsweek interview she gave:
NEWSWEEK: You looked at some common assumptions about why emergency rooms are so crowded. A lot of them turned out to be untrue. What were these myths, and how did people come to believe in them?

Manya Newton: First, there was a belief that the uninsured are all coming to the emergency department for non-urgent care. That's a tricky one to talk about, because there's no good definition of what "non-urgent care" is—if you have a big cut on your face, or if your baby has a fever and it's one in the morning, that is coded as "non-urgent" by doctors even though it's urgent to you. But when people talk about crowded ERs and the uninsured coming in for "non-urgent care," they're thinking about things like the sniffles, or the back pain these people have had for 11 years. And if you actually look at the uninsured, they're not coming in for sniffles or back pain, because they're the only group that bears the full cost of an ER visit. Yes, a $50 co-pay is painful, but a $5,000 bill is really painful.

So they actually come to the ER less often than people with insurance do?
Yes. They're underrepresented in ERs compared to the overall population—17 percent of people in our country are uninsured, but they account for somewhere between ten and 15 percent of visits to the ER. When they do come in, they tend to put it off until the last possible moment, until they're really sick. So it's not the uninsured who are causing crowding. It's everybody.

This is also consistent with my experience regarding who tends to over-utilize office visits. People who are self-pay (or who have high deductable plans) tend to avoid coming in if they can help it, whereas people who pay nothing for the visits are apt to come in "just in case" for minor complaints. Even though I am a proponent of universal health care, I must concede that this last phenomenon is something that will need to be dealt with. While we obviously don't want people to defer needed care, neither do we want people to be completely divorced from the cost of their care, to the point that they opt for visits or treatments they could easily have skipped.

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