Mike the Mad Biologist

Let’s just say that throwing up between 1am and 5am the week you have to prepare for a scientific conference (ASM) is, well, suboptimal. Anyway, I’m fine (thanks for asking), but Tuesday I had plenty of time to think about this NY Times article about the increase in healthcare deductibles (the amount of money you have to pay out of pocket before your healthcare kicks in):

But Dr. King said patients were also being more thoughtful about their needs. Fewer are asking for an MRI as soon as they have a bad headache. “People are realizing that this is my money, even if I’m not writing a check,” he said.

For someone like Shannon Hardin of California, whose hours at a grocery store have been erratic, there is simply no spare cash to see the doctor when she isn’t feeling well or to get the $350 dental crowns she has been putting off since last year. Even with insurance, she said, “I can’t afford to use it.” Delaying care could keep utilization rates for insurers low through the rest of the year, according to Charles Boorady, an analyst for Credit Suisse. “The big question is whether it is going to stay weak or bounce back,” he said. “Nobody knows.”

Significant increases in how much people have to pay for their medical care may prevent a solid rebound. In recent years, many employers have sharply reduced benefits, while raising deductibles and co-payments so people have to reach deeper into their pockets.

In 2010, about 10 percent of people covered by their employer had a deductible of at least $2,000, according to the Kaiser Family Foundation, a nonprofit research group, compared with just 5 percent of covered workers in 2008.

Doctors, for one, say patients’ attitudes are changing. “Because it’s from Dollar 1 to Dollar 2,000, they are being really conscious of how they spend their money,” said Dr. James Applegate, a family physician in Grand Rapids, Mich. For example, patients question the need for annual blood work.

High deductibles also can be daunting. David Welch, a nurse in California whose policy has a $4,000 deductible, said he was surprised to realize he had delayed going to the dermatologist, even though he had a history of skin cancer.

While this no doubt encourages people to buy perfectly fine generics instead of brand names and skip unnecessary tests, it’s also forcing people to forgo medical attention they need.

Which brings us back to my vomit–don’t worry, I’m not going to get gross and tell you what color it was or anything like that.

Anyway, vomiting. It’s pretty clear that I had some kind of food poisoning, combined with a naturally peptic stomach I’ve had since I was a kid, along with a bad previous night of sleep, as well as not eating what I usually eat. Basically, everything that could break wrong, did break wrong (well, I suppose I could have been shot in the face or something). And for most of those four hours, the most disconcerting thing wasn’t the vomiting–and this is from a person who absolutely hates throwing up–it was the uncontrollable shivering. I don’t mean goose bumps and feeling cold, I mean the kind of bodywracking convulsions that hurt and make you feel sore (and I keep reasonably fit). Getting sentences out–the ‘subject-verb’ kind of sentences–and walking the eight feet to my bathroom was difficult. Fortunately, after the second time I got sick, the symptoms went away (I guess I got rid of everything–actually, not much guessing is involved…).

But I had decided that if the symptoms didn’t go away after a couple more hours, that I was going to the emergency room. For all I knew, it would have meant a very serious infection (or other problem), or it simply could have been infection-related dehydration (this has happened to me before), and I would leave the ER the same day. Either way, the last thing I needed to be thinking about was the fucking deductible. Suffice it to say, keeping my basic shit together was pretty taxing by itself–and if someone had been around (relative, etc.), I doubt he or she would have been making ‘objective’ medical decisions either–in fact, I very well might have been convinced to go to the ER sooner, rather than give it a few hours (I have no idea if I was being stupid by waiting a few more hours). And in my case, I’m fortunate that the Iron Law of Increasing Income applies: as your income increases, you’re less likely to get nickeled and dimed–or two thousand ‘dollared.’

I understand the need to cut down on unnecessary spending–and many plans’ ‘unnecessary’ ER deductibles are low, especially in the People’s Republic of Massachusetts–low for me, anyway*. But for some people, they can’t even afford a $100-$200 deductible. That is what poverty means. This ‘efficiency’ is going to get people killed.

*In Virginia, where I grew up, the ER deductibles are much higher, especially if the ER trip is deemed unnecessary.

Comments

#1 Mary
May 20, 2011

I had a thought process on my deductible last year that insurers might not anticipate. Mine is kinda high, but I can swing it (MA Bronze level plan). But last year I wanted to have a procedure done. It was relatively expensive (involving a bit of surgery). But because I knew I was going to rack that up, I did a whole bunch of additional stuff that I might have otherwise spaced out over time into that year. I figured once I met the deductible it was time to keep going.

The barrier that causes it to be put off can also work the other way. Once you jump the barrier you might as well pile it on….
#2 Russell
May 20, 2011

My condolences. Food poisoning is miserable.

But it seems to me that you’ve ducked a hard issue. The problem with “everything is (almost) covered from dollar one” is precisely that it does encourage excess utilization. Given our medical delivery system where patient choice plays a large role, and physician income depends on those choices. There is a health cost as well as financial cost to that. Medical attention is risky, and America health in general may suffer from excess treatment as well as under treatment. (For different patients and different circumstances.)

Changing that requires either changing the delivery system, which doesn’t seem likely any time soon, or putting a bit more financial burden on patients in making those choices. Cost will have to be controlled in the future. One way or the other.
#3 Vene
May 20, 2011

I love how hard this is for us to figure out when the rest of the 1st world has done so long ago. Oh well, it may not matter anyway, what with the debt ceiling issue. Who knows, maybe it will push us out of the first world.
#4 Ross
May 20, 2011

Here’s the deal. I like televisions. I like computers. If money weren’t an issue, I’d get a lot of televisions and computers, more than I’d ever need.

No matter how cheap they are, I am not going to suddenly decide to get a whole bunch of unnecessary prostate exams.

People are not, in general, going to *choose* to have unnecessary medical intervention. They may be *mistaken* about whether intervention is necessary, but they are not going to go out and say “Well, as long as it’s free, g’head and stick that camera up there.”

I may be incorrect from time to time — even frequently — in determining whether or not to seek medical attention. This is because *I am not a medical doctor*. Using the price tag to “encourage” me to choose correctly is, in essence, fining me for *not being a doctor*.
#5 Russell
May 20, 2011

Ross, I partly agree with you. People don’t run out to get medical care because it is a fun thing to do. They typically go when they have a problem. But once in the system, it can be tempting to believe “more is better,” when your physician is offering you more. And it is tempting for the physician to believe “more is better” because he is selling his product. If you doubt that happens, read this:

http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande
#6 Mike
May 20, 2011

When I was a grad student at Ohio State University, I could go to the clinic for no charge. I went about once week for numerous trivial things. I had sore knees checked, I had my callouses on my feet checked, allergies, etc. These are things that if I had to pay, i would not have gone. But it was free and it was convenient so I told myself it was better to get it checked out just in case it was not something minor.
#7 Always Curious
May 20, 2011

I recall a study being bandied about on NPR a few months back where insurers had done a study and discovered that raising deductibles wasn’t always a sure way to increase health savings for exactly the reasons listed above: routine checkups/visits are put off until a more expensive, sometimes preventable, health emergency appears.

My next two-bits: we cannot expect to bring about reasonable change to the cost of health care until there is a price tag available for every procedure. Even if your insurance covers 90% of the cost, there is no way a patient can make a financially informed decision if they have no clue what it costs to visit Dr. Joe to have Procedure X. Or that Procedure Y and Procedure Z both solve the problem but one costs 5X more than the other. And this price tag should be invariant between patients. Different people might have different coverages, but insured patients should NOT immediately get a 10-20% discount off what uninsured patients pay.

And lastly, health care needs to be better accessible at times that make sense. Why do people go to emergency rooms so often? They may not know of any other options (and in more remote places, there may not be many alternative options for care). If someone’s usual doctor is booked solid for the next two days or it’s the middle of the night or a weekend, and the patient wants/needs care the usual answer is: head for the emergency room. Insurance companies (and health care providers and government to some extents), could create incentives to have doctors’ offices open during the night or on weekends; incentives to open urgent care facilities; publicize advice nurse lines; and do basic health education (not every complaint is an emergency).
#8 Yasemin Unlu
May 22, 2011

When I was a grad student at Ohio State University, I could go to the clinic for no charge. I went about once week for numerous trivial things. I had sore knees checked, I had my callouses on my feet checked, allergies, etc. These are things that if I had to pay, i would not have gone. But it was free and it was convenient so I told myself it was better to get it checked out just in case it was not something minor.
Turk Yasemin Ünlü