Attempting to alter the health care marketplace so provider decisions are based on patient value has shaped my career for the last 20 years. Often use of the health care delivery system creates a learning opportunity for me as well as the poor, unsuspecting provider of care. A recent experience was instructive.
A close encounter with a jungle rock while mountain biking sent my husband back to our cruise ship with a deep gash on his shin. Our ship’s doctor cleaned it, stitched it and sent him to our room with antibiotic cream. Two days later, with red streaks around the wound and swelling puffing up around his stitches, his foot and ankle looked like a balloon with toes. A day of oral antibiotics followed by a few rounds of IV antibiotics on the ship got us to the end of the cruise and back to the states, but things still looked bad.
Landing near midnight, we headed straight for the ER for a dose of American medicine. Efficient service quickly led to a very pleasant doctor assessing the situation. “Yes” she said, “That’s definitely infected. Let’s start by getting an ultrasound.” “Why,” we asked, “Would we get an ultrasound?” She replied that we had just taken a long plane ride and it could be a blood clot. We said, “It looked exactly like this before we got on the plane. We have a $5000 deductible and really would prefer not to spend $300-400 for an ultrasound if it can be avoided.” She said, “I’m sure it would cost a lot more than that!” and agreed that we could proceed without it.
Then she said, “Well, let’s get him admitted.” We asked why he needed to be admitted since they could clean up the wound and get him an IV antibiotic right there in the ER. She said they would watch him overnight to make sure he was doing all right. Having some idea of exactly how much he would be watched after midnight on a weekend, we suggested that since we lived 10 minutes away I would watch him and rush him back if things went south. She agreed that we seemed like responsible people who could be trusted to come back if necessary.
The next step was to remove the stitches and clean the wound. This was going to be quite painful and the doctor said they had a new pain med that works really well. Then, finally catching on, she looked back and said, “On second thought, we can just add some morphine to his IV. That will work and it’s a lot less expensive.”
An hour later, armed with 4 prescriptions we headed home. We filled the oral antibiotic ($16 at a local pharmacy) but skipped the antibiotic ointment (we already had this from the boat) and the Vicodin and Naproxsyn since OTC ibuprofen was managing the pain.
The wound slowly healed and all is well with the injury, but certainly not with our health care system. We got great customer service, but how many thousands of dollars would have spent on this one event absent a few probing questions? How many millions of similar episodes occur every day across the country? Even for insured, middle class families, spending thousands out of pocket on a health care episode crowds out other needs, say a down payment on a car, a sizeable chunk of college tuition, or worse, the next few month’s rent or mortgage payments.
Yet how many patients have the background and temperament to ask challenging questions, especially in the midst of a health crisis? Certainly, for the doctor all the incentives point in the direction of more care. A well-intentioned desire to be thorough combines with fear of malpractice and the fee for service system where erring on the side of doing more results in greater revenues for the care providers.
Patients can’t solve this, even if they are armed with “skin in the game” and a handful of quality and cost measures. It has to be treating physicians and their teams who consider and discuss with patients the cost/value tradeoffs of their care recommendations. I believe most doctors would be sincerely concerned about the implications their recommendations have on their patients’ financial health if they really understood what these expenditures meant to them. Hopefully, this particular ER doc now has an altered perspective.