Wednesday, May 29, 2013

A Little Bit of Controversial Rumination

So... I'm not talking about gardens, or flowers, or hiking, or home improvement projects. Or even the most recent scrumptious meal the philosopher has created. I'm going to rant - just a little - about health care.

Back when Obamacare was about to get passed, I read an interesting article about Whole Foods Market and their approach to employee health care in the Wall Street Journal, written by Whole Foods CEO John Mackey.   A couple of things caught my eye: they have two companion plans that most everyone uses: a high deductible catastrophic coverage plan plus a well-funded health savings account.  That forces employees to think hard about the choices they make when deciding on health care options.  (This article from the Harvard Business Review talks about their other health care initiatives that go along with these two main plans.)

I admit I was dubious about Obamacare, and it looks like my concerns are well-founded.  (But actually, I'm not going to rant about that, not directly, anyway.)  So I read this article today written by Walter Russell Mead, talking about the *wildly* variant pricing for the same procedures at hospitals around the country - or even hospitals in the same state!

Now, my two readers know that I have several chronic illnesses, and I do spend a good bit of time in doctors' offices and labs.  After I read the Mead article, I thought about the appointment I had this past Tuesday.  My primary care doc had referred me to a specialist due to an abnormal reading.  It turned out to be nothing - a common "blip" for women my age - but he wanted me to have a couple of baseline imaging tests done so if anything changes over the years we'll have a "normal-for-me" scan to make a comparison.

So, you might think that an HSA-plus-catastrophic-coverage plan would not be the way I'd want to go.  I benefit a lot from the free or almost free stuff I get through my conventional HMO.  Paying out-of-pocket for my several prescriptions (including insulin which doesn't have a generic equivalent - but that's a rant for another day, those darned biologics!!!) plus my every-three-month doctor visits would eat up an even well-funded HSA in a hurry.  But it would also make me think harder - and more importantly, ask my doctor more questions - about recommended tests.    Do I need both an echocardiogram AND an aortic ultrasound just to run a baseline for heart rhythms?  Do I need to see a specialist every three months for diabetes, or can my primary doc cover things unless something goes wrong?  Do I need to take a prescription drug if ibuprofen will do the same thing?

I already ask a lot of these questions, and have made decisions accordingly.  (yes, no, no)  But if I were paying out of pocket for prescriptions too, I might *also* ask: Do I need to go to a lab and pay $50 or more for an A1C test, or can I buy one of those new off-the-shelf versions for $20? Can I use a cheap glucometer, or are the name-brand ones that much better? 

So why don't more people ask these questions?  Certainly Obamacare isn't going to encourage folks to ask questions about cost.  If we give people more control over their medical dollars (with a fall-back plan for major events/issues) two things would happen.

1) People would know and understand more about their health and their health care.  They would talk to their doctor more and have more input into what happens.  And they would spend less.

2) Doctors and hospitals and labs would start to be competitive on pricing.  If someone can choose any doc they want, they're going to look for a good physician of course, but also someone who has reasonable office visit pricing. Think Angies's List, or Kudzu, or any of those other sites where people can review businesses and the service industries! We can't really use those sites now because we have to look for in-network docs, or docs affiliated with a particular hospital. If we could, we'd find a doc who got great reviews, and had pricing we're willing to pay.  If someone can choose where to buy their medicine or have labwork done, they're going to look for the lowest pricing (labs and medicines are the same wherever you go!)

All that would reduce costs.  And that would be a good thing, even if it meant that I had to kick in more dollars for my health care.  Because I think I agree with Walter Mead:

What’s becoming clearer and clearer is that the US health care system is more distorted, less transparent, more dysfunctional, and packed with more perverse incentives than most people realized. Right now, it’s about as far from a functioning market as it can be. If we fix health care, all our other policy problems get easier. If we don’t, we’re going to go totally broke in a few decades.


J said...

Another effect, and not such a good one, is that some/many people's health would drop if people were forced to make more decisions. (typical economics disclaimer of "all other things held even" which wouldn't actually be the case)

As weird as it sounds, I've seen enough studies that all confirm that even when it comes to serious health decisions, people are ... "lazy" is a term. We virtually always take the easiest short-term path, especially when the benefits aren't obvious and immediate.

Doctor strongly recommends some tests because of some difficulty with using the bathroom? It costs $500? He doesn't know that something is wrong? Well, I'll pass since I'm feeling fine, and it might be nothing. I'll start eating more fiber and less meat. That'll fix it and it won't cost $500.

That said, there are a bunch of positive effects that would result in forcing people to make more careful decisions about their healthcare, and I think they would significantly outweigh the negatives.

Susanna King said...

Actually, one beneficial side effect of Obamacare so far is that more of this pricing information is becoming available. The main reason a lot of people don't ask the questions you do is because they don't know who to ask and/or when they do ask, they can't find an answer.

I think we really need to make pricing more transparent so that people can take control of their health care. Better data won't solve every problem, but it can get us part of the way there.