Health care spending: Let’s talk

Posted Dec. 01, 2008, at 6:45 p.m.

Drunken sailors cannot hold a candle to physicians when it comes to spending money. Come to my office, get a few blood tests and a gallbladder ultrasound ordered, have an EKG, and the total bill could be $500. A new titanium hip courtesy of your orthopedic surgeon could cost $25,000 or more.

In the good old days of medicine this did not seem to matter much because your insurance company paid most of these bills. Now, however, if I order a $1,000 MRI scan of your head to make sure your brain does not contain a tumor (and reassure your spouse that your head contains a brain), you are paying at least $100 if your co-pay is 10 percent, and perhaps all of the bill if you have a deductible you have not yet reached.

When I recently ordered about $200 in blood tests on a patient of mine, I did not realize that money was coming right out of his pocket (and probably right out from under his Christmas tree). When he called about the costs, I remembered a little late that with patients paying more of their own medical bills, they rightfully expect me to help them spend that money wisely.

And they are going to need a lot of help. Increases in co-pays and deductibles have been one of the principle ways American employers have responded to rapidly rising health insurance costs for employees. The pocketbook of the average American patient is therefore being ravaged by those costs to a far greater extent than has ever been the case in the past, and the impact has been dramatic:

In 2007, 41 percent of working-age adult Americans — 71 million people — reported a problem paying medical bills or accumulated debt because of medical expenses. That was up from 58 million in 2005.

Thirty-six percent of American families earning between $40,000 and $60,000 spent more than one-tenth of their incomes on medical care in 2007. That percent has doubled since 2001.

Twenty percent of patients with advanced cancer delayed or missed needed care because of costs, according to a 2006 study in the medical journal Cancer.

A quarter of American women postponed or went without medical care they thought they needed in 2005, according to a study published in the British Medical Journal.

The hot seat of helping patients spend their own money on health care in a way that avoids waste has many providers accepting the job, but squirming for good reasons. Most importantly, health care providers do not want to make a mistake in your care just because we worried about the cost. Inevitably, however, as millions of patients and providers try to spend less money on testing and treatments, mistakes will be made and the patient’s health may pay for that mistake. Cancers may be missed, or diagnosed late. (It should also be noted that some complications will also be avoided because tests or procedures were not done.)

Another dilemma: What happens when I want to spend more of your money on tests to help reduce the risk that you will sue me for missing some hidden problem you might have? This is the common practice of “defensive medicine,” and it potentially puts you and me at cross purposes in discussions about whether the test is necessary. You might object to me spending your money to cover my butt, and rightly so, but I object to you suing me if I miss something. How do we resolve that? Would you waive your right to sue me in order for me to spend less of your deductible dollars on defensive medicine?

Finally, no insurance company is paying me for the time necessary to have a good discussion with the patient about spending his or her health care dollars wisely, even though such a conversation might save lots of money. That time comes out of our time talking about some other health issue you have, or is added on to my already long day.

Despite all of this, it’s high time patients and health care providers all started talking frequently about the money being spent on the patient’s care. This elephant has been in the exam room with us for a long time and can no longer be ignored, because now, more than ever, it is sitting directly on the patient.

Erik Steele, D.O., a physician in Bangor, is chief medical officer of Eastern Maine Healthcare Systems and is on the staff of several hospital emergency rooms in the region.

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