My Health Care Car

Years ago I had a position that required a fair amount of traveling. My employer provided me with a car and paid for all gas and repairs. I received a new car every two years or 60,000 miles, whichever came first.

An acquaintance in a similar position who had to drive his own car and was reimbursed for mileage objected to my generous arrangement on principle. “You take better care of a car when you own it and pay for it yourself,” he said smugly. “It’s easier to abuse something when you’re not invested in it.”

I thought of his remark recently after undergoing major surgery and not paying a cent of it myself. I saw the summaries from Medicare and my supplemental plan, and I waited for someone to bill me for my share, but it never came. In fact, ever since being on Medicare I’ve paid for nothing out-of-pocket except medications. I thought one prescription cost too much and asked my doctor if there was something less expensive but just as effective. It turned out there was – but I had to ask for it.

Supposedly in this new era of patient-centered medical homes and accountable care organizations, the patient – not the provider – will be the center of attention. We’ll pay for outcomes, not procedures; coordinated teams will help us take our meds, watch our diet, get regular check-ups, monitor our vital signs at home, and keep us tethered to an electronic and real-time communications network where accurate information is handy and transparent, and we are fully engaged “partners” with our team in making healthy decisions.

Good luck with that, especially in a system where someone other than the patient continues to select the plan and pick up the majority of the tab. Truth be told, most Americans with comprehensive public or private health insurance like what they’re getting now: decent access to care with bearable out-of-pocket costs. Even when comparative information on quality and cost is available, the majority of patients don’t bother to check it. They trust their doctors, they accept the providers in their plan, and they are rarely motivated to “shop” for value. Getting them engaged in using the health care system more effectively and efficiently is going to require much more than enrolling them in a medical home.

The use of tools and techniques to inform and motivate patients is all well and good, but when it comes to real motivation, nothing works quite so well as money: the financial consequences of both paying and not paying attention. For example, being able to significantly reduce your insurance premiums by enrolling in a wellness program and meeting certain health benchmarks is a step in the right direction, but we could do much more. Moving to a system where the patient is responsible for paying his or her outpatient bill for most care and then is reimbursed in whole or part by the health plan would presumably motivate one to inquire into such things as price, value and options. There are millions of people who lack the resources to pay their health care bills – that’s why we need a robust safety net system – but there are millions more who do have the resources and would pay closer attention to what they were getting if they had to write an initial check for it.

At an appointment some months ago with a specialist to discuss a follow-up preventive procedure to my surgery, he advised me to take advantage of Propofol, an anesthetic that requires an anesthesiologist to administer it, as compared to a previous occasion where he administered Versed, and I became conscious during the procedure.

“I’m sure it’s great,” I said. “But it will be more expensive to have an anesthesiologist there. Is it worth it?”

“Sure,” he said. “But don’t worry. The British Health Service is paying for all of it.”

We laughed, but we both knew what the issue was. Cost wasn’t a factor to either him or me. He ordered it, I received it, and Medicare paid for it – admittedly at rates most doctors believe are too low.

Would I have chosen to have Propofol administered if I had to pay the extra charge myself? I don’t know, but surely I would have inquired further into the cost-benefit equation and perhaps saved both myself and the government a few bucks.

As it stands, the government is buying me a decent health care car to drive, and I don’t have to pay for the gas or maintenance. Until the patient has more financial skin in the game and full access to what’s under the hood in order to determine value, rearranging the seats won’t change a thing.

Feedback? Send it my way: Roger.Hughes@slhi.org.

*The Drift reflects the views of the author, and does not represent the official view of SLHI’s Board of Trustees and staff.