Our healthcare system is unfair and unbalanced

About six weeks ago, while in clinic, I developed pain in my stomach — specifically, in my right upper quadrant, just below the ribs.  I had experienced this a few times before, but this time it seemed more persistent than usual.  Following the rule that physicians make the worst patients, I kept working through it until my nurse told me I looked poorly, and made me see my own primary care doc.  This led to an ultrasound that afternoon, a diagnosis of gallstones with mild acute cholecystitis (inflammation of the gallbladder).  I was in the surgeon’s office the next week, and in the OR a week after that.  Fortunately, I had an uncomplicated laparoscopic surgery, and was home within 24 hours.

Things are fine now.  I was back at work within a few days, and was fortunate to have received prompt and effective care.  However, I realize that my experiences are not typical.  I am a physician, and my primary care physician is one of my partners: I was seen the same day because I was part of the “family” of docs with whom I work.  The ultrasound was arranged two hours after my doc saw me.  My surgery was scheduled so quickly in part because someone else’s elective procedure was bumped to make room for me.  If I had been an average person calling my primary care doc for belly pain (or presenting to the ER with the same complaints) I doubt this process would have been this efficient.  I was fortunate to have privilege on my side: the privilege of being a healthcare professional, in his own system, knowledgeable about how to make the system work to my advantage.

This highlights the fact that our system is not fair.  Why should I get these special considerations?  Obviously, the easy answer is that I work in the health system where I received my care: much of what happened could be considered a form of professional courtesy where I was extended opportunities not available to patients not employed by the system.  But at the heart of health care, shouldn’t this sort of care be available to everyone?  Why should it be so difficult for an average, non-medical person to be treated in just this way?  Some systems (likely some of the top systems in the nation) work to make easy and prompt access available to all comers, but they are the exception to the rule.

We need to fix our system to make sure that meaningful, necessary, and prompt access will be available to all, whenever they need it.  The system needs to be truly patient-centered.

Over the course of the next few weeks, I began to get my explanation of benefits (EOB) forms from my insurance.  These EOB forms highlight how much the hospital charged, what my insurance wrote off (or “discounted”), and what I needed to pay.  I am unable to list the costs here due to our system’s insurance contracts, concerns about anti-competitive activities, etc. This is unfortunate, because they expose another area where our system is unfair and unbalanced: if you are uninsured, you will be expected to pay more than if you are insured.  This is because insurance companies negotiate with hospitals on their patients’ behalf, and reduce the costs for which patients are responsible.  If you are uninsured, and if you don’t know how to seek financial assistance, you pay the full (non-discounted cost) of your medical services.  That cost is usually set high enough to ensure your healthcare provider will get the maximum payment possible from insurers…so the uninsured face the full burden of this increased cost.

It is not unusual for insurance companies to negotiate deep discounts for medical services.  Discounts of up to 40% are not uncommon.  This means that if a hospital charges $1,000 for a given procedure, the insurance company will only be required to pay $600 of this–because they have negotiated a discount.  This $600 will then be shared by the insurance company and the patient, who might have a required co-pay or deductible.  If you are uninsured, you do not have access to this discount and you are responsible for the full $1,000.  The $1,000 price will be set because this is the level the hospital needs to set in order to recover all available payment.  Different hospitals and healthcare systems will have mechanisms for patient assistance, but this programs exist at the decision of the system, and levels of assistance will vary greatly.

So: if I were uninsured, I would be required to pay more than any insurance company pays … and my increased liability would be the result of other peoples’ insurance companies negotiating discounts for their patients.

This is crazy.  Why do we have healthcare systems that charge so much?  Because they feel they need to in order to be able to accommodate insurance companies’ demands for discounted services and still turn a profit–if systems charged the actual cost of the procedure, then they would take a “discount” on that amount and end up losing money.  Why do insurance companies expect/demand discounts?  Because it helps justify their existence: if that “discount” were the actual price people were charged, there might be less need for insurance.  Why was my co-pay a small fraction of the total charges?  Because I am fortunate to have really good insurance coverage.

Presumably people who lack health insurance lack it for a reason.  Most people who are uninsured are not doing so because they like to live on the edge or save money, but rather because they cannot afford it.  What rationale is there, then, to charge them 40% more than those who are insured?

If you have ever wondered whether healthcare costs are really that bad and whether they can bankrupt people, here is your answer.  This is a one-person survey (N=1, to use a medical inside joke), so I can’t claim these costs are representative of others’ experiences.  But, here in Richmond, if I was uninsured and did not have enough in savings to cover the bill, then I would be scrambling to find a way to pay this sudden medical debt.

It is unfair and unjust that people are exposed to back-breaking medical costs for illnesses that are beyond their control.  We can argue about the individual responsibility patients have for diabetes or high blood pressure, though I would suggest it is less than many claim.  But how much individual responsibility is present if someone has gallstones?  Appendicitis?  Retinal detachment?  Breast cancer?  Why does our system penalize the uninsured if they have the bad luck to actually get sick?

Our healthcare system is unfair and unbalanced.  Too many lack meaningful access and struggle to afford the care they can get, while a few have easy access and much lower costs.  We need to fix this broken and dysfunctional system.

Mark Ryan is a family physician who blogs at Life in Underserved Medicine.

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  • http://twitter.com/ButDocIHatePink Ann Silberman

    I had c-diff colitis and ended up in intensive care, with my colon on the line.  I was septic and on the verge of death.  My entire colon had pseudomembraneous colitis.  But, I survived, after 8 days in the hospital – barely.  I was sent home with a prescription for vancomycin, which is very difficult to fill.  After running to 4 pharmacies, we finally found one that had enough pills to tide me over until they could order more.  

    When the ten days for taking the antibiotic was up, I was still unable to walk, still had a belly that looked like I was 9 months pregnant and still very ill.  I was down to 90 pounds and couldn’t eat.  I had severe belly pain and still had mild diarrhea.   I didn’t know if I should get a refill (allowed) on my vancomycin and keep taking it or stop. I needed a follow-up appointment with an infectious disease specialist, which my insurance approved.  But, could I get one?  

    Nothing available until mid-January.Not even with the help of an insurance case manager would anybody see me earlier.Fortunately, I happen to have a friend who is a doctor.  It was only after she called me and I explained my situation was I able to get an appointment – for the next morning.  The doctor was quite concerned about my condition and requested a CT “STAT” for suspected abscess or perforation.  But could I get the results?  No.  The doctor went on vacation and nobody else would see me; it was “policy” in their practice.I have metastatic breast cancer as well, so I managed to get everything sent to my oncologist so at my next appointment with him I find out what was going on. Good news was that the colitis is resolving and I did not have a perforation or abscess as the doctor had thought.   If I had those things, where would I be now?I don’t know where the problem lies.  With the Christmas holiday? With the “office policy” that only one doctor can see a patient (although they have 40 doctors on staff?)  With the receptionist who didn’t understand the seriousness of my condition?  Had I not had a friend who was a physician, I still would not have had that follow-up appointment and I’d still be taking vancomycin and wondering if my colon would explode.  I am still waiting for that follow-up appointment, and I suspect I’ll never hear now.  I won’t be calling back.

    There is nothing wrong with professional courtesy but there is also nothing wrong with helping your patients in a timely manner.  I hope this experience helps you be a little swifter in seeing people and if you can’t, then for God’s sake, refer them to somebody who can.

    • http://twitter.com/RichmondDoc Mark Ryan

      I am sorry that you have had such difficulties accessing care.  As I noted in the article above, “We need to fix our system to make sure that meaningful, necessary, and
      prompt access will be available to all, whenever they need it.  The
      system needs to be truly patient-centered.”

      I use my experience to contrast with that of the average patient.  Our system needs to address this imbalance and make truly patient-centered care available for everyone.

  • http://warmsocks.wordpress.com/ WarmSocks

    Why is your system set up so that your treatment is so much different than what the average patient would receive?  If I call my family physician’s office and tell them I’m sick, I will be seen that same day – unless it is already 4:30 pm, in which case they’ll apologize that they can’t see me until the next day.  When I was referred to a surgeon, the surgeon’s office scheduled me to be seen promptly.  I had the option of surgery the following day, or waiting until the next week.

    My insurance company doesn’t say that I can’t disclose information, so if you’d like real numbers to illustrate just how much more the uninsured are charged, costs for my lap-chole: 

    Office visit to meet surgeon: billed $364, insurance allowed $270
      Hospital:  billed $30,248, insurance allowed $4,320
      Anesthesia: billed $1,040, insurance allowed $870
      Surgeon: billed $1,704, insurance allowed $1,275
      Radiology: billed $60, insurance allowed $32
      Pathology: billed $136, insurance allowed $91

    I agree with you 100% that there’s something wrong with a system that charges people who can’t afford insurance so much more than it charges insurance companies.

    • http://twitter.com/RichmondDoc Mark Ryan

      So, over $27,000 written off by your insurance company–that an uninsured patient would have been expected to pay.  A glaring imbalance.

      Re: your comments on access–our office tries to get people in to care as soon as we can.  But in settings where primary care doctors are in short supply (or if patients lack insurance), the quick path through care I experiences would be unlikely to be available for others.

  • Anonymous

    What a horrible article… Dr. Ryan spends his whining about “unfair” while having no problem taking advantage of his “special relationship/treatment” . Yes there’s a lot that’s unfair, but as this story proves, there are very few who practice what they preach. After ignoring his symptoms for who knows how long, Dr. Ryan then muscles his way to the front of the line and then blmes the system and not himself. Sir you are the system that allows such unfairness to exist.  You sound like my lawyer friends that protect the same “unfairness” in the legal profession…

    • http://twitter.com/RichmondDoc Mark Ryan

      Sorry you misunderstood.

      Is I wrote in the article, “We need to fix our system to make sure that meaningful, necessary, and
      prompt access will be available to all, whenever they need it.  The
      system needs to be truly patient-centered.”

      I attempted to contrast my experiences with that of many others.  I realize I was lucky and had access many others lack, and a truly patient-centered system would make my experience the standard, not the exception.

  • http://www.facebook.com/people/Mark-Ard/646302001 Mark Ard

    This is ridiculous. The discount is provided as a means of business to ensure more stable inflow of capital. If you choose to be part of the insurance group, you are absorbing the cost of overhead for the insurance company through premiums, along with your relative health compared to others covered. That, along with the discount, reflects your price of healthcare. You could, on the other hand, choose to pay for care yourself. It would be more expensive should you use it, but very cheap if you didn’t get sick. You take on more risk, and balance that with the higher cost to individuals compared to large buyers, and choose accordingly. Nowhere in there does the system look at anything but money. Money is fair. Empirically it means the same thing to everyone; it’s just that some value it more. In fact, fairness implies imbalance. The only way to balance the outcomes of a system whose composite parts are fundamentally different, i.e. individual human beings, is to treat each unfairly.

    Therefore, it is more important to focus on fairness, and let the balance be what it will. Fairness would be more open competition between insurance companies and removing forced, unprofitable operating rules such as equal premiums for unequally health customers. Fairness would be removing the tax credits to companies that insure their employees so that unemployed people could continue to afford their care. This does not mean removing discounts that insurers offer to employers, as that constitutes a free trade agreement as above between hospitals and insurers. Let’s bring back fairness and watch patients find for themselves the level of care that best fits what they can afford. I imagine it would be a lot better than what we have.

    People who look at economic inequality (in whatever specific form they argue) and decree that we as a society should intervene by normalizing the outcome are fundamentally proposing that we supplant freedom for need based social engineering.

    • natsera

      See my post above. The level of care that fits my need, and that I can afford, is death. Is that what you’re REALLY advocating?

      • http://warmsocks.wordpress.com/ WarmSocks

        I wouldn’t say that you have to die if you can’t afford your meds.  I would say that 1) we need to make the market force the cost of meds down, 2) you might need help adjusting your budget to see if maybe there’s money available that you don’t realize, or 3) you might need to get another job to bring in enough extra money to cover the cost of your meds.

        I’ve had people tell me that they don’t have any extra money, but when I sit down with them to look at where their money is going, we easily find ways to free up $300 every month.  What it boils down to is that they want to spend their money on luxuries, and that doesn’t leave extra unspent at the end of the month.

        That doesn’t mean you are one of those people.  Maybe you really don’t have any wiggle room in your budget  People are often happy to give a hand to those who are genuinely in need of assistance.  What people object to is a handout to those who squander what they already have and want someone else to bail them out. 

        Maybe your budget is perfect, but many people could change their spending habits and discover that their money could go much farther than it doees now. Money can be saved by switching to a basic voice-only cell plan instead of texting/internet smart-phone options. Money can be saved by going together with a friend and sharing a cell plan (second phone is $10 per month). Money can be saved by getting rid of a cell phone entirely. Money can be saved by using the public library for internet service. Money can be saved by not paying for dish/satelite/cable television. Money can be saved by cooking meals from scratch instead of using boxed mixes or eating in restaurants. Money can be saved by shopping the perimeter of the grocery store, instead of going up and down the aisles. Money can be saved by listening to free radio stations instead of subscription radio or buying cds/downloading to ipod/mp3 players (the cost of which is an additional luxury that can be foregone). Money can be saved by walking sometimes instead of driving everywhere. Money can be saved by owning a bicycle instead of a car. Money can be saved by using the public library instead of purchasing books/kindles/nooks/magazines. Money can be saved by shopping when things are on sale, and by purchasing things second-hand. Money can be saved by buying household items at estates sales and thrift stores and through craigslist instead of paying top dollar for brand new items. Money can be saved by buying generic lemon-lime soda pop at the grocery store instead of buying the name-brand equivalent out of a vending machine. Money can be saved by brewing coffee at home instead of buying a latte every day. Just a few ideas on where people can start looking for places to save money.

        • http://twitter.com/susanholly2 Susan Hancock

          This is the attitude that does a disservice to us all.  I am working 30 hours a week (the minimum to get health benefits), when my health and medical conditions (I have a genetic condition that was only recently diagnosed when I was 40 but spent years trying to get an answer so I could perhaps lead a fuller life and actually work) really don’t allow me to work more than 20 (so I have to stay home a lot to recover from overdoing) and you want me to go find another job to pay my medical bills?  This is nonsense.  We have had to declare bankruptcy 3 times because of medical bills.  My husband (who has his own chronic medical issues) lost his job and works freelance jobs (because that is all that he can find at the age of 55) that include writing and editing that REQUIRE us to have the cable/internet that you suggest we don’t need, but he wouldn’t be able to do his work without.  Financial assistance from providers only goes so far.  Since we are insured and do make some money, the local hospital provides no assistance whatsoever.  We have provided all our income and expenses (primarily medical, BTW) and they apologize, allege that we are unique, wish that they could help us, but we are out of luck.

          I am so sick of this attitude that all we need to do is work more or rework our budget.  Bottom line = our income does not meet our medical expenses and it is not for lack of trying to make it work.  I could stop getting the medical care altogether, but then I would be unable to work altogether, which is what I had to do for a few years.  Maybe you would prefer that we both try to get on disability (which frankly I find to be a joke) and not work at all.

          Please stop blaming the victim.  I am doing the best I can.  Really.

  • Michal Haran

    From my personal experience physicians do not receive better treatment when they become ill, although they do receive different treatment. 
    A private healthcare system has many flaws and this is only one of them. A public health care system has other flaws. I don’t think anyone has yet found the optimal solution. 
    I think it is important that we, as physicians, will be aware of the various flaws in our specific system and try to protect our patients as much as possible from being victims of those shortcomings. 
    In general, in most modern medicine systems, patients that have a clear-cut problem that nicely fits the “book” and responds to commonly used treatment will get much better and timely care than those that don’t. 
    In general those who have more money and power, will get better bargains than those that don’t. The health care system is only one such example, but there are many more. 

  • Anonymous

    I think that you are wrong when you say this about the insured vs the uninsured.  The system is very unfair to both parties.  Most nonprofit hospital systems give those same discounts to uninsured patients.  The overall bill may be $1000 but it can be negotiated down by the patient.  The insurance companies, not the hospitals are the culprits.  Most hospitals by law have to care for the uninsured whether they want to or not. The hospitals can charge whatever they want to insurance companies.  The insurance companies determine how much they are going to pay them just like they do providers.  So, if I were a hospital administrator or CEO, I would negotiate on a set price or discounted price as well & yes, I would charge more just to get that discounted $$ high enough to help meet my bottom line.  This would allow me to continue safely caring for the uninsured who I know will not be able to afford the costs of their care.
    And just because you are insured doesn’t lower your overall healthcare spending.  First of all, you pay a monthly premium for insurance whether you use it or not.  The uninsured don’t pay and usually can’t afford to pay premiums.  Yes, you are fortunate to have a great insurance where your deductible may have been only a fraction of your total cost.  What if you have a high deductible?  above that $600?  You would be responsible for the total cost of the procedure plus your usual monthly premium.  If you are fortunate to have good health, there would be no further need for use of your insurance.  So, let’s see….we will assume you pay about $200/month in premiums and your deductible is $500.  For the year, you pay $2400 and for this procedure, you end up paying $500 more.  A total cost of $2700 in health expense.  The person without insurance in the same position will pay $1000 for the year possibly less depending on whether or not its negotiated down.  See, it really doesn’t matter, we all end up paying more than what is fair.  There needs to be one Universal health insurance plan that everyone pays into run by folks who don’t make quarterly profits.  The government should not have anything to do with this plan.  So who would be in charge of running this company?  The people should vote in each state a few representatives to not only keep up with the financial aspects of this company but also bring and compare health statistics in their respective states.  Sounds complicated I know but I can’t imagine that it is more complicated than what the system is already.

    • http://warmsocks.wordpress.com/ WarmSocks

      1) You say that a person’s being uninsured doesn’t lower his/her overall healthcare spending.  Not necessarily true. My dad lost his job and had no insurance. One basic rule of decent behavior is that you don’t incur debts you can’t pay, so being without income and insurance, my dad didn’t see his doctor for a few years.  Even when he had a heart attack, he didn’t get help because he didn’t see any point in leaving my mom with a huge hospital bill to be paid off.  If no insurance = no healthcare, then spending is lower.

      2) You’re proposing a different way to try to fix insurance, and have an admittedly complicated theory on how to make it work.  There’s no need for a complicated system.  How about the radical idea of making it simpler.  We don’t need to fix insurance.  We need to eliminate it.  Return to patients directly contracting with physicians for their services. Doctors would be able to care for patients instead of being paranoid about jumping through all the insurance documentation/coding hoops.  No expense of employing coders and billing clerks. No expense of paying a pre-auth nurse.  No multiple layers of administrators overseeing the hoop jumping.  No government employees living off taxpayer dollars to track the taxpayer dollars that go toward people’s healthcare.  Fewer employees making healthcare more expensive.  Less taxes needed out of our paychecks.  Return the focus to doctors/nurses and their patients.  Of course this won’t fly because too many people think they’re entitled to have someone else pay for their care.  Some say that it’s unfair that one person gets care and another doesn’t. Guess what?  Life’s not fair. There will always be some who get care and some who don’t. Without a 3rd party payer, people who want to see a doctor will determine whether they believe that it’s something worth spending money on. It would be the person affected who’d self-ration instead of some heartless bureaucrat. Hospitals and doctors would lower their prices, because patients would demand clear prices up-front and shop around for the best value for their dollar.  Hospitals and doctors could afford to lower their prices because they’d be able to eliminate a significant amount of overhead.  It’ll never happen, but I can dream.

      (fwiw, your sample numbers seem to be a bit dated. When my policy renewed, the insurance premium went up to roughly $1200 per month with a $1500 deductible.  Signficantly higher than your example)

      • http://www.facebook.com/people/Mark-Ard/646302001 Mark Ard

        Insurance is not simply “someone else paying for your care.” It is cooperative agreement among individuals to take on risk instead of direct debt. Part of paying for that risk is employing an insurance company, which in turn must deal with the physicians. Your solution is right in a sense though, in that prices need to be disassociated from arbitrary standards set by government that insurance companies then adhere to. Remove Medicare and let individuals (or insurance companies representing a cooperation of individuals) negotiate prices. Let the purchase of medicine be founded on quality and affordability, not the lowest common denominator that a social system seeks.

      • natsera

        Warm Socks said: Of course this won’t fly because too many people think they’re entitled
        to have someone else pay for their care.  Some say that it’s unfair that
        one person gets care and another doesn’t. Guess what?  Life’s not
        fair. There will always be some who get care and some who don’t.
        Without a 3rd party payer, people who want to see a doctor will
        determine whether they believe that it’s something worth spending money
        on. It would be the person affected who’d self-ration instead of some
        heartless bureaucrat.

        But there’s a LOT wrong with this statement. First off, no one with any sense is walking around saying they’re ENTITLED to have someone else pay for their care. It’s more like house or car insurance — you pay the premium and hope to H*** that you don’t get hit. But if you do, you have a safety net. Health is the same thing. No one CHOOSES to get sick — it’s darn unpleasant! So you pay your premium and hope to H*** you don’t get sick.

        As far as some people getting care and some not, well isn’t THAT a nice, virtuous democratic, caring stance to take! It’s easy to say that when you are lucky enough not to have a chronic disease. Take away my insulin (at over $100 per vial) and I’ll die. You’re totally OK with that because it’s not you, but what if it was? This is not a case of self-rationing, or believing that treatment is something worth spending money for. This is a matter of life and death. Are you saying that your life is worth more than mine, because you were lucky enough not to get a chronic, treatable disease that is NOT my fault? Your argument is the height of selfishness, and I hope you never see the other side of the picture.

        • http://warmsocks.wordpress.com/ WarmSocks

          “..no one with any sense is walking around saying they’re
          ENTITLED to have someone else pay for their care

          I might grant you that, if you’ll grant me that there a lot of people
          walking around without any sense ;) 

          Take Steve, who was working and pounded a nail through his finger. He went
          to the hospital emergency room for a tetanus shot. Two weeks later, Steve
          violated many safety rules while using a saw, and consequently cut his finger.
          He returned to the emergency room to have some stitches put in. Both of those
          things could have been handled in a doctor’s office for much less money, but
          Steve doesn’t have a family physician. Steve would have to pay his own bills if
          he saw a doctor in a clinic, so he gets all his care though the ER because the
          hospital accepts Medicaid. Since Steve qualifies for Medicaid, he thinks he’s
          entitled to have someone else pay for his care. 

          Take Jessica, who took her two children to the hospital emergency room when
          they had runny noses. She was sent home with instructions to keep the kids
          comfortable, and see their pediatrician if they got worse. The next day she
          took the kids to the pediatrician, who wouldn’t write a prescription for
          antibiotics to treat the kids’ colds. Jessica then took her kids back to the
          ER, where she was told that the kids would be fine and she should take them
          home, give them plenty of fluids, and let them rest. The next day she took her
          kids to the ER athird time, saying that now the kids were
          coughing. The doctor told her that they had an upper respiratory infection,
          which made her think that her kids had some horrible infection and she was
          right to keep going back to the ER. When she told me this story, I said, “You
          must be on state aid. Only welfare mothers take their kids to the ER for a
          cold. A URI is a cold . Why would you think it is acceptable
          to use taxpayer money to run up thousands of dollars of medical bills for a
          couple of colds that will go away on their own?” I was right; she was on
          welfare, and would never dream of going to the doctor for a cold if she had to
          pay for it herself. 

          Take all the pregnant women who come to the U.S. from Mexico, knowing that
          they can have their babies here without having to pay. The fact that they don’t
          pay doesn’t make their care free. Someone else pays. 

          Go volunteer in a hospital emergency room and see if you still think there
          aren’t a whole lotta folks who think they’re entitled to have someone else pay
          for their medical care. They might not have much sense, but that doesn’t mean
          they don’t think they’re entitled, and it doesn’t mean it’s not costing our
          taxpayers a ton of money.

          (sorry – edited to delete duplicate copy of comment)

        • http://warmsocks.wordpress.com/ WarmSocks

          You are mistaken in thinking that I’ve been lucky enough to not get a chronic disease that is NOT my fault. Cash price on my prescriptions is roughly $2800 per month. Without those meds I’m in excruciating pain and would probably already have disfigured hands and feet, be confined to a wheelchair, and have a much higher risk of heart disease. With the meds, the pain is usually tolerable instead of excruciating, and it will (hopefully) take many years until I need a wheelchair.

          I understand about expensive meds.  Without insurance to pick up a large portion of the cost, pharmaceutical companies would find a way to get their medications on the market at a price patients could afford. Right now they have little incentive to do so, and patients often don’t realize the cost of their meds. Without insurance, patients would be much more aware of treatment options and associated costs.

          Without insurance bureacracy, doctors would be able to lower their fees because they would not have to pay people to jump through insurance hoops. I
          believe that the price tag on obtaining medical care would be lower if we had a
          self-pay system instead of the current system.

          In a 100% self-pay system, it would cost less to obtain medical care and get
          treatment for diseases. Your $100 insulin would cost less, and so would my
          $2800 meds. You would set your own priorities and decide how to best spend your money, and so would I.

          As for diabetes medicine purchases being a case of self-rationing, I think
          that’s a great example. If patients paid out-of-pocket, they would evaluate
          their treatment options and choices very carefully. My mother is a skinny
          type-1 diabetic whose treatment choices include publicly acting as if she is
          extremely careful about her diet so all her friends think she is well-controlled, but privately munching on chocolate chip cookies and then taking extra insulin to try to counteract that decision. She must not always calculate correctly, since she’s had two DKA hospital admissions. She insists that her doctor says she is well-controlled, but when we ask her what her A1C is, she won’t tell us (knowing my mom, this means she is not well-controlled but doesn’t want to admit it). If she knew that the extra insulin she takes to handle her cookie/cake/pie splurges would cost her extra $$, and that she would owe tons of money for the cost of her hospital admissions caused by her dietary decisions, she would eat differently. Instead, medicare picks up most of the expense; her cost is minimal. She doesn’t self-ration because the financial cost isn’t hers to bear.

          Even type 1′s can benefit from exercise, but my mother (and many other diabetics)does not exercise because it’s easier to just take the insulin than
          modify her lifestyle. Without insurance, she would be much more discerning in
          her choices. Self-rationing here would look like someone having the healthiest
          possible lifestyle to need the lowest possible amount of insulin.

          My father was a type-2 diabetic. He did self-ration his care. I happen to disagree with his choices, but they were his choices to make, not mine. He could have been in much better health if he’d lost weight and been careful about his food choices. Instead, he ate so much that when he died, the grocery bill was cut in half. That would be reasonable if there were only two people eating, but when there are six people in the house, one of them shouldn’t have been eating half the food. He had a heart attack. He knew the signs of a heart attack but did not get medical help. Instead, he phoned his parents, his siblings, and his children for one last conversation (not cluing anyone in to that’s what was going on). A week later he had another heart attack – which he did not survive. Twice he chose not to seek help when he knew he was having a heart attack. He died. This is a perfect example of self-rationing.

          Everyone dies sometimes.  Sometimes it’s due to bad luck, and sometimes it’s due to choices we make (including the choice not to spend money for medical care). Family and friends are sad when someone dies, but nobody lives forever.  If you think it’s uncaring to state the truth, well… that doesn’t make it less true.

  • William Dawson

    Good to hear another voice of rational. I heard Rick Santorum speak 2 days ago in NH. He gave the same, tired lecture about individual responsibility—that is such a small part of the problem.  And if one were to blame the rest of us for our medical problems (in my case, presbyopia, loose calcium crystals in the ears, MVP, irritable gall bladder, BPH, aching joints) we would all be going around with a case of undeserved guilt. Which brings me to the co-pay and deductible: what is the rationale for those?!  To encourage me to take better care of myself or to stop going to the doctor needlessly? As tho i want to go to him at all.  If it is to help pay for my share, it is a pittance; why not make it 50%? Now that would help the insurance companies stay in business and stop me from using the system so much!

  • Anonymous

    Hospitals set the over the counter prices high for negotiating strategy. Doesn’t sound better that you received a 40% discount off the MSRP versus only 10%. Let’s be realistic, hospitals know where the bulk of their income is generated along with losses. The higher prices also reflect the high loss ratios and expense incurred when trying to collect from a person who had no insurance.

  • Anonymous

    My local hospital in Schenectady, New York advertises on their website “our streamlined triage & registration process reduced average time to getting into an exam room in just 14 minutes.” I recently was transported there by Emergency Services and then waited for 3 1/2 hours before being examined by a physician. They have large poster size adverisements in every one of my doctors’ offices extolling  their excellent care. The hospital was recently awarded a $100,000 grant to continue their advancement stratiegies. It would seem that to hire an additional doctor to serve in the  emergency room would have been more beneficial to patients. In any case after my 3 continuous months in   3 hospitals this past summer I  am permanently disabled so I have had time to review my dozens of EOB documents. Thank goodness for the fact that I had my children  to act as my patient advocate. If they hadn’t hadn’t challenged all of the initial rejections from my insurance company I would be just ashes in a jar on the mantle. The percentage that is paid to the hospital from my insurance carrier differs from decent to minimal. I have had to pay co pays and co-insurance. Actually I am still paying since they do offer a payment plan. I almost felt sorry for the hospital until I saw that the lack of insurance reimbursement hasn’t hurt their advertising. The trips bi-weekly to check my Coumadin levels probably weren’t so bad after all since the Pradaxa didn’t work out.

  • Anonymous

    Thank you. We need Medicare for all with the government as the single payer. We all pay in as part of our taxes. I would much rather pay for healthcare for all than for bombs, wars and bailing out banks to big to fail. If we band together, everyone in this country, we can get better rates from big Pharma and no more ridiculous overhead and no millionaire health insurance CEO’s. Think of how much better the care would be if we unloaded these blood suckers who take their cut first. Without health you have nothing. It behooves us as a country to insure that everyone has healthcare in order to be better tax paying citizens.

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