A tale of two doctor's visits

One of the major problems with health care costs in America is that the insured consumer is insulated from the real cost of care. Health care providers take great offense when consumers ask how much care costs - and doctors choose not to know, even when the doctor himself/herself set the prices. Doctors act as if their work is too holy to be muddled with financial realities - but, the truth is, finances are a major part of health care. Finances are the reason many doctors become doctors (if doctors were not motivated by money, why are soooo many doctors going into the higher-paying specialty fields today, rather than going into primary care medicine? Why aren't more doctors taking advantage of government-sponsored debt forgiveness programs for primary-care doctors serving under served populations?). Finances are the reason many people "can't afford" * health care. Let's face it - in a money-based economy, finances are both currency and culture, a way of measuring things and a way of communicating the value we apply to things.

In a free market, consumers are free to choose how to spend limited finances. The "invisible hand" of the market is what happens when many peoples' choices aggregate - if lots of people value, say, a house very highly, the price of the house will rise to reflect all those consumers' choices. But the invisible hand relies on people making rational choices, and rational choices rely on clear and accurate information. Health care price information is not clear and accurate, and it is not readily available. If a consumer does not know that doctor A charges twice as much as doctor B, the consumer cannot make a rational choice to compare the relative value of the two options and choose the best value. We need to increase the clarity and availability of medical price information.

I changed insurance plans this year. Last year, I paid a flat co-pay for any service, and the insurance company paid the rest. No paperwork, no fuss - I thought it was more efficient. However, with no paperwork, I had no idea how much services cost. This year, I changed to a plan where my co-pay is a percent of total cost. It is actually cheaper than the flat-rate plan, and I finally know how much health care costs.

We had two doctor's visits this year - one to an Urgent Care clinic, and one to our regular doctor. Both doctors pay to rent an office, both pay malpractice, both pay a receptionist, a billing clerk, and an assistant or nurse. Both negotiate fees with insurance companies, and both participate in multiple insurance networks. Both doctors deal with uninsured patients and unpaid bills (although the Urgent Care clinic has more uninsured patients and deals with more unpaid bills). The only real difference in overhead is that the Urgent Care clinic is open 24 hours a day, 7 days a week - requiring 4 times as many staff hours as the doctor's practice, and more electricity, too.

My better half sliced open a finger a few months ago. It was an evening incident, and our doctor's office was closed. A doctor at the urgent care clinic looked at the finger, performed a quick exam, and directed a medical tech to clean and dress the wound. The bill was $80.

I pulled a shoulder muscle a couple months ago. I went to my regular doctor, who spent less than five minutes listening to my symptoms, diagnosed a pulled muscle, ignored all the symptoms of a pinched nerve, and wrote a prescription. My regular doctor is completely computerized, so she was able to pull up my chart, read it, and enter the visit notes right there in the exam room - she actually spent just minutes interacting with me. The bill was $120.

Last year, we visited the primary doctor and the Urgent Care clinic for two different situations. Honestly, the Urgent Care clinic provides better care. I simply assumed that the Urgent Care clinic was more expensive than my primary doctor. Now that I know better - and now that I know how unreasonably expensive my primary doctor is - I can make an economically rational decision about my health care spending. Oh, sure, the insurance company is paying the bulk of the cost, but they are, in effect, paying the bills with my money - if total expenses exceed what the insurance company has set aside to pay expenses, my insurance costs will rise next year.

* Some people truly can't afford health care. Some people "can't afford" health care - they have sufficient cash after paying basic expenses, but they value other things more highly. As an example, my SIL who died of something that is easily detectable and easily treatable - she "couldn't afford" health insurance because she "had" to pay for private school for her child, she "had" to pay for cigarettes, she "had" to go shopping for knick-knacks (and buy some) every week, she "had" to have supplies for her hobbies, she "had" to go out with her friends, she "had" to take her kid out to eat....

When I was 18, I couldn't afford health care. While living and working in Hawaii (yes, Hawaii - the state that Hillary Clinton held up as the model for universal health care, the Hawaii that requires employers to provide health care to their employees), I became ill. I had "aged out" of foster care, with no family to fall back on. My college went bankrupt, and I took the first job I could find to keep a roof over my head. I was poor. I had no health insurance. Without health care, I couldn't work to make money to save to pay for health care. In order to pay my health care expenses, I moved out of my apartment and became homeless for a while, as I saved money for health care. My employer, though required to provide health care to employees, did not offer me health insurance. As an 18 year-old, I didn't know any better. I could not afford health care.

So when I put quotes around "can't afford" health care, it is meant to reflect the full range of people claiming that health care is unaffordable - from the people who must choose between food, shelter, and health care, to people who choose to drive a BMW because it is a necessity, while foregoing health insurance because it is "too expensive." And you would do well to keep that distinction in mind when the inevitable Universal health care debates arise again. If health care is a necessity, then it should be paid along with other necessities (food, clothing, shelter) and before luxuries like cell phones, car payments, cable TV, etc. Before we give a family government help to pay for health care, we should make sure that health insurance is truly unaffordable for them, and not merely "unaffordable" in the face of life's many temptations.