Q. Do you have or know of a post on the best practices for minimizing costs of health care services?
A.
This question came in via Twitter, and after a snarky comment about how impossible that would be to do in 140 characters, I promised to write the post. I then promptly wrote a sweet 2300 word post that completely disappeared when I hit save. So after throwing a few things across the room and screaming a few times, I sat back down to write it all again. This happens to me about once a year. The good news for you, dear reader, is the second iteration is always better written than the first.
This is actually a pet topic of mine and one I have considered turning into a third career at some point in the future. There are also excellent blogs on the topic, such as Costs of Care, although they're generally focused on the macroeconomic consequences and not the microeconomic issues I was asked about. Macroeconomically speaking, the main problem with health care costs is that we pretend we have a market-based health care economy, but don't actually have a working market in place. A working market requires both price transparency and skin in the game. The first doesn't exist for almost anyone or anything and the second isn't applicable for the vast majority of Americans who have the majority of their health care costs paid by government or an employer.
As one of the few who pays every dollar of their health care costs, whether through insurance premiums or deductibles/co-insurance, I'm all too aware of the problems inherent in the system. Luckily, my family has been blessed with extraordinarily good health and we've always been able to maintain insurance coverage for potential catastrophes (which we haven't had yet), so we've been able to avoid any health-related financial pitfalls. But given my work in the ED and in the financial lives of thousands of high-income professionals, I've definitely got some great tips to reduce your own health care costs. So let's ignore the politics and macroeconomic issues and focus on what you, Joe Consumer, can do to reduce your health care costs.
Consume Less Care
Health care, like financial advice, is expensive stuff. The less of it you need to consume, the better off you will be. No matter how efficient we make our system, or how the system is paid for, it's going to eat up a large part of our economy and your budget. That's because it is a highly-valued, high-liability service provided 24/7/365 by highly-educated providers using expensive technology. Does any of that sound cheap to you? So any crazy idea you may have that health care shouldn't be a major percentage in the budget of a middle-class American needs to be taken into the corner and have an anvil dropped on it. If you really want to save money on health care, consume less of it. There are three main ways you can do this.
# 1 Live a Healthy Lifestyle
While there are plenty of medical problems that cannot be prevented, there are many that can be. Don't drink alcohol, but if you must, do so in moderation. Don't smoke. Don't use drugs recreationally, even if prescribed by a physician. Exercise regularly. Maintain a healthy weight. Don't eat crappy food. Spend time, but not too much time, in the sun. Don't work night shifts–they're the equivalent of a cardiac risk factor. Maintain healthy relationships. Seek help for suicidal ideation BEFORE a suicide attempt. Practice safe sex and use contraception. Wear a helmet and other protective gear. Wear a life jacket. Learn to swim. Don't drive a motorcycle. Choose a career that won't wear out your back or joints. Don't play football. Lock firearms up, if you must own them at all. Get your immunizations. Prevent what can be prevented.
# 2 Understand Number Needed to Treat
This one concept of evidence-based medicine could save our entire health care system. The number needed to treat (NNT) is the number of a people who must undergo a test or a treatment in order to help one of them. Its corollary, number needed to harm (NNH) is also quite useful. If you are under the misunderstanding that the NNT for most medical tests and treatments is 1, and the NNH is infinite, you are sorely mistaken. When you understand the NNT and NNH of the various tests and treatments offered to you, you can make a rational economic decision about their merits.
For example, consider the NNT of antibiotics for bronchitis. It turns out they don't cure bronchitis, but if you treat six people with antibiotics, one of them that would have had a cough at the follow-up visit will no longer have that. So NNT = 6 in that regard. The NNH? 37, due to adverse effects of the antibiotic.
What about an aspirin for a major heart attack? Everyone knows to chew an aspirin as soon as you start having chest pain, right? Well, what's the NNT? It turns out to be 42. NNH? 167.
Now aspirin is cheap, so no big deal if we have to pass out 42 of them to save one life. But what about something more expensive, like Copaxone, used to prevent flare-ups of MS. What's the NNT? It's 8. But Copaxone costs >$6,000 per month. $6,000 * 8 * 12 = $576K. So now your choice is to either avoid one MS flare a year, or buy a fancy new house every year. If you were paying for that drug yourself (and actually had the means to do so) chances are good you might pass on buying it once you knew the NNT wasn't 1.
How about antibiotics for conjunctivitis? Even in culture-proven bacterial conjunctivitis (most of it is viral), the NNT is 7. Priced out ophthalmic antibiotics lately? Vigamoxx costs $142 for the tiniest bottle you've ever seen, and that doesn't include the cost of the ED or ophthalmologist visit.
Zofran for pediatric gastroenteritis? NNT = 5
Blood pressure meds to prevent stroke? NNT = 67 (NNH = 10)
Antibiotics for ear infections? NNT = 16 (NNH = 9)
Notice that none of these numbers 2 or 3, much less 1. The bottom line is that a great deal of medicine doesn't work at all and even much of what is considered “standard treatment” doesn't work all that well. When you know the NNT/NNH, you can make much wiser economic decisions about how much of your hard-earned income to spend on health care.
# 3 Delay, Delay, Delay
Just like any major financial purchase, delaying expensive medical care allows you to save up more money and shop around for the best price. But there is an added bonus. Thanks to the remarkable ability of our bodies to heal themselves, you will often find that delayed medical care won't need to be done at all.
Obtain Free Care
There is a great deal of medical care that can be obtained for free. For the lower socioeconomic class, this might involve going to a homeless, charity, or sliding scale clinic. For the upper socioeconomic class, it might involve going to call on your neighbor who just happens to be a doctor or physical therapist or PA for a curbside consult. I can't tell you how many of the neighbor kids I've sutured up on my kitchen table. A great deal of medical care is just providing education and reassurance. A surprising amount of information is available from Dr. Google, although extreme care is required in this regard. A class in first aid or basic physiology can pay great dividends.
For the physician readers, we can provide much of the medical care our family needs ourselves. Now I think it's important to only be doing “no-brainer” treatments and stay within your scope of expertise, but I've done lacerations, I&Ds, fracture care, and plenty of ear infections. I don't try to treat my wife's hypothyroidism or my dad's rotator cuff tear, but I certainly provided the (expensive) initial ER treatment for my wife's corneal ulcer before ensuring (inexpensive) next-day follow-up care with an ophthalmologist. Plus a doctor is far more likely to know when something actually needs care and when it doesn't.
You may also be able to take advantage of professional courtesy, which I never expect but often receive. Just be sure you're offering it to your colleagues as much as possible! For example, our group routinely writes off the physician portion of the ED bill for members of our medical staff and other referring doctors.
Have Someone Else Pay For Your Health Care
Almost as good as free care is having someone else pay for it. This might mean signing up for Medicaid, CHIP or other government programs. It means signing up for Medicare at 65 and taking advantage of any Tricare of VA benefits you may qualify for. It might also mean staying on your parents' health insurance until you're 26.
It doesn't, however, mean stealing health care from hospitals and doctors by not paying your bills. Not only is this unethical, but it usually results in your credit score being trashed and collection agencies hounding you for years. You are far better off asking for a cash/hardship discount and setting up a payment plan in that sort of a situation.
Another way to have someone else pay for your healthcare is to take a job with an employer who pays all or part of your health care premiums. They might also fund a Health Savings Account (HSA), Health Reimbursement Arrangement (HRA), or a Flexible Spending Account (FSA.) Take advantage! Health care is expensive stuff. Between our health insurance and HSA contributions, our family spends about $20K a year on health care. Even knocking $5-10K off of that is a huge raise.
Discuss Cost With Your Provider
Here is one of the most important ways to reduce your health care costs–actually talk to your doctor or other health care provider about the costs of care. Let her know that you'd like to keep costs down as much as is safe. Ask whether a test is really necessary or whether it can safely be delayed. Ask if there is a cheaper drug that will be about as good. If you can't afford a prescription, tell your doctor, don't just not fill it. There's often a drug that costs 1/10th as much and works about as well, although there may be more side effects or a less convenient schedule. Carry a copy of the Wal-mart $4 list and ask your doctor if any of those drugs would work for your problem. If prescribed a spray, injection, inhaler, or liquid, ask if a pill would work just as well (pills are almost always cheaper.) Tell your doctor frequently that you're not going to sue her and that you understand that she doesn't have a working crystal ball and that you'll come back or call if there is any problem, especially if it would help you to possibly avoid some additional expenses.
If you're being transferred to another hospital, ask if it is safe for you to go in a private vehicle instead of an ambulance. If an MRI is recommended, ask if a CT would be adequate. CT recommended? Ask about an ultrasound or even a plain x-ray. Go over your medication list at every visit and ask if you can come off any drugs. Ask your pharmacist if there is a cheaper alternative drug or a generic and have them check with your physician about substituting it. Doctor recommending admission to the hospital? Find out if it will be an observation admission or a true admission and what that means for your insurance plan. Can you just hang out in the ED for 6 hours and get a stress test as an outpatient instead of being admitted? Do you really need both a colonoscopy and an endoscopy? Can you get them done at the same time and would that save you any money? Had a dozen normal pap smears and in a monogamous relationship? Do you really need another pap? Find out the costs as much as you can and actually talk about them with your doctor. I'm amazed how rare these conversations are and even when I bring them up, many patients don't even want to have them.
Shop Around
Due to systemic issues with transparency of pricing and the urgency of some medical problems, you can't always shop around. But that doesn't mean you NEVER can. Lots of things can be shopped- recurring prescriptions and labwork, outpatient MRIs and x-rays, cataract treatments, elective surgery, LASIK, and uncomplicated deliveries. Spend a little time and you might find you can cut the cost of care dramatically.
Obtain Care in the Cheapest Possible Setting
A clinic is usually the cheapest place to get care, as it can be provided during banker's hours and with a minimum of technology and staffing expenses. Urgent care raises the price but provides more access and treatment options. True emergencies belong in an ED, but can often be treated as an outpatient. The most expensive setting is the acute inpatient hospital, so avoid admissions whenever possible and get out of the hospital, even if it means going to a rehab facility, as soon as is safe.
The hospital usually isn't the cheapest place to fill prescriptions, get outpatient lab work, get x-rays or MRIs, or have elective surgery done. Become familiar with outpatient pharmacies, labs, imaging centers, and surgery centers. We'll treat your silly, little problems in the ED as best we can, but don't be surprised when it costs you five times as much for the convenience.
Treat Your Anxiety
The most expensive medical problem I know of is anxiety. Anxious people seek care more frequently, have more testing done, and have more treatments done. This results in more “incidentalomas” being found, which then need to be worked up. It also results in more adverse medical effects and other complications. Anxious people are more likely to get addicted to controlled substances, more likely to be admitted to the hospital, and more likely to have defensive medicine practiced on them. If you can get your anxiety under control, you might be surprised how much your health care costs go down (and how much healthier you feel.)
Don't Be Stupid
Finally, it should be noted that many of the tips in this post could potentially result in you getting sicker or even spending MORE on health care if improperly applied. When in doubt, sometimes it is best to spend the money to make sure something isn't serious. You need to be practical and remember moderation in all things. I saw a patient in the ED recently with glaucoma which I treated with the exact same acetazolamide his ophthalmologist had prescribed to him but he didn't fill due to the expense. He could have paid for A LOT of acetazolamide pills for what his ED visit cost. Don't be penny-wise and pound-foolish.
What do you think? What tips do you have to reduce health care costs? Comment below!
Really interesting post.
One other thing I would add is this: know your insurance coverage well and be willing to call you insurance provider BEFORE you get something done to see what it’ll cost and if it’ll be covered.
Unfortunately, your doc is often not going to know what something costs you because every insurance company is different as is every plan.
One time in early med school, I tried saving the system and myself some money by getting a laceration sewed up on my dominant elblow (couldn’t reach). I didn’t go to the ED because I thought it would have been more expensive. Went to my PCP. Well, that actually cost more under my insurance. They considered it an in office procedure ($450 towarda my out of pocket deductible) which cost more than the co-pay for going to the ED ($100).
Know your plan. Make the call.
I do agree that knowing others who could do this for free would be helpful, too… I just didn’t know any yet in my medical training. Wasn’t quite far enough along.
Great post overall. The only color I will add is that it can be extremely difficult and frustrating to try to shop around and cost compare b/c pricing transparency is rare to non-existant. My wife recently tried this for a routine ultrasound and spent most of her day working to the sounds of hold music, frequently interrupted by a voice telling her how valuable her call was. She eventually found costs carried by over $300 for the test and thought it may have been worth the effort, but now is dealing with issues on the back end with billing. It’s a frustrating system to try to navigate. I’d love to see much more transparency from providers and skin in the game for consumers, with insurance reserved for more catastrophic situations, but I think that’s highly unlikely.
I second this. Want to get a quote from the insurance company? Gotta give them a billing code to look up. How to get the billing code? Ask the doctor’s office. Call the doctor’s office… and then get told you they can’t diagnose you (e.g. give you a billing code) until they’ve seen you. Defeats the purpose of price-checking ahead of time. Joy.
As soon as someone tells me they have financial concerns, I advise to stay awake and not have IV anesthesia. A ton of money is saved that way and I can still make people comfortable. Obviously it depends on the nature of the planned procedure, but for most of the stuff I do it should at least be a consideration.
Probably good advice. We anesthesia docs aren’t cheap.
To this day it makes no sense to me why anesthesia is involved in eye procedures under topical (local) and 1 my of midazolam.
Probably for those times when a patient starts talking to random people not in the room, or moving their head side to side to get a hand off their face (the important one in their eye), or squeezing so tight a lid speculum will barely go in the eye. There is also the case where something unexpected happens and a 15 min procedure turns in an hour. I could rattle off many more but maybe the patients in your area are more well behaved.
My patients and I thank you, and your colleagues. 😉
Yup. I get RFA ablations done for facet pain about every 6-9 months. Pretty painful. Ive found with a Norco and an airplane bottle of Jacks that I can get through them both without an IV AND without the staff realizing how buzzed I am. A delicate balance. Sometimes Uber comes into play.
Using GoodRx for prescriptions helps too if you have a high deductible and have to pay out of pocket. It is usually very accurate as far as pricing at the various pharmacies for the cost of a certain medication.
I found sometimes pharmacies don’t want to honor what goodRx says, any experience like this?
Then I would go to a different pharmacy. My son had to have a form of Accutane, and we have a high deductible plan. I definitely did some shopping around for drug prices. The price varied from $400 to around $800 for generic per month. Worth the savings for sure. GoodRx certainly helped me get the lowest price.
After reading the delay delay delay section, I thought “uh oh, where’s the disclaimer?” I was relieved to see the last paragraph. For any non-medical people reading, remember this is a site for financial advice, NOT medical advice!
Yes, that’s the problem isn’t it? There’s that low percentage chance that something is actually going on that needs treated. That low chance explains about 90% of the testing I do.
I think this is a really good post. I personally find that just putting up with minor aches pains is very useful. I rarely take antibiotics also. I recently saw a Neurosurgeon. I have never received a bill from him. The MRI that he ordered has a $300 out of pocket cost per my insurance so I did not shop around. Reading the fine print of your policy is important so you understand what is worth shopping around. Professional courtesy is harder to find as fewer docs own their practices. I never ask for it but I have always given it.
Great post. The curve on health care needs to be bent a little (or maybe a lot) for it to be sustainable long-term. Your suggestions would do wonders for the long-term affordability of health care in all segments (out of pocket costs, uninsured, private insurance, and Medicare and Medicaid sustainability) P.S. loved the ophtho shout outs 🙂
Very good post (but I don’t think you need a third career!). I do have a bit of trouble with the idea of professional courtesy, especially considering that physicians are well-compensated and well-insured (for the most part – I have no problem with professional courtesy for students or residents or colleagues who have fallen on hard times). Especially problematic are statements like:
>>For example, our group routinely writes off the physician portion of the ED bill
>>for members of our medical staff and other referring doctors
which might be considered by the feds to be a kickback/Stark violation.
When I am offered professional courtesy, my standard response is “I’m well-paid and have good insurance, and I put great value on the fact that, as my colleague, you work hard to fit me in your schedule, give me the highest quality of care, discuss my problems at a high level, and provide outstanding follow up. If you really insist on it, instead of giving me professional courtesy please just bill me the normal rate and give my discount to one of your patients who really needs it.”
No, you’re misunderstanding. We’re not writing off the co-pay or co-insurance. We don’t send the bill to the doc or their insurance. The hospital, a completely separate company, still sends their bill. There’s no violation there.
Writing off co-pays or co-insurance is considered insurance fraud, which is a different issue.
Giving a referral source something of value (free medical care) could legitimately be considered to be a kickback, no matter if it is you or the hospital doing it. Larger organizations like hospitals, labs, and imaging providers tend to be more at risk in these situations because of their size and scale of operations and large number of potential whistleblowers, but I don’t think that there is any safe harbor for physicians to do it; I think that physicians end up escaping notice because they are much smaller targets.
I think they would have a very difficult time prosecuting a doc for not charging a colleague. According to this:
https://www.medprodisposal.com/professional-courtesy
as long as you offer it to all doctors in your geographic area, you’re fine. Discussed here as well:
http://www.miramedgs.com/web/54-focus/past-issues/fall-2016/606-when-may-physicians-offer-professional-courtesy-co-payment-and-cash-payment-discounts
I am a private physician. I am specifically forbidden by the hospital medical staff by-laws to offer professional courtesy or charity care. I have to treat every patient the same. If I bill anyone I have to bill everyone. Also, agree with the OP above that your professional courtesy could be seen as a kickback.
I’d take that one to MEC, that’s ridiculous. I guess I’ll agree to disagree with you. I’m with the attorneys that say it isn’t a kickback.
The other thought I had is going to a dental school for dental work to be done. Yes, you will be seen by a student, but the student will be closely supervised by a “real” dentist. It will take way longer to get anything done, so this might be better for someone who is retired. If it is time for them to take their boards and you have a problem that qualifies, they will sometimes pay you to be a good board patient. I was actually a board patient when I was in dental school. My student passed and tried to pay me. I refused, so he put money onto my account at the school store.
What do you think about medical tourism? I just read a post on that topic over at My Groovy’s blog. It’s an interesting concept for sure.
Works for some things, but you can’t rely on it as your “plan” because emergencies happen.
Awesome post! Great information, I have used several of your ideas all ready and it saved me hundreds on meds and procedures. Great to have such a great mind of our time giving us impeccable financial advice!
Although it is technically illegal (but rarely enforced), buying medicines abroad. Pharmaceuticals are probably the most unfree market in the US.
You mentioned Tricare/VA briefly, but what about a return to your roots Dr. Dahle? It’s a terrible reason to join and according to recent data only about 30% of the country is in good enough shape to do so, but if you really want lowest possible costs, active duty military can have out of pocket health care cost as low as zero. Never made a difference to me when I was joining as a med student, but now with four kids (and four more years on my contract) I’m starting to consider it as a legit part of my compensation. Pediatric OT biweekly for six months for the one, pediatric ENT and audiologist four times a year for two of them, in addition to four deliveries ( three C-section) and four just routine vaccines/etc…it would be adding up by now.
For sure it’s a legit part of your compensation. I had someone that other day arguing with me on Twitter that soldiers aren’t paid $3K a month. The lowest paid E-1 gets over $2K between base pay and BAS, and when you add on a typical BAH, that puts you over $3K, completely ignoring the value of Tricare which is at least a few hundred bucks for a single soldier. Between the HSA contribution and health insurance, I pay $20K a year.
Yes! I have had 2 children who required emergency lifesaving surgeries, along with all the child deliveries, routine maintenance items. I highly value my access to military care. Interestingly I may value it more as a retiree in a couple of years – it seems healthcare is what stops many from leaving jobs they don’t enjoy.
Yes, surprisingly people always blame it on health care instead of groceries or gasoline even though it all comes out of the same pot. Probably because few people actually know how much is being paid on their behalf for health care throughout their careers.
Using NNT and NNH to make medical decisions is poor form. I am not going to go into details regarding short comings of NNT as a statistic. I would encourage physicians reading this to think hard about what it means and compare it to Odds ratio and Absolute risk reduction as better metrics. Does make for a great click bait though.
“Things should be as simple as possible, but no simpler”
Totally disagree. Each statistical measurement has its pluses and minuses of course, but the NNT/NNH is the best one to use when discussing cost and benefit with a patient because it is the most easily understood. Try explaining odds ratio to a patient with a high school education sometime and see how that goes. My least favorite is the relative risk reduction because it makes very minor effects seem large.
Disagree with your statement. Easily understood doesn’t mean it is the best measure of effective treatment. I never mentioned relative risk, I said absolute risk.
I am not out there explaining Odds ratio to patient. I am surprised you discuss NNT with patients actually. But hey whatever floats your boat.
My comment is for physicians who understand statistics to look into these measures. There are short comings of NNT that one needs to be aware of.
I ran across NNTs several years ago when my physician recommended taking statins because my cholesterol was borderline high though I was otherwise healthy. I’ve seen NNTs for this particular application of statins from 50 to 100. I conversed with the doctor about side effects I was having after a month of being on the statin and and asked if there was another reason to take the statins other than reducing cholesterol. The doctor said statin use was not necessarily required in my case, but was a useful precaution to prevent possible heart issues on my part (so the NNT I was using was accurate) and a protection against malpractice suits on his part should a patient claim the doctor wasn’t providing the best care possible (NNT unknown for this). Both he and I felt comfortable in discontinuing the statins based on the cost and benefit.
I’ve since used an NNT to determine whether I needed to get a sleep apnea test since the initial consult suggested I was borderline candidate there as well.
Thanks for posting. Sorry to hear about your side effects. To be sure, I am not saying its not useful. Its a good stat, but realize its for normally distributed population so it’ll ignore “individual” risk. I can get into details but its beyond scope of a financial blog (if I put in effort to write all that I should be payed 🙂 ). Also “eye in the beholder” concept here – an NNT of what is too much to anyone? to some NNT of 100 is totally worthed and to others its a heck no (outcomes matter).
Absolute risk reduction and NNT are directly related from a statistical perspective.
NNT = 1/ARR
There is no valid statistical reason to say absolute risk reduction is more valid/useful/reflective/significant compared to NNT. They literally represent the same thing, just presented in a different form.
I absolutely tell people things such as “this medicine has about a 2% chance of helping you” or “only 1 in 10 people who get this will see any benefit” or the NNH corollary “1/1000 kids who get a head CT at a young age will get cancer later in life because of it” (I’m not that dramatic or absolute in my wording about the cancer risk though).
> Absolute risk reduction and NNT are directly related from a statistical perspective.
> NNT = 1/ARR
I’m a physicist, not a physician, and was wondering if NNT isn’t just the reciprocal of “probability per treatment that it will help. ” So it is, not so?
If you haven’t already, you should read “Overdiagnosed” by Gilbert Welch. Will make you think differently about screenings, in the same vein as what you have written in this post.
Great summary of ways to save on health care costs. Another one coming from an ex-trauma surgeon is “don’t do dumb stuff.” Old people climbing on ladders to fix the roof, teasing a rattle snake, jumping your bike over things, putting things in your anus that don’t belong there, racing with your car,…… A large number of the traumas seen in the ED could have easily been prevented.
If you are a Christian who pays your own medical insurance, you can save a lot on health care insurance by using a medishare plan instead of traditional insurance. We save about $15,000 a year.
Dr. Cory S. Fawcett
Prescription for Financial Success
Or as we say in Florida: “Here, hold my beer!”
Lol, Louisiana too. Nothing good happens after 2am or after those words.
“…putting things in your anus that don’t belong there…”
Good thing I wasn’t drinking anything when I read your comment!
Unfortunately, an occasional complaint in the ED, and when we can’t get it out, we call surgeons like Cory.
I was once told during training that “Trauma is not a random disease.”
This is true.
Also, “Normal people do not get hit by cars.”
Trauma is a chronic disease with frequent acute exacerbations. You haven’t lived until you’ve brought an x-ray into the patient’s room to ask him which one is the new bullet.
Trauma accounts for some strange things. I noticed that many of the people I treated for gunshot wounds or stabbings were not only repeat customers, but none of their friends were surprised. Their mother might have been surprised, but their friends were not. Many of their friends had done the same.
Dr. Cory S. Fawcett
Prescription for Financial Success
You’re not usually hit by the first bullet shot at you. 🙂
Thanks for sharing this WCI. When I asked this question a few months ago on Twitter I realized that healthcare is a huge expense line on many budgets. Yet, most of us non-medical professionals have no clue what the NNT or cost is for the tests being run or meds being prescribed. Unfortunately, many times the care provider has no clue about the costs either. This makes sense in an emergency situation. In a non-emergency, I think that medicine should have to have a printed price list and approval from the customer before any treatment is being offered. You know, like any other service business does.
I agree with the sentiment, but there are a lot of times where this wouldn’t make sense. Say you are admitted because you have high low sodium on routine exam. There’s literally hundreds of things that could be wrong with you, and no one has the time for you to OK every test we run and medicine we give every morning. Plus NNT is great for something like aspirin with multiple trials funded by millions of research dollars. Most things in medicine and surgery are much less quantitative. I don’t want my GI waking me up and saying he didn’t get a polyp because I didn’t ok the charge and it only has a 10% chance to turn malignant before I die of heart disease.
Saying there are times it wouldn’t make sense is very different than *never* doing it. The clearest analogy is veterinary procedures. I’ve paid thousands of dollars for procedures and have ALWAYS received a reasonably accurate estimate in advance. Not only in advance, but have often pre-paid entirely or made a hefty deposit before treatment is given. Just like everyone else who owns a pet.
The problem isn’t the difficulty in providing an accurate estimate of treatment costs in advance. It’s the complete unwillingness of the medical industry to provide any kind of cost transparency. Emergency care and the necessity of testing “hundreds of things could be wrong” are serious outliers that shouldn’t define routine, scheduled and basic medical treatment. I challenge anyone to name a single industry outside of health care that functions without providing an estimate of costs and getting client approval before moving forward with the actual work.
Totally agree. Lack of transparency is a huge problem, perhaps even the biggest, in our health care system. Just because we can’t be fully transparent doesn’t mean we can’t be a whole lot more transparent than we are now. But since there is no benefit to us being transparent, it will probably have to be mandated/regulated to occur, at least in the beginning until it becomes the “cool thing” to do.
As usual, an interesting and well written post.
I would like to read what the WCI’s prescription would be for how to address what he wrote early on in this post, specifically: “Macroeconomically speaking, the main problem with health care costs is that we pretend we have a market-based health care economy, but don’t actually have a working market in place. ” That is, what is the prescription to cure the main problem with our health care system?
I’m curious to read the reactions that the WCI and the doctors who read this blog have to Dr. Elisabeth Rosenthal’s book “An American Sickness”. There is only so much individual patients can do in a broken health care market place. What do Dr. Rosenthal’s fellow doctors think of her book?
I’m curious to read the reactions from members of the medical community who work in emergency rooms to Sarah Kliff’s reporting in VOX on the 1,000 plus ER bills they’ve collected and are analyzing: https://www.vox.com/policy-and-politics/2018/1/29/16906558/anthem-emergency-room-coverage-denials-inappropriate. How are patients supposed to protect themselves from this complexity and opaqueness from ERs, hospitals, and insurance companies? Just stay healthy?
As health care costs reach 17% of our GDP, it seems to me that the health care system in the US is essentially broken. Prices go up to what ever “the market” will bear, even though most people understand the health care market is “not working”. Something’s gotta give. Or in the words of the late economist, Herbert Stein, “If something cannot go on forever, it will stop.”
Yup, it’s broken. Good luck fixing it. Anyone that thinks the fix is easy doesn’t understand the problem adequately. In the meantime, do what you can to navigate the broken system.
Obvious the Anthem issue is a big deal.
Excellent post, i wish more people discuss this topic. When I was working my wife needed a bone density exam and she did a research prior to it and found that doing the test without insurance cost less that a co-payment using the insurance (a very good insurance in reality) in the same diagnostic center!! Crazy, right.? Two good news in the horizon: first, Assocition Health Plan(AHP), which allows small businesses to join health insurance in the same playing field that large companies and the other is extending coverage back to one year for short term insurance( we have been using this modality since my retirement, but you have to renew every three months), stay tuned because both options would be out there in a month or two .
I have very mixed feelings about your advice to delay. For a lot of aches and pains it’s probably fine, but I recently had a pt with a new breast lump put off being seen for 8 months and now has a stage 3 cancer. Same with postmenopausal bleeding. Maybe the general public just needs some intense education about what you can put off and what you can’t??
One of my favorite procedures for NNT reasons is a LEEP. Risk of CIN3 progressing to cancer is about 30%, so my NNT to prevent a case of cancer is only 3! (Progression is virtually unheard of after LEEP if there is good follow-up)
3 is great!
Thus you see the purpose of the last paragraph in the post. If there is any doubt about whether delay is safe, spend the money and come in now. Knee pain, delay it. Post-menopausal bleeding? You need an appointment this week. The problem with creating a list/educating patients is that there is always that tiny percentage chance that something is serious- just a nose bleed? Maybe it’s thrombocytopenia! Run to the ED! Got a headache? Maybe it’s meningitis? Run to the ED! It goes on and on. Thus why anxiety is such an expensive medical condition.
I get where the post is coming from, but as a pathologist and being heavily exposed to all things neoplastic, I caution about the recommendation to delay things. Anything that could signal cancer should be checked out sooner than later (lumps/bumps/unexplained weight loss etc).
Depends on what you mean by sooner rather than later. If sooner is at 2 am in the ED, then I disagree. If sooner is this week at the PCP’s office, then I agree.
Totally agree about ED vs PCP this week. Especially for the postmenopausal bleeding example- the ED will just make sure you are stable and not hemorrhaging, then tell you to follow-up with gyn (which is appropriate!), when you could have skipped the ED visit and just seen gyn in the first place
Exactly. Happens all day long. At least 1/2 of my patients spent money they didn’t need to spend.
You probably have a bit if bias though. To a plumber, everyone’s house has leaky pipes. I think what WCI was saying is don’t come to the ED unless you think your life/limb is in immediate danger. If you really need to be reassured that your shoulder pain is osteoarthritis not osteosarcoma, it’s still much cheaper to take some naproxen and call your PCP in the morning than running to the ED.
Nice post, I hope you do make it a 3rd career so I can learn about it once I get to possible retirement age if its long before medicaire age (which I hope it is!)
Your NNT argument doesn’t take into account the downstream costs of non-treating and the severity of the result to the patient of not treating. In radiation oncology (my specialty) we often use a recurrence rate of 10-15% to justify a several thousand dollar radiation treatment course (10-80K depending on type of radiation, cancer type etc). However, omission of radiation could results in failure which will be associated with life-long chemotherapy, more surgery, palliative radiation later which can exceed upfront curative intent radiation costs, and new immunotherapy (hundred of thousands) not to mention the failure will likely be fatal.
Discuss with a provider is a big one. If I know a patient is very cost sensitive we will have a discussion about using older radiation techniques, lower dose, delaying treatment, radiation alternative etc. I try to be cost conscience for all patients, but if they bring it up, I use that chance to exercise that part of my brain a bit more.
Thanks for posting. I agree NNT shouldn’t be the sole measure. NNT totally disregards “degree” of benefit.
Don’t have time to do a stats lesson, but plenty of numbers thrown on this blog are shock factor with little statistical rigor.
If you don’t like my peaches, don’t shake my tree. 🙂
Personal family bias, but being able to walk versus not(admittedly don’t know which one of the 8 this family member is and never will) makes Copaxone worth it. Of course, if it wasn’t subsidized with insurance and pharmaceutical kickbacks, it wouldn’t be >$6000/month. But that is a different argument that won’t be won in a country where everyone wants everything to be free(ie, really expensive)
Yes, there can be multiple NNTs associated with a given therapy. It would be great to know what they all are.
Another favorite of mine is doubling the dose and cutting tabs in half. It cuts the cost of prescription meds in half on most occasions. As a provider, I have all of my patients who are on expensive tabs do this. I figure it is my small contribution towards reducing healthcare costs.
Good idea. Every little bit counts.
Until the insurance company won’t let you have more than 15 pills when you cut in half.
Received that letter a few times from the PBMs.
Doubling the dosage works for not just tablets which can be cut in half but also topical creams, or something you can take every other day vs daily etc. Anyone on some long term maintenance dosage of an expensive med can benefit from this strategy.
{Disclaimer: I am not a physician. I am a retired CPA who on occasion helps medical students in financing their education.]
I take a number of medications daily.
The last of my medications ($480/ 90 days) FINALLY went generic. The cost of the generic through my pharmacy provider was $605/ 90 days which was a ridiculous increase. The mail order pharmacy would not give me the lower cost name brand as there was a generic.
I returned to my specialist to discuss alternative and he prescribed the older non “extended release” medication at a cost of $6/ 90 days. Yes, no zeroes.
In addition, I was taking a medication that was a dual drug and gave me the generic versions of the two separate drugs which saved about $100 per quarter.
My drug cost dropped from $1025 per quarter to $225 per quarter.
I have to give credit to my specialist and well as one of the pharmacists who I have been mentoring over the past three years for giving me some ideas as to lowering drug costs.
Great tips, thanks!
Recent research would disagree with your post.
Comparison of us w other countries was done and it showed us was middle of the pack in healthcare utilization.
Knowing this its hard for me to take this post and reconcile it with current research.
So how do you suggest people save on health care costs given the issues with our current system?
Great post!