Blog | Tuesday, May 29, 2018

Just one eye

“Don't worry, doc. It's just one eye.”

That statement from a recent patient was a summary to me of what is bad in our health care “system.” It's a terrible summary of what is seen all over this country with people who must make the choice between financial solvency and health.

Here's what happened: It was a new patient I saw, who is a veteran who owns two businesses. He went out on his own when he “kept getting laid off.” He has largely been successful in what he's doing, but as is the case with many these days, he couldn't afford health insurance. This was especially bad because he had a heart attack last year, which required stenting and a significant hospital stay. He didn't fill me in on the financial details, but there's no doubt that this hurt him significantly.

Unfortunately, he has another problem: glaucoma. His glaucoma is bad enough to need surgery done to avoid losing vision in one eye. Sadly, he can't afford that surgery. We talked about the difficult choices he had to make with his health and his money. ”It seems to me that the eye problem is the most urgent problem you have. You don't want to lose your vision,” I told him.

That's when he smiled, waved his hand over his right eye and said, “Don't worry, doc. It's just one eye. I've got two.”

My stomach lurched to hear this statement. A guy who has done nothing wrong aside from choosing self-employment (and perhaps inheriting less-than-stellar genes) is left with the choice: financial devastation or blindness in one eye. He works hard, has served the country, didn't complain to me at all, yet here he is about to be swallowed by the ever widening maw of impossible medical expense.

How can we help people in this situation? How can we care for those who need care without increasing already out of control spending? There are many who give simplistic answers to that question, but most of them ignore the cause of our problems: the out-of-control cost of care.

In my practice, which is (by the way) a direct primary care practice, where I don't accept payment from insurance companies but rather am paid by my patients in the form of a low ($35-$70) monthly payment. Because I am paid directly by my patients I am motivated to save them money whenever possible, as it justifies paying me the monthly fee. Also, me being much less busy (I see between 5 and 12 patients on a normal day), I can work to find ways to avoid unnecessary care. This is especially important because many of my patients don't have insurance, and those who do have high-deductible plans.

This patient experienced this aspect of my care on this same visit. He was also interested in being screened for colon cancer. Some friends had urged him to do so. ”But when I called to find out what a colonoscopy costs, they said it would be more than $6,000! I can't afford that!” I sent a quick message to my nurse and she relayed that there is a gastroenterologist in town who can do a colonoscopy for $1,600 (extra for biopsies, of course).

He was impressed by this, as are many of my patients when we do lab tests for more than 80% discount, dispense medications that are more than 70% cheaper than the average discounted price from GoodRx, and when we know where to get $100 ultrasounds, $250 CT scans, and $450 MRI scans. These prices are out there for any doctor to use, but my business model makes it to my advantage to give patients the best value possible. So there are ways to cut the cost of care for many people. Unfortunately, not many doctors use these resources, much less know about them.

A deeper question in this man's case is the fact that his heart disease was treated at a local hospital which specializes in heart disease. While much of the public may see this as a positive thing, those who know health care realize that these hospitals are very quick to do procedures that are not always necessary. In his case, he had a stent placed on a 65% lesion, which doesn't have great evidence supporting its placement. Much of interventional cardiology treads the ground lightly in the area of solid epidemiological evidence of benefit for some very expensive procedures. It seems to be based largely on the visceral response all of us (me included) would have: “It could only help to stent the 65% lesion, wouldn't it? What will it hurt?” It turns out that the evidence for much of this is light.

In this case, the stenting of a 65% lesion could result in blindness, as the money he would have spent on eye surgery was instead paid to the interventional cardiologist and the “heart specialty” hospital.

Much of what I just said is controversial (and I expect significant objection from the interventional cardiologists), but the details are not as important as the overall point. The hospitals and procedural specialists benefit hugely from a very permissive payment system that doesn't demand great evidence of benefit for payment to occur.

Our system is based on sickness, not health, so expensive procedures are favored over preventing those procedures from happening in the first place. Until we address the elephant in the room, the “what will it hurt” mentality that justifies costly procedures for dubious benefit, we can't expect to make any progress in fixing our system regardless of who pays for that care.
