Identifying the Distance between Healthcare Cost and Patient Care

May 7, 2012
Bryan R. Fine, MD, MPH

I’m not saying that healthcare services are a commodity in the classic widget sense, but I have grown to concede that the service we as doctors provide is a commodity.

My father, a plastic surgeon, often makes the following point when we discuss the economics of medical practice:

"My cosmetic practice is rarely covered by health insurance, and as such 100 percent of people ask me how much things cost. My reconstructive practice is generally covered by insurance, and zero percent of people ask how much it costs, because they expect - and will accept nothing less - than nothing out-of-pocket."

I’ve paraphrased his sentiment, and unfortunately for the reader I can’t accurately recreate the gesticulations and strategically placed emphases that my father employs. For example, he often says "100 percent" several times to ensure the listener understands he means every-single-one. And he will pinch his thumb and index finger into a circle and hold it up to demonstrate what he means by "zero."

This exchange, a variation of which we have fairly often, represents both his impression of what is wrong with the healthcare system - the disconnect between patient care and cost - and how passionate physicians can be about the topic. While not everyone will enthusiastically embrace his proposed solutions (which generally revolve around free-market tenets), almost everyone will agree that the distance between consumer and commodity has become too far for most people to navigate intelligently.

Yes, I’ve used "consumer" to mean "patient" and "commodity" to mean "healthcare services." I recognize some people cringe at this analogy, and over the years I have read well-written humanities essays and letters to the editor decrying the "industrialization" of medicine.

"I am a doctor, not a healthcare provider. I see patients, not customers," some physicians have eloquently declared.

But I believe that the words are synonymous when you consider that physicians generally expect to get paid for their work. I’m not saying that healthcare services are a commodity in the classic widget sense, but I have grown to concede that the service we as doctors provide is a commodity. Thus, when we are discussing the economics of medicine, it is fair - and in fact appropriate - to categorize the conversation in economic terms.

These terms can be mutually exclusive. The child / family in front of us can be both patient and consumer, and can still receive honest, compassionate, quality services even if we’re sub-acutely aware of the fiscal machinations that influence every patient encounter we have. I would argue that this awareness - irrespective of the semantics - ultimately benefits the patient, both during the bedside encounter and in a broader, public health sense.

Patients and doctors have indubitably been drawn further and further away from the financial implications of the decisions we make in the course of a doctor-patient relationship. It is a fun exercise to imagine how decisions we make on a daily basis might change if even a hint of economics were incorporated into the decision-making process.

For even the noblest doctors, would risk assessments "change" if there were dollars more closely involved? In the pediatric world, this might be represented by the classic case of a young infant with fever. We hold steadfast to the notion that even the most well-appearing infant should be admitted to the hospital for 48 hours if she present with a low-grade fever, citing loose evidence of one-in-a-thousand chance of meningitis. We stick catheters in urethras, and needles in veins and lumbar spaces, and implore families that this is the standard of care.

But what of the family without insurance, who would have to bear the brunt of an $8,000 hospital bill for a short stay? Might the standard of care not shift a little, should the baby be particularly well appearing, the fever spuriously documented and since resolved, and the initial lab work reassuring?

So few people, when seeking acute care, ask about costs. In the pediatric hospital, it darn well approaches zero percent. Which is probably a good thing for now …because so few doctors would know even where to begin with an answer.

Find out more about Bryan Fine and our other Practice Notes bloggers.