Sunday, February 13, 2011

Cost-awareness anecdote: Getting an estimate

The following story is from Monte Jaffe, an accountant and patient from Massachusetts.

A couple of years ago my primary care physician suggested that I have a colonoscopy at the age of 47. My father died from Hodgkin’s disease at 34 and my mom survived breast cancer in her 40’s. I suffer from irritable bowel syndrome so she suggested that I have my colon checked out just in case. She recommended a very experienced gastroenterologist at a major Boston hospital.

My insurance would not cover the procedure because I am younger than 50, so I called the hospital to investigate how much it would cost me to have the procedure. Their first answer was that they did not know because no one had ever called in with that question before. This is a hospital which probably does more than one thousand of these every year.

I was transferred to someone else who was more helpful. She said it would depend quite a bit on what they discovered while I was undergoing the colonoscopy, but gave me a range of $2,000 to $4,500. I asked if there would be other charges and she said that the physician screening could cost $770 or more.

I asked if there were other charges. She then mentioned that there would be a fee for an anesthesiologist, but they didn’t know how much that would be. I asked whether I should call that office, but they said that they use several different anesthesiologists and there is no way in advance for them to know which one will be there for the procedure. Finally, they mentioned that there may be several other charges as well. I asked for something in writing about the various charges, but she said they did not have anything like that.

That’s the point where I gave up. We were already potentially over $5,000 and it was going to take some time to figure out an estimate for the anesthesiologist. Also, I had no confidence that we had gotten to the bottom of all of the potential charges. I was not going to get an estimate before agreeing to do this procedure.

I liken this experience to hiring a general contractor for a recent major home improvement. I received three estimates from three different general contractors which included all of the costs including the electrician, masonry, disposal, painting, etc. Sometimes there are unexpected costs with construction, and sometimes there are unexpected costs with colonoscopies. However, the inability of our medical system to even identify all of the costs, or to even appreciate that this is an important element to making the decision, was emblematic to me of a much deeper problem.

I will celebrate my 50th birthday in less than 2 months and will let the insurance company sort this all out while I focus on the procedure.

Tuesday, February 8, 2011

Cost-awareness anecdote: Cruel Shoes

The following story is from Dr. John Henning Schumann, a primary care doctor at the University of Chicago. He blogs @

A thirtysomething friend of mine, let's call her Sally, started running last year in an effort to get in better shape.

As often happens in these scenarios, Sally developed some foot pain. So she went to a "foot" doctor (I'm not sure whether she meant a podiatrist or an orthopedic surgeon specializing in feet).

Reasonably enough, the doctor ordered an x-ray of her foot. The official reading showed no fracture, but there was a "questionable" finding on the edge of one of the midfoot bones such that the doctor couldn't rule out some more insidious process. A stress fracture, perhaps? Those can be awful, and take a long time to heal.

So, again in reasonable fashion, the doctor ordered a CT scan of Sally's foot. This is the logical next step if a plain old x-ray is abnormal. Heck, a lot of the time, even when an x-ray is normal, we still order the CT scan looking for something that we can't see on the x-ray.

And though I said this was a reasonable choice, if you really think about it, was it so reasonable?

I mean, did Sally really need a $1000 test to see what was causing her foot pain? If you're Sally, you sure might think so. You want to know what the heck's wrong. You want to know why you're having pain when you run. You want to keep running. After all, as a primary care doctor, I LOVE it when a patient tells me that they're serious about exercise. Aside from not smoking, that's the best thing I can hear from a patient.

But Sally hadn't traumatized her foot. She hadn't dropped a bowling ball on it. She probably had an overuse syndrome. A repetitive stress injury. A running "tweak."

The x-ray showed that, for heaven's sake. We knew there was no broken bone. No smoking gun. [I told you, we hate smoking.]

So a week after sitting for the CT, Sally still didn't know the result of her scan. She called the doctor's office to no avail. She was put off by the staff, even told by a nurse she'd have to come in for an appointment to discuss the results with the doctor.

By this point, she's worried. "Is there something terrible that he's waiting to tell me?" she wondered. "Do I have foot cancer?"

Sally adjusts her schedule, dutifully shows up for the appointment, to hear the doctor tell her that her CT is normal. Did she really have to wait a week and have an office visit to find this out? That is one shoddy patient experience in my book.

Nevertheless, she reasonably asks the foot doctor what she should do about her pain.

Physical therapy? Low impact exercise (use an elliptical trainer, perhaps, or bicycling)?

She doesn't get much of a concrete answer.

She decides to buy some new shoes.

She goes to a local shoe store that caters to runners. Let's call it Fast Feet.

There, they measure her feet. No charge. Lo and behold, her feet have grown a whole size.

Sally was running with shoes that were too small! That was the source of her pain. No CT was needed. In fact, probably even an x-ray was unnecessary. And the $300 orthotics that she' been prescribed.

Now, this story shows how when a patient comes to see a doctor, we often go right to diagnostics. We want to get you an answer, after all. We're not shoe salesmen, for heaven's sake. We don't even have those thingie-dingies that measure feet. [Do foot doctors?]

Next time someone comes in complaining of foot pain, I'm going to ask them when they last had their feet measured.