Problems with consumerism in healthcare

The major trend in the past fifteen years in health insurance has been an embrace of high deductible health plans (HDHPs) under the guise of “consumerism”.  The theory is that if people are on the hook for the first $1,000, $1,500, $2,500 or $5,000 of medical expenses, they’ll aggressively shop for care as well as take the necessary preventative steps.  The preventative steps are no longer just moral nagging (dropping 40 pounds might help your knee) but financial cost avoidance (dropping 40 pounds will help avoid/delay a knee replacement and a $5,000 bill you don’t want to pay). 

This is an analysis and a solution set that comes out of the assumption that most people consume too much care, and furthermore most people are fully rational consumers of everything.  It is very much an Econ 101 problem where the assumption of low information costs, and low confusion costs can lead to optimization behaviors. 

Two interesting pieces on decision making popped up at the Incidental Economist today that highlights the basic fact that there are significant decision, search and processing costs as well as strong social pressures that move people out of the rational man realm.

Quantitative intuition is a tough skill to build, but one that is required to make relative risk assessments and value judgements.  Most peope suck at it (that is why the scam of actively managed mutual funds are still an ongoing concern instead of seeing the bottom 98% of the income distribution dump their retirement savings into either a Target 20XX fund or an index fund depending on risk tolerance):

These researchers got together more than 1800 adults, about half of whom had diabetes. Then they showed them lab results of A1c values randomized to be either slightly or moderately high. They mixed these in with other random lab values. Then they asked them if their A1c level was outside the normal range, what this said about their glucose control, and if they would call their doctor out of concern.

Just over half of participants correctly realized that the A1c was out of the normal range. Those that HAD DIABETES only realized this 56% of the time.

The people who have been exposed to A1C (the diabetic population) still sucked at recognizing what the numbers meant. 

Under a rational regime of treatment and screening, priorization should take place.  If I enter a trauma center with a sucking chest wound, a sword cut to my abdomen and coincidentally a blown ACL, the prioritization of care is simple — keep me breathing, keep my heart going, and then deal with the big issues that could kill me in the next twenty minutes and work the way down to referring me to an orthopedic surgeon to take care of my knee sometime in the next six months. 

That makes sense.  However, on non-acute situations, we screen people for diseases that may kill them after they’ve already been dead for a decade:

 if you have a limited life expectancy, or a short time to live, then screening for some diseases really doesn’t make much sense. If cancers have a very high 10-year survival rate, then it doesn’t really pay to do much screening if you have less than 10 years to live….

Patients with a very high 9-year mortality risk were screened for cancer quite often. Women who had had a hysterectomy were screened with PAP smears between 34% and 56% of the time within the last 3 years. Men were screened for prostate cancer at a rate of 55%.

A patient who is told that they won’t last long enough for a cancer screening to matter will scream bloody murder and get on the front page of the major local papers and on at least two 6 o’clock news hours and be placed before the weather and sports report.  We don’t have the discussion that an 87 year who is already fairly frail probably won’t make it to 100 so we should not care about things that will kill them when they turn 100. 

Those are flaws to rational man; they are not particular flaws to satisficing/most rational with known human heuristics, schemas and decision process weaknesses, but consumerism as a means of saving money is designed for rational man.

97 replies
  1. 1
    Betty Cracker says:

    The manufacture and sale of many commodities works reasonably well in a free market model. Cars, boats, shoes, umbrellas, bicycles, smartphones, flip-flops and ice cream to name a few. Healthcare isn’t one of those commodities.

  2. 2
    Villago Delenda Est says:

    Yes, shopping for a doctor is just like shopping for a new big screen TV.

    Sure, right. Whatever. If you assert this, you’re demonstrating what a blockhead you are.

  3. 3
    Baud says:

    if you have a limited life expectancy, or a short time to live, then screening for some diseases really doesn’t make much sense.

    Doesn’t a simple life expectancy analysis ignore possible differences in quality of life if some diseases are caught and treated earlier?

  4. 4
    Villago Delenda Est says:

    @Baud: Can’t fit that on a spreadsheet.

  5. 5
    Stella B. says:

    @Baud: If you are likely to die of your COPD within the next two years, what is the improvement in quality of life, if we continue to screen you for breast cancer which might kill you over the next 5 years? Would knowing that you had “cancer” but that it was unlikely to kill you make your remaining life more pleasant?

  6. 6
    Baud says:

    @Stella B.:

    You’re giving a very specific example. I’m asking about a mode of analysis that seems to only take life expectancy into account, and wondering why that’s the only relevant consideration.

  7. 7
    JCJ says:


    The examples cited (PAP smears in women who have undergone a hysterectomy, PSA screening in men with a life expectancy of under 10 years) are screenings that are hard to justify in any scenario. Women who have undergone hysterectomy for non-malignant reasons have an extremely low chance of having a malignancy discovered on PAP smear. The natural history of prostate cancer is such that diagnosing the disease in men with a life expectancy under nine years is unlikely to impact survival or quality of life.

    I heard a story many years ago on Nice Polite Republicans where primary care doctors claimed they still did PAP smears after hysterectomy (which had been done for benign reasons) so they wouldn’t get dinged by whoever was tracking quality of care metrics which stated the women should have a PAP test done.

  8. 8
    Calouste says:

    The theory is that if people are on the hook for the first $1,000, $1,500, $2,500 or $5,000 of medical expenses, they’ll aggressively shop for care as well as take the necessary preventative steps.

    The problem in the US is that those amounts are too small to incentivize people to aggressively make cost conscious decisions, or more accurately, the problem is that the consumer is on the hook for the first $x, instead of $x after a reasonably expected amount of medical expenses.

    Why would I waste my time and energy looking around for a doctor to safe a few dozen dollars when a single visit to the ER would blast me straight through my deductible, and everything after that gets paid for me anyway? I doubt that there are a lot of families with kids that spend less than $2500 on healthcare most years. Pregnancy alone will be way more than that.

  9. 9
    Violet says:

    The people who have been exposed to A1C (the diabetic population) still sucked at recognizing what the numbers meant.

    Isn’t that what the doctors are for? To tell us what a high A1C is, means, and suggest appropriate treatment? A1C isn’t one of those things a diabetic patient may check every day, like blood sugar with finger sticks.

    From the actual link:

    We assessed (1) whether respondents identified the hemoglobin A1c level as outside the reference range, (2) how respondents rated glycemic control, and (3) whether they would call their doctor.

    Fuck no. The doctor is supposed to call us! But guess what–they don’t. So patients are stuck managing their own care. If you don’t manage your own care you are doing yourself a disservice. Maybe these patients are expecting the doctor to do their fucking job but they don’t always.

    I’m a relatively healthy individual and I’ve diagnosed my own thyroid problem, figured out I’ve got a problem with gluten, got tested, and despite my doctor telling me I don’t have a genetic issue with it, I noticed it on the lab paperwork and pointed it out and, oh, guess, what, I DID test positive for one of the genetic markers. Oops. I’ve saved myself thousands of dollars by following bloodwork closely prior to a procedure being done and discovered it wasn’t an appropriate time for it, insisted on follow up and look there–I was right and the doctor was wrong.

    That’s just a small example of things I’ve personally experienced. There are more. I get copies of all my labs, check them myself and check those against reputable results online I’ve been doing this for at least a decade. Even labs can be using out of date reference ranges–this is a HUGE problem with thyroid TSH ranges–and even if your doctor says, “Look–your TSH is within normal range”, guess what–that may not mean the doctor or the lab is up to date. I fell into this crack and my TSH was woefully elevated but the fucktarded lab was using an out of date range so it was “normal” according to them.

    I’m not sure what this study is supposed to show. Patients shouldn’t be completely in charge of their own care. But patients should have access to their labs and other records. The doctors need to do their jobs. Patients should be secondary to that. Too often they’re not.

  10. 10
    Villago Delenda Est says:

    @Violet: Yup, I can check my blood sugar every day. A1C, not so much. My blood sugar may be doing just fine, thanks, but my doctor tells me my A1C is still to high, so we’re going to alter the medications a bit to address that, and come back in three months and we’ll see where your A1C is.

    This is how it works.

  11. 11
    Baud says:


    The natural history of prostate cancer is such that diagnosing the disease in men with a life expectancy under nine years is unlikely to impact survival or quality of life.

    Thanks. So if I understand, the focus on life expectancy is specific to these examples but may not be the only factor in determining who should be screened in other cases.

  12. 12
    Violet says:


    The problem in the US is that those amounts are too small to incentivize people to aggressively make cost conscious decisions, or more accurately, the problem is that the consumer is on the hook for the first $x, instead of $x after a reasonably expected amount of medical expenses.

    The other problem with that is that the deductible begins again at the beginning of the year when holiday bills are rolling in. People can’t afford to pay the high deductible for whatever the procedure is at that time so they put it off. I did it this year. It was a routine thyroid ultrasound but it got put off until July because I couldn’t afford it then. Fortunately it was routine and no big deal but people put off more pressing tests as well because they can’t come up with the money they need for the $1500 test and the deductible isn’t met.

  13. 13
    JCJ says:


    This is a link to a report on the PIVOT trial – prostatectomy vs observation followed for 10 years.

    Interestingly the Swedish study that was cited for years (if I recall correctly – no difference in survival at 8 years, differences started showing by 12 years) had a recent follow up article in the NEJM with 23 years of follow up where there was an advantage favoring prostatectomy over observation.

  14. 14
    Liberty60 says:

    Yeah, I don’t buy the “everything is a toaster” theory, where healthcare is just another consumer good.

    Suppose all healthcare was free tomorrow- No copays, no out of pocket, just free, and instantly available, no questions asked.

    What medical procedure would you rush in to get done? A liver biopsy? Maybe have them take out your spleen, since its now free? Or maybe get an MRI just for kicks?

    Healthcare is a strange sort of consumer good, one that no one really wants to get.

  15. 15
    cleek says:

    The theory is that if people are on the hook for the first $1,000, $1,500, $2,500 or $5,000 of medical expenses, they’ll aggressively shop for care as well as take the necessary preventative steps.

    if i’m the kind of person who goes to the Dr a lot and i know i have to pay that first $1K, i’m going to use that $1K up ASAP. i’m not going to shop around and scrimp and save, if i know i’ll be going over that $1K anyway.

    $2K might make me cautious. but i’m married, so no – i know we’ll hit $2K by EOY.

    $5K would make me cautious.

  16. 16
    PJ says:

    How can people shop for medical care when it is practically impossible to get the prices of procedures from hospitals beforehand, or to obtain information regarding probably outcomes from those procedures at those facilities? For much of our health care, as far as the consumer is concerned, there is a dearth of information regarding what might or might not be advisable. Where are people supposed to obtain if from – WebMD?

  17. 17
    JCJ says:


    Another link – the New England Journal of Medicine article requires a subscription, but this article summarizes fairly well…

  18. 18
    Violet says:

    Since this is a healthcare thread, I have a question but it’s a bit OT:

    I got bit by a dog this morning. What should I do about it?

    It’s owned by a neighbor. I was walking by and had to squeeze between the neighbor’s truck, which he’d illegally parked over the sidewalk, and his fence. The dog lunged at me, got his muzzle through the wrought iron fence, and bit me on my calf.

    While I was trying to figure out what to do, the neighbor came out to go to work, I told him his dog had bit me, and we chatted. He assured me the dog’s shots are up to date. He says they kennel it all the time and the kennel requires that. I know he owns the dog and it’s not some stray he just picked up because the dog has been there for months.

    The dog mostly just scratched me, but there is one teeny tiny pinprick-sized spot where the bite may have drawn blood. The dog is a blue heeler, so a reasonable sized dog. It barks like hell out of the blue when you walk by and lunges at pedestrians. Scares me every time because you don’t see or hear him coming. He just lunges through the fence. This time I was too close but that isn’t really my fault. The fault is the owner who doesn’t have an appropriate fence for his aggressive dog.

    I washed my leg when I got home. It hurts and is bruising. I took ibuprofen and iced it but then I had to go out. Do I need to go to the doctor? Report him? I really don’t feel like doing either. Any other suggestions? Any input is welcome.

  19. 19
    A Humble Lurker says:

    OT But now we know why Rand Paul ran away from those Dreamers so fast. He’s been down in Guatamala saying the DACA should be rescinded. (Warning, Huffpo link)

    I think he’s actually stupid enough to think that no one up here’s going to know he said that because he was out of the country at the time.

  20. 20

    That’s kinda how they do it in Norway. When my friend tore up her foot our first day in Oslo and it was turning scary colors of purple, green and yellow alarmingly fast, we were sent to a legevakta, where you go for accidents and emergencies. Things like sucking chest wounds. And then you have your regular clinics for things like diabetes and whatnot.

    Anyway, when I saw the headline “consumerism in healthcare,” I thought you were going to address that dreaded, trite little meme that Centrsit Dems and Republicans loved to use during the healthcare debate: “shopping for healthcare.” Have I expressed how much I despise that wretched phrase? How offensive and mind-numbingly stupid I find it?

    I don’t want to fucking shop for healthcare. That is the absolute LAST thing I want to shop for. I actually don’t even like to shop, even though it’s supposed to be America’s pastime. But the idea of having to compare prices and plans and what gets me the most value, etc. is anathema.

    All I want — I repeat, ALL I FUCKING WANT — is to be able to go to the doctor of my choice when I need to and not have to take out a second mortgage for the privilege. That’s all. Is that so fucking hard?

    By the way, when I wrote this very thing on my blog a few years ago the Libertarians were aghast. You don’t want to shop? What’s wrong with you? That’s anti-American!

  21. 21
    Older says:

    There are other reasons why comparison shopping isn’t practical for medical procedures. I’m the same person I’ve always been, and I have the same medical insurance I’ve had for years, but I can’t find out what various medical procedures will cost, or which provider will be least expensive, because the only way anyone can tell me what something will cost is to send in their bill to my insurance companies and wait to see what they say. And what they say can change from time to time, and apparently no one knows why.

    Another problem arises from decisions made by the providers. My aunt and I have both had cataract surgery. I’m entirely happy with mine, because I’m in pretty much the same situation I’ve been in most of my life; that is, I’m near-sighted and wear glasses. My aunt isn’t so happy. She now needs several pairs of glasses, because she is obligate far-sighted. The clinic I went to for the surgery asked me if I wanted to be near-sighted or far-sighted, while the one she went to provided only the far-sighted lenses, to save themselves trouble, I guess. They didn’t offer her a choice and it didn’t occur to her that another clinic might do so.

    If you don’t realize there could be a difference, you won’t even try to shop around. And if you do try to shop around, you will probably run up against situations where you can’t even get the information.

  22. 22
    Violet says:

    @Southern Beale: I hate shopping too. HATE IT. Going to the mall is my nightmare. In and out with a targeted trip is how I shop. Guess I’m un-American too.

  23. 23
    Calouste says:


    That’s another effect, probably not only limited to the beginning of the year. Lots of people are low on cash as well towards the end of the summer, after a vacation and with the costs of kids going (back) to school).

    Let me expand btw with some numbers. Say I have a $5000 deductible and expect $6000 in health care costs this year. That means that I need to find at least 17% savings on that $6000 to make it worthwhile to go doctor shopping, and depending on your time-money values, it might be more. If instead, the deductible only kicks in after the first $5000, I would have an incentive to go doctor shopping, because everything up to $1000 below $6000 would be mine.

    The problem basically is that the insurance providers try to get the consumers to do their work for them without giving them much of an incentive to do so.

  24. 24
    Baud says:



  25. 25
    Violet says:

    @Calouste: I’m confused by your example. Maybe I’m being stupid but could you explain it a different way?

  26. 26
    piratedan says:

    @Violet: and this is another pitfall of our system. Updated Medical instrumentation costs money and there’s not much that gets done without some serious cost benefit analysis going on. So while there may be machines that run these tests with different ranges of tolerance and measurement, there’s not always money in the system to stay up to date with the latest and greatest. Not all hospitals are profitable per se and in the model that we’re currently living in, where does the money come from and who gets it and decides where to spend it? The Lab in your modern hospital is more likely a cost suck these days than a revenue generation scenario. Plus, with the advances that have come in most Lab reports, the docs have been conditioning themselves to look for abnormal flags, if there’s no flag, there’s no concern. The amount of time that most medical schools devote to the understanding the actual numbers from Lab results, be they from blood, serum, urine or whatever the specimen, is not much more than a couple of weeks in the course of the entire curriculum. Your local hospital organization does not have a staff of Dr. House’s on call to review and educate the medical masses as to what these results might mean and could mean in regards to the interpretation of testing that is ordered much less paid for by the local insurance company. I’m glad that you’ve taken ownership of your own diagnosis and what needs to be done with your care, but the parallels to our politics are kind of striking in many ways… so many folks just sit back and listen to what they’re told.

  27. 27


    { waves }

    Let’s hear it for the un-American anti-consumerism contingent!

  28. 28
    sam says:

    I haaaaate my HDHP. My company forced everyone into one this past year and everyone hates it.

    As a bonus, last fall I finally decided to “do something” serious about my weight. Meaning that I started seeing a specialist endocrinologist at what is considered the best fancy-pants hospital-affiliated clinic here in NYC for that sort of thing. It’s been great. But I have to see her every couple of months. Before, it was a straightforward $40 copay. Now, it’s some convoluted process that results in me paying $168 for each visit. And that’s after the hospital system remembers to first submit the bill to the insurance company so they can knock it down to the insurance company “negotiated rate”. The hospital system forgets to do this half the time, so I get the bill, have to call, remind them to do this, wait for them to submit it, wait to get the notification that it’s been submitted, then log in to my health insurance account and pay the lower bill through my HSA. And that’s for a doctor that takes my insurance – if you want to see a nutritionist, it’s completely out of plan. In addition, none the newer obesity-fighting drugs that have been approved in the past few years are covered by insurance, despite the fact that obesity is such an “epidemic” (whether or not you should take this is another question – my doctor kept me away from them for my first year of treatment and only uses them once you’ve hit a plateau/wall).

    But over the last year I’ve reduced my BMI to the point where I would no longer qualify for bariatric surgery even if I wanted it (which I didn’t), my ankles don’t swell up like balloons anymore, and I generally feel great. I’m still “plus-sized”, but I’m about a thousand times better (and I have no real desire/need to be skinny, I decided to see a specialist because I couldn’t seem to stop gaining weight, which seemed to me to be a bigger issue than just being heavy in and of itself). I’m also lucky in that I make a nice enough living that the money isn’t actually an issue other than being really annoying. I’d hate to think that health care plans like this actively discourage people who might need this sort of help and don’t have the extra cash lying around.

  29. 29
    Violet says:


    I can’t find out what various medical procedures will cost, or which provider will be least expensive, because the only way anyone can tell me what something will cost is to send in their bill to my insurance companies and wait to see what they say. And what they say can change from time to time, and apparently no one knows why.

    This is true. A year ago I spent two full days trying to find out how much a CT scan of the sinuses would cost. I could not find that out. It simply was not possible. I remember talking to the insurance specialist at the practice and saying, “If you were me and were getting this procedure done and wanted to know if this was going to cost $1,000 or $100 or some other number, what would you do?” And she simply had no answer. She was kind of upset about it. She just didn’t know what to tell me.

    This year I called my insurance company to find imaging places in-network for the above-mentioned thyroid ultrasound. Hilariously the person on the phone couldn’t even tell me what imaging centers in a certain area were in-network. Seriously. She It was astonishing. I was on my laptop and googling “imaging centers” using Google’s map feature and reading them off to her and having her check them. That’s how convoluted it was.

    After we found a couple I tried to get her to tell me how much the thyroid ultrasound would cost. She had no idea. She told me to call the centers and if they couldn’t tell me I had to ask them to call a third party, who would then find it out and then I had to call the third party back to see what they found. It’s fucking nuts. That all took me about four hours.

  30. 30
    Calouste says:


    You also don’t have a lot of choice with purchasing health care. You can live without a toaster, you literally can’t live without antibiotics if you have a serious bacterial infection.

  31. 31
    raven says:

    What is the point of icing a MOHRS surgery site when there is a big ass bandage over it.

  32. 32

    @Stella B.:

    My dad’s kidney failure killed him before the COPD or the tumors on his kidney and liver, but they still needed to know about those tumors since it affected his dialysis.

    Also, I’m very opposed to not telling patients their entire health history. I’ve heard way too many horror stories of people being blindsided by a terminal illness their doctor decided they didn’t need to know about.

  33. 33
    Violet says:

    @raven: If you ice for long enough the cool should go through the bandage and shrink the inflammation and aid healing. How long did they tell you to ice? I mean how long at one go? 10 minutes? 15? 20? It’s on your face, right? That might be slightly less because of more delicate tissue than on, say, your leg, which should be about 20 minutes.

    Icing helps. Keep it up.

  34. 34
    Baud says:

    @Mnemosyne (iPhone):

    Agree. Although I think the debate is about screening protocols rather than the ethics of hiding known information from patients.

  35. 35
    Violet says:

    Richard, @ top:

    We don’t have the discussion that an 87 year who is already fairly frail probably won’t make it to 100 so we should not care about things that will kill them when they turn 100.

    We sure do have that discussion. It’s called “death panels” and we had it plenty, led by Sarah Palin, when the ACA was being discussed.

  36. 36
    Chris T. says:

    @Betty Cracker: Why, Betty, whatever do you mean? I live in a Republican Paradise state myself, and everyone here waits for the hospital to have a sale on kidney transplants, and only then goes in for the operation.

    ‘Scuse me, I see there’s another craniotomy discount in effect now. :-)

  37. 37
    Calouste says:


    Ok, I’m talking about two different scenarios. The first is the current HDHP implementation, where I am on the hook for the first $5000 (example number). The second is an alternative implementation, where I still have a $5000 deductible, but that only kicks in after the first $5000 for the year has already been paid by the insurer.

    In both scenarios, I expect $6000 in medical costs in the year, without shopping for treatment, but I might find savings if I shop around. In the first scenario, I would have to pay the first $5000, but the next $1000 would be paid by my insurance. Now, for it to make sense for me to go shopping for treatment in this scenario, I would need at least $1000 in savings, because the insurance pays the last $1000 anyway. In the second scenario, I pay the last $1000 (and my insurance the first $5000), so it makes sense for me to go shopping because any savings up to $1000 is money I don’t have to pay, and only if I save more than $1000 it will benefit the insurance provider (at which point there is no longer an incentive for me to continue shopping, because I no longer safe any money.

    A solution could be to make the deduction 50% of the first $10,000, in which case there is only ways an incentive for me to shop around, because I will always safe money, and I will always safe the insurance company money as well.

  38. 38
    Violet says:

    @Chris T.: Did you see the Groupon for the heart bypass? Such a good deal!

  39. 39
    Baud says:

    If eBay and WebMD would merge, we wouldn’t have any of these problems.

  40. 40
    gelfling545 says:

    @Violet: GET TO THE DOCTOR. I got bitten by my own tiny dog trying to keep her from going after another dog (she loves people; other dogs are the enemy) which left a mark the size of a pencil point. I washed it out, put antibiotic ointment on it, etc. It hurt. A lot. Within 2 days I was in unbelievable pain. Even after oral antibiotics it took about a week to control the infection & I still had to have surgery to drain the area along with pain such as I have never experienced. I lost about 50% use of my right index finger. You need to have it looked at at once. It may be nothing so dire but do not take the chance.

  41. 41
    Chris T. says:

    @Violet: Yep, I had that same sort of thing happen.

    I was on one plan, had a recommendation to go get a CT (cervical spinal), called several places to find out what it would cost on my then-current insurance (change of insurance due to change of jobs in progress at the time). It took a lot of calling and questioning, but I did actually get some numbers. Base price was something like $5k, with insurance knocking it down to about $700.

    Got the new insurance, called again, got new and different costs. It turns out that with the new insurance, the CT cost a lot more, but got knocked down a lot more, with the end result being that I paid less, at the place I ended up going to. The base price was now over $6k but insurance knocked it down to $500, and then there were some mystery add-on fees that brought it up to $600.

    (PS: base prices above are serious guesses, I don’t remember them well at all; it’s the end price that I remember)

  42. 42
    Violet says:

    @gelfling545: Thanks. Did your dog bite bleed? This one did not. Mostly scratched except this one teeny pinprick mark that might not even be from the dog. It’s sore right now but it’s also bruised and swelling so that’s part of the pain.

    Ugh. It’s Friday. I can’t get in to see a doctor unless I go to an ER type place. Ugh again.

  43. 43
    raven says:

    @Violet: 15 minutes three or four times today. I held a bag of peas on and around it. This is just such a thick compression bandage but I guess it did get cold after a while. It is on my mug, 2 weeks out of the water!!!!

  44. 44
    🚸 Martin says:

    The primary problem with ‘doctor shopping’ is that the vast majority of people blowing enough money to make shopping worthwhile are in no position to go shopping as most of them are either unconscious or about to bleed out. When my daughter’s appendicitis took off, how many hospitals was I expected to visit with a screaming little girl before I settled on a price or she died from infection from a burst appendix?

    Free markets require time to operate. ‘Time’ is one of the principle variables on which cost is determined. You want your package today, that’s $8. You want it next week, that’s $2. Health care sometimes affords time, sometimes doesn’t, which is why Medicare is split into A&B, hospitalization and doctor visits (why we started with Blue Cross, and Blue Shield – hospitalization & preventative care). As a general rule you can afford the time to shop on B, you can’t on A. Until we learn how to treat these two health care components separately, we will always have this failed debate. Other nations do. In fact, we do as well within Medicare. But only there. Nowhere else. ACA unfortunately doesn’t help on this front.

  45. 45
    Violet says:

    @Calouste: I see where you’re coming from but you’re forgetting that when you pay the deductible you pay that out of pocket right now. That is your money. You have to come up with it. I had to do this for the thyroid ultrasound so I shopped around. The place I’d been going, which was in-network, was $149. Another equally as convenient place, also in-network, was $95. That’s a massive difference percentage-wise. I chose the $95 one. Because that meant I didn’t have to come up with the other $54.

    Do most people have an idea of how much they’ll spend per year? I don’t. I can guess how many times I’ll visit a doctor but if the insurance company or plan is different I can’t guess at my out-of-pocket contributions to each doctor or procedure because that sort of thing is not divulged. It’s a guess as to the contracted rate and your part of that.

  46. 46
    Egypt Steve says:

    @Violet: Reminds me of a story about a guy who got bitten by a dog. At first he didn’t think anything of it, but when it didn’t heal after a couple of weeks he went to the doctor. The doctor tested him, and sure enough, he had rabies.

    So when the doc gave the guy the news, the guy asked for a pad and pen and started writing furiously. The doc says to him — “you know, maybe it’s not so bad. I wouldn’t start making my will just yet.” And the guy replies: “I’m not making my will. I’m making a list of people I want to bite.”

  47. 47
    Violet says:

    @raven: My dad had Mohs on his foot. They told him to ice for the first day or so. It helped. He had a huge bandage too. He had a skin graft.

    You don’t want to be in the water with that. Don’t take any chances. Let it heal.

  48. 48
    raven says:

    @Violet: I know :(

  49. 49
    Violet says:

    @Egypt Steve: Har har har. The neighbor assures me his dog has his shots up to date. He was adamant about that. Should I trust him?

    Fucking dog, biting me through the fence. How the hell does that happen?

  50. 50
    Violet says:

    @raven: Did they give you painkillers? By tomorrow it might hurt enough that you don’t want to swim. Take it easy. Let your body heal.

  51. 51
    Pogonip says:

    @Violet: Thirded. I HATE shopping.

  52. 52
    raven says:

    @Violet: Yea, the hydrocodone/acitam 350. I ain’t crazy about them but the last time I got cut they really helped me over the hump.

  53. 53
    Pogonip says:

    @Violet: Shoot the dog, reverse the shotgun and whap your idiot neighbor upside the head with the butt end, and listen to the cheering from the rest of the neighborhood.

    More seriously, file a police report, or report with Animal Control, however it’s done in your town, and see a doctor ASAP. A dog’s mouth is not clean (remember, they like to eat poop) and you could get infected.

  54. 54
    A Humble Lurker says:


    Should I trust him?

    Gonna go with a big fat no on that one.

  55. 55
    sam says:

    @🚸 Martin: Also, when it comes to health care, people are not necessarily incentivized by the free market to go to the least expensive service provider. It’s not like buying widgets. A cat scan may be a cat scan, but you can be darn sure that if I need heart surgery, to the extent i can get the information (and I’m not actively having a heart attack!), the info I care about is going to be things like patient outcomes rather than bottom line cost.

    Case in point. My mother went to a very good doctor affiliated with an excellent hospital in NYC. She was diagnosed with liver cancer and given a six-month prognosis. A friend who had connections then got her in to see the best doctor specializing in that type of cancer in NYC affiliated with MSKCC. Turns out she had an extremely rare (like, less than 10 people in the world at the time, rare) cancer of the neuroendocrine system that was localized in her liver. There wasn’t really any treatment for it, but through various “experiments” the docs at MSKCC kept her around for another seven years (and relatively up-and-about until the last year). And cost? Everyone in our family would take bets at the beginning of every year as to when she’d hit the threshold with Aetna where they started paying for 100% of everything. How do you even do a cost-benefit analysis for something like that?

  56. 56
    Violet says:

    @Pogonip: @A Humble Lurker: GAH. Seriously? I don’t want to deal with the fucking doctor. I didn’t have time to do it today and now it’s too late. It’ll have to be Urgent Care. And that costs money. FUCK.

  57. 57
    Mnemosyne says:


    I think I would be okay with asking patients to consent to not doing a particular screening anymore. There are probably a lot of women who might be okay with not having to get their annual boob-squishing mammogram if nothing has shown up so far and what they already have will probably kill them first. But IMO it should be up to the patient, with the doctor explaining why s/he thinks the test is no longer necessary.

  58. 58
    pseudonymous in nc says:

    There’s a place for consumerism in healthcare: it’s whether you want HBO in your room, fresh cut flowers by your bed every morning, the gourmet menu for meals. There’s no place for consumerism in medical treatment.

    Consider it a bit like economy vs premium air fares: skin in the game there doesn’t mean the cheap option is being strapped to the wing or shoved in the cargo hold.

    Skin-in-the-game arguments are abstract ideological bullshit from those who want to find yet another way to punish non-rich people for the temerity to get sick.

  59. 59
    Mnemosyne says:


    Can you leave a message with your doctor’s answering service and ask him/her to call a prescription for antibiotics in to the pharmacy?

  60. 60
    Mnemosyne says:

    Argh! Can I please be freed from moderation for daring to mention the type of store where Violet can get antibiotics?

  61. 61



    Tetanus shot. Antibiotics. Ask the neighbor for the dog’s vet’s name and call yourself to verify the rabies.

    My dogs spend all their time licking their assholes. Dogs mouths are NOT clean.

  62. 62
    Pogonip says:

    @Violet: File a claim against your neighbor’s homeowner’s or renter’s insurance and they’ll reimburse you (you’ll need the police or animal-control report).

  63. 63
    Violet says:

    @Southern Beale: My tetanus is up to date. September 2008.

    I’m going to reiterate. It did not break the skin except maybe this one tiny, tiny place. So small I almost didn’t notice it. Could be from something in the garden–I’ve been out working there every night this week. My leg is scratched from the teeth. No blood spilled anywhere. Does that warrant the hyper-vigilance? If so, why?

    I don’t like antibiotics. They mess me up. I want to avoid if at all possible.

  64. 64
    Trollhattan says:

    @Southern Beale: Agreed. And medical expenses to be picked up by the neighbor.

  65. 65
    pseudonymous in nc says:


    A year ago I spent two full days trying to find out how much a CT scan of the sinuses would cost. I could not find that out. It simply was not possible.

    That’s because the bullshit amount that gets billed is made up after the fact in order to calculate the bullshit insurance discount to get to the number they really want, oh and don’t forget the other five line items that nobody will tell you what they are and are coded under “Squirrel!”


  66. 66
    Trollhattan says:

    @Violet: FWIW rabies can be transmitted by saliva.

  67. 67
    Violet says:

    Okay. So what should I do now? Go to the doctor? Call the police? Call animal control? What should I do and in what order?

    The neighbor isn’t right next door. It’s several streets away–I was on a walk. I know which house it is but I didn’t get his name. A friend was with me so she can corroborate the story if necessary.

  68. 68
    A Humble Lurker says:

    My philosophy on dog bites is treat every one as if the dog has not had shots, no matter what their owner says. They could be lying or wrong or have missed something.

  69. 69
    Violet says:

    @A Humble Lurker: So you get the 14 day series of rabies shots no matter what the owner says?

  70. 70
    raven says:

    Get the shit bit out of you by a cat and then come see me about dogs.

  71. 71
    raven says:


    Anyone who has been bitten by an animal, or who otherwise may have been exposed to rabies, should clean the wound and see a doctor immediately. The doctor will determine if they need to be vaccinated.

    A person who is exposed and has never been vaccinated against rabies should get four doses of rabies vaccine – one dose right away, and additional doses on the third, seventh and fourteenth days. They should also get another shot called Rabies Immune Globulin at the same time as the first dose.

    A person who has been previously vaccinated should get two doses of rabies vaccine – one right away and another on the third day. Rabies Immune Globulin is not needed.

  72. 72
    Mnemosyne says:


    When my brother’s cat bit me, they gave me a quadruple antibiotic that included Cipro. You know, the stuff they give you if you contract anthrax. IIRC, cat bites are actually more likely to get infected than dog bites — the ER doctor’s explanation was, More slobber with dog bites.

  73. 73
    raven says:

    @Mnemosyne: Damn right, nasty little killers.

  74. 74
    gelfling545 says:

    @Violet: No it didn’t bleed. A dog bite is considered enough of an emergency to go to an ER but if there is an immediate care place near you I’ve found them quick & thorough. And even though I knew my dog had her shots, rabies is not your only or even most likely possible complication. Really, don’t wait. Also ask your neighbor for proof of vaccinations or dog license. Tell him you doctor wants to see it, so there’s no question. You probably will get a tetanus shot, though, unless you are up-to-date.

  75. 75
  76. 76
    JustRuss says:

    The preventative steps are no longer just moral nagging (dropping 40 pounds might help your knee) but financial cost avoidance (dropping 40 pounds will help avoid/delay a knee replacement and a $5,000 bill you don’t want to pay).

    It must take a special level of obtuseness to believe that someone who isn’t motivated to care for himself to avoid the pain, inconvenience, and dangers of surgery will change his behavior over the possibility of being out 5 grand.

  77. 77
    Chris T. says:

    @Violet: It doesn’t really matter if the dog’s shots are up to date (well, it’s good for avoiding rabies, which really is pretty serious). The problem (as everyone else noted) is that mouths are full of bacteria. Most of these are pretty benign but a few are quite nasty.

    Your own skin also carries some bacteria on it (staph for instance, you can pick it up pretty much anywhere). (This is why hand-washing is so effective: after providing clean water to a community, getting the people in that community to wash their hands with ordinary soap, before/after doing various daily tasks—food prep and disposal of, er, “used food” being the big two—is the next biggest return-on-investment thing there is, in health care.)

    A puncture wound can force bacteria into a place where the subsequent battle (between your immune system and the invading army, as it were) leads to problems. The main warning sign is redness, heat, and sometimes pain. If you get any of those, you may need the wound drained and antibiotics applied, possibly even IV. The chances that you need this are not very high, but if you do need it, you really need it. It’s usually easier and more cost-effective to just get it—by “it” I mean surface-care and prophylactic oral antibiotics—done right away, than to wait and see if you need it…

  78. 78
    gogol's wife says:


    Those cats really are jerks!

  79. 79
    A Humble Lurker says:

    @Violet: As opposed to getting rabies? Yeah, pretty much.

  80. 80
    azlib says:


    Interestingly the Swedish study that was cited for years (if I recall correctly – no difference in survival at 8 years, differences started showing by 12 years) had a recent follow up article in the NEJM with 23 years of follow up where there was an advantage favoring prostatectomy over observation.

    I do not find this result all that surprising. I had prostate surgery 1 1/2 years ago at age 62. At this point with an undetecable PSA I am basically cured. If I had been 10 years older, I suspect I would opted for observation since surgery and the potential side effects are no picnic. The whole life expectancy angle is a tough conversation for a physician to have with a patient and it takes a lot of effort to have a rational conversation when you have just had a cancer diagnosis.

  81. 81
    WereBear says:

    It’s not just a lack of perfect knowledge on the part of the patient. There’s also the lack of perfect knowledge on the part of the doctor.

    Case in point: I can get further help with my deductible if I take those health questionnaires my insurance has online. But I avoid them because, on paper, I’m a heart attack about to happen.

    For a dozen years I’ve eaten a high fat, low carb diet which helped me lose a lot of weight, and keep it off. My A1C and blood pressure is great. My cholesterol is “too high” in total, but the triglycerides and ratios are fantastic.

    I’m a medical paradox.

    I’ve heard of companies who fine you if you aren’t within certain health parameters. I’d be in trouble then. And what if they are wrong? They’ve been pushing polyunsaturated cooking fats for decades now… and the latest research indicates that was a big mistake.

    Assuming perfect knowledge in anything is perfectly stupid.

  82. 82
    Mnemosyne says:


    When was the last time you got your thyroid checked? I nagged MomSense into getting the full panel done on hers because she had persistently high cholesterol, and she said she turned out to be mildly hyperthyroid. So now I’m nagging everyone with unexplained high cholesterol to get their thyroid checked.

  83. 83
    WereBear says:

    @Mnemosyne: It’s an excellent nag, and I applaud you. I did have my thyroid checked… my doctor broke a record for amount of blood drawn for the tests he ordered, I kid you not. And it’s fine.

    However, it is a hormone issue that can be driving up my cholesterol… cortisol resistance. And I’m responding to treatment. So when things settle down, I’ll get tested again and see what happens.

    But in any case, I’m not worried about that at all… I don’t believe the evidence supports the lipid hypothesis. Which means it’s really Syndrome X: cholesterol is high when inflammation is high. It doesn’t cause the problem… it’s trying to fix it!

  84. 84
    Bill Arnold says:


    At this point with an undetecable PSA I am basically cured.

    Curious story: My father (who hated going to the doctor), 10 years after his prostrate removal (for cancer) had a hunch and asked (insisted on) a PSA test, though the doctor insisted that it wouldn’t show anything because “undetectable PSA”. It showed a high level (somewhere between 10 and 20). They confirmed a recurrence through some other means, and the recurrence was successfully treated with radiation. (No clue what the correct testing protocol is in such a case.)

  85. 85
    TF79 says:

    I dunno, not bothering to shop around because it’s a massive pain in the ass sounds pretty rational to me

  86. 86
    Mnemosyne says:

    In health-related news, all of the over-50s here who’ve already had their colonoscopies managed to talk me down from being freaked out about the prospect, so that’s good. It even turned out that MomSense and I will be long-distance colonoscopy buddies that week. ;-)

    The big things I’m probably going to be doing to prep for the prep are get some extra exercise the week before (including yoga that focuses on the digestive system) and switch to a low-fiber/low-residue diet, which is gonna be weird. I don’t think I’ve had white bread in 10 years.

    ETA: Yes, TF79’s comment above mine triggered the thought. Because I am 12 years old forever.

  87. 87
    satby says:

    Violet, which state are you located in? You can check if there’s been rabies reports in your area. It’s better to be safe than sorry, but from what you’re describing I’d wash, peroxide, neosporin the wound and see how it is tomorrow. If it was me, YMMV.
    Human bites are more bacteria laden than dog bites, and cat bites really are the worst. If you do go to the Urgent care (and that’s not a bad choice, just sayin) they probably will report the dog bite as mandated reporters anyway.

  88. 88
    MomSense says:


    I hate shopping, too! Of course I have to do it sometimes. I need to take my son school shopping this weekend which I am dreading. I would brave crowds for a good exhibit at a museum or a concert but malls are the worst. Just buying more stuff is not appealing at all.

  89. 89
    jl says:

    Thanks for another very good and useful post. ‘Consumer driven health care’ has been used in so many ways for so many purposes, that it is good to read about one of the principal, but unspoken (at least to the average person), rationales for one version of that buzzword.

    At the risk of being a cynical economist, I think consumer driven health care also goes along with the idea of ‘personalized care’ and very detailed specialized products, which is a way to rake off more consumer surplus from the patient.

    On the other hand, if very regular dosage of a drug is important in controlling a chronic condition and preventing adverse events, getting to a one pill a day product is a big benefit for some patients, at least what I see from reading the literature. So that kind of product differentiation could be useful.

    So, this is a complicated issue that needs attention and close examination.

  90. 90
    revrick says:

    You know there’s a much more basic problem in health care as delivered here in the US than how well people do/do not make decisions. We’re dealing with two wildly different ethical systems! Health care is based on an ethic of care. Health insurance is based in an ethic of profit-making. Square peg, round hole.

  91. 91
    GHayduke (formerly lojasmo) says:


    I reached my OOP limit with treatment, so I’m going to get a bunch of nagging problems cleared up this year. I visited one of the practitioners today, and got a CBC, glucose, lipid panel HIV and HepC screens (I guess because I was a drunk, I am also assumed to be a slut) got a repeat liver ultrasound, scheduled a BLE duplex ultrasound and a referral to a vascular surgeon to assess a varicosity, and scheduled an appointment to have a nevus and a skin tag removed next year.

    Might as well, I guess.

  92. 92
    Rekster says:

    @Violet: Call Animal Control!

  93. 93
    Kent says:

    No one has mentioned the main reason to get a High Deductible health plan. Doing so allows one to open a Health Savings account (HSA) and contribute up to $6550 (2014 contribution limit) into the account. HSA accounts are a huge tax giveaway to the upper middle class and wealthy who can afford them because they are triple tax deductible in contrast to regular IRAs or Roth IRAs.

    When you contribute to an HSA the money you contribute is tax deductible. In fact, if you do it through payroll deduction, even the medicare taxes are deductible. What this means for a typical wealthy professional in the 33% tax bracket is that a $6550 contribution to an HSA allows them to get back an additional tax refund of $2161.50 which alone practically pays for the entire deductible on an HD health plan. In fact the tax refund more than covers the deductible because we are comparing the HD deductible to a standard plan deductible, not to no deductible.

    So the owner of an HSA has a nice little tax-free account he can dump about $6500 into every year tax free. But it gets better. As long as withdrawals are for medical reasons there is no tax paid at the withdrawal end (unlike say a traditional IRA). And they let you store up your medical expense receipts year after year and then take the money out later. So one can say…pay $1000 in out of pocket medical expenses every year from ordinary accounts and not touch the HSA, just save the receipts. Then in 10 years one can withdraw $10 grand from the account tax free and use the money for a trip to Europe or whatever.

    Finally, after one retires one can take money out of the HSA for any purpose without penalty just like an ordinary IRA, or for medical purposes tax free.

    Point is, for the wealthy the HD medical plans are an incredible deal when paired with an HSA account because the tax payers are basically paying for your deductible and you get a nice completely tax sheltered account to dump money into when you have tapped out your other tax sheltering opportunities.

    On the other hand, if you can’t afford to do an HSA or are in a low tax bracket the HD plans make little sense and one would be much better off getting a traditional subsidized Obamacare plan.

  94. 94
    Fred Fnord says:

    @Violet: You will be fine. Don’t worry about it. The chances of a dog in the US having anything that could make you seriously ill (the obvious example being rabies) even WITHOUT shots is small enough that you might have more of a chance of being hit by a car on the way to the doctor’s office.

    This map is interesting, as long as you know how to read it. The red squares are all of the rabid dogs found in the entire country over the course of an entire year, including both domesticated dogs and feral dogs. Each red dot is one dog. That is out of about 80 million pet dogs (and I have no idea how many feral dogs). (Notice there are a lot more cats? Partly that’s because there are more feral cats, and partly it’s because people don’t get rabies shots for their cats.)

    4.5 million people are bitten by dogs in the United States. On average 1 to 2 people die of rabies in the US each year. In comparison, on average, between ten and fifteen people are killed by vending machines each year. But ten thousand people in the US get rabies shots each year, with probably over 99% of them being unnecessary. Nobody seems to ever get vaccinated against vending machines.

  95. 95

    […] Problems with consumerism in healthcare » Balloon Juice […]

  96. 96
    Nutella says:

    The company I used to work for tried the high-deductible plans a few years ago. The idea that people will use medical care more intelligently when they’re paying for the first $1000 themselves sounds good but what really happened was this: Employee hurt his foot, perhaps a sprain or a break, who knows without a doctor checking, right? He decided to wait and see and walk through the pain because the idea of paying hundreds of dollars in case it was bad seemed unreasonable. So of course it got worse and cost more to fix.

    Add that to the fact many noted above that no one can or will tell you how much any medical thing will cost before it’s billed, so every time you walked into a doctor’s office you risked spending all of the deductible.

    That’s why it’s so sensible for the ACA to have no-copay on diagnostic and maintenance services — people will go to them, then, and overall costs are lower.

  97. 97
    The Pale Scot says:

    @Southern Beale:
    But the idea of having to compare prices and plans and what gets me the most value,

    And there is no way to confidently find out who the “good” doctor is, I trying to find a good surgeon to have my foot remodeled, And other than whether they’re being sued, there are no records of a surgeon’s success rate, especially for something as variable as this procedure.

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