A pair of recent articles on Kaiser Health News provide a first-hand account of Canadian and US healthcare following a nasty bike wreck. Michelle Andrews was in Canada last summer when she hit a patch of gravel on her bike and found herself in a Canadian emergency room. They patched her up, but her injuries were significant enough that the recovery process is ongoing, and she’s had to endure surgery on both her thumb and shoulder back home in the US.
Michelle writes about the differences between the US and Canadian healthcare system, including the fact that in the Canadian ER she was x-rayed but didn’t get a full body CT scan as she likely would have if she’d been taken to a US emergency department. But the x-rays missed a few fractures in her pelvis and femur, and those were discovered on a subsequent CT scan done once she returned home (she notes that patients in emergency rooms in the US are twice as likely to get CT scans when compared with patients in Canada). That would seem to be evidence in favor of doing more CT scans, but it turns out that the prescribed treatment for hairline breaks and fractures like the ones Michelle had is simply rest and exercise (this was what the Canadian docs had recommended based on their assumption that her hip/pelvis injuries were soft tissue damage). Knowing about the fractures didn’t change the course of treatment. And CT scans are a lot more expensive than x-rays. Obviously this is just one case, but it would be interesting to know how often CT scans detect fractures that wouldn’t show up on an x-ray but that don’t need specialized treatment in order to heal. In those cases, is knowing about the fracture worth the cost of the scan?
I found this section of Michelle’s story particularly interesting:
“Advocates of consumer-driven health care argue that patients make smarter decisions if they have more financial skin in the game. For my part, I don’t think having to satisfy a $1,500 deductible and then 20 percent of the charges for most subsequent care made me a wiser consumer. Lacking evidence-based data, I had no way of judging whether I needed the surgeries, or the MRIs and the CT scan. I was just worried about being able to function again, and I opted for the more aggressive treatments.
I do know that all this care will make me poorer, for sure, to the tune of several thousand dollars. I’m grateful that I could make my decisions based on what I thought made sense medically rather than on what I could afford. Many people are not as fortunate.“
I’ve long been a fan of high deductible, HSA qualified health insurance policies (our family had one until very recently when we switched to a high deductible plan that isn’t HSA qualified but has much lower premiums). But I’ve also always been aware that we’re fortunate to be able to utilize a high deductible health insurance policy – both in terms of being healthy and not needing much in the way of healthcare, and also in our ability to make contributions to our HSA to cover the cost of care we might need in the future. People who have serious health conditions and/or those with very limited funds (and thus no realistic way to cover the high out-of-pocket costs that go along with a high deductible health insurance policy) probably find high deductible plans to be much less useful.
Although high deductible health insurance policies have become increasingly popular over the last several years, the driving factor behind that trend is most likely premium increases. The push towards so-called “consumer-driven” health insurance policies is ostensibly aimed at encouraging patients to make better decisions and be better “consumers” when it comes to their healthcare. But from the perspective of the individuals who are shopping for health insurance, a higher deductible means lower premiums every month. That motivates a lot of people – especially those who are facing a large rate increase on their traditional, lower-deductible policy – to opt for the higher deductible.
When it comes to actually being a savvy consumer of healthcare, the vast majority of us wouldn’t even know where to begin. Google? Asking friends? Maybe, but chances are, we’re going to go to a doctor and follow (at least roughly) the recommendations the doctor makes. Most of the time, providers are the ones who control how much care a patient receives ie, it’s the supply that’s driving things, rather than the demand. We might know that something’s not right and take the initial step of going to the doctor. But what happens next (surgery? PT? wait and see? Medication? etc.) is generally up to the doctor. As Michelle pointed out, the patient’s number one priority is going to be getting better, especially if the problem being treated is a serious one. Shopping around for the best price and poring over comparative effectiveness research data probably isn’t going to be high on most patients’ lists.