Peter A. Ubel—
I had a persistent skin condition, and my dermatologist thought I should see someone with more experience caring for that kind of lesion. So, I went to a new dermatologist—I will call her Dr. Freezeitoff. At the front desk, the clerk reminded me that Dr. Freezeitoff wasn’t in my insurance network, and therefore I’d have to pay for my visit out-of-pocket, as little as $180 and as much as $250, depending on the length of the visit.
Dr. Freezeitoff was great. She had some new ideas about how to treat my condition. The visit wasn’t very long, but it didn’t feel rushed either. She injected my lesion with some medication and then zapped it with liquid nitrogen, the injection and zapping adding maybe two minutes to the visit. I expected that meant I would come out on the higher end of the clerk’s estimate, probably $250 or so.
But I was charged more than $400. The difference in cost was all related to the three minutes of zapping. There is an idea, quite popular in the US these days, that if we expose patients to higher out-of-pocket costs, they will respond as empowered consumers, demanding low-cost, high-quality medical care, thereby helping the country rein in soaring healthcare costs. My visit to this well-intentioned dermatologist illustrates one of the flaws of this idea of consumer empowerment.
Dr. Freezeitoff didn’t mention that the treatment would cost me a couple hundred bucks. And of course I hadn’t asked what the treatment would cost when she gave it to me. I suspected, at the time, that my out-of-pocket expenses were about to rise. I’ve written about and studied this topic for years. But I didn’t have the nerve, the chutzpah, to slow down her treatment momentum and inquire about the cost of the care she was about to provide me.
In some ways, my appointment with Dr. Freezeitoff was a model of economic transparency. Because the clinic was out-of-network, the clerk knew, up front, that I’d be responsible for the cost of the visit. She gave me a responsibly tight range for the price of my visit, and I was free to tell her that the price was too expensive and walk out of the clinic before seeing the doctor.
The US healthcare system would benefit from having the kind of price transparency I experienced when I checked in at Dr. Freezeitoff’s office. Too often, patients don’t receive that information in time for them to decide whether to receive care.
Unfortunately, the end of my appointment falls in line with the more typical American healthcare experience. Even though Dr. Freezeitoff knew I was out-of-network, she gave me an expensive treatment without asking whether I wanted to pay for it. In fact, part of the treatment she gave me was a no-brainer: a medication my previous dermatologist didn’t use in her practice. I would gladly have paid to have that medicine injected into my lesion. But the next part of the treatment—a couple seconds of liquid nitrogen—Dr. Freezeitoff added that almost as an afterthought, saying “this might help, too.” That cost me an extra $132. At my other dermatologist, the cost of freezing my lesion would have been subsumed under my modest co-pay.
To rein in healthcare spending, we need to discuss healthcare costs early enough in the course of care for patients to decide whether, or how, to spend their precious dollars.
Peter A. Ubel, M.D., is the Madge and Dennis T. McLawhorn University Professor of Business, Public Policy, and Medicine at Duke University.