A few weeks ago, my wife and I spent our Friday night waiting for test results in a cold exam room that reeked of ammonia. In a kennel at our feet, Jixie, our oldest cat, meowed pitifully and licked the wounds of a fresh blood draw. We were both worried and neither of us felt like speaking. Between us, Jixie meowed again. She had been sick for a few days, barely eating, and vomiting up copious amounts of mucus. She looked like a skeleton with hair pasted to the bones, and when she walked, she stumbled around as if she were drunk, and paused every few steps to catch her breath. She had been sick before, and we had taken different approaches to the level of care we thought she needed. But this time, there could be no doubt—we needed help.
The vet entered the room with a smile and a packet of papers. These, she explained, were the results of the tests they had done thus far, and a breakdown of the costs of all the interventions and diagnostics that might be necessary. The sticker shock was immense, and as we looked through the itemized list, a lump began to rise in my throat.
We couldn’t afford it and hard decisions had to be made. The diagnostics she had requested were all logical, and if Jixie were a human they would already be underway without consultation. But because she was an elderly, uninsured cat, we were forced to actually grapple with how much money and effort we were willing to expend. It was gut-wrenching, but our financial situation left us with no choice—her care needed to be rationed, and we had to decide how much risk we were willing to tolerate.
To a non-medical person, this choice would have been insultingly futile. How could a layperson be expected to know enough about medicine to make a truly rational choice? With my medical background, I was able to ask the right questions and together, me, Hannah, and the vet decided on a plan. We would give empiric antibiotics, but we refused culture and susceptibility testing. We refused ultrasounds of the kidneys and gut, with the understanding that we couldn’t afford to do anything about these problems if they were found.
Thankfully, our gamble paid off and she recovered completely with the antibiotics, but the episode left its mark on me. Even under a perfect system where patients are educated enough to make informed decisions, have complete control of what is ordered, and have enough money to cover the minimum costs that might arise, we still struggled to make the right choices and ended up spending much more money than was necessary. This was frustrating to us as individuals, but even more frustrating when I projected it on to society at large. Too often patients and doctors are unaware of the costs of the medications and diagnostics they prescribe, and a simple ‘peace of mind’ exam may wind up costing a patient thousands.
Some have argued that the solution to this problem is transparency and that if patients could see the price tag they would shop around and let the free market sort it out. I am sure this might work in some areas, but a BMP and a CBC are not like Nike and Sketchers. They have specific indications and the information they provide matters depending on the context. Even set up with the ideal scenario that night at the vet, I still made choices that resulted in inefficient and over-expensive care, and if expanded to medicine at large I don’t see how this would improve the state of healthcare.
The transparency that allowed us a modicum of control over our situation nearly drown us in choices. This model of healthcare, where patients are presented with the costs upfront and chose each test as if it were a menu, is impractical and is likely to lead to inefficient and lower-quality care. However, this experience has taught me the value of well informed, doctor-patient communication. The most critical component of this interaction was an honest discussion of our goals and the lengths we would be willing to go to achieve them. As team, we had to decide how much risk we were willing to accept, and what degree of certainty that we could find tolerable, and from these first principles, someone with medical expertise is required to translate these wishes into action. Therefore this transactional model of healthcare is unlikely to replace the traditional doctor-patient relationship anytime soon. Patients need to depend on their doctors to make informed decisions on their behalf so as the future of healthcare unfolds, new solutions will need to focus on making doctors more aware of the costs to the care they provide.