Recently my husband had some health issues, so we had to deal with the medical system. There were some aspects I found baffling and irritating, but cheap. Others made sense, but were expensive.

Just to clarify: I straddle two worlds, the “complementary/alternative” health system, and the “standard biomedical” system. Both my husband and I have health insurance, with separate entities. Still, if there is some “alternative” practitioner we want to see, and is not covered by insurance, we pay out of pocket, as we refuse to be enslaved by the insurance system.

For the issue in question, we fist decided to go see an alternative practitioner. When I made the appointment, I was clearly told that a) how much it costs; and b) no insurance accepted. So we made our decisions accordingly.

Next we went to a famous standard medical institution, to review the situation. We were told that our insurance was accepted, not to worry. We were not told how much anything costs. I assume the mindset is - after all, insurance was paying, why should we care?

Then, during one visit, they decided that my husband’s heart rate was too low (it’s always been low, they didn’t ask) and he had to be admitted for “observation.” Nothing was said about costs, no questions asked. So Bernie was admitted to the hospital; they did all kinds of tests, didn’t find anything particularly wrong, and with some hesitation (his heart rate was still low) he was let out the next day when I went to get him. Then I saw the bill that was sent to insurance: more than $6,000! I still don’t know what, if anything, we have to pay on this bill. Sometimes they take months in letting you know if it is all covered or not.

This got me thinking. If I had been responsible for the payment, I would have expected advance notice of what they were planning to charge me for – how much for the tests and which ones, how much for the medications, how much for specialists. I would hope to have a choice here – no, I don’t want that medication, no, I don’t want that test, but I do want this other one. But the system assumes that all “patients” are totally ignorant, have no way to judge what is needed and what not, and therefore should be “treated” with no feedback. “Patients” are expected to be “good,” that is, they should accept everything with no worries and do as they are told – to be “compliant.” That is what is expected. Interestingly enough, research shows that there are good reasons why patients do not do as told. See the abstract below from a 2009 research paper:

A large quantity of research concerning issues of patient compliance with medications has been produced in recent years. The assumption in much of this work is that patients have little option but to comply with the advice and instructions they receive. Studies have shown, however, that between one third and one half of all patients are non-compliant, but different authors cite different reasons for this high level of non-compliance. In this paper, the concept of compliance is questioned. It is shown to be largely irrelevant to patients who carry out a ‘cost-benefit’ analysis of each treatment, weighing up the cost/risks of each treatment against the benefits as they perceive them. Their perceptions and the personal and social circumstances within which they live are shown to be crucial to their decision-making. Thus an apparently irrational act of non-compliance (from the doctor's point of view) may be a very rational action when seen from the patient's point of view. The solution to the waste of resources inherent in non-compliance lies not in attempting to increase patient compliance per se, but in the development of more open, co-operative doctor-patient relationships.

So it seems to me that the “cost/benefit” analysis is something that patients do automatically – but are not allowed to do when “insurance pays” because there may be not costs to them. So who actually “pays”?

Here is the conundrum of insurance. I’ve written about this before, but have been loudly ignored. However, I won’t repeat what I’ve said before, but take another tack.

Health insurance is paid for by those who buy it. If enough people buy in, there will be enough money to pay for the medical costs of a few, with enough left over to pay the officers and staff of the insurance companies. The cost of it goes up every year – they have asked for a 12.7% raise in 2012 premiums. Nice raise. Most people do not get that kind of salary raise. The rationale is that their costs have been going up a lot – well, duh! Do they question the bills, other than refusing to pay some?

Twenty-five years ago I had no insurance. I didn’t want to buy it as it was too expensive for me. People freak out – what if something happens? Well, what if nothing happens? If something happens and insurance pays, you feel you got your money’s worth. But if nothing happens, you’ve been paying out all those premiums – don’t you feel you’ve wasted your money? Well, I do. The risks are you either pay and all you get is “peace of mind”, or you don’t pay and you take the risk yourself. Most of the time that worked out fine for me, as I didn’t have the money to pay for something I was hardly ever using anyway. But one time I had a strange thing in my throat and I ended up at Manhattan Eye and Ear (and throat). I was there for four days. They finally realized I had no insurance; I told them not to worry, I would pay the bill myself. So they sent me a bill for $3000 (this was 1988, mind you). I wrote them back and asked for an itemized bill, which they duly sent me. I looked over the bill carefully – ah, this treatment I didn’t have, this I didn’t take, this is erroneous – sent the bill back with questions. Got back a new bill, $2000, no answers, no comments. I paid off the $2000 over a year and was done. And I felt I had gotten my money’s worth, was perfectly happy with the results, and much the wiser about health care costs.

Now with all the complaints about the rising costs of health care, the one element no one seems to be looking at is the input of the patient. First of all, the consumer, or “patient,” should be told up front what will be done and how much it will cost, regardless of who pays. Then the patient should have some say and be part of this “cost-benefit analysis.” The insurance companies should work with patients to review the bills and see if they are correct. I am mystified as to why they don’t do that automatically. Don’t you think they should? Hi, Mrs. Jones, the hospital sent us a bill for this much, do you recognize the charges? If she doesn’t know, she can say so. But if she was awake and paying attention, she could give some feedback that would be useful to the insurance company and perhaps lower the bill.

There must be a reason why this doesn’t happen. There must be politics, or kickbacks, or rewards of some kind for this to not happen. We the customers, the “consumers” of health care, will probably never know the back-deals and the secret handshakes. But we pay for them when we pay our premiums.

One of the stranger provisions of the national health care bill that was passed during the last Republican administration and ratified during the health care reform of 2009 was that the US government, and Medicare in particular, is NOT ALLOWED TO NEGOTIATE drug prices with Big Pharma. (http://www.huffingtonpost.com/2009/08/07/white-house-confirms-deal_n_254408.htm) What a deal! The US Government is obliged to accept any price the pharmaceutical industry sets for its products – even if they sell them cheaper in other countries, which they do. And as drugs are the number one health care product, insurance companies and the US government are held hostage to this industry.

So what to do?

That is totally up to you. I choose to use the “alternative” systems and avoid the biomedical system as much as possible; sometimes it is helpful and I have used it, and then I am willing to pay a fair price for their procedures and products. Other times they give you mostly problems and side effects. All I ask for is increased transparency regarding costs. But let’s be clear on this one: we consumers are just cash cows for a huge industry that includes physicians, hospitals, pharmaceutical companies, and their corollaries, which on the whole doesn’t give a flying fig for its customers, only for the money they bring in. Individual practitioners and physicians are often kind and caring – we’ve met many of those – but they too are caught in this huge roller coaster. Years ago I knew the daughter of a pharmacist, and she was studying with me. She mentioned her father used to say, “Drugs are for selling, not for taking.”

As it’s said in the vernacular, caveat emptor, that is, buyer beware. We need to be clear and conscious about what we are choosing to do for our health, and how we will take care of it. This includes taking care of what we eat, and using only those products and services that we personally feel good about taking, whether mainstream or alternative.

Here is a refreshing smoothie for the fall –

FALL SMOOTHIE

2 cups mixed ripe organic fruits (e.g. peaches, strawberries, apples), cut up
1 cup apple cider
1 tablespoon organic lemon juice with a little zest
1 cup cold filtered or mineral water

1. Put all in the blender and whizz for a few minutes until smooth. Add more water or juice if needed to get desired texture. 2 servings.

REFERENCES:
¹Patient non-compliance: Deviance or reasoned decision-making?” Social Science & Medicine, Volume 34, Issue 5, Pages 507-513 - Jenny L. Donovan, David R. Blake - 2009