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$800 or your life?

Critical Decisions
From Peter Ubel, M.D.,  author of Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices Together.

No matter who is elected president in November, one thing is clear about the US health care system: patients will be expected to have more “skin in the game”—i.e., more financial interest in deciding what health care services to receive. Even before Obamacare was passed into law, insurance companies and even government payers like Medicare were increasingly requiring patients to pay a portion of their medical expenses, from routine checkups to emergency services. That trend is likely to continue no matter what happens to Obamacare.

Rita Volk, a busy college student, learned firsthand what it means to have skin in the game. She experienced a nagging sensation in her right ear, but ignored it for a while. Even though she felt like she was traveling in an under-pressurized airplane, Volk assumed the problem would go away.

But it persisted, and her primary care doctor recommended she see an ear, nose, and throat (ENT) specialist.

The clerk at the ENT’s office took Volk’s insurance information at check-in and swiped her credit card to cover the $35 co-pay. Volk was led to an exam room where a physician asked her a slew of questions before looking inside her ears. Then an audiologist tested her hearing. The doctors couldn’t find anything wrong, so she headed back to campus reassured about her health and hopeful that the pressure in her ear would soon abate.

A couple of weeks later, Volk received a bill from the clinic for $800. Not a bill, as in: “We sent an $800 claim to your insurance company and just wanted you to know we are waiting for their payment,” but, instead, a document stating her audiology test was “not covered by her insurance” and the clinic expected payment by the end of the month.

Not surprisingly, Volk was stunned. She had already spent $2,000 on insurance—money she and her social worker parents had scrounged together—and now the insurance company wouldn’t pay for the test?

When Volk called the insurance company, a clerk explained her plan “doesn’t pay for routine hearing tests.”

“But my test wasn’t routine,” Volk stated incredulously.

“Your test result was normal,” the clerk said.  “We only pay for the test when it is related to an illness or a problem, not when it is routine screening.”

“But I had a problem. That’s why they ran the test!”

“I’m sorry, but the test wasn’t indicated, so we can’t pay for it.”

Such is the strange world of health insurance. Volk’s insurance company, understandably concerned about increasing health care costs and striving to reduce unnecessary testing, had decided not to pay for routine hearing tests. That in itself might have been a reasonable decision. But how do they decide when a test is “routine”?

Because of the high cost of medical care in the US, many health care experts are calling for patients to have more “skin in the game.” If patients bear more responsibility for their health care costs, the experts contend, then they will become savvier consumers, thereby pressuring the system to become more efficient.

But, as Volk’s case illustrates, these experts are not accounting for the way most patients make their health care decisions. It was the ENT physician who ordered this test, not Volk. Patients cannot be expected to know when they need audiology testing.

Fast-forward eighteen months. Volk was nearing the end of her college career when her doctor, performing her annual exam, noticed a lump on her thyroid. He recommended an ultrasound.

The old Volk, the one from eighteen months ago, would have nodded along passively, doing whatever her doctor told her to do. The new one refused to get the test until he told her how much it would cost. The doctor didn’t know, but was confident it would be covered by insurance. And, he told her, the test was “necessary.”

She reluctantly agreed. And the ultrasound revealed a tiny mass: “Most likely benign,” her doctor told her, “probably nothing but an inactive growth. But you should get a biopsy.”

More tests? More expenses? All for what would turn out to be “probably nothing.”

“Is this test really necessary?” Volk asked once again.

“I don’t know if it’s necessary, but it’s a test I think you should get. On the off chance that this is something serious, you don’t want it to go untreated for six or twelve months. You want to nip it in the bud.”

But Volk wasn’t keen to nip anything. She wanted to graduate with enough money to put down a deposit on an apartment in Los Angeles, where she hoped to launch her career as an actress. So she refused further testing.

And that is where her story now stands. She graduated from college and moved to California. A small mass still sits on the right side of her thyroid. Probably nothing. Hopefully benign. But only time will tell. These types of potentially tragic endings show why the “skin in the game” approach isn’t the simple fix that many experts would have you believe.

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