Regular Maintenance

See if you recognize this typical scene, played out from time to time in workplaces all around the country.  One of your co-workers is late coming to work.  Upon his arrival, he meets the office’s quizzical looks with a verbal response that amounts to something like “Yeah!  My car had problems this morning.  I think I need a new…”.  I am willing to bet that most everyone has been on both the giving and receiving end of this exchange.

The next segment in the exchange goes something like this.  Everyone gathers around and discusses the problem.  Opinions fly as to what is exactly wrong, how much to pay, where the best place is to go to get the repairs done, and how to make sure that the mechanic doesn’t cheat.  Typically, there is a lot of varying ideas about the specifics.  “Take it to the dealer”, says one.  “No! don’t go to the dealer.  I know a guy.”, responds another.  “Check the internet first”, comes yet another bit of advice, and so on.  But there are really no differences in the general goal.  Everyone involved is trying to find the best value, the best repair relative to the price.  And every one of them is engaged and has knowledge that can be put to use.

Let’s be specific and consider the case where you need a new set of brakes for your Honda Civic.  A simple internet search with the search string ‘new brakes cost honda civic’ returns as one of the top hits a link to Civic Forums, where the same type of dialog happens in the medium of the chat forum.  For this particular repair, the generally agreed upon estimate of the cost is $150.

Also note that no one suggests that the owner file a claim with their car insurance.  No one even entertains the notion, since replacing the brakes is part of the regular maintenance on a car.  Everyone recognizes that car insurance is meant to hedge the risk of an accident that damages life, limb, and property.  Most people go through life hoping that they never have to draw on their car insurance policy.

Now consider another type of regular maintenance – maintenance of the human body.  The comparison between this activity and the situation described above is quite stark in the differences.

To begin, our natural shyness about the body tends to dissuade us from talking about the standard types of treatments we all need.  Few have the same enthusiasm for discussing trips to the doctor with their co-workers as they do trips to their mechanics.  But wait, you say, here is where the internet comes into play.  A person can set up an avatar, assume a cyber-identity, and maintain his personal dignity while getting answers to some of the more delicate questions that can be posed.  And this is absolutely true.  One need only surf the World Wide Web for a while to see that people are quite willing to discuss (and display) just about any matter concerning their body with the mask of anonymity that a computer account affords.

So then, why is there so very little general knowledge about how much various medical treatments will cost?  And what questions should be asked?  And so on.  As a society, we know far more about how to be informed and savvy consumers in almost every other market that is out there, and yet we are total dunces when it comes to the medical markets.

Again to be concrete, let’s look at a specific medical maintenance issue.  Suppose you’re now of the age where your doctor wants you to get a regular colonoscopy.  Where do you go?  How much should you pay?  How good is the doctor and how much risk is involved?  All of these are valid questions, but I am willing to bet that very few know meaningful answers.  Let’s take a look at the first two questions in detail.

A simple internet search with the search string ‘colonoscopy cost’ returns as one of the top hits an article in The Health Care Blog entitled ‘How Much is My Colonoscopy Going to Cost? $600? $5400?’ by Jeanne Pinder.  As the title suggests, there is a vast range in the costs of a colonoscopy ranging, according their research, from $600 to $5400, a factor increase of 9 from the lowest value to the highest value.

Pinder lists six items in the total cost that should be examined before committing to the procedure.  These are:

However, Pinder points out that it is difficult to get straight answers for most of these items.  The doctor, anesthesiologist, lab, and facility all bill separately.  All play the shell game between listing the charged price and the paid price.  The charged price seems to be the cost that these service-providers initially ask, while the paid price is what they settle on once the haggling with the insurance company is completed.  Having so many moving parts also makes it easy for each group to avoid accountability and, indeed, their usual response, as cited in the article, is “we don’t quote prices in advance.”  Imagine going to your mechanic and being told something to the effect “we’ll let you know how much it costs when we figure it out” – you would never put up with it.

Recently I discussed the stark contrast between regular maintenance for a car and for a boy with a co-worker.  He raised the objection “do you really want to have a procedure performed by the lowest bidder?’  On the surface this may seem like a cogent argument but some reflection shows that it is inadequate.

What logical connection is there between paying more and getting better health care?  There is some truth in the old maxim “you get what you pay for”, but that really only applies to situations where the consumer is trying to get a ‘sweet deal’ by cutting corners. This maxim is utterly devoid of meaning when the consumer knows next to nothing about the goods or services he’s buying.  Perhaps a doctor who charges more for his services may be worth it.  On the other hand, he may be a shady character who talks a good game, gives poor or even dangerous service, and is putting his profits before the patient’s needs.   He may have to charge high prices to cover his malpractice claims and you just don’t know it.  It is also possible that a good doctor is one who possesses enough skill that he can diagnose your problem without groping through unnecessary and costly tests which consume your time and put you through needless pain (both physically and mentally).

There is a related objection that asks why would you want to skimp when it come to your health.  This objection is also patently fallacious.  My health depends intimately on a day-to-day basis on the condition of my brakes and tires but that doesn’t stop me from seeking the best price. By seeking the best price, I am actually conserving my resources for other things that also have a positive impact on my health, like going to the gym, or buying better food, or moving to a better neighborhood.   The word ‘skimp’ is merely a red herring that is meant to stop us from realizing that purchasing medical services is done, like every other purchase in life, in a market.

The short of it is that when it comes to car, home, or appliance maintenance, each of us is reasonably knowledgeable in the marketplace.  Each of us tries to find the best value and each of us understands what insurance covers and why.  In the medical market, few if any of us have enough knowledge or enough courage to seek the best value and to understand what the role of insurance should be.  We trust that doctors and hospital and medical practitioners will protect our interests in a way that we don’t trust mechanics.  But this trust is predicated on nothing more than the fairy tales we’ve been told on television and in the movies.  Until each of us takes responsibility for being informed health consumers the system will remain in critical condition.