Thursday, January 26, 2017

Choice in health care

Choice is such an important term in health care. People want to choose their doctors, their treatment options, their hospitals, and their insurance plans. Every informed consent form spells out the alternative to make it clear that you made a choice to consent.

Choice is a proxy for agency, the notion that we control our destinies. We believe that if we get to make choices, we will make the right choices. We will find better doctors, more effective treatment options, kinder hospitals that will soothe us and salve us. Placebo effects suggest that this belief can actually be important.

We extend this preference for choice into insurance plans to our own detriment. Insurance plans are deliberately complex, designed to limit care and limit payments for care. It can be very difficult to understand all the details of the insurance plan you have, let alone all the plans you might choose among. Choosing an insurance plan also requires you to guess at your future health needs, which are inherently unpredictable. You may be able to make reasonable guesses, but serious injuries and severe acute illnesses are unplanned.

Our employer-based insurance allows us to choose among four plans, all with an identical provider network and similar plan limitations. Choosing is made easier by knowing that we have chronic illnesses in our family which require expensive care, and by knowing that shifting thousands of dollars from premiums to out-of-pocket expenses allows us to seek third-party reimbursement for some expected medical expenses. (Would you rather pay $10,000 in premiums and $4000 for specific care, or $4000 in premiums and $10,000 for specific care? That’s an easy choice if you know that half of your specific care might get reimbursed.) Despite that, there are two plans out of the four that could make sense for our family, and no way to be certain which was the right choice until after the year is completed.

Choosing between plans with different provider networks is far more error-prone. You may know one or more of the doctors you expect to see regularly, and should choose a plan which includes those doctors. You may be fortunate enough to have them continue practicing and stay in network for the entire year. But a new medical condition may require one or more new specialists, and even in a doctor-rich area like Boston there may only be one specialist who is the right one to see. How can you possibly know ahead of time which specialist you will need for a condition you don’t yet have, and confirm that they will be in your insurance network?

There are also many medical specialties and situations where you have no choice in provider. The canoncial four specialties where providers often refuse to join networks because they are reimbursed far more being out-of-network are radiology, anesthesia, pathology, and emergency room care. Those happen to also be specialties where the patient typically has no choice in who is providing the care. Being in a hospital is also a vulnerable time when you have no control over who is providing the care. You may never even meet the person who will be billing your insurance, and then you.

The flip side of telling people that they have choices in health care is assigning them blame when those “choices” don’t turn out optimally. Lousy doctor? You should have chosen a different one. Side effects from medication? You should have read the pages of boilerplate warnings.

And that blame gets worse with insurance catastrophes. We can tell ourselves and each other that we would not have ended up seeing a provider who is not in our network, or that we would have chosen a different insurance plan that had the right network, or the right limits on the right services, or the right assortment of deductibles and coinsurance and copays. When we tell that tale in a year when we ourselves had few serious or unexpected medical issues, it has the ring of truth. That just makes the falseness of it all the more pernicious.

It doesn’t have to work this badly, but the plans being floated -- plans to allow more choices in insurance plans with smaller networks, plans to allow balance billing even in network (a long-time favorite idea from Tom Price), plans to shatter the core of Medicare into a voucher system paying into a fractured assortment of privatized plans -- those plans make the situation worse. We end up with more risk, more expenses, more medical bankruptcies, and more blame assigned to people who “made the wrong choice” when they discovered their plan didn’t adequately cover the newly discovered cancer, or the birth defect, or the premature baby, or the medicine they suddenly need that costs $100,000 per year.

Don’t fall for these sorts of changes. Work for health insurance for everyone, with no annual limits, no lifetime limits, no balance billing, no narrow networks, and no constantly shifting exclusions. Work for a public option, for single payer, for transparent and reasonable pricing, for affordable cost-sharing, for sane financial policies, and for choices that provide benefits rather than blame. Work for an end to medical bankruptcies, so if you like your house, you can keep it.