On costs

Asks Jaybird in a comment from my last post:

Is there *ANY* dollar amount at which we, as a society, can say “we’ve spent quite a lot on (individual) and, from this point on, we’re only going to pay for pain relief” or something similar?

That’s a very difficult question to answer, though I think the ultimate answer will end up being “yes” in some cases.  But I’d like to step back at talk about medical costs in general.

Every medical decision is predicated on a cost-benefit analysis (or, at any rate, should be).  We may not think of it in those terms, but that’s what drives what tests to order, medications to prescribe or consultations to request.  However, it’s important to understand what is meant by “cost.”

There is the obvious sense of cost as dollars spent.  Truth be told, for insured patients this consideration probably plays a relatively small role.  (Or, at least, it does until the bill arrives and the patient is left to discover how much or little was covered by their insurance.)  In all honesty, it should probably play more of a part, but since insurance insulates patients from the full cost of most medical interventions, the subject rarely comes up when making a plan for any given patient.  It came up with some frequency when I worked with a population comprising both insured and uninsured (“self-pay” is the euphemism frequently deployed) patients, but I currently work in a state where everyone has some kind of insurance and thus rarely encounter it anymore.  (A shiny new nickel to the first person who can figure out where I work.  You’re not the only one who can challenge your readers, Burt!)

Discussion of monetary cost does figure into medical decision-making, but usually in the broader context of a clinical study. Whether a certain test is cost-effective in a specific clinical situation or if a particular medication improves outcomes sufficiently to justify its expense is a common subject of investigation.  Whenever these investigations ramify into the political realm, there is the potential for things to get messy, but it is self-evident that we would want to know if what we’re using is worth the money we’re paying for it.

However, once one gets to decisions about individual patients, dollars and cents fade into the background.  (Again, this is the case only for patients who are insured.  Uninsured patients are quite apt to ask if a prescribed medication is expensive, and if a cheaper alternative can be found if so.)  Instead, medical providers think in terms of risk.  And almost every intervention has some degree of risk attached.

Take as an example a frequently-encountered clinical situation for most primary care pediatricians.  A parent brings in her child for cough, runny nose, maybe a fever for a few days.  Should I prescribe an antibiotic for this child?  Chances are his symptoms are due to a viral infection, and will resolve with time, but I could always call it an early sinus infection and write out a prescription.  Being somewhat stubborn on the subject of antibiotic use, I opt not to do this.  A course of amoxicillin is cheap, so it’s not the price that prompts me to spend an additional ten minutes explaining to a frustrated mother why I won’t just hand her a prescription (which is much, much easier).  Rather, I am concerned about risks to the patient (side effects, adverse reactions, resistant infections in the future) and the population at large (increasingly-resistant strains of bacteria), such that it’s worth my time to have the discussion rather than placate the parent.  While there may be monetary costs associated with some of these risks, they’re pretty indirect and they’re not on my mind at the time.

It’s for similar reasons that we don’t routinely order spiral CTs of the chest to detect lung cancer, for instance.  It may indeed help detect lung cancer earlier, which for those lucky patients is a major benefit.  But the downsides include not merely the price, but also the risks of irradiating patients every couple of years or detecting something anomalous but benign, thus requiring further risky investigation.  This latter kind of spurious detection was what prompted a revision in the guidelines for ordering mammograms a couple of years ago and the predictable brouhaha that followed.  Even a simple blood test can yield erroneous results that diligent providers must clarify with yet more tests.

Determining at what point further medical intervention is an unsuitable use of medical resources is a fraught question.  While we are ethically bound to consider risk when choosing a course of action for our patients, we are conversely ethically barred from refusing care because of inability to pay.  I don’t think there’s an easy answer to the question of how to weigh cost in the overall risk-benefit analysis, particularly for chronically, severely or terminally ill patients.  No matter how the issue has been distorted by misleading and inflammatory rhetoric, part of the solution is better communication about end-of-life care between patients and providers.  It is, however, ghoulish to consider allowing an otherwise curable patient to sicken or die simply because healing them is expensive.

Update:  Via Andrew Sullivan, found a wonderful post on health care costs at a blog new to me.  One particularly apposite quote:

[I]f you should ask your surgeon what the cost of the arthroscopy will be, the answer will probably be “I don’t know.” Price transparency is poor to begin with but there is the very real fact that based on a patient’s individual payer status the cost will vary dramatically, and the surgeon probably does not know what the cost will be for your case. Finally, when consumers make health care providers compete against one another to decide by whom and where the care will be given, they tend to be concerned primarily with quality and with cost as, at best, a secondary concern.


Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.


  1. I was blessed to be arguing with a co-worker who gave me this set-up line a few months back.

    “Do you just want the elderly to die?”

    (I’m sure that he was asking something to the effect of “do you want the elderly to just lie down and die?” but, thankfully, that’s not what he said.)

    I just looked at him and said “I’ve got some very bad news for you.”

    Which is the cold, unpleasant fact at the very bottom of the debate here.

    • Hypothetical for Amusement:

      Let’s say I’m totally wrong, and Kurzweil is totally correct, and the Singularity will occur within our lifetime.

      Does Medicare have the right to say, “We don’t need to provide you healthcare, as your physical body is not necessary for your continued survival. Blip, upload! Die away, corporeal husk.”

      If getting into the Singularity is expensive, is it covered under Medicare?

      If it’s covered under Medicare, do we have a right to demand that you take the option, if you’re going to take it at all, in lieu of expensive treatments if you get a terminal disease? Can we say “shit or get off the pot”?

      Does the Right-to-Die vs. Euthanasia debate get more interesting, or less? Can I opt-out of the Singularity, according to the anti-Euthanasia crowd?

      • “Does Medicare have the right to say, “We don’t need to provide you healthcare, as your physical body is not necessary for your continued survival. Blip, upload! Die away, corporeal husk.” ”

        Heck, if you can upload your mind into a computer, then what’s the use of having medical care at all?

  2. Indeed.

    Of course, helping people avoid dying is what I’m paid to do. Sometimes it’s costly to do so, but effective. Sometimes it’s just costly. In the former cases, I hope we (as a society) consider it worth our while to pony up the cash. In the latter, probably not so much.

  3. I’m reminded of a magazine I read in an auto body-shop waiting to get some door damage sorted. The magazine, a body-shop industry rag, had a helpful article describing the process for making an estimate when the customer was actually paying cash as opposed to letting the insurance handle everything.

    It pretty much went like this: Customer has a scratch and a dent on the door.

    Customer paying: Pull trim panel off door; pound dent out with hammer until it’s flat-ish. Sand down the area, repaint with OEM’s called-out paint color, buff. Charge customer for cost of labor and paint.

    Insurance paying: Disassemble entire door, remove to workbench, sandblast down to bare metal. Hammer dent flat, using laser-tracker tool to ensure proper contour. Re-prime and re-paint with paint that’s computer-matched to the original color. Sand neighboring body panels, apply additional paint to “blend” the colors between the repaired panel and the existing panel. Throw away all existing exterior trim in the painted areas; order new trim from manufacturer, paint with computer-matched color. Charge customer for insurance deductible.

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