Fiscal fallacies

We're shopping for a new dentist, and the reasons illustrate one of the cherished fallacies driving opponents of healthcare reform. This fallacy is that if providers don't have third-party payers to pick up the tab, then they will lower prices to the level their patients can afford (like two chickens or a couple of dozen eggs?).

That Hippocratic horse left the barn a long time ago.

Our particular tale begins with my wife's last semi-annual prophylactic visit a few months back. The hygienist thought she detected decay under one of my spouse's old fillings. Hold that thought while we move on to my semi-annual visit this summer. I told the hygienist that I was feeling a little sensitivity in the vicinity of my bridge.

See if you can detect the similarities in the next steps. In my wife's case, the dentist recommended a full porcelain crown, not a new filling, a cost difference of about $2000. In mine, although I got prescription toothpaste for sensitive teeth (which has worked, BTW), I got a recommendation to remove my nine-year-old bridge (which means breaking it, according to this dentist) and replace it with two crowns, an implant, for about $6000 more than the average cost of a permanent bridge.

"Of course," he said, even though we don't have dental insurance, my wife's flexible spending account (FSA) would cover the costs.

Oh no it won't. Even though FSAs are supposed to be usable at the discretion of the person who owns the account, her account informed my wife that they won't cover either crowns or implants, which they consider cosmetic. Even if they would cover these procedures, the total tab would still be many thousands more that the account would cover.

Two weeks ago, I told the dentist there was no way in hell I could afford such costly treatment. Now according to the Republican rubric, that should prompt a counter-offer from the provider. There has been silence, no more than I expected. We're both looking for second opinions, and also for treatment that we can afford: our budget isn't much over the two chickens level.

When we started with this dentist, I had a fair income and a good dental plan. Now we have neither. This dentist's treatment programmes and pricing models are indeed based on what the third party will pay. But when he deals with a third-party payer, he is obliged to justify his treatment. This is known in the business as proving medical necessity. He proposes A. The payer says, "if you can't prove the necessity we'll only cover B." Provider, patient and payer end up somewhere in the middle.

With a self-pay patient, providers have no incentive at all to hold down their costs. The can trade on the innocence of their patients to bill them for as much as they can. They know that once they present the bill, the law will be on their side when it comes to collection from a self-pay patient. That's why you can kiss that two-chickens payment model goodbye. As patients, our only choice is to say no to this dentists, and hope we can find treatment we can afford. If we can't, we'll go without.

Not even the Affordable Care Act helps much. Although good dental hygiene is now proven to be the first line of defence against many internal diseases, it remains glaringly absent from most discussions of healthcare. It's a frill, an extra. Most dental treatment can be shuffled off as cosmetic by payers, even those who sell dental insurance.

Opposition to real affordable care in this country is driven by equal doses of delusion and greed. Nothing about that will change until the bodies start piling up in the streets and frightening the horses.

Adventures in defensive medicine

Nearly two weeks ago my right shin began to hurt. I manned up, decided it was only a shin splint, and toughed it out. I chose poorly, for several reasons.

Last Saturday I slipped just a bit on the back stairs and came down hard on my right leg, which objected loudly. After spending the rest of the day on ice and ibuprofen, and not sleeping much at all, I dropped on my PCP Sunday morning.
It was the duty physician--no slouch, one of the founders of the practice--who suggested compartment syndrome. He had me doing more ice, more elevation, and as much Ibuprofen as I could tolerate. If, said he, the leg is still uncomfortable in two days, go directly to the ER.

It was and (reluctantly) I did, not without wondering why we didn't instead try an orthopedist. Emergency Departments always have an element of black comedy about them. In my view they are places to avoid unless one is actually bleeding out, has about six fractures, or both. People with mystery issues should stay away, House notwithstanding.

The sole bit of good luck this visit was that it wasn't very busy when I got there. Dr. S's hint of compartment syndrome was enough to get me through registration and triage fairly quickly. But EDs, like the military, operate on the "hurry up and wait" principle. Having hurried through the first two steps, I waited. I had brief visits with an RN, a PA (who dosed me with Vicodin), and a very young physician, and waited some more. The cubicle TV was set to Dr. Phil, and he was the only doctor over 25 within ten feet of me all day.

The upshot of all this was to send me for ultrasound. Dr. S had already ruled out fracture by palpation, and by the fact that while I could only put weight on the limb with pain, I could put weight on it. I'm not endorsing this Dx, just reporting it. The limb only swelled when I tried to use it. I had been in cold storage for nearly an hour when Doogie Howser saw me, so the swelling was reduced. With all this my position on the triage scale was degrading, and it was some time before the transport person arrived to schlep me to Radiology.

I'm not remarkably tall, but my feet hung over the end of the gurney (cost cutting?). If you've ever made a gurney trip in a hospital, you know that transporters usually open doors by ramming them with the gurney. The prospect didn't appeal, and I tucked my legs up after the first near miss. We did make it to radiology without incident, where I--wait for it--waited some more. I figured by this time that my triage status was worse than that of a dog with a cold nose.

When the rad tech did show up, he was friendly and cooperative, indulging my professional curiosity by angling the ultrasound screen enough for me to watch. We looked, as it happened, he looked in detail everywhere but where the pain centred. Techs aren't supposed to diagnose, but this one said he saw neither clots nor vascular compression. Again, I'm just reporting here. He finished, we shook hands, and he wheeled me to the corridor...to wait for the return trip.

Through much of this, everybody I encountered was worried that I was cold. Actually, the temperature was very pleasant. What I was was bored...and hungry. Wanting to be ready for anything, I hadn't had breakfast. It was midday by this time, and we had arrived at the ED before 9. This got to be a preoccupation, because medical staff with lunch were strolling past the gurney.

The transporter eventually showed up. I hauled in my feet and he wheeled me back to my cubicle: only to find it wasn't mine anymore. There was a moment of confusion, whereupon the nurse said, "take him to 7 1/2."

Room 7 1/2 is, in that ED, a stretch of corridor wall between Room 7 and the john. I took this as a measure of how far my triage status had fallen. Eventually the RN dropped by to say that I was awaiting the radiologist's interpretation. Note the word "wait."

In a perhaps misguided bit of humanity, the staff went out and fetched my wife. "Room 7 1/2" had no chair. She had had breakfast but not lunch, and so was beginning to share my preoccupation.

Located just inside the trauma entry to the ED, "Room 71/2" made up for its lack of amenities with a considerable amount of traffic. One reader has commented elsewhere about the one thing that modern hospitals lack: peace and quiet. He was in a room: try it in a hallway. Actually, I thought it fairly peaceful as hospitals go. Had I not been obliged to carry on domestic conversation, I would have dozed off.

Eventually, the RN showed up with the radiologist's interpretation. I know a little bit about the nuances of medspeak. I observed that the interpretation carefully avoided anything resembling a declarative statement. After six hours in the toils of emergency medicine, the closest thing we had to a diagnosis was my own. Thank you, Einstein. But I was free to go, clutching my Vicodin scrip.

On my health plan, the co-pay for all this theatre is $50. The Vicodin does what Vicodin does best: blunts pain, rather than relieving it, and adds its side effects to the amusements.

We'll figure it out eventually, right? House always does, after four or five false starts. Heh.