Americans love a bargain. Getting our money's worth is a national game and, in some quarters, runs to an obsession. Cash-back credit cards, airline miles for just about everything, phone services with no long-distance fees. Extra-value meals are happy meals, and bigger (though less nutritious) than ever.
But are Americans getting a health care bargain? Should the cost of care be information a patient should possess to give informed consent to treatment?
Few patients know that their monthly premium goes for everyone else's care too. What people and their employers pay monthly supports the health plan that delivers care, or sometimes delivers and finances it too. This supports population-based health — the unsung moral basis for managed care. Unsung because Americans have a hard time pulling for public health and cannot see that too little care for someone else could also mean too little care at home.
Neither doctors nor patients usually know the real costs of the medical encounter. Not for the lab tests, or the confirmatory consultation, or the late night phone call for four more Zocor for the patient who calls on his way to Missouri and forgot his meds. All have direct and indirect quantifiable costs.
From a moral perspective, insulating doctors and patients from costs is crazy. Who can make an informed choice or express real preferences or balance competing interests if they are unknown? Who can blame insecure physicians who see practice incomes stagnant or declining, and who eye the annual report of the branded supplement company with respect and wonder?
Separating people from prices distorts moral impulses in a predictable way. Where else do we hear, "It doesn't matter how much it costs — go ahead and buy it. Someone else pays." Maybe on a trip to Disneyland or in a dream. But definitely in a fantasy land.
Who should pay and how they should be allowed to participate in decision making is the real tension in managed care. HCFA began prospective payment for hospital services, and thus the ethical issue of futility was born. (Before HCFA paid prospectively, did anyone talk about futile care at the end of life? Or medical futility near the end of life? No!)
Managed care promoted capitation as a fair payment and delivery mechanism. Thus, extent of coverage and payer status became ethical issues. (Do you remember ever hearing, in 1980, "This is the first hospital admission for this 61-year-old Blue Cross Blue Shield indemnity patient"? Or from a nurse, "She has Aetna. Maybe you should recheck her chem panel this month again"? No!)
If doctors and patients knew exactly how much the components of care cost, perhaps all would choose differently than they do now. Perhaps individual physicians would not cut their prices to HMOs without improving their own productivity. The result is a decline in market share and income.
Informed consent consists of three elements: adequate information, reasonable understanding, and volition. Of course, how much information is adequate, what constitutes reasonableness, and which circumstances are coercive and which are merely persuasive are subject to interpretation.
I think informed consent to ordinary outpatient treatment should include its costs. Why? Here are five reasons.
What's wrong with telling patients how much things cost? Here are five arguments:
It's true that some things are no bargain at any price. The triple-meat Big Mac. The New York pizza with three ZIP codes. Eaters know the cost of their meal. But what they don't know — that their bypasses will be more than 20 grand, and that they are likely to be a direct result of their lifestyles — will kill them.
People who are protected from costs cannot look out for themselves. They cannot know whether they are getting a fair deal, a raw one, or a bargain. Doctors cannot price their services equitably. Patients cannot judge what or how much to buy. But don't tell America that until it pays the bill.