Tuesday, January 17, 2017

#2 The Medicofinancial Uncertainty Principle

Dear Dr. Tumoriffic,

Why does my doctor always seem to know little or nothing about the cost of the treatment * options s/he is asking me to choose between?


Pecunious in Pittsfield

Dear Pecunious in Pittsfield,

This is a very deep and complicated question that those not familiar with either medicine or quantum mechanics have difficulty understanding, but I'll try to explain. 

You see, it is impossible for a doctor to know both the proper treatment and the cost of said treatment at the same instant in time. Some theorize that should such an event occur, there would be an explosion on the scale of several hydrogen bombs together. **

It follows then, that if your doctor proposes a treatment and can tell you the precise cost of said treatment, they must be wrong about one or the other, and you should alert them immediately.

Now for some shameless, but, essentially, true exaggeration. The reason your doctor almost never knows the cost of a given treatment is that the cost depends on your insurance plan. There are more insurance plans than there are kernels of corn in Nebraska, and there are more words in each policy than there are atoms in the entire solar system (not including the Kuiper belt). 

Your insurance company has entire cadres of bureaucrats whose business it is to pay as little as possible for your care and to make it as hard as possible for you to figure out what the cost to you will be before you choose your plan. Some may find that upsetting, but it's the way our system works. 

Meanwhile, the amount charged for treatments and, especially, medications varies over time, even from month to month. In recent years, generic drug manufacturers have raised the prices of even the oldest, most conventional medications. Different pharmacies charge different prices. **** Your insurance company may have a deal with a certain pharmacy chain or may charge a lower co-pay when you use a mail-in pharmacy. 

For treatments, your insurance company may have a special deal with certain treatment facilities. As a rule, these are always on the opposite side of town, no matter which side of town you live on.

So, most of the time, at least, my colleagues and I are as clueless as you are about costs.

Now, occasionally, a doctor may know ways to get medications or treatments at lower prices or even free. Drug companies may hand out samples to doctors to give to patients. (I don't participate in this except in very special circumstances. It's a way to influence doctors to change their prescribing practices and eventually leads to higher costs all around.) Patients can also sometimes get special deals or even free medications from drug companies if they qualify for those programs. Your doctor may know about some of these.

So, apart from the exception above, your doctor does not know jack doo doo about drug/treatment prices.


Dr. Tumoriffic

* I am going to limit this answer to actual treatments even though you may have meant to include tests in the question. Variable test prices is a related topic but deserves its own post.

** There are rumors that the Department of Defense hopes to harness this effect for military purposes. That would explain the famous and mysterious disappearance of the entire medical faculty of the University of Nebraska Medical School faculty in 1997. **

*** The previous footnote is a baldfaced lie. But what does it mean to be baldfaced? I just shaved. Does that make me baldfaced? Is everything I say, therefore, a lie? Contemplate this.

**** For a good discussion of this, check out http://www.consumerreports.org/cro/pharmacies/buying-guide.htm. Big box stores like Costco and Sam's Club tend to have the lowest out-of-pocket prices, but local Mom and Pop stores also can have deals. If you are paying out-of-pocket, avoid the big pharmacy chains. They take advantage of their market dominance to stick it to the customers. My family uses our local Mom & Pop pharmacy, even though our insurance company tries to force us to use CVS Caremark, a mail-in service. I think it's safer to have a pharmacist who actually knows you, and I actually look forward to going there. Besides, it supports the local economy. (And they give my dog treats.) 

Want to drive a hard bargain? You can get a great deal on 20mg sildenafil tablets (generic Viagra) at Costco. No kidding!

A picture thoroughly irrelevant to the above:

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