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Posted on Fri. Feb. 22, 2013 - 12:01 am EDT

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High deductibles ask nonexperts to discern good medical practice

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I have a confession to make. I don’t trust my doctor.

It’s not that I think he’s a bad guy. It’s just that he’s like everyone else: He’s got to get paid. And the way he gets paid is by doing “procedures.” And so, if he needs to make some extra money, he might recommend things that I don’t need. I don’t know that my doctor’s ever done this, and in fact, I kind of doubt that he has. But I have to watch him. Because some day the pressure might get to him.

Until recently, if my doctor recommended that I get my cholesterol scores, I would have just gotten my cholesterol scores. My family had a nice co-pay insurance plan. As a result, almost all of our health care costs were hidden from us — they were covered by a generous employer benefits package and by our premiums. This year, however, things are different. My employer made a high-deductible plan so economically attractive that I felt obligated to take it. It has been a learning experience.

Many hope that high-deductible plans will improve the health care system’s efficiency. In the United States, we currently spend more money per person on health care than every other country but rate worse than many of these other countries on metrics like infant mortality and expected life span. The high-deductible plan pushes consumers of health care (patients like me) to spend fewer health care dollars.

The theory is if patients “feel” the cost of health care, they’ll pick less expensive providers, refuse unnecessary tests and cut health care spending. They’ll only pursue the medical care they really need. It’s a sound theory, and I know this because I’ve had a high-deductible plan for two months and I’ve been paying a lot more attention to our health care costs. Here’s how it’s played out.

First, I avoid going to the doctor. For me, this isn’t that different. I didn’t really go to the doctor even when I had a co-pay plan. For my son, it’s a little different. We decided to forgo an egg challenge (to see whether he’s really allergic) because he already never eats eggs, so it’s not clear it’s worth the cost.

Second, when I do go to the doctor, I challenge anything he recommends that costs money (which, under a high-deductible plan, is everything). I know he needs to make money and the only way he makes money is by getting me to pay money. So if he wants me to do something, he had better have a pretty good explanation for why I need it. So I ask questions to evaluate the quality of his judgment. After all, if I’m going to spend money on something, it had better make sense to me.

But how, exactly, am I supposed to decide whether he’s making legitimate recommendations? The high- deductible plan works by having me, the consumer, challenge my physician. But challenge him to what? Illustrate how well he can sell me on something?

How is he supposed to justify his recommendations to someone who has never taken an anatomy course in his life? And, even when he tries, how will I know if his justifications are any good? I’m not a medical expert. And so here’s how the high-deductible plan works to cut costs: It makes the health care system perverse. It asks nonexperts in medicine to decide what makes for good medical practice.


Abraham P. Schwab is assistant professor of philosophy at IPFW.


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