F070 Why is getting sick in the US financially toxic for many people? (Christopher T. Robertson)

As of 2017 healthcare is the leading category of the 78,5 billion in consumer debt collected each year, which is more than 40 times the size of credit card debt. While the number of uninsured individuals is reducing, it is being replaced with the issue of underinsurance.

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Christopher Robertson is an associate dean for research and innovation and professor at the James E. Rogers College of Law, University of Arizona. He is also affiliated with the Petrie Flom Center for Health Care Policy, Bioethics and Biotechnology at Harvard. He has previously taught at Harvard Law School and NYU School of Law. His latest book includes over a decade of research about the current state of costs patients in the US face, and how the US healthcare system could be reshaped to function better.

Underinsurance

29 percent of insured were classified as “underinsured” in 2018, according to a Commonwealth Fund survey. These patients might struggle to pay their contributions to their care.

Three in ten people reported costs caused them not to take their medicines as prescribed in the past year, Christopher T. Robertson mentions in his last book Exposed: Why Our Health Insurance Is Incomplete and What Can Be Done About It.

This is especially critical in situations as the current Covid-19 crisis. New York Times and Financial Times warn that the US is at high risk for a fast spread of Covid-19, because many people don’t have the option to work at home. On top of that the uninsured - and there are 27 million of them in the USA - are reluctant to seek healthcare.

Lack of transparency in healthcare costs

The problem for reluctance to seek care when in need lies in the lack of transparency of final medical costs one might receive. Two policies may have had the same 5,000$ cost exposure limit, but a breast cancer patient would pay 7,641$ in cost exposure under one plan and 12,907$ under another, mentions Roberts in the book.

Patients, in essence, can’t know what their final cost of treatment will be and in some cases, they can be denied reimbursement by insurance, because insurance companies can demand pre-authorization review and deny payments. This results in either lack of treatment or lawsuits.

In 2019, an Oklahoma jury awarded $25.5 million to the widower of a 53-year-old woman diagnosed with stage IV nasopharyngeal cancer who was denied coverage for proton therapy by her health insurer, Aetna.

Doctors with price lists?

Dr. Robertson believes doctors should take part in informing patients about therapy costs, so patients can make informed decision about their care. The doctor’s medical explanation however is crucial for patients who lack medical knowledge to decide what would be best for them.

However, researchers observe, that doctors feel monetary discussions would hinder their identity as caring for the best care. This could have a negative impact on the doctor-patient relationship.

Out-of-pocket costs don’t exist

Robertson is also critical of the expression “out of pocket costs” in healthcare since “the pockets of patients are often empty when they receive medical bills.” This forces patients to take on debt and turns medical institutions into debt collectors. On top of that, several disease-related costs, such as transport to a medical facility, diapers in case of incontinence because of surgery, etc, are not included in the debate about what is the actual final cost of healthcare treatment for an individual.

Finance induced stress hinders healthcare outcomes

Thinking about financial impact of individual’s medical condition causes immense stress which impacts health outcomes. Consequently, cost exposure does not turn patients into rational consumers as it was supposed to. Severe and unclear cost exposure degrades patients’ decision making, because they have to decide between all of their financial obligations and prioritize them, which can put their health low in the hierarchy.

In this discussion with dr. Robertson, you will hear more about what kind of costs patients are exposed to in the US, what the role of technology could be in curbing those costs or at least make prices transparent and clear before a patient get the bills, and how could the healthcare system be improved.

Some questions addressed:

It seems like in the US, Coronavirus is going to be a big wealth/social status and insurance-related healthcare issue. How are you observing the developments of the spread of the virus from this cost/job security perspective?
What are the differences between deductibles, cost-exposure maximum, out-of-pocket limits and co-pays, which you explain thoroughly in the book?
It seems that the first thing people think about upon entering the healthcare system in the US is, how much it will cost them. In the book Nudging health: Health Law and Behavioral Economics, which you co-authored, it’s shown that patients exposure to out of pocket costs may undermine their cognitive abilities to make good healthcare choices -Who should talk to patients about costs? Elizabeth Rosenthal notes that it should be considered a doctor’s obligation to provide you with financial information. Whereas doctors don’t want to discuss costs as this would hinder their identity as caring for the best care?
How is it possible, that an insurance company can reject a treatment request, under the justification that it is not medically necessary? A doctor can prescribe a therapy, but insurance companies can demand pre-authorization review and deny payments.
How can patients be sure about their potential healthcare costs, given that they can have separate deductibles for prescription drugs, out-of-pocket limits may not include co-pays, etc?
Do you know how many patients have their own advocates and lawyers to manage costs and are able to navigate the system?
The US healthcare system is based on a historical agreement around at least a partial cost-exposure of patients — sizeable deductibles, copays, coinsurance etc. A full coverage would be seen as wasteful and irresponsible. Seems like there are a lot of irresponsible countries around the world. Comment?
Did anything surprise you in the course of writing the book and the research you had to do?
The aim of the book was to set the agenda for the next wave of reform in the US healthcare system. Care to comment on the current debates around the healthcare reform? What are your realistic expectations, knowing how divisive topic healthcare is?
Can you briefly share your very general opinion about the healthcare system in the US compared to other countries?
Do you know, did any of the politicians read this book?
Negative effects of cost exposure on health outcomes — what’s then the point of medical progress?