I have bad ankles. They hate me. My messed up right ankle was the proximate cause of my retirement from soccer refereeing.
I use the following system to determine if I need to see a medical professional for diagnosis and treatment:
| Maximum Symptoms | Initial Treatment Location | Initial Total Cost |
| Bones poking out | Emergency Room | $600 |
| No weight bearing and hearing a “POP” | Emergency Room | $600 |
| No weight bearing for 2 days | Orthopedic Urgent Care | $300 |
| “POP” + significant swelling and pain | Orthopedic Urgent Care | $300 |
| Significant Pain, minimum mobility by Day 3 | Orthopedic Urgent Care | $300 |
| Consistent pain, impaired flexibility for 5+ days | Specialist appointment | $200 |
| 10 days of impairment | Specialist appointment | $200 |
| Typical Twinge | Home (RICE + ankle brace) | $5 |
I’ve never had bones poking out of the skin. Things have gone “pop” a few times too many. Most of my first line treatment is to use some of my stored durable medical equipment to immobilize the injured ankle, and then apply ice, NSAIDs and elevation. Usually that is enough to get me to a point of reasonable restored functionality after a couple of days. Any treatment modality beyond home treatments also have significant non-cash costs of taking time off from work, co-ordinating appointments, arranging for changes in child care responsibilities with my wife and then actually waiting at the office. Those costs, for the insurance that I have, are usually at least equal to if not greater than my out of pocket cost sharing for anything other than an emergency room visit.
Why does this matter?
We need to think about the introduction of technology that lowers the hassle costs of the moderate and low level treatment cases.
Let us imagine that there is a tele-medicine service that has a total cost of care of $100 per instance and very low self-administration costs. If that tele-medicine service is good enough to resolve most of the orthopedic urgent care cases and the specialist cases, we should expect total net costs of treating my ankles to decline significantly as the instance cost goes down dramatically.
However there is a limitation here. In the above scenarios, only medium intensity cases were served by the tele-medicine service at $100 per instance. Thankfully, those intermediate ankle injuries are fairly rare events at this point in my life. I will worry about them as I think those types of injuries significantly increase my probable future fall risk in twenty five to thirty five years. However, I frequently have little ankle tweaks. Most are merely twinges or slight rolls where nothing quite goes out of place but I could feel the loose ligaments let go for a smidgen of a second.
Right now, those twinges and micro-rolls aren’t enough for me to treat beyond perhaps an NSAID pain reliever at a few pennies per dose and a few doses per day. However, if the cost sharing of getting a professional to look at my ankle is near nil and the hassle costs are near nil, some of the minor injuries that I currently self manage will get checked out at a total system cost of $100. Given that I have many more minor injuries than intermediate injuries, the percentage of minor injuries that now generate low cost tele-medicine visits does not need to be too high in order to cancel out any savings tele-medicine generates from shifting some of the intermediate level ankle visits from in person visits to virtual visits.
This same logic applies to many claims that tele-medicine or virtual visits will save net money overall as it may be cheaper on a per-visit basis, but that very cheapness may move a significant number of very low acuity incidents from never being treated to being treated. Tele-medicine is likely to be cost-effective but being cost-saving is a far higher hurdle to clear.
On the Road and In Your Backyard
Victor Matheson
My first center of my 32nd college season is this afternoon. Also the first college center of my 50s. Technology is helping prolong the career. Added contact lenses last season. Switched from turf shoes to running shoes for most games 4 or 5 years ago. Communication head sets also help control the game as my usual distance from play rises.
Of course, none of this really solves the main problem with college soccer which is every year the players are the same age but we are, well…
Butch
The insurance I had before I was laid off last year offered a tele-medicine service (I’m guessing not well received because we got an advertisement for it with almost every paycheck) but it cost more than twice the co-pay for an actual in-person visit so I never even considered using it.
David Anderson
@Victor Matheson: I miss the whistle.
I don’t miss not being around on a Monday afternoon to take my daughter to diving practice or being able to go see Angry Birds 2 with my son on a Saturday matinee though (well worth the $9 total I spent for the tickets)
Another Scott
I’ve probably told this story here before…
In the ’70s there (briefly) was a TV commercial for a new Handi-Wipes competitor. Some tall teenager took one, rolled it into a long rope, looped it over the top of a door, and gently hanged from it while his “mom” talked about the wonders of it. Oooh. See how strong!
Naturally, I wanted to try it. But I wasn’t tall enough to loop it over the top of the door, so I had to jump up to do it. After several attempts, I was successful and as gravity pulled me down with a jerk, the wipe ripped and I hit my jaw on the doorknob.
Ouch!! (And I learned my first important lesson about the difference between static and dynamic stress.)
Of course this happened on an evening on a weekend, so my mom had to drop what she was doing to take me to the emergency room to get checked out.
Luckily, nothing was seriously damaged.
A telemedicine system probably would have saved some money there.
Back on topic – I don’t see how, in aggregate, a well-designed telemedicine system can’t save the economy as a whole money. Especially when real-people-costs are included. But the friction in using it has to be very low to get people to change their normal thought processes when something happens. And it has to provide a real service to people – not just try to lecture them about COPD when they do not have COPD (long story).
Thanks.
Cheers,
Scott.
Raven
The VA has that option.
David Anderson
@Another Scott: I’m primarily subtweeting a press release from an insurer that claimed that every time someone used its telemedicine service huge savings occurred although the example that they used is for a disease that most people currently treat with over the counter medication, hot tea and an extra hour of sleep per night for a week.
Ceci n est pas mon nym
You may find Allie Brosh’s pain chart helpful as well.
Just One More Canuck
I appreciate your insurance posts (as a Canadian, they make me appreciate our system more), but I miss your refereeing posts. My daughter’s team (U14 competitive – she plays holding mid) is running into more and more issues with referees – (refs celebrating with the home team after a game? really?) and I find your insight really helpful
Another Scott
@David Anderson: Yeah, … I assume those cases can be worked through over time as the system administrators and techs learn more about what works over the phone and what doesn’t. It only takes a tiny percentage of the population with some minor ailment to clog up an emergency or urgent care waiting room for everyone else who actually needs to be there.
And telemedicine is probably a lot more defensive right now than it will be in the future when ‘everyone’ is making video calls routinely. “Well, it’s probably nothing, but it could be the onset of Ebola so you better go down to the hospital to be sure…” vs “Let me see your jaw/tongue/arm/toes…” We may not really know how much it can really save, yet.
Thanks.
Cheers,
Scott.
Litlebritdifrnt
Very OT but there was a 2.9 earthquake in Blackpool, Lancashire this morning, next to the only fracking site in the UK. Who could have known?
LeeM
@Just One More Canuck: Here in southeast Georgia there is an urgent demand for new refs. When my kids played U12 – U14 state league travel ball, we would see a few assistant refs take off opposing team jerseys to ref, with predictable results, the younger team of their club.
What Have the Romans Ever Done for Us?
I too have f’ed up ankles from years of playing soccer. Back in the 1980s when I was in high school I sprained both of them in the same season, pretty badly. Went to the school athletic trainer who evaluated them and said there was no break – just a physical exam though, no X ray. Turns out both had bone chips that have since become spurs that limit my ankle mobility to some extent. Right now I’m blaming the biomechanical effects of these on the fact that I have a case of plantar fasciitis that won’t go away. I sprained each of them several more times over the years playing rec league soccer and other sports. There’s not much they can do with ankles, but mine don’t cause me daily pain so there’s probably not much I would do about them anyway. Well, the plantar fasciitis is daily pain but I’m not sure the ankles are the cause. Suppose I could get the bone spurs removed and find out but none of the specialists I’ve seen for the PF think much of that idea, or my theory that the bone spurs in my ankles are really the factor causing the chronic plantar fasciitis.
Yarrow
Are these telemedicine consults being outsourced to Bangladesh and Cambodia?
ruthie
I messed up one ankle badly over many years starting as a teenager. I don’t think I ever broke it but ligaments were torn regularly. Eventually, it seemed like I couldn’t walk without my ankle turning. After 30+ years of abuse, it finally hurt so bad I could barely walk Fortunately, sports medicine had become a thing and my doctor sent me to a clinic that specialized in chronic injuries. The ankle was so messed up they did surgery,repairing some badly healed ligaments and removing scar tissue and a few other gross things. I had a walking cast for a month and then they sent me to therapy.
They told me, in simple terms, that after one bad sprain or break, the ankle loses connection to the brain so you never really know where your foot is positioned and you keep re-injuring it. The therapy was designed to correct that and it did. I have not had a single incident with that ankle since that therapy, which was 27 years ago.
Amir Khalid
@Ceci n est pas mon nym:
She doesn’t do Hyperbole and A Half any nore, does she? I found it both very funny and very sad to read: so much pain always came through in her humour.
Amir Khalid
@Yarrow:
Yes; the specialists there are just as well qualified as in the US, but work much cheaper.
TomatoQueen
After spending 6 days in hospital with various things complicated by arthritis in both hips (bilateral hip replacement please), I like that new pain chart, especially the one about blood will explode from my face.
FlyingToaster
I think that the utilization will definitely go up (so it will cost to have it, duh). However, it may well turn out like the sick-kid visits we did with WarriorGirl; one was probably unneccesary, but the other one had everyone on notice for when things went pear-shaped and it was dealt with in 2 additional office visits and a scrip rather than with hospitalization.
Having an ongoing record of “this is going wrong” means that you can get a better sense of which thing it actually is, rather than “somewhere around there”. Any number of chronic condidtions could be managed better with telemedicine, if the goal were to reduce total cost rather than today’s cost.
Doug R
No weight bearing-any time-call ambulance, transported to ER.
$80 ambulance bill shows up in the mail in a month, $10-100 of antibiotics plus any extra ankle wraps.
Yarrow
@Amir Khalid: That’s how it works these days. I wonder if the medical professionals who are pushing telemedicine have thought that they’re outsourcing their own jobs?
Ohio Mom
Warning: unsolicited advice ahead.
If I were you David, and was having issues with my ankle, repeatedly over time, I would look for a very good orthopedist who specializes in ankles.
I would want to be reassured that I was not setting the stage to making thing things worse. I would want to know if I needed PT, special shoes or braces, or to be followed periodically.
No, I don’t like going to the doctor and I don’t like throwing money around. But I value my health and well-being and lack of preventable discomfort more than saving myself and “the system” a few bucks.
We in Ohio Family have a good handful of stories about fighting to have our symptoms taken seriously. Here’s one: I took Ohio Son to the Sleep Clinic screening nurse three times in three years before she reluctantly agreed to schedule a sleep test; she called the day after the test to tell me he had severe apnea and needed his tonsils out immediately.
This was after years of me telling doctors he could not wake up in the morning, and them, as part of the exam routine, looking down his throat, remarking his tonsils were huge, and not putting those two clues together. Yes, I didn’t put those clues together either but I did not go to med school.
Here’s another one: six years ago, after finding a lump in my breast by chance over the weekend, going to the internist’s office first thing Monday morning, seeing somebody else in the practice, and being told it was a cist. I insisted on being scheduled for a mammogram, anyway. I had breast cancer.
After five years of the follow-up estrogen-blocking, recurrence-preventing medication, against my oncologist’s recommendation, I insisted on having a slice of my tumor sent for a new genetic test. It showed I had a high chance of recurrence if I did not stay on the hormone blocker. (Some background: My type of BC is triggered by estrogen. Hospitals routinely keep tumors, encased in wax, for many, many years.)
The point of these stories — and I have more — is that you really have to be a squeaky wheel when it comes to your health.
And in case anyone is wondering, these two stories include a very highly-regarded children’s hospital and a university-affiliated health system. Fortunately, both are responsive to patient self-advocacy.
The moral of the story is, don’t worry about saving your insurer money, worry about getting thorough care.
Jackie
I wonder what the video really adds over a phone consult., some things are just based on the patients description, like how are the new meds going, but most new things need an exam. Other than insurance and patients being reluctant to pay for phone consults and dangling new technology on it makes it reimbursed.
jl
Thanks for an interesting post on outrageous prices. The prices are too damned high.
It’s The Prices, Stupid: Why The United States Is So Different From Other Countries
Gerard F. Anderson, Uwe E. Reinhardt, Peter S. Hussey, and Varduhi Petrosyan
Health Affairs, 2003
https://www.healthaffairs.org/doi/full/10.1377/hlthaff.22.3.89
I’m reading ‘Priced out’ by the late Uwe Reinhardt. So far it is pretty good.
Reinhardt was kind of unique in being a health economist who understood finance in detail, and could present things in an intuitive but rigorous way.
The main flaw I see in the book so far is his neglect of the implications of asymmetric info in his welfare analysis. As Joseph Stiglitz and his collaborators have shown, when asymmetric information causes things like lack of competitive equilibrium, efficiency and equity can be increased at the same time. So the usual depressing standard economic analysis that we always face ‘hard trade offs’ (which be some odd coincidence, in the US means that consumers should get hosed) and such like really don’t apply. So the contrast between efficiency and social ethics Reinhardt portrays is very probably much too stark.
But otherwise an excellent book so fare.
The perfect book on US health care economics would have been written by Reinhardt and Stiglitz, but too late for that now.
Amir Khalid
@Yarrow:
I emember the argument for telemedicine back in the day was access to expertise not available locally, so it wouldn’t be like a rural primary-care doctor was losing work to the foreign specialist. Do specialists in the US lose work to foreign doctors now because of it? I flat don’t know.
Robert Sneddon
I used the NHS24 tele-medicine option here in the UK back in April when I got home around 10:30 p.m. with a problem after a long drive (500km plus). After five minutes of going through a script checking my symptoms the person on the other end of the phone told me he had arranged a late-night outpatient appointment for me at a city hospital for 00:30. I got there, got treated and got home at around 02:00 muchly relieved (TMI elided).
Total cost to me: £0.00 (other than the taxi fare there and back). Ongoing treatment resulting from that incident including drugs, appointments with my local GPs and nurse practitioners and a specialist consultant topped with an MRI yesterday, total cost to me: £0.00.
Amir Khalid
@Robert Sneddon:
You’re just rubbing it in with our American friends, aren’t you? :)
David Anderson
@Ohio Mom: I’ve had my ankles treated and care continuity from the doc who was on the Celtics orthopedic consult crew from the late 80s to late 90s. I have similar ankle issues to issues that pre-maturely ended at least one Hall of Fame career. His surprise at my outcomes is that I am walking with neither a limp nor a cane as I approach 40.
Brachiator
@jl:
Jargon is a bit thick here.
Dupe
Well, I am now navigating insurance market and finding out it is ugly. Was laid off end of July and after comparing costs in Texas exchange plus the fact my current doctor does not accept any exchange insurance I will be using COBRA at least for now. It’s actually only $100 more than the lowest plan available.
WhatsMyNym
@Yarrow:
You’ve got some underemployed med professionals that you aren’t telling us about?
There is an extreme shortage of them and it’s getting worse with baby-boomers retiring. The younger ones are hesitant to work outside of urban areas. Foreign medical professionals are needed in most first world countries to make up the shortage anyway.
Villago Delenda Est
That emergency room charge is fantasy. Try three times as much.
jl
@Brachiator: Try this Stiglitz powerpoint presentation
The Revolution of Information Economics:The Past and the Future
http://pubdocs.worldbank.org/en/261465395285689/Joe-Stiglitz-PRESENATION.pdf
Brachiator
@jl:
I will actually take a look at it later!
Thanks.
daveNYC
@Amir Khalid: It’s the big difference between American insurance and nearly every other medical insurance/single payer/socialized medicine system in the rest of the world. It’s not just that you’re covered, it’s that you really have nothing to worry about financially if you ever need medical treatment. All the analysis of plans that Mr. Anderson (your predicted usage, cost sharing elements, deductibles, etc) just aren’t really in the mix. It means that 20 year olds are probably overinsured, but the flip side is if you’re that poor bastard that gets hit by a bus, you don’t have to worry that your bronze level coverage is gonna send you straight into medical bankruptcy.
I was always lucky enough to have very good insurance in the States, and the Czech Republic has a pretty solid system too (10 bucks for an ambulance ride, some tests for a torn muscle, and a few drugs), and I think that some of the technical discussions of insurance plans make an assumption that the goal of an insurance system should be some actuarially efficient system where everyone gets a plan tailored to their expected needs. This is different from my take on insurance, which is that it should be a ‘and now I don’t have to worry about X happening’ system.
jl
@daveNYC: ” actuarially efficient system where everyone gets a plan tailored to their expected needs. ”
That kid of insurance may well only exist in a fantasy world, so too bad it is sold to voters as the automatic outcome of under regulated health insurance market in the US.
Not at all clear that can happen without locking out many people from the market, and destroying what we intuitively think of and expect from insurance for the rest.
jl
@Brachiator:
Here is an empirical analysis showing that there is no trade off for the average OECD economy. There may be a very weak trade off for those countries that are very efficient and/or equitable.
The trade-off between efficiency and equity
Torben M Andersen, Jonas Maibom 29 May 2016
https://voxeu.org/article/trade-between-efficiency-and-equity
The Golux
@Robert Sneddon:
Yes, but how much is that in dollars?
Villago Delenda Est
@The Golux: Oh, the snark is strong with this one!
daveNYC
@jl: it does exist, just only for very specific people. The person in Iowa who cost their insurance a million bucks a month for example. They know they’re going to rack up huge claims and can calculate which plan works for them accordingly. But that’s not exactly insurance like most people will use it.
Capri
I have recently been involved with a DCP clinic. That’s direct care physician – a new model (or, maybe more accurately, a very old model) of providing health care. You pay a flat fee for physicals, basic medical services, and a certain number of blood tests per year. They help you shop around for the best deal for the more expensive preventative things they can’t do in house. The premise is that it treats medical insurance more like car insurance. You have insurance help you with repairing a car crash, but you pay for changing the oil out of pocket. The practice is very friendly, the doctors spend a ton of time with their patients because there isn’t the rush to meet quotas.
I found a provider for a friend who is self-employed, is going through the hoops of getting on medicaid but that’s a ways away if he ever qualifies, and hadn’t been to a doctor in 40 or so years. Since DCP doctors don’t deal with insurance, they took him in as a patient even though he wasn’t covered at all. He had his initial physical examination /screening blood tests last week. Come to find out (through the on-line patient portal) that he has diabetes and high blood lipids and his doctor recommends that he immediately begin two medications.
Perhaps just to prove that DCP are still, after all, doctors in America, when he called this morning for more information about getting an actual prescription for the medications they recommended and questions about how to alter his diet he was unable to get through to anyone and has been left hanging. Plus ça change…
Just One More Canuck
@LeeM: in one recent road game, one of our girls received a pass, beat two defenders and was in the clear from about 30 yards and scored. The linesman somehow managed a way to call her offside
Kent
My wife works for Kaiser Permanente in the Northwest.
The have a system of telemedicine where you can get a phone consult for free but an actual office visit costs the co-pay. So she spends 2 afternoons a week at home in her sweats with her feet up answering phones instead of seeing patients in the clinic.
I guess it works out better for Kaiser to defer a lot of routine stuff to phone consults. Cheaper than an office visit. I don’t know what percentage of her calls get referred back to an actual office visit compared to how many are dealt with over the phone.
Miss Bianca
@Doug R: Where do you live that you were able to get an $80 ambulance ride?
Just One More Canuck
@Miss Bianca: I believe Doug R is in BC – here in Ontario, it costs $45 for Ontario residents with a health card
Zinsky
Dupe – sorry to hear about your employment situation. My son also found COBRA to be cheaper than insurance on the exchanges after Moscow Mitch and Gravedigger Barrosso and the GOP butthole boys for Trump gutted Obamacare and left it for dead. May they all burn in the hottest circles of Hell forever!! ?
Doug R
@Just One More Canuck: Yes, BC. Used to be $45 about 15 years back.
Ohio Mom
@David Anderson: Okay, good to hear you’ve gotten expert advice, I can stop worrying about you now.
On to the next item on my To-fret-about list…