This story appears in The New York Times ‘Your Money’ section on Wednesday, Nov. 20, 2013.
Peter Kreutzer is, in many ways, an ideal patient. Mr. Kreutzer, a 57-year-old Brooklyn writer, is in good health, eats well and follows his doctor’s instructions.
That includes getting routine colonoscopies. Because he is insured, Mr. Kreutzer pays only a $300 co-pay, a fraction of the cost of the procedure.
“It doesn’t cost the $2,500 that shows up on the insurance statement,” he said. Mr. Kreutzer said that he sometimes wondered whether the tests were necessary but that the low out-of-pocket cost made them easier to justify.
Mr. Kreutzer is unlike most patients in that he knows how much a procedure costs beforehand, but he is far from alone when it comes to choosing treatment based not on cost but on a personal definition of value.
“I think the system disincentivizes rational economic behavior,” he said.
The United States health care system, in which providers are generally paid per procedure in an arrangement known as “fee for service,” may be undergoing a fundamental change, driven in part by the Affordable Care Act. The law pays for better coordination among caregivers, as policy makers seek to reward value in care rather than volume. But that does not necessarily mean costs will become less opaque, nor that individuals will prioritize economics over emotion as they seek value in their health care.
Emily Watts, 32, of Houston, said she valued transparency and responsiveness in her physician.
“My auto mechanic gives me the time of day, and I pay him a lot less,” she said. “It’s become totally acceptable for a doc to just breeze in and breeze out.”
Ms. Watts is a performing arts curator who spent much of her 20s uninsured. She finally got a high-deductible insurance plan while working for a group that helped artists get coverage. And after moving to Massachusetts, she became eligible for a subsidy thanks to the state’s mandatory insurance law, which predated the national law.
She said years without insurance taught her to focus on her out-of-pocket cost and on getting the most out of each medical appointment.
“I will physically block the door and say, ‘You will stay in here and answer my questions,’” she added.
Researchers who study value in care usually consider effectiveness in terms of health outcomes per dollar spent.
“When you talk to patients about value, that’s not the metric they have in their heads,” said Dr. Steven Woolf, a family physician and a professor at Virginia Commonwealth University who has studied value in primary care. Patients focus instead on “convenience, personality, chemistry,” he said. “Whether they are getting time and attention.”
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