Medical Malpractice on the Decline

Last Monday, as is so common, I got an email from one of the several medical organizations of which I am a member. This was a fundraising pitch, and I can't recall the details, but it contained the usual breathless rhetoric regarding how important their advocacy efforts are to fix the SGR, enact tort reform, save the practice of medicine, ensure domestic peace and tranquility, yadda yadda yadda...

Honestly, I don't even read these things any more before I hit delete, and I have actually developed a blind spot over the text where they hysterically predict catastrophe and doom. But this caught my eye — tort reform? Who's still talking about that as a priority? Mostly because it's a pipe dream that couldn't get through a republican congress with a republican president. In this day and age it's a dead letter. But also because I kind of thought the medical malpractice crisis was over.

I'm so old now that I've been through a full cycle of the boom-and-bust in med mal. When I came into practice, insurance rates were low, and then they spiked, nearly driving our practice out of business. It was horrible. Several local groups went under, and several others were hit with huge costs as their insurers left the market or went belly-up. Ugly times. But also, long ago, and the world looks very different now. Recently we've had no trouble getting multiple carriers to bid on our professional liability insurance, and at competitive rates. We are shifting towards a self-insurance model and currently enjoying the lowest insurance costs in well over a decade.

So I got wondering -- what is really going on in medical malpractice these days? Are real numbers available? The answer turned out to be fairly difficult to find. But a nerd with a computer and a couple of days off work can be a dangerous thing. So I did some legwork (with the help of Austin Frakt and Aaron Carroll of The Incidental Economist, among others) and I was able to come to some decent conclusions.

The data I used came from several sources:

• The AMA has a nice mother lode of (member-only) data regarding medical liability and insurance. 
• The Physician Insurers Association of America publishes a claim trend analysis annually, which is also member-only. However, my insurer is a member, so I got a copy of their 2011 report.
• The National Practitioner Data Bank had oodles of public data available, including a top-level summary of reported payments and a HUGE downloadable database of all 900,000 (!!) cases reported since 1985.
• For cost & demographic adjustment I used BLS and Census data.

I had a little trouble reconciling some of the variation in the data sources. For example, the median loss for a closed medical malpractice case in 2010 was $200,000 according to the PIAA, and $135,000 according to the NPDB. This refers to the amount paid to the claimant, whether by judgement or settlement, and excludes the cost of case management and defense. This variation was consistent across the board -- for all cost figures, the PIAA numbers were 15-30% higher. I am not sure why this would be. Not all carriers report to the PIAA; its dataset is much smaller, including only about 20% of all paid claims, so there may be a sampling bias at play. Payments made to claimants other than insurance payments would not be recorded in the PIAA data, and smaller insurers (or self-insured physicians) might be more tenacious in defending and thus the smaller payments might be excluded from that claimset. I would tend to view the NPDB numbers as more definitive. Still, the trends correlated well enough that I could draw some reasonable conclusions from the data. Additionally, the NPDB, which casts the wider net, gave better data on the total volume of cases, and the PIAA data had good numbers on the cost of defense.

The top line conclusion:

Medical malpractice costs are down quite a bit — about 35% from their 2001 peak:

This includes all professional liability claims against all individual providers: physicians, dentists, nurse practitioners, nurse anesthetists, etc. The vast majority is physician cost. I factored in the costs of defense as well, since that generally contributes about 25% of the cost of the median case. Note that the scale of the graph is adjusted to highlight the trend. Again, I suspect the PIAA line significantly overstates the actual cost, but I included it to show its trendline against the NPDB trend. I also note that the 2001-2003 peak in medical malpractice insurance rates did correlate with a historic high in malpractice losses. (At the time there was much speculation that the insurance companies were exploiting their rate-setting power to recoup reserve losses from the stock market implosion.) The actual cost is probably slightly higher since claims management and defense costs for cases the physician won are not included.

The decline in costs is not driven by increased losses per claim, which have remained remarkably stable over time:

Note that these costs are adjusted for inflation, and exclusive of defense costs. The median claim loss was in fact highly stable at the above-noted levels ($135,000), but the average cost was more reflective of real-world experience, I thought, since it shows the effect of the occasional very large verdicts/settlements. Which as it turns out, do not seem to be on the rise; quite the opposite.

However, the claim frequency is down dramatically. This seems to be the major driver of the decreased cost:

And even more when you control for population growth:

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So what we are seeing is a 40% reduction in the frequency of claims which result in payment to a patient. Not claims made, but closed claims with payments. Important distinction.

What's the driver of this trend? I have no idea. There could be fewer cases being filed, or physicians and insurers could be more aggressive in defending claims. Tort reforms were enacted in a couple of states, but I do not think that has contributed enough to change the national picture.

One suspicion I may have is that the lawyers who specialize in med mal cases may simply be more selective in the cases they are willing to take to trial. The costs of defending a malpractice claim has risen from $35,000 to about $50,000, and claims which go to trial cost about $150,000. If the plaintiff's costs are anywhere near that scale, it's a very expensive and risky proposition for a plaintiff's attorney to front that sort of money in the hope that they will win at trial. Since the very few cases which go to trial (about 8%) result in a defense verdict the vast majority of the time (~90%), it's quite possible that many lawyers are discouraged from gambling on a case which is anything other than a sure win. It's also possible that physicians (and their insurers) have become more savvy in settling losing claims quickly and at less cost.

There's a lot more to glean from the data, and when I get a chance I intend to break out the state-level distributions. I'm curious to see whether the "crisis" states are really in crisis, and how well state-level premiums really correlate with the case rates. But, in summary, it is accurate to say that malpractice cases and costs are significantly down across the nation. I would add, as a cautionary note, that the history of medical malpractice is quite cyclical and unpredictable, and it's highly likely that in the future we may —will — see another crisis when rates spike.

But for now, make hay while the sun shines!

I will post the raw data for those who are curious when I get a chance to clean it up a bit -- it's right now all helter-skelter in a huge, ugly spreadsheet.

The Indestructible Man

You know, writing about poor old Boomerang Bill made me think of another notorious alcoholic we used to see on a regular basis when I was a resident. I seem to think that I've written about this guy before, but I can't find him in a quick scan of my archives.

This fellow was another who was frequently found by EMS slumped on the ground under a bar stool. We knew him well. He was surprisingly high-functioning, though, in that he managed to maintain some semblance of a job and a stable social situation. He even had family that would sometimes come and get him from the ER, which is pretty rare for a hard-core alcoholic. He didn't talk much (a welcome trait in an alcoholic frequent flyer) so he got nicknamed "Silent Bob," after the character in Clerks.

Like many heavy drinkers, Silent Bob was tough, and near indestructible. Something about really pickling yourself over many years can for some people give them the ability to survive the lethal insults of physiology. I've seen the same phenomenon at VA hospitals as well. But this guy took the cake.

• Perforated gastric ulcer: Survived
• Necrotizing pancreatitis: Survived
• Subdural hematoma: Survived

Nothing could touch him, and he kept coming back, over and over.

One memorable week, he was brought in by the same EMS crew three times in a row. The first time they found him passed out on the sidewalk outside a bar. The next day he was trespassed in the public library but was too drunk for jail. A couple of days later he was found passed out in the firehouse underneath the fire engine!  He had crawled in there when the door was open and fallen asleep under the fire truck itself. They nearly ran him over heading out on a call, but someone noticed his legs sticking out before they drove away. Fortunate for him.

So a few days later, when the same EMS crew was called out and found Silent Bob passed out under the railroad viaduct, they weren't too surprised, and just bundled him up and brought him back in. They did not notice that he was not moving his arms or legs, because, well, he was passed out and not expected to be moving much of anything. It turned out that Silent Bob had fallen off the viaduct and had a horrible C4-5 fracture/dislocation. I used to have the images somewhere — they were impressive.

So once we figured out that he wasn't "just drunk," which is incidentally the most dangerous diagnosis it is possible to have in an ER, we got him admitted to neurosurgery. They did some sort of procedure; I wasn't clear on the details. What was memorable was that a few days later, word filtered through the ER that Silent Bob had walked out of the hospital against medical advice. First of all, how shocking is it that he was walking at all? Second, who the hell leaves the hospital AMA with a broken neck? He apparently had some residual weakness in his lower extremities and still had a halo in place, but he was not going to hang around the goddamned hospital where they wouldn't let you have a drink, was he?

So, another bullet dodged, another lethal diagnosis to add to the list of things he had survived.

We saw Silent Bob in & out of the ER for the next year or so. He never followed up in neurosurgery clinic, but when he came in we'd call them down to adjust, and eventually remove, his halo. He needed a cane to walk, but otherwise had survived his most recent brush with the reaper very well.

Finally, one day, he was brought in dead by the same medic crew who had seen him so many times before. Apparently, Silent Bob was passed out on a park bench when he was witnessed to have been hit by lightning. Really. EMS did their bit, and we did our bit, but his heart did not restart and that was the end of Silent Bob.

One of my attendings reflected, and eulogized Bob after we had terminated the resuscitation. "You know, this was probably the toughest mother fucker I have ever known. He shrugged off more disease than any of us mere mortals ever will. You want to know how tough this guy was? It took an act of God to kill Silent Bob. We won't see his like again soon."

Nor have we.

What does planned parenthood actually do?

One thing which has long pissed me off about the christianist faction in US politics, with regard to their never-ending quest to impose their definition of "life" onto everybody else in the country, is the way they put their ideology and their theology above the actual health and lives of real, actual, living and breathing women. Their belief in a magical spirit force in a clump of nonsentient cells is important enough they they are willing to lay waste to the rights, privacy, and also the health of the women who sinfully misuse their ladyparts.

For years, the symbol that women's health activists have used to communicate this was the coathanger -- the implication that if abortion is driven underground then women will die from back-alley botched septic abortions. I always thought that was a bit over-the-top, though: too hypothetical and unlikely to carry much punch nowadays. It may have had more relevance in the '70s, when the era of illegal abortion was fresher in people's minds.

But now, if you are looking for real, actual evidence of how the radical christian right is willing to put women's lives at risk to save the spirit babies, look no further than the war on Planned Parenthood. Over the last two years, it has come under constant assault from conservative politicians, seeking to cut off its funding and force it to wither on the vine. The tactic is simple, and possibly effective: if you can kill or cripple an institution which is a major abortion provider, there will be fewer abortions. If all you care about are abortions, the math works out fine.

It is important to remember, though, that Planed Parenthood does way more than just abortions. They are a comprehensive provider of women's health services, primarily to low-income women who cannot afford to see a primary doctor or a gynecologist. Abortions are, in fact, a tiny minority of what Planned Parenthood does!

Planned Parenthood is caricatured in right-wing circles as no more than an abortion mill. As you can see, however, of all the patient contacts Planned Parenthood has, only 3% are for abortions. 35% are for STD screening and treatment, 35% are contraceptive, 16% are cancer prevention and screening. They perform nearly a million breast cancer screening exams annually, and a similar number of screening tests for cervical cancer. (source: PDF)

In fact, Planned Parenthood estimates that they prevent over 250,000 abortions annually, as a result of their contraceptive services preventing nearly 600,000 unintended pregnancies. Never mind the number of cases of tubo-ovarian abscesses and ectopic pregnancy they prevent by treating STDs and the number of lives they save through their cancer screening services -- particularly cervical cancer screenings.

Now, if you kill Planned Parenthood by pulling its federal funding, as Congressional Republicans tried, or by restricting its access to medicaid clients, as Indiana Republicans tried, or by burdening it with onerous and prohibitive pointless regulations, as Kansas tried, then you could possibly prevent 300,000 abortions a year. The consequence to that, however, would be that millions of women who have no other alternative would lose access to these other services, and some of them would die as a result of that.

That's not being hysterical, just simply pointing out the fact that policy decisions have consequences and some of those are what are drily euphemized in the medical literature as "increased morbidity and mortality," which is to say -- increased sickness and death. And to the true believers, the holy warriors (I won't say jihadists) of the anti-abortion movement, they are OK with those collateral human costs.

Planned Parenthood is an important provider of health care for women, particularly vulnerable women. And it's important for those of us in the health care community to stand up in its defense against the religious extremists who want to shut it down.

When politics trump health care

Seriously, this is bullshit:

Susan Komen Foundation halts grants to Planned Parenthood

NEW YORK – The nation's leading breast-cancer charity, Susan G. Komen for the Cure, is halting its financial partnerships with numerous Planned Parenthood affiliates. 

Komen says the key reason is that Planned Parenthood is under investigation in Congress - a probe launched by a conservative Republican who was urged to act by anti-abortion groups.
The result is a bitter rift, linked to the national abortion debate, between two iconic organizations that have assisted millions of women. 

Planned Parenthood says the cutoff, affecting grants for breast exams, results from Komen bowing to pressure from anti-abortion groups. Komen says the key reason is that Planned Parenthood is under investigation in Congress — a probe launched by a conservative Republican who was urged to act by anti-abortion activists. 

The Komen grants, which totaled about $680,000 last year and $580,000 in 2010, went to at least 19 Planned Parenthood affiliates for breast-cancer screening and related services. Planned Parenthood hopes to raise new funds to fill the gap.

Planned Parenthood used these grants to fund 130,000 breast exams and 6,500 mammograms.

As usual, the so-called "Christian" right puts their ideology and politics above actual women's health, whether it's blocking the HPV vaccine or forcing women to undergo unnecessary medical procedures.

For the record, the pretext for this decision is fairly thin; Komen has a policy which prohibits funding of any organizations under congressional investigation. Congress is investigating Planned Parenthood. Ipso facto, case closed, not at all political, right?

However, according to the Washington Post, this is a new policy, adopted after Komen hired conservative Georgia politician and failed gubernatorial candidate Karen Handel as their senior Vice President of Public Policy. Handel, who is pro-life, ran for governor on a pledge to defund Planned Parenthood if elected. No other organizations have been similarly affected at this point. It is also worth noting that the "investigation" which triggered the termination of the partnership is nothing more than a partisan fishing expedition led by pro-life government oversight chairman, Daryl Issa.

There's nothing wrong with any of that: Komen is a private organization and they have the right to follow any ideological agenda they choose. But don't believe any apologists who may claim that this was not driven by politics or a pro-life agenda.

Still, it's disturbing and disgusting to see a formerly reputable organization dedicated to women's health become co-opted by the christian right.

The founder and chairperson of the Komen Foundation is Nancy Brinker, whose email address, I am told, is nbrinker@komen.org, and Elizabeth Thompson is the CEO, reachable at ethompson@komen.org. I have reached out to both of them and politely expressed my concern about this politicization of their organization.

For my part, I will no longer support any Susan Komen Foundation activities or fundraisers so long as this situation persists. Frankly, there are plenty of other organizations doing great work for women's health in general and cancer in particular:

The American Cancer Society
The St Baldrick's Foundation
and, of course, Planned Parenthood itself.

I'll be directing my dollars and charitable efforts there instead.

Boomerang Bill

One perk, or drawback, of working in the ER is that there are no shortages of interesting characters we see. Many of them we see over and over, and get to know very well. There was the old guy with the pacemaker who we saw >500 times for chest pain over a three year period. And the asthmatic who every doc in our group has intubated at least once. And the brittle diabetic who could somehow survive with a bicarb of five. They stick in your minds.

One guy we will never forget around here was the alcoholic we called "Boomerang Bill."  As his name implied, he was in the ER pretty damned regularly. He had money, and was actually rumored to be independently wealthy. (A repellent figure, he once confided to me that he spent all his money on "booze, hookers, and taxis.") He was routinely found passed out under a bar stool somewhere, or puking on someone's lawn in the middle of the night, and the medics would routinely bring him to us to sober up. He was kind of an ass when he was drunk, and the nurses hated him because he would grope them every chance he got. But once he sobered up he was pretty polite and pleasant.

But every once in a while, he would run out of money or get too sick to drink, and then he would go into fearful DTs. I mean, his shakes and seizures and delerium were a thing to behold. We nearly used up all the ativan in the hospital chilling him out on more than one occasion. He would camp out in the ICU forever and the hospitalists hated dealing with him. But he was hard to kill, as so many of these hard-core alcoholics are, and he always rallied and made it back out to the street, where his first order of business was always, of course, to go get a drink.

Once, after dealing with him in withdrawal four times in four months, the hospitalist who was in charge of his care decided to try something new. He located Bill's brother, who was in New Orleans, and convinced him to agree to take Bill into his home and care for him. Bill was himself willing to go and try to start over. The only problem was getting him there. So a collection was taken up among the medical staff — hospitalists and ER docs alike contributed eagerly — and we bought him a plane ticket as well as some new clothes. When he was ready for discharge, the hospitalist drove him to the airport himself and actually put him on the airplane.

And that was the last we saw of "Boomerang Bill." Until (you must have known this was coming) about four months later when he showed up in our ER again, drunk but starting to go into withdrawal. I'm not sure whether we were more astonished or horrified to see him again. When the hospitalist came down to admit him (the same one who had driven him to the airport) he asked, in dismay, what had happened, why wasn't he in New Orleans with his brother? Bill replied in his gravelly voice, "Man, it's too damn hot down there. I couldn't stand it." He added, in an aggrieved tone, "And it took me forever to hitchhike all the way back up here, too."

The hospitalist's shoulders just slumped in defeat. The boomerang had come back once more.


Epilogue: We continued to see Bill on and off for the next couple of years, on his usual irregular schedule. One day he staggered out into traffic and was hit by a car and left for dead. He was brought into the ER in critical condition and died a couple of days later. Some of the nurses noted that he had seemed more despondent in his final ER visits and wondered whether this was a passive (or active) suicide attempt. And so it goes.

Things that are not at all surprising, part 26

I remember way back in the paleolithic era when the debate was actually going on over what health care reform would look like (before we settled on "greatest threat to liberty ever," that is) and my comment section was deluged with folks who railed against the very concept of universality in healthcare insurance. They, further, denied that such a thing as involuntary uninsurance existed, or that underinsurance was a problem at all. These commenters tended to be the rugged individualists of our great nation, and their testimonies were along the lines of: "I have type 1 diabetes and I've had three limbs amputated and I do just fine with my catastrophic health insurance plan" or "I have chosen not to buy health insurance and I'm just so badass that if I ever get sick I will go off onto an ice floe so as not to be a burden to society, so why should we hand out free healthcare to goddamned moochers?"

Or something like that.

So, it actually turns out that catastrophic/high deductible plans actually kinda suck. I'll take a moment to allow you to recover from the shock of that.

Now we already knew that being uninsured made you (that's the general you, not you in particular) more than four times as likely to skip or delay needed care. That makes sense. Healthcare is expensive, even if you're only paying charity rates, if you can find them. If you have to pay, and you don't have a lot of money, in many cases you just don't get it. And it turns out the same phenomenon is at play with high-deductible "catastrophic" plans. When you have to pay out of pocket (which is the central concept of these plans), you're more than twice as likely to skip or delay needed medical care.



Still, high-deductible plans are great if you never have to make a claim, but there you have it...

Fun factoid: if you have a high-deductible plan, and someone in your family is ill, then the effects on your own health trickle down, as you also tend to skimp on your own health care.

And back to the subject of the truly uninsured, the CDC came out with a report which found that (again, brace yourself for the shock) being unemployed makes you about 3 times as likely to be uninsured.

Aaron Carroll takes on directly the myth of the "uninsured by choice" cohort:

Many people like to think that being uninsured is a “choice”. And they’re correct, in the sense that you can “choose” not to buy insurance. I get that. But many people “choose” not to buy insurance for the sole reason that it’s crazy expensive. The average – not gold plated, but average – employer sponsored insurance plan for an individual plan in the United States last year was $5429. And that was just the premium. It didn’t include deductibles, co-pays, or co-insurance. The average family plan was $15,073. The median salary in the US, on the other hand, was less than $50,000 for households. For individuals, the median paycheck is $26,364. When you’re making that amount, and you lose your job, paying for that insurance plan is no longer possible. Paying for COBRA is even harder, as it’s usually more expensive.

I kind of wonder why I am wading back into this topic. Experience has shown me that it's become such an ideological shibboleth that the true believers are completely impervious to reason and data. I'm like a moth to the flame, I guess. I just can't leave it alone. Someone is wrong on the internet.

Selling the ACA, 2 years too late

This is a cute and informative video about the health care reform act:



My favorite drawing is this, of economist Jon Gruber about to be crushed by the ogre of uncontrolled health care spending:

In fact, I think this will be my new twitter avatar.

Still, it would have been nice to have seen more of this sort of education and messaging two years ago when public opinion regarding the ACA was more malleable. Now people's ideas are pretty well set, hardened in part by their partisan stances. I was shocked to see that 55% of Americans now think that the individual mandate is unconstitutional. This is evidence, I think, of how effective the impassioned rhetoric from the opponents of the ACA has been in shifting the way the law is viewed. I don't think that many people have done a deep dive into Wickard v Filburn and come to this conclusion on their own; I suspect that more have been influenced by the persistent and angry denunciations of the mandate by its many opponents, with flaccid or nonexistent defenses of the law from its supporters. Consider, by the way, that when the court challenges were filed against the ACA's mandate, it was considered hopeless by legal observers; now we are truly a coin flip away from its invalidation. That's how far the frame has shifted, and it's entirely due to the effective case that has been made by conservatives and the failure of defenders of the law to respond.

Hopefully, this will be moot. If SCOTUS doesn't decide to overturn decades of precedent, and if Obama does manage to win re-election, the law will be completely implemented. In that case, I suspect it will becomes less of a partisan football, and we can maybe move beyond repeal to more productive arguments.  I can dream, can't I?

Doctor Cat

A friend alerted me to the existence of this:

Unfortunately, the Doctor Cat cartoon seems to be on a bit of a hiatus for health reasons (here's hoping the author gets better soon).  It works for me on a number of levels:

1. Cats are cute (no explanation needed)
2. Cats are like doctors in that they are variably narcissistic, imperious and inscrutable.
3. Did I mention the cute factor?

Reminds me of this brilliant series from Medium Large:

The Myth of the Cost Sensitive Patient

It simply will not go away, and the fact that anyone who has ever interacted with the health care system thinks this will ever be more than a pipe dream is simply delusional.  The offender (this week) is former CBO and OMB director Peter Orszag. (Disclosure: I once had a man-crush on him as the uber-wonk of health care reform, until he left government and cashed in at Citigroup.)

Orszag writes in Bloomberg: To Shop Smart, Patients Need to Know Price of Care, in which he argues for greater price transparency "with the goal of helping people become smarter shoppers."

Sweet baby zombie Jeebus help me.

To his credit, Orszag notes that the extant experiments towards this goal "have not been overwhelmingly successful," in perhaps the same way that the captain of the Costa Concordia was "not entirely prudent" in his navigation. He also acknowledges that cost-conscious medical bargain hunters are "unlikely to play a dominant role in reducing health expenses." So he at least relatively connected to reality, unlike the free-market fanatics who continue to insist that if only patients were obligated to bear the costs of their medical care, they would magically demand only the most cost-effective care and our health care cost inflation crisis would be solved.

But it's just not so. I've made this point before over and over. But again, it bears repeating:
The patients who are the drivers of health care costs (you know, the sick ones) are neither equipped nor situated nor interested in pursuing the cheapest health care.

Bear in mind that we are talking about a relatively small slice of patients: half of all health care costs are concentrated in the sickest 5% of patients in the US, and 80% of costs are accounted for in the top quintile!

These folks are sick, which means in many cases they are not feeling good, what with being sick and all, and when you are not feeling good it's hard to be really rigorous in making sure that your procedure of the week is being performed by the cheapest possible surgeon. What's more, when you are sick, you often have a doctor, and that doctor has associates and affiliations which you may find yourself being steered towards. And you may even trust your doctor, and when he tells you that a certain consultant or hospital is a good one, then you might just take him at his word and go there without first creating a spreadsheet of all the local options and their variation in costs.

This is all assuming that you have a choice in the matter. The ambulance may take you to the closest ER, or the surgeon who offers the best price on your cardiac bypass might happen to practice at a hospital with the most expensive ICU (which you weren't expecting to need so you didn't put that line item in your spreadsheet).

This is assuming that you live in an area with more than one network of providers; many regions have evolved a near-monopolistic health care ecosystem.

Finally, it's all academic because the typical patient who is a real super-user of medical care is spending so much money that even an insurance policy which is designed to have a high level of cost sharing and encourage patients to be highly cost-conscious cannot have a hope of paying a reasonable fraction of the actual costs of their care.

For example (a not-entirely random example): when I got the bill for my wife's radiation therapy last year, it was the largest invoice I have ever seen that did not have a mortgage attached to it. If I recall correctly, it was about $80,000. Worth every penny, I might add. So what threshold would be effective in getting me to choose one provider over another when the treatment is so insanely beyond my means to pay? None. At least none that exist in the real world. If I were on the hook for 25% of that $80K, it would be a horrible burden (even for a rich doctor, yes). I would have been able to scrounge the money I am sure. But then, I'm in the 1%. Well, maybe the 2%. What about a median-income patient? Someone earning $60,000 a year (well above median, I might add) would find medical co-pays of $5, 10, 20,000 crippling and completely beyond their means. Which means that healthcare insurance either insulates the typical patient from the cost or forces them to defer needed care.

There's very little middle ground. Yes, it's theoretically possible to find the magic level that would motivate a patient to become a "smart shopper" without resorting to self-rationing, but that sweet spot is so small and so variable from person to person that I am skeptical it could ever be implemented on a large scale, and certainly will never ever "bend the curve" on health care costs.

None of this should be interpreted as an argument against transparency in health care costs. The system is so distorted that the typical gross charge is triple the actual cost, and just like airline fares, no two people pay the same price for the same service. It's an outrage, or it should be. Transparency might be a good thing in and of itself. There might even be merit in linking costs to quality, if it can be done rationally (of which I am not entirely convinced). But I wish to god that people would stop pretending that patients who are seriously ill and marginally informed about the economics of health care can ever be utilized as a tool for reducing the national cost of said care.

Because it's a fricking delusion.