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How Much?

Joey, a family member with whom I’m not on speaking terms, had a bad GI bleed a few months ago. I’m pretty sure he hates trips to the doctor as much as I do. Fortunately Joey knows nothing about his right to consent, so I half-dragged him to the car, told him to quit complaining, tossed him in the back and tied him to his seat. We were going to the hospital whether he liked it or not.

All you champions of the sick and helpless out there—chill. Joey is an 8-year-old Cavalier King Charles spaniel. He’s a good dog but a bad patient, which, on a very weird level, makes us similar. Or so I’ve been told.

I liked the way the veterinarian and her staff treated Joey. The receptionist asked if our dog might like a snack, then quoted a minimum charge for office visits. Next the vet introduced herself and said she’d go over the rest of the costs after Joey’s exam. That was fine with me—much better than the price gouging that sometimes follows care of two-legged patients.

That trip to the vet made me wonder why we can’t do the same for our customers. Not the part about giving them biscuits when they behave; I mean discussing pricing prehospitally. The antiquated attitude that dollars shouldn’t sway treatment decisions is unrealistic in this era of sky-high deductibles. If I were a stable patient, I’d want to know about costly interventions while I still had a chance to delay or dismiss them.

I think the Affordable Care Act makes consumers more aware of healthcare costs. Suddenly there’s a marketplace where competition forces underwriters to detail prices and services. I’m not any happier with insurance premiums than I was before the ACA, but at least I know better what I’m getting for what I’m spending.

Looking at healthcare as just another service might help us understand the importance of pricing to our patients. I certainly wouldn’t commit to home repairs, for example, without knowing the cost. My willingness to incur those charges would depend on the degree of damage; I wouldn’t want a contractor to assume I’d pay for a new roof just because of a water stain. Even a big hole in the ceiling wouldn’t change my right as a homeowner to decide what work should be done.

It’s the same in EMS, where water stains could be blood and holes are, well, holes. As medical professionals, we’re supposed to get informed consent from alert patients before taking action, no matter how routine or necessary treatment seems to us. The consequences to healthcare providers of making decisions without patients’ involvement can be, at best, unsettling and at worst, devastating.

I’ve been indirectly involved in one lengthy lawsuit alleging transport without consent. I don’t know how it turned out—it was still going on when I left that agency—but I remember how the adversarial process haunted the defendants. I’m not sure how well I could do my job with that sort of judgment pending.

Should prices of medical procedures be required for informed consent? Perhaps. According to Thefreedictionary.com, informed consent is “assent to permit an occurrence…that is based on a complete disclosure of facts needed to make the decision intelligently.” I don’t know if that’s the best definition of informed consent, or even the correct legal one, but it’s a good starting point for discussion.

To me, making an intelligent decision about healthcare often involves an awareness of the dollars involved. I’m not saying cost is the most important factor—just another consideration, like difficulty, discomfort, complications, recovery time and likelihood of success.

Unlike most service providers, EMS agencies don’t usually set prices according to supply and demand, because patients don’t get to pick whose ambulance will respond to their 9-1-1 calls. Without competition, the biggest advantage to knowing prices up front is the opportunity to decline a particular intervention. Some would argue it’s dangerous to give nonmedical people that much discretion, but I think it would be possible to associate prices with brief, dummied-down summaries of recommended services. With a little cooperation from our employers, accessing such details wouldn’t have to be any more complicated than looking up a medication on our smartphones.

The Lovely Helen agrees costs should be a bigger factor in healthcare decisions. Like me, she doesn’t understand why more patients don’t ask us for prices. She also says the next time I’m sick, she’s calling the vet.

Mike Rubin, BS, NREMT-P, is a paramedic in Nashville, TN, and a member of EMS World’s editorial advisory board. Contact him at mgr22@prodigy.net.

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