Thursday, June 7, 2012

I fell in a hole and it hurt

There I was, at the pickup counter in my local pharmacy. The pharmacist, a handsome young man about my daughter's age, raised an eyebrow as he looked at the label he had just printed, and allowed as how I had a pretty big copay this time around.

$230.30, to be exact. That's ten cases of St. Pauli Girl beer at Philly prices, if you'd like some context. For one Advair Diskus.

The Advair Diskus is a neat device. I will grant you that. But the one I'd gotten a month before had cost me $0 - that's zero dollars - and I was unprepared.

What happened? I fell into a donut hole. The most famous donut hole is the one in the Medicare prescription plan, but these days there are donut holes everywhere in health insurance, and not just in prescription plans.

The idea behind this plan design is that people tend to use too much healthcare. So the plan erects a roadblock, aka the donut hole. If you're healthy during the year and don't go to the doctor too much - maybe the internist for a checkup, the dermatologist, the eye doctor - it's all free. But if you go beyond that, as I did, all of a sudden you're paying for everything - 100 percent instead of zero percent. Then, if you're really sick, the plan relents and you only have to pay, say, 40 percent of the bills.

The donut hole is supposed to alter your behavior. It's supposed to make you stop and think about whether you really need this particular medical treatment. The plan wants you to say no.

So what happened in my case? I left the Advair at the counter and went home and contacted my doctor, using the fancy new secure email system that his practice has. It turns out that there's nothing less expensive that's as effective for what I have.

What I have is a little perplexing, but we've agreed to call it exercise-induced asthma. It turns out there may be a downside to running long distances in all weather.

In the end I went back to the pharmacy and bought the Advair. They had it waiting for me. They knew.

The donut hole got me to stop, and to search for alternatives, but it didn't alter my actual behavior one iota. Just my mood.

Why didn't the donut hole work? Because the premise of the donut hole is false. People simply don't buy healthcare the way they buy a car. Price sensitivity in medicine is very low. If you've ever had a child with asthma, and watched him say, "Mommy, I can't breathe," you'll know why.

People pay until they can't. When it comes to medical care, using price to motivate is a failed experiment.

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