While I don’t usually write about my personal health, I was recently asked about health care reform during a discussion at the American Pathology Foundation meeting recently in Las Vegas. While the discussion centered on the main issue – not a full reform of the current healthcare system but rather insurance reform, it prompted me to put to words a few personal experiences and ask the question “What is the real cost of healthcare?”

In May of last year I came down with what I thought was a community acquired pneumonia. This was about the time of the first reported cases of H1N1 and out of fear of quarantine at the time for what I was sure was not H1N1 I avoided doctors and hospitals. After trying a couple courses of antibiotics prescribed by a colleague, without relief, I found myself at an “express care” facility on a weekend morning desperate for relief from my symptoms of fever, cough and chest pain.

After completing a short medical history, I was seen by a nurse practioner with minimal waiting who was professional yet focused her questions and examination on the current problem. Within a few minutes I had prescriptions for another course of antibiotics and medication to relieve the cough and subsequent chest pain.

“Are you going to do a chest x-ray?” “No.

“Sputum culture?” “No, why?”

“Referral to infectious disease or pulmonary?” “Huh?”

By the next morning, my symptoms were gone. Of course, this likely would have resulted had I not seen this healthcare provider but for fifty bucks that my employer sponsored healthcare plan paid for I feel like it was time well spent and was able to sleep through the night for the first time in a couple of weeks.

Some time after this I asked a pulmonary colleague had I been seen by him or one of his colleagues what may have transpired. At the least he claimed a chest x-ray and consideration of bronchoscopy and possible PFT testing to exclude other underlying conditions. Seems like a stretch compared to what I needed and with the treatment being an inexpensive visit, antibiotic and cough supressant.

During my acute illness one of our fellows presented with acute flank pain to the ER on the same weekend. After sitting in pain for four hours in the ER it was determined he had a kidney stone and conservative managment was warranted. An ultrasound and CT later, twelve hundred bucks for the ER visit plus radiology costs. No pain relief. By the next week after conservative measures failed and he underwent additional urology consultations, lithotripsy and eventually surgical removal of the stone. Tack on another five grand. A post-op follow up, subsequent IVP and his bills were pushing $10K. This does not count time off from work and lost productivity. The insurance covered a minority of the expenses.

While I am not a pulmonologist or urologist and do not manage acute clinical conditions I wonder what may have happened if my colleague had gone to see the nurse practioner on the weekend as I did. Save the ER costs for same diagnosis, perhaps some more immediate relief of symptoms, quicker appropriate referral as this could not be managed in their setting and definitive care rendered with less delay and patient suffering.

Perhaps this model can be expanded. What is the real cost of healthcare by being overly investigative or delaying definitive care at the expense of conservative measures? It is obviously a difficult balance without the medicolegal implications either way.

I think that we should be looking at outcomes and a cost per outcome (or expected outcome) as function of dollars spent as a significant factor in terms of appropriately providing care while insuring the standards of care are met.

Would I have benefited from a more extensive work up? Would the outcome been different? Probably not. While it may not have been contraindicated and not harmful, or low risk, the costs beyond using emperical data may not justify a similar outcome.

Physicians are driven by data. But what is the data worth as a function of its cost?