Rationing through self-triage, my patient perspective

As I fell off the curb, my first thought was about my deductible.

Earlier in the year, I had tried to save a little money and chose a high deductible plan. This meant that I would have to pay the full cost of any doctor visit (including my primary care provider) until I had spent down my $6500 deductible. With an emergency department visit costing hundreds of dollars, I worried that my clumsiness had effectively wiped out whatever premium savings I had achieved with this choice.

In choosing a high-deductible plan, I had gambled that I could get through a year without illness and in the process fallen victim to my own optimism bias. As my ankle rolled inward and I heard an extremely unsetting *snap*, I felt very stupid about it.

Luckily for me, I remembered my Ottawa Ankle Rules. I was able to put some weight on the ankle and had no point tenderness over the lateral malleolus or fifth metatarsal and thus was at an extremely low risk of having a fracture. This is self-triage. I was fortunate enough to have the medical training to do it effectively.

However, without medical training, I could have ended up in the Emergency Department, paying several hundred dollars for some reassurance and an Ace bandage. After all, the fear or chronic pain or permanent disability due to an untreated ankle fracture really scares me. I already have Morton’s neuroma and patellar tendonitis. That’s more than enough slowing me down, thank you very much.

Worse, I could have tried to walk off a broken ankle leading to much more severe and expensive problems down the line. This decision about whether or not to have a professional evaluate my ankle should have been based off my perception of injury severity, not financial considerations.

I think its great that the Affordable Care Act has allowed more people to get insurance. However, getting more people on to the high deductible plans that are prominent on the exchanges is an extremely low bar considering that spending down a typical bronze plan deductible  ($5,700 for an individual, $11,600 for a family) is enough to deplete the savings of most families.

This is the context in which America very much rations healthcare via self-triage. The very mildest form of this rationing looks like my sad self, limping down the sidewalk, convincing myself I probably don’t need to see a doctor. But far more serious is the fact that a fifth of Americans delay medical care of a serious condition each year because of costs, most of them with much more pressing needs than my swollen ankle.

If all self-triage were effective, this wouldn’t be a problem. Many actually argue that high deductible plans are a good thing because they make patients “put skin in the game.” The idea is that the deductible makes patients think twice about medical care that is ineffective or unnecessary.

However, study after study has shown that patients are unable to effectively self-triage and instead respond to this disincentive by cutting their use of care across the board, eliminating both high-value and low-value care at the same rate. This means more patients trying to walk off broken ankles, skipping their meds, or otherwise risking their physical health to preserve their financial well-being.

Forcing a population without medical training to perform cost-based self-triage is the most insane way to allocate scarce healthcare resources. Moreover its a method that systematically disadvantages vulnerable populations such as the poor or those with low levels of educational attainment. Yet each year, high deductible plans only grow in popularity.

As the cost of healthcare and medical insurance rises, the surface appeal of high deductible plans is understandable. I am well aware. However, if we want a system that allocates scare health resources in a rational and just way, we must look elsewhere.

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Author: Harrison Kalodimos

I'm a family medicine resident at Swedish Medical Center in Seattle.

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