• The other precious stone

    kidney stoneForgive me for romancing this stone a bit, but I like to blog about personally important precious stones. Besides, a good deal of my health care use over the past six months has been centered on this 7mm kidney stone. Ain’t he cute? (My only son.) The numbered markings in the picture are centimeters.

    Last I wrote about this gem, I had been to the emergency department to manage the pain and was beginning to consider prevention (still ongoing) and overuse. In hindsight, I’m not entirely sure that ED visit was necessary, if I had only had the right drugs on hand. (I have them now.) In fact, I’m not certain some of my other care was necessary, had I only had better information about expected symptoms.

    An understatement of the total cost of care for this stone is about $7,000. That’s what my insurer paid. I paid another 10% in cost sharing. It’s an understatement because I’m not entirely done. There’s some post-delivery analysis yet to go. On the other hand, the delivery was by natural means, sparing my insurer (and me) the cost of more invasive procedures that would have likely run another couple thousand dollars (my best guess), maybe more.

    What cost so damn much for a stone that essentially worked itself out on its own? Well, the ED visit was $1,300 or so. The contrast dye CTs were nearly that much, and I had two of them. Already this is (possibly) overuse because x-rays would have been fine and a fraction of the cost. In defense of the health system, we didn’t know we were looking for a stone the first time, and that CT was more informative about anything else that could have gone awry internally. That initial CT showed the stone in its embryonic stage, so the second CT was probably overkill, though it was over three years later than the first.

    Where the more obvious overuse cropped up was in the unnecessary visit to a walk-in clinic that led to an antibiotic prescription (which was absurd) and some x-rays. I’d not have bothered — and I won’t in the future — had I known exactly what to expect from a stone. I blame my first urologist and his office for insufficient communication. I tried, I really tried, to get more information. They were not helpful.

    By my calculations, I used at least 10% more health care (in dollars) than necessary, and far more if I could have avoided that ED visit. My next stone, should it take the same course, will be cheaper, but no less precious.


    • Ah… look at that. He’s got all those lovely hooks and pointy bits.

      During my kidney stone, I also learned I was allergic to codeine. I’m not sure any Urologist can really prepare you for passing one of these things.

    • Hopefully your next “stone” will not be a AAA in disguise. While there certainly is waste in the health care system, there is also uncertainty in the practice of medicine. That uncertainty is where some of the cost exists – using technology to arrive at accurate diagnoses.

    • Might I suggest buying the wife a diamond solitaire next time, its much less expensive.

      So if a renown healthcare economist has this type of information problems, how does a regular patient, in pain, shop wisely. It’s the information imbalance within healthcare between patients and providers that is health care’s market failure.

    • See, this is why I’m skeptical of the idea that high deductible insurance plans will reduce waste. You spent how many years studying medicine? Not to mention science? And if you failed to make the most cost efficient choices, how can the average Joe?

    • The main reason I drink lotsa water. Flushes ’em out before they grow big. At least it seems to work. The urologist said I had a 70% chance of recurrance within 7 years. That was 1997.

    • I’m not sure I understand where the waste came in. Given the uncertainty involved in a patient presenting with abdominal and pelvic pain, a CT with contrast is probably the standard of care at this point (helped along by the physician bearing all the liability risk) rather than x-rays. What evidence did the physician have that your pain came from something that would be treatable without surgery like a stone?

      Also, you did not mention whether the antibiotic prescription was due to a fear of pyelonephritis, etc.

      There is waste in the health care system yet this anecdote does not really convince (absent new information).

      • There was no pain at the time of or proceeding either CT.

        Trust me, the antibiotic was a CYA. Three other docs far more knowledgeable about my case (two specialists in this area) told me so. The culture was negative, as expected. Like I said, I’d not even gone to the walk-in clinic had I known the symptoms to expect.

    • -All of the above comments indicting information asymmetry as the primary cost driver in this case are puzzling. What characterized this case was uncertainty. Neither the doctor nor the patient were certain what was causing the pain at the outset. Acquiring the information necessary to make such a determination and definitively rule out all other potential causes of the pain required expensive imaging – despite the fact that the probability of something like a malignancy causing the pain was (probably) extremely low, but non-zero..


      Any thoughts on the extent to which having to pay the entire cost of every diagnostic test, etc up to a particular deductible would or would not have affected your decision-making throughout this process?

      • Yes, paying more up front would have changed my care. Interesting how few are willing to take my judgement of waste here. I was the patient with a lot more information than the commenters. I’m saying some of the care (10% at least) was worth less than I would have paid. I consider that wasteful.

        I can put this another way: Care that was at least 10% cheaper would have still been well within the bounds of normal, adequate care. I would not have even had a few visits (that led to prescriptions and imaging) had I only had more information. I won’t repeat that mistake because I’ve learned. My care will be fine in the future, and cheaper. It could have been so this time around too. This feels appropriately patient-centered. Why so much resistance to it in the comments?

        • -I think that this is a commendable exercise, but it’s not clear precisely what information a physician who you interacted with could have shared with you at any particular point in your chronology of treatments that would have changed the course of treatment in any material way.

          -I’m sure that you are well aware that doctors confront a great deal of uncertainty when confronted with diseases or conditions that can manifest in complicated and overlapping symptoms, and much of the initial diagnostic regimen involves trying to rule out things that are, or can become, life threatening first. They care about trying to keep you alive and/or avoiding malpractice more than saving you money – unless you provide them with a reason to incorporate the cost of treatment into their clinical priorities.

          Once the diagnosis is complete and clear, it’s easy to rule out the elements of the diagnostic regimen that made it possible to rule out alternative causes of the symptoms as “waste” in hindsight. That’s the rough equivalent of claiming that the detective work necessary to rule out possible suspects before conclusively identifying the criminal is “waste.” I’m not sure if that’s what you are doing here, but that’s the impression I get from a great many retrospective evaluations of care.

          -I think you’d be surprised how different your interactions with physicians are when you make it clear that you are paying out of pocket. All of a sudden you start discussing both the costs benefits of every significant step in your diagnosis and/or treatment, along with various alternatives.

          Instead of assuming that you want everything that can be done, to be done immediately, you have a dialogue where your own convictions and judgments about the costs and benefits of a particular approach stay at the forefront throughout the interaction. You don’t always end up spending less, but you almost always get way more information and better care.

          • All fine points. But I’m making a fairly narrow one. I made a call to go to a clinic that I believe a reasonable person with slightly more information would not have. That information wasn’t obtained at the visit. In fact, the visit led to a bunch of useless stuff. I received the crucial information later. It’s generic and I could have known it in advance. Now that I know it, when in a similar situation in the future, I will choose differently.

            Another way to put it is that I needed a different kind of visit. I needed to talk to one of the knowledgeable docs familiar with my care, not to see the random doc at the walk-in clinic who was responding (reasonably — in some sense — but myopically) to the short-term symptoms as presented. I actually blame myself, even though I also behaved reasonably.

            Of course I’m not typing out all the details in the post or in comments. I think I’ve shared enough!

            • Interesting.

              Much of the waster purported to arise from “information asymmetry” between an omniscient doctor and a helpless patient actually has it’s origin elsewhere. Per your account it seems like provider mismatch was a significant driver of inefficient care. .

              Without direct personal experience, or a knowledgeable insider, it’s often very hard to find the best doctor/hospital/clinic for your particular situation.

              In so many other domains where consumers need access to specialized/technical/insider information in order to make a decision, mechanisms ranging from agents/consultants to ratings companies, to consumer alliances to websites have emerged to help them do so. The contrast with medicine is striking.

              The consensus opinion seems to be that this is due to the inherent complexity of medicine relative to say – say – buying a home, but that when you compare process required to navigate through a home purchase it’s not at all clear that it’s less complicated than navigating one’s way from waking up with abdominal pain to gallstone removal.

    • “I’d not have bothered — and I won’t in the future — had I known exactly what to expect from a stone. I blame my first urologist and his office for insufficient communication. I tried, I really tried, to get more information. They were not helpful.”

      I dont get it. Arent you capable of looking up info on kidney stones from the internet? I’m pretty sure it has all the info you need.

      When the info is free it doesnt make any sense to waste a doctor’s time by asking about stuff that is out there on Dr. Google.

    • The hideousness of that stone will haunt my dreams forever.

      Seriously though, wasn’t there a temptation to go for a more invasive (and expensive) procedure if only to unburden you of what, I assume, must have been an extremely painful “passage”?