I envy my dog’s health care

When my dog Molly got sick a few years ago, we hadn’t intended to take her to the veterinarian — the problem was a simple gastrointestinal bug — but she refused to eat, then became lethargic. The vet prescribed fluids, antibiotics and a half-day stay at the animal hospital. She got better quickly.

The cost was about $250, paid in cash.

I didn’t realize how affordable this was until my husband developed a similar ailment later that year. The vomiting didn’t stop until he had received three liters of intravenous fluid, the same elixir Molly received, plus anti-nausea medicine in the E.R. He was back at his desk the next morning. But shockingly, the bill came to almost $4,000, more than 10 times the cost, for essentially the same care our dog received.

Many people see veterinary care as discretionary — a luxury. By contrast, most would say human health care should be widely available and that no one should die for lack of care. Usually, luxuries cost more than necessities. So why does human health care cost so much more?

Our veterinarians practice in a cinder brick building in a low-rent part of town. The receptionist checks us in, answers phones, schedules appointments and also pulls charts, does basic triage and takes payment after the visit. Nobody in the office spends the day haggling with insurance companies. For every veterinarian on staff, there are two or three supporting employees. Compare that with the typical primary-care clinic, where the ratio of physician to support staff is approximately 1 to 5, with some of the support staff there just to make sure the practice gets paid.

In the veterinary world, there’s no hiding the raw cost of vet care. The customer typically pays in full at the time of service, and even those with pet insurance must pay vet charges first and receive insurance reimbursement later. If a vet doesn’t offer good value, customers walk away. It’s more or less a free market.

Then there are the veterinarians themselves. This group spends half an hour listening and responding to concerns. But they’re more than just nice people. They don’t suggest expensive tests and invasive treatments unless there’s clear benefit; we feel we’re paying for veterinary expertise rather than unnecessary medication, superfluous staff or nice furniture.

Cut to any hospital room in the U.S., where a patient would be hard pressed to discern value. Nobody will say up front what that ultrasound, blood test or dose of ceftriaxone costs, never mind what a patient will owe when the bills arrive three months later. It may be that it’s uncomfortable to draw a direct connection between a sick individual and health care’s profit motive. Third parties handle most health care payments, and because each reimburses at a different level, initial prices must be high enough for negotiated discounts to still cover costs. Pricing must also account for the uncertain number of patients who can’t pay their bills. In other words, sticker prices need to be as high as the hospital can get away with, even if they bear little relationship to what is ultimately paid. As the journalist Steven Brill documented exhaustively last year in a feature for Time magazine titled “Bitter pill: Why medical bills are killing us,” hospital prices no longer reflect expenses with a reasonable markup. The resulting costs are driving uncontrolled growth in the health care sector, which accounted for about 18 percent of U.S. GDP in 2013.

When you don’t know how much you’re paying for health care, it’s hard to tell if you’re getting good value. And if Americans are not making health care decisions based on value, doctors and hospitals don’t have incentive to provide it.

It’s tempting to think that a free market for health care would boost competition and push prices down, as it does with veterinary care. But one critical difference between health care for humans and animals is that it is considered acceptable to decline veterinary care on the basis of cost — which arguably creates real incentives for veterinarians to manage expenses and offer good value. By comparison, many Americans view health care as something akin to a right, which all should receive, even without the ability to pay for it.

The problem for most doctors and hospitals, then, is not that customers might suddenly disappear. The problem is high demand, which almost certainly means fewer incentives to improve services and keep costs down. (Lawsuits also disproportionately increase human health care costs, especially in high-risk specialties like obstetrics and surgery, though the added cost overall may be less than is commonly perceived; lawsuits against veterinarians add little to pet health care costs, since typically only the replacement value for a pet can be recouped.)

That’s why we must do better at making health care resemble a real marketplace. The pressure must come from the consumer side, which includes not only patients but also third-party payers, such as insurance companies and state governments. My experience as a consumer of both human and animal care suggests that clear prices, combined with information about the quality of physicians and a hospital’s timeliness in providing appropriate care, is needed for patients to make smarter decisions about where and how often to obtain health care. If the marketplace functions, price and quality information should force hospitals and doctors to bring prices in line with the value they offer or risk losing customers.

Medicare has led efforts to measure the quality of health care by publishing data about individual hospital performance in relation to several common diseases. The current data don’t fully capture the complexity of what patients experience, and as a physician, I know it’s a lot easier to individually beef up the half-dozen stats Medicare tracks than to make meaningful system improvements. But the Medicare data still give a sense of which hospitals might really be trying to do better. In an effort to increase price transparency, several state government websites offer comparative price data on services from X-rays to orthopedic procedures. (Massachusetts’ website lets you compare prices alongside hospital quality ratings and gives users a sense of how powerful this type of transparency could become with more sophisticated data.) Similarly, some health insurance companies provide price data for their beneficiaries, presumably to encourage comparison shopping. As these databases grow, I can imagine referring to them regularly when I counsel my patients.

Refined price and quality information will be vital to consumers who want to make smarter health care choices and should help improve the value of what they are receiving. In our family, we’ve learned that the hard way. If my dog Molly were to get sick again, you bet we’d take her to the vet. But when we humans got hit with a stomach bug last winter, we opted against medical care. There was a clear price — it took longer to catch up on fluids, food and sleep, and my husband and I missed two days of work to be home with sick children — but nobody suffered long-term harm. For anything more serious, I would want to know much more about what we’d be getting before engaging with the health care system.