You Owe Me a BMW

flying cadeuciiDuring a move necessitated 20+ years ago by my change from a “private practice of medicine” life to a “back to school” life, I decided to undertake the move on my own using a rented van. I also had to affix a small trailer packed with furniture to the van. As I lifted the not so heavy trailer to the hitch, one of my children ran toward the trailer. I stopped my child’s progress with a holler and an out-stretched hand. As I did that, a disc in my back popped and dropped me to the ground. I have had back pain every day since. I have managed my back pain on my own. But, I now think it is time to start using my medical insurance to pay for the care of my back pain. So, fellow insured, you owe me a BMW.

Yes, a BMW. I know that my back pain is a subjective complaint and you can’t prove or disprove that I have it. I also know that there is no measure of my back pain; I can grade it on a scale from 0-10, as some do, but that is such a difficult task that I can’t internally come up with a number. I am sure, though, that the number changes daily. Even if I could assign a number to my pain, there is no guarantee that you would assign the same number should you suffer the exact pain as me, or that you could assign a number to my complaint better than I could. The pain is there, though. I feel it and alter my activities to not exacerbate.

Recently, a friend gave me a ride in his BMW. The seats fit my back to a t and as I sat there, my pain abated. I asked him to turn on the heated seats. Even more remarkable pain relief followed. In fact, after the ride in his car, I had no back pain for over 3 weeks, the first 3-week, pain-free stretch of time in over 20 years. So, since insurance plans often pay for some types of interventions such as heaters, buzzers, or needles, as examples, to help people with their back pain, so, then, shouldn’t insurance pay for a BMW for me? I think so.

But, you don’t, I bet. Why is that? What makes some things reimbursable by insurance and some things not? If we are to pay for outcomes, the BMW seats improve my outcomes. That should be good enough to get some cost covered. I would be willing to pay the deductible if the insurance would pay the rest. Medical care, at present, is as much a social/philosophical construct as it is a science. Hence, my supposition cannot be dismissed offhand. We pay for physical therapy, chiropractic and massage therapy, as examples, and, even, we are willing to pay for placebos. All of these sorts of interventions aim to improve, purportedly, subjective outcomes – like my back pain. If we pay for those interventions, let’s follow through and pay for a BMW for me.

One debate lacking in the discussions about health care improvement and quality is a debate about what sorts of outcomes are worth measuring and, hence, worth being considered for insurance payment. Personal preferences, or, “It makes me feel better and worry less”, don’t seem worthy outcomes for shared payment medical interventions. Those outcomes reside in our mind’s unique perspectives and we are uniquely responsible for how we feel. Satisfaction with care, also, is another subjective matter, yet we collectively pay for that outcome. Again, why?

The reason why paying for a BMW for my subjective outcomes, and paying for subjective outcomes, in general, is folly is that these outcomes are not scientifically measurable or reproducible. Outcomes that are subjective are just that, and we should not collectively pay for the vagaries of people’s perceptions and wishes. If I would have succumbed to the whims of the personal preferences of my children I would be broke. There has to be some “no” to what outcomes should be measured and paid for.

Evidence-based-medicine is an alleged way to reduce the costs of medical care by limiting payment for things that do not provide measurable benefits. Measurable means that we accurately quantify an outcome and assure that what is being measured reflects the same things for all of us. Subjective outcomes fail this feature. When it comes to my preference for a car and your preferences for interventions to improve your subjective outcomes, we should pay on our own and not ask others to contribute. However, if subjective outcomes continue to be miss-measured and paid for, then, please, insurer, make my BMW a red one.



7 replies »

  1. Thanks to all; kind.

    Peter1; I laughed out loud. Actually, your response was insightful. You, jokingly, mirrored our present approach to cost and care; the BMW should not be paid for nor should the seat, as my outcomes are subjective and not your outcomes. Rather than cut the ties (as Steve O’ states) of the whims of the present payment systems, we aim for the lowest cost for a reasonably equivalent outcome. I am not sure if the seat is all I am owed, however, as it won’t fit in my Prius so I don’t know if the outcomes will be the same. Guess I am just going to get used to going to some higher cost system than the cost/effective car(e) [ Thanks, Bill] (think I will take massage and manipulation) and will likely spend nearly the same as the BMW as I was willing to take a used one – with seats.

    Don, your comments spur me on. Thank you.

  2. There is a measureable component here, namely, can the improvement in your back pain and productivity be quantified objectively? If you were only able to work 4 hours each day as a physician due to back pain, and the BMW treatment allows you to work 10 hours each day in this capacity, then there is value produced by the treatment in terms of your ability to engage fully in your activities of daily living. If your labor is valued at $100 per hour, this translates to an additional 1,200 productive hours, or $120,000. If I’m your employer, then the BMW may be a cost-effective treatment when examined from the value it produces.

  3. What a terrific article.
    Dr. McNutt:
    Your ability to weave in personal experience to make a strong point is a real gift.
    What is interesting about your experience is that it is pretty objective.
    Your back did improve!

    Taking that to an extreme and making the car subject to payout is an exaggerated way to make an objective point – the car is not reimbursable.
    It seems like we have evolved over the last 20-30 years into a more subjective society.
    I am sure I am part of that more subjective bent, even though I am careful to not fall into the collective trap of ultra conformity.
    As I age, I am becoming more confident in abstracts being more concrete.
    Values become more black and white, more clear and less subject to interpretation, from my subjective viewpoint!
    Don Levit

  4. The heartbreak of the Soviet style of communism was the loss of the ability to value and compare anything. The recourse was to set up an authoritarian bureaucracy to dictate whether Mr. X would get surgery, but Mr. Y would get nothing. This is the formula for “the aristocracy of pull.” Them’s that’s got the political contacts, gets the cherries off the sundae.
    This is what we’ve got, and too many people are entrenched about the trough to let it change. Your BMW has gone to someone else, friend.