By ROBERT McNUTT, MD

During 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.