I agree about the impact of out-of-pocket, for most people, and it’s not limited to the consumers themselves – it affects provider attitudes. A couple of anecdotes.

1. Many years ago a physical therapist was billing me for sessions where I was being ignored for long times, left in a room with a hot pack that had long gone cold. I said I didn’t want to be charged for a whole session. The desk looked at me like I was crazy and said “But your insurance is paying for it – it doesn’t affect you, does it?” Arg!

(btw, I was self pay, but that’s not my point.)

2. Ten years ago, still self pay, I had a bladder infection. The local retail health stop sent out for a test, $90 out of my pocket. It came back negative and the doc said they must have screwed up so he was going to disregard it(!). So I asked if I was going to get my money back – and he looked at me like I was crazy. Arg!

It’s pretty clear to me that there’s lots of senseless, avoidable waste and a LOT of people in the system figure the waste doesn’t affect consumers so they don’t need to do anything about it, nor do they hold each other to ordinary standards of commercial competence. (“Hey, this didn’t work – I’m not payin’ for it.”)

And the mechanism that causes this disconnect is the big, thick insulating factor called insurance, which somehow makes people shrug and think that the waste doesn’t increase costs or affect care.

We can change this. All it takes (a big all) is for the people having those “doesn’t matter” conversations to stop accepting that from each other. I have a sense that this is happening at Beth Israel Deaconess, and I certainly hope it’s happening at more and more places.

(This is finally starting to change in, for instance, the issue of paying for consequences of medical errors.)

I keep saying that when my family’s next need arises I want the system to work well. Every single person who works *in* the system should know they have a personal role in moving things in that direction – and they can make a difference.

Consumers need to have more skin in the game. Price will rapidly become important when it’s coming directly out of their pockets – no one cares about gas when it is $1/gallon.

Primary care can be insurance-free – my doc’s providing a fee/service structure, and it costs me less than a usual deductible plan. He’s available by email/phone 24-7 and I don’t have to go to his office unnecessarily. Make health insurance “sickness insurance.” I agree with Charlie Baker: transparency is a good thing.