Finding out, deciding what to do (episode 1)
This is the first occasional column about my experience as a cancer patient, in the U.S., as a trained economist. I was diagnosed with prostate cancer earlier this year, and I will report things I observe that I find interesting, particularly with respect to all the controversy over the health-care system in the U.S. versus other countries. The column will not dwell excessively on medical matters.
I have taught economics at Wright State University since 1994. My department has a radical cohort, insisting on teaching how markets fail in producing the greatest good for the greatest number. In proposing that these claims should be subject to criticism, they have resolutely censorious in agreeing to my right to do this. But because my wife and I have felt that living where we live is very good for our two children (of whom we are both very proud), this has basically been water off my back. So I have stayed. Despite WSU’s terrible (even pre-COVID) financial troubles in recent years, my health insurance is good, at least as far as I know.
This series is meant to document how an economist sees the American health-care system, as an economist who is using it in the most intense way in his life to this point. It interprets how the American health-care system functions when one has cancer in particular. The straw-man standard model that many noneconomists and some economists (of a variety of ideological flavors) like to tear down is one of perfect competition of many firms, with well-informed consumers. And the market for health care in the U.S. is certainly not that. So, I will note the anomalies, both good and bad, that pop up in the actual American health-care system when seen from this perspective.
On January 18, 2021 I was diagnosed with prostate cancer. Any time one hears the word “cancer,” preceded by “you have,” it is jarring. I was diagnosed after my primary-care physician, a member of a practice of dozens of physicians in the Dayton area of every specialty which I will call practice A, saw that my PSA test, periodically administered, had now after having risen the past few iterations finally crossed a barrier (4.0, if you are curious) that indicates I should have a biopsy. (Throughout the series I will refrain from naming people or the companies they work for.) This practice, like an eye-treatment practice that I use, and which a few years ago merged with another one in Cincinnati, is evidence of a growing trend, of physicians banding together in ever-larger practices to increase their bargaining power against the handful of large health-insurance companies that are so important in providing health insurance via private institutions in the US. So health care in the U.S., it is said, is fewer and fewer firms in medical provision and insurance (plus the resultant emerging specialists who manage the negotiations between firms and insurance companies) arguing over how to allocate the costs.
But the conduct of my physician in particular also reflected the importance, because of what combination of insurance-company profitability and the doctor’s genuine concern I cannot say, of investing modest amounts in prevention to lower much greater costs down the line. If I had waited until I had been symptomatic before my primary-care physician looked into it, the cancer would’ve been far more advanced. See Nicholas Kristof of the NYT on the compelling story of his his longtime friend, who got the cancer diagnosed very late, and what happened. As cancer goes, there are much worse things that can happen than prostate cancer detected early, so I am blessed.
So my PCP arranged an appointment with a urologist also in practice A. I got a biopsy on January 9, and cancerous cells were found. The urologist informed me over the phone at about 6:30 PM on Martin Luther King Day, Jan. 18. He was very professional, and presumably had done this many times before. He actually recommended that I read a book on prostate cancer co-authored by a doctor with a lot of experience treating it. Having long been a good student, I read it and had about a dozen questions prepared when I got to his office.
In the visit, in early February, I told the urologist (after getting all my questions answered) that I would like to get a second opinion, and he was perfectly comfortable. He recommended I consult with one of his partners, the radiation oncologist. I indicated that I might want to consult a doctor in another largeish practice in the Dayton area (practice B). I knew practice B because lots of people here did, and because I had once spent a couple of days in one its hospitals because of a serious bicycle accident.
The urologist at this point reacted negatively to this desire, indicating that practice B, at least when it came to prostate-cancer treatment, was as best he could tell not as good as practice A. A cynical economist would react to that by citing the urologist’s narrow personal monetary interest, but I would be surprised if that were actually what he was thinking. I don’t think, in other words, he was being dishonest. He recommended doctors he knew, and was dubious of doctors in practice X. Still, to criticize practice B without presenting any details was a little jarring.
Alas, when I tried to make the appointment with a doctor in practice B, it was first a lot of work escaping the voicemail “For..., choose 5” maze. Finally I spoke to a human, and there were of course some forms to sign, the bane of American patients. Alas, several times the human I finally spoke to sent me a file, and I could not open it. (I use an iPad for all my computing work. I cannot imagine this would make a difference, but perhaps it did.) I got in touch with the particular office assistant in practice B again. She had given me a direct phone number. She hypothesized that perhaps the fact that the file included some confidential information about me and my medical problem, toxically (not her word) interacting with federal medical-privacy laws, made this so difficult. So (to her credit) she stripped the possibly problematic information out, and resent the file. But still it wouldn’t open.
After a few rounds of this I gave up, and proceeded to make an appointment with the radiation oncologist in practice A. His credentials are sterling, his online reviews are all good (although they refer only to his personality and the competence of his office, and not to any medical outcomes), and after talking to him I felt that he was on the ball. He outlined how things would go if I chose him. As with the urologist, I was struck by how free I was to decide for myself. My wife is from a foreign (developed) country, and she says that the doctors there are basically to be obeyed, while here they are to be consulted. So this is a plus for the American system, at least as well-insured I am encountering it. I do wonder about the sensitivity of Americans though. The first time I called the radiation oncologist’s office, his office assistant sternly corrected me, as if she were used to doing it, when in setting up the first appointment I referred to him as a “radiologist.”
After several weeks of pondering over whether to have my prostate gland removed (which my urologist said he did frequently) or to undergo radiation therapy (again, by a radiation oncologist in the same practice). I chose the latter. But in arranging radiation treatment, there were what were probably uniquely American difficulties. More on that next time.