My cat died just before Thanksgiving. Twelve years before my girlfriend had told me she wanted a cat, and we traipsed through animal shelters until I saw this beautiful, white, frightened creature, huddled in the back of a metal cage until she was given a hand to snuggle with.
We named her Bonny, after the Scottish folk song we sang to get her to creep out from under the couch or down from the tiny, filthy space above the fridge. I’ve never felt so close to an animal. Bonny would sit near me while I wrote, close her eyes and purr at the sound of my voice, and follow me around the house. My girlfriend, now my wife, would joke that I’d stayed with her to be with the cat.
When we had children, Bonny taught them. My son, as a toddler, adored the cat, and when she meowed at him for being too rough he would cry. Yet the same cat walked over to my baby daughter before she could crawl and let her clasp at tufts of fur. She helped us learn to be a family.
I think that's what pets are for. A pet is not a person, even if our hearts sometimes tell us different. But the way we relate to animals is an expression of our humanity. One of the reasons we have pets is because they let us learn about the challenging parts of life – birth, love, arguments, illness, death – in a way that is very real, and very emotional, but far safer than when there is a human life involved. And this is what happened when I carried Bonny to a veterinary urgent care center, singing to soothe her, and never saw her again. She led me to rethink my ideas about healthcare, technology, and how we pay for them, and most of all about the role of doctors and their relationships with human patients.
As cats do, Bonny got sick very suddenly. At her last vet visit she’d been ten pounds, but it seemed as if in a week she’d dropped to six. When I took her in for an exam, the vet took her blood, gave her IV fluids, which led to a brief resurgence, and sent us home with highly caloric food that Bon ate for only a day or so. It was the weekend, and while watching my daughter’s swim lesson I got an urgent call: Bonny’s levels of the liver product bilirubin were ten times the upper limit of normal. She needed an ultrasound, fast.
I came home and picked Bonny up from my son’s bed, where she had taken to sleeping. I interrupted my kids and my wife to have them say goodbye. It was the first time she didn’t resist being put in the bag. As I walked to an all-night veterinary hospital, I tried singing to her, changing songs to try to get her to stop crying. We settled on R.E.M.’s “Man On The Moon,” which I sang aloud while walking past brownstones.
At the vet, Bonny was literally scared to death, limp and flat against the steel examination table. The vet and I discussed her illness, and decided that she’d probably caught a cold (she had been sneezing), stopped eating, and damaged her liver. (This is a common problem with cats.) A veterinary assistant brought me an itemized estimate of what it would cost to treat her: at least a few days in the animal hospital while they tried to get her to eat or fed her with a tube. It would cost at least $2,500, perhaps a thousand or two more.
How would they get the cat to eat when she was so terrified that she could hardly move? Wasn’t it possible that hospitalizing her would actually make her worse? Would a cat with a feeding tube still be able to act like, well, a cat? The vet assured me that they could. I worried about whether I was worrying about Bonny or just being cheap.
I called my wife. “Of course we’ll do this for her,” she said. They took Bonny off for an ultrasound. I paid the $2,500 in advance.
But the ultrasound showed a liver covered with dark spots, more consistent with cancer than the bright, reflective fatty liver that would have been caused by self-starvation. The vet wanted to take two liver biopsies; I talked him down to one. I said goodbye to Bonny, and promised her we would all visit the next day. I went home, made myself dinner. My wife and the kids were out.
Just after everyone returned, the phone rang. It was the vet. His voice was calm in the way a voice can only be when it is staying cool because something is wrong. Bonny had taken a turn for the worse as soon as the biopsy needle went in. Her blood pressure had dropped, her heart rate slowed. They were trying to revive her. If it came to that, should they do CPR?
I imagined my little cat with broken ribs. No, of course not. She died while I was on the phone. My wife, my four-year-old daughter and I all started wailing. My seven-year-old son went into his room to be alone.
The next day I went to the veterinary hospital and collected a $1,500 refund for services not rendered. I was angry. Three-thousand dollars didn’t seem like too much to keep Bonny, but a grand seemed way too much to pay to have her die in what I could only imagine was the worst possible way. Her poor cat brain must have felt entirely abandoned by the people she trusted. In her book, Zoobiquity, UCLA cardiologist Barbara Natterson-Horowitz writes about how animals can have heart attacks purely from fear. I wondered if that happened to Bon.
The whole process of hospitalizing a living thing seemed like a giant rip-off. I remembered my grandfather, the proudest man I knew, a three-piece tweed suit kind of guy, struggling in his dinky hospital gown, demented and terrified, after his heart-bypass operation twenty years before. He caught pneumonia in the hospital and died. It’s easy to remember the failures at times like this, harder to remember my father-in-law, a decade later, having a similar operation – and thriving.
My first reaction was simply that the whole of medicine was too expensive. I was, as it happened, due for an MRI of my knee, which has hurt since I had an arthroscopy procedure on it in fourth grade. My doctor, at the Hospital for Special Surgery, had ordered up a scan at that hospital’s imaging center. It was going to cost $2,000, according to a calculator provided by my insurer, United Healthcare, four times more than what United said the average MRI in the area cost. I called the doctor and got her to switch the prescription to a place where the cost would only be double – but still provide pictures she thought she could trust.
In the end, the scan found nothing, and she prescribed physical therapy, which I never signed up for. It felt good, though, to save United Healthcare about as much as Bonny’s death had cost me – a kind of symbolic victory.
I didn’t save that much money, though. As an employee of Forbes, I’ve been part of a grand experiment: I have a health plan with a deductible for my family of four ($3,600, which is actually low by ObamaCare standards) but Forbes puts $2,500 into a health savings account for me, in four installments. I add more money, tax-free, to that account. After the deductible, in-network expenses are covered at 80% until we have spent another $2,000, at which point all in-network expenses were covered. The year was almost over, and I was nearing the out-of-pocket cap anyway. The effort I put into getting a cheaper MRI, in the end, made no difference.
Plans like this do result in lower costs. A study by RAND Corp. and another by the University of Minnesota both show that they reduce health spending. “The unanswered question and the critical one is whether they reduce the use of inappropriate care or if they reduce the use of appropriate care,” says John Thomas, a professor at the Quinnipiac School of Law. There’s not really any doubt in my mind that giving people a real stake in their healthcare spending is important when it comes to lowering health care costs.
What strikes me these many months later, though, is how much my experience matches the vision lots of people have for human healthcare, where prices are transparent before procedures are performed. Castlight Health’s whole business is about providing price transparency, both to patients and to those that manage health plans so they can root out wasteful spending. Steve Forbes frequently complains that you wouldn’t buy a car without being told the price, yet we do exactly that with healthcare procedures all the time. “Patients could check on the phone, get a real estimate, and proceed with that knowledge,” predicts Ramji Srinivasan, the chief executive of genetic testing startup Counsyl, which has built such functionality into its tests.
Certainly, being told what it would cost to treat Bonny was far better than what happened when my son was admitted to the hospital for suspected appendicitis, and the bill came in at $16,000. (Mercifully, he didn’t have appendicitis and insurance covered most of the bill.) But I’m struck by how complicated it made my discussions with her vet. Was I trying to save money or spare her unnecessary treatment? Even I wasn’t sure. On the other hand, how much can he ethically charge? “It’s wonderful that people are willing to spend $10,000 or $20,000 to deal with their sick pet, but ethically it puts us in quicksand,” Douglas Aspros, the former president of the American Veterinary Medical Association told David Grimm in Slate. “If a client wants me to do a $20,000 surgery on a cat, the practicality has to go beyond, ‘There’s someone willing to pay for it.’ As a society, should we be promoting that?”
With a pet, and so much more so with a person, the answer of a patient or her family, put on the spot, is going to be the one my wife gave about our cat. “Of course we’ll do this for her.” That leaves not consumers, but health insurers as the group most able to negotiate lower prices, or to help convince doctors and patients, ahead of time, that an expensive test or procedure is not needed. You need only look at the $1,000-per-pill price of the hepatitis C pill Sovaldi, made by Gilead Sciences, and at its broad use to know that insurers in the U.S. don’t do a terribly good job of doing this. At the same time, though, our very system, and its opacity, let physicians off the hook when it comes to cost – to everyone’s detriment.
What made the discussions about Bonny’s care both bearable and detailed was the fact that the vet and I both were working with an itemized list of what he was going to do, and he had to be open to changing his plan. A few months later, in a human hospital, I had the opposite experience.
My son had just had his adenoids out. (I know, the poor kid, right? He’s fine.) Watching him recover, in obvious pain, I started to feel very hot. I took off my buttondown, and sat down. Then I fainted.
I’ve watched surgeries, I’ve seen blood, and I try to blame the fainting spell on a virus that was going around our family at the time. But, whatever. You faint in the recovery room, you wind up in the emergency room. So I wound up in a bed with a bald, argumentative emergency room doctor who insisted that I needed a saline IV, a chest X-ray to check for an aneurysm, and a CAT scan.
I let him put the IV in, and eventually consented to the chest X-ray. But I remembered a story on the need for a CAT scan after a fainting spell – or, rather, the lack of any need for one. I hadn’t hit my head. It was a pretty classic case of vasovagal syncope, which means, basically, you got all emotional and you fainted. I tried calling my primary care doctor, but then my cell phone ran out of battery. The ER doc couldn’t tell me how much the CAT scan would cost. Bonny's vet did a better job communicating what he would do, why, and for how much.
I was there for a few hours, while my wife took my son home to his grandparents and came back for me. When she came back, the doctor had talked me into getting my head scanned. She took me home. Bonny, of course, was long gone, and I missed her. And I wished I didn’t feel so much like her, where, after 14 years of writing about medicine, in a relatively minor encounter with the medical system, I’d felt only a bit more in control than a tiny, scared cat curled up against my chest.
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