Generals can say some ridiculous things. A dentist with stars on his shoulders once told a room full of medical personnel that we needed to approach our patients like they were F-15s. The only good news is he likely had not been near a set of teeth in years.

There was one thing that caught my attention about a decade ago at Wilford Hall Medical Center. General P.K. Carlton mentioned in a speech that the average military patient went to see a physician 8 times a year versus 3 visits in the civilian world.

The numbers were no surprise. It is not uncommon for military patients to use the Emergency Department just hours after developing a nasal drip. Why not? It does not cost them anything.

Physicians around town will tell you about a phenomenon this time of year. Deductibles are paid so patients will often rush to get elective care done. My office gets many calls from people who had something recommended in July and want it done now before the magic date of January 1.

It is completely legitimate economic behavior. People will always take advantage of free or less expensive services, especially when it is a needed service.

Patients almost never ask about the total cost of a treatment. They tend to only be interested in what it will cost them.

A classic example is the proton pump inhibitors (PPI). The best known of these medications is Prilosec which has been available over the counter for some time now. Many people will opt for a prescription PPI even if the over the counter product works because the co-pay is less than the cost of Prilosec.

Drug companies can play games and give vouchers to cover the co-pay so the cost to the consumer falls below the over the counter product. It may be great for the patient but it costs the system money.

Patients who are double covered never ask questions about cost. Medicaid patients who pay a $3 co-pay never ask either.

Patients with high deductibles or no insurance always ask more questions. They always want to know the cost. They are also far more likely to ask about cheaper alternatives and whether they are legitimate.

That can be sticky business. It is not unusual for uninsured patients with inflammatory bowel disease to want the cheapest therapy which is corticosteroids. It is not an acceptable long term therapy for a wide variety of reasons but patients without resources often do not want to hear that reality.

Some testing and treatments are done specifically because there is insurance coverage present. It would be naive to think otherwise. I had consults sent to me when I was in the Air Force for colonoscopies for no other reason than patient desire even if the test was not indicated.

As a physician, I want to believe every doctor would only do what is medically indicated. It is the same way we all want to believe there really is a Santa Claus.

It is easy in this debate to concentrate on the other side of the issue. The side that sticks to the part of the insurance companies that denies coverage at every possible opportunity. The rage at such behavior is the source of the consternation over the new USPSTF breast cancer screening guidelines.

The argument against Health Savings Accounts and High Deductible Health Plans is that people cannot afford the initial outlay of cash for the year. It is a decent point but consumers with a real stake in the game make better decisions.

All health care plans should cover the basics. They all should be there for the catastrophic illness or accident that can occur.

The rest of it should be on a menu of what the consumer wants. Deductibles should be larger instead of smaller. Mandates on what has to be in plans should be minimal. Patients need to be put in a position where they get to make decisions on what best fits their needs.

Some thought must be given to the consequences we have suffered for taking the consumer of the equation. The system now is driven by the providers of the service. It is a supply curve without a demand curve to cross it.

This bill in DC wants to squeeze the consumer out almost completely. That is what happens with low deductibles and mandates.

The answer is also not a Medicare solution. That scenario is one where you could just drive up to a gas station and pay $1 a gallon for gas even if it cost the station $2 to put it in your car.

If you give the consumer power, the provider will have to respond. That is how economics is supposed to work. And like it or not, health care is a business.

A funny thing about health insurance over the decades. The CBO graphs on reports linked here many times show the percentage of health care paid by the patient has dropped precipitously over time.

Do you think it is a coincidence that over that same time the overall cost of the system has risen?