ControlsFreak's profile

ControlsFreak 7mo ago

I don't understand your first objection. There were a lot of "beliefs" hinted at in my post, not all of which I hold or think someone else holds.

Your second objection seems to entirely make my point. What counts as "beneficial" vs. "harmful" seems to significantly hinge on other politics. People select politics first, then determine "beneficial" or "harmful", and then decide whether something is 'corruption' or 'negotiation'... or whether it's 'righteous gatekeeping' or 'evil profit-seeking gatekeeping'. Your politics are baked in to your statements, which is why you think other politics can be just brushed aside and totally ignored. Moreover, because we've essentially nationalized policy (while retaining nominal private ownership), the entire arena is fundamentally a matter of confused national-scale politics, rather than distributed optimization to local and personal values.

Your third objection, and the responses it's already produced, absolutely seals my point. People are divided about the politics, which leads to all sorts of confusion in trying to 'design' a nationalized system with clear purpose and vision, instead leaving the matter ripe for all sorts of politicized framing effects.

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ControlsFreak 7mo ago

I think this is getting at what I mentioned as "the confounding factor of people wanting to use it to transfer incomes or the sheer constitutional (little c) inability of folks to allow people to make choices with prices". I have two thoughts.

First, I'm not sure that fixing that would fix the other irrationalities I mentioned. Regardless of how you pay for it, questions like whether doctors' prescriptions are sacrosanct or whether they're actually dumb and bad will persist, for example. In the comment I linked to, the question of whether doctors should play a gatekeeping role is one that we've sort of stumbled into, via unintended consequences, rather than being a rational, clear, and vision/purpose-driven choice.

Second, I would say that people "want" this for literally everything. Of course people want world-class, free/cheap food provided to them, paid for by someone else. Of course people want world-class, free/cheap housing provided to them, paid for by someone else. Etc. Once you go down the rabbit hole of thinking that you can make some argument to justify forcibly spending other people's money on your consumption (be it because you think there is some 'positive right' involved or have some ideological preference to transfer incomes or whatever), the question reduces quickly to just one of how much you can force them to pay, how much income you can transfer, and how much consumption that will get you before the well dries up or political constraints take hold.

In many of those other arenas, we actually can/do "design" systems that work to give people what they actually personally value (via revealed preferences) - a price system. This usually has to give up on the idea that they're going to strong arm others into paying for it, but it allows consumers to locate themselves on their own pareto frontier, rather than imagining that they can just take more from the imaginary well of other people's pocketbooks and magically push the world to a state far to the top right of the pareto frontier. They can choose for themselves how much they value speed or quality or money. It's when they think that they get to choose between speed, quality, and other people's money that we run into problems; of course they're going to sacrifice other people's money. Guaranteed they'd sacrifice other people's money if they could get away with it to give themselves endless steak rather than spaghetti. No, this problem is not unique to healthcare; it's just one of the domains where we perpetually fail to acknowledge what we've truly figured out about the world and somehow keep being confused about why doing this obviously perverse thing keeps producing the same well-known failures.

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ControlsFreak 7mo ago

If I had a point, which I'm not sure I did, it would be that how you view it turns on other politics. How many people who are screaming about how they want the gov't (Medicare) to "negotiate drug prices", presumably making them cheaper and pulling profits out of drug companies, are going to call these rebates "corruption"? ...can they do so with a straight face, when Medicare plans were getting the biggest rebates of them all? How many people viewed all doctor prescriptions (and their charges for their own services) as sacrosanct, with any gatekeeping by insurance companies being evil, and will now be dissembling that these doctor prescriptions totally need gatekeeping, because doctors are apparently dumb and bad? How many people who would be crying, "Legalize all drugs!" with arguments about how important it is to have quality-controlled pharmaceuticals available are going to say that Purdue actually was "Good Guy Pharmaceutical Company", just fighting for the cause of reducing fentanyl deaths by taking the hit in profits to get their product in the market?

The whole industry is an awful mess, with kludge upon kludge, and many folks can't even figure out what they want from a system. They're easily swayed by framing, and so "negotiation" becomes "corruption" if it's framed that way; doctors are sacred and we need to stop insurance from getting in their way or they're dumb and need gatekeeping depending on how it's framed, etc. The lack of a clear vision and susceptibility to framing makes the whole thing prime for more kludges promising to be fixes, more unintended consequences from a lack of clear purpose in the heaping of regulation upon regulation. (I didn't even mention the confounding factor of people wanting to use it to transfer incomes or the sheer constitutional (little c) inability of folks to allow people to make choices with prices.) It lets anyone be the temporary Bad Guy in the fervor for the latest Current Thing. We broke it, now we've clearly bought it, with no bloody clue what to do with it. So the best thing people can do is try to part it out in favor of their political goal of the minute.

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ControlsFreak 7mo ago

A Window Into How Health Insurance Companies Harm Consumers by Threatening to Deny Coverage

From the New York Times, we learn about how health insurance companies hire PBMs (Pharmacy Benefit Managers) to help them restrict access to doctor-prescribed drugs. For all the talk of insurance companies directly denying coverage, when it comes to pharmaceutical drugs, specifically, they're able to offload a significant amount of Delay, Deny, Defend onto third parties, in this case PBMs. By restricting coverage, insurance companies are able to reduce costs and increase profits. A bonus is that they don't even have to be The Bad Guy; they can pawn that off on a third party, who is ostensibly making the choices for them. They don't have to personally defend the decisions to deny; they can just obfuscate, wave in the direction of the third party, and let the complexity of The American Healthcare System stymie consumers.

The Times does a deep dive into a Good Guy Pharmaceutical Company and the lengths they have to go through to navigate this minefield to get their high-quality, purity-assured drugs into the hands of the market. Primarily, they've gotta give the PBMs a cut of the money, who in turn share it with the insurance companies and employers they represent. For a while, they were rebating 23% on average, allowing patients to access the drugs their doctors prescribed at prices that were reasonable to them, their employer, and their insurance company. One PBM reportedly wanted (and got) more - 60% rebate to keep prices low and avoid inflaming popular anger with denials. Of course, that still doesn't quite reach how good some Medicare plans were at 'negotiating'; they got about 70%!

The Good Guy Pharmaceutical Company knew how much people wanted its product; they knew that doctors were prescribing it; they knew how dangerous the alternatives could be for many in the market. They were offering a well-known, well-tested product, clean from any adulteration, and outrage would surely rule the populous if folks had to turn to alternative products or sketchier outlets, possibly with less-stringent quality control. So, they selflessly paid the toll to do the right thing, to get their product into the market, to save lives. NYT rightly applauds their admirable efforts to do what they could, at cost to their own bottom line, to protect consumers from the restrictive, denial-focused tactics of health insurance companies and their lackeys.

Oh wait. NVM. It's Purdue. It's Oxy. Flip everything 180 degrees. Apparently, nobody (other than Purdue and their supporters) thinks it's good to flood the market with high-quality, pharmaceutical grade opioids with well-known potency properties. They somehow don't think that this is preferable to folks getting funneled toward lower-quality, potentially dangerous alternatives. They're back to liking the gatekeeping of insurance companies and their lackeys, ya know, so long as they're doing so in keeping with their own political proclivities. Gatekeeping is Good and Right, so long as the folks who buy digital ink by the barrel can browbeat the gatekeepers into doing things the way they want it to be done. ...and they sure ain't even thinking about including libertarian politics on drugs in the list of their demands. ^{Woke politics, tho? Sure, why not?}

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ControlsFreak 7mo ago

I believe you said that you were paying up front in cash, and then getting reimbursed on your own. Probably the most likely places that are going to be top-tier in terms of price transparency are lower-rent places with cash-paying customers. They're way, way above the median. Especially when the vast majority of places get a whiff of it being insurance-involved on their side, they very quickly start with the whole "it's fundamentally unknowable" dance.

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ControlsFreak 7mo ago

the whole thing doesn't function as a market and shouldn't really given the reality of population irrational decision making and the amount of money involved.

Are there any other industries that you think satisfy these conditions? Are there any "near misses"? I.e., some industry where there is enough money, but consumers need to be just a liiiittle bit more stupid... or some industry where the consumers are stupid enough, but there needs to be just a liiiitle bit more money involved... and if there was that little bit more, we'd want to declare that it shouldn't be a market? Do you have any objective metrics for these conditions, or are they just sort of gut feel?

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ControlsFreak 7mo ago

I'm not really sure it is ever relevant. [emphasis added]

You really cannot be serious. You do not get to decide that it is never relevant. There are many many many stories of it being relevant (some on the storied pages of the Times). You may be in a narrow slice of a specialty where it happens to be rarely relevant, but across the entire swath of healthcare services, with the entire swath of different patients, with different insurance terms and different financial situations, it's going to be relevant often enough. At times, you've even admitted that it "is viable for some services". It beggars belief that you can say with a straight face that you think it is never relevant.

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ControlsFreak 7mo ago

The mechanic will have a plan for what he is going to do (e.g., "I'm going to replace your CV joint."). He will then assemble an estimate for how much that is likely to cost. He will probably even break down that estimate in terms of parts and labor. He might even provide you options for different brands of parts at different price points.

Everyone involved knows that there is some uncertainty in that estimate. They might get in there and discover that something else needs to be done, too. Usually, at that point, they will reformulate their plan, potentially with multiple options, assemble similar price estimates for those options, then contact the customer, try to explain the situation (knowing that there is an inherent knowledge gap), and ask which of the options the customer would like to take. I did this as a job long ago. There are some sketchy mechanics out there, for sure. But if you want to succeed, especially in a market where being sketchy will become 'known', you need to be very proactive in your communication with your customers, including on pricing information.

Doctors take the same exact sort of uncertainty in their work as a gospel truth that the price is "fundamentally unknowable"... and so, they just refuse to tell you. If you really press them, sometimes they'll do it, but sometimes, they just won't (and sometimes, they'll lie to you and make something up; there are sketchy mechanics everywhere). They certainly don't provide anything comparable to what the 25th percentile auto shop provides on a routine basis.

Perhaps you were thinking of a slightly different concept, that they're similar in that there is a significant information asymmetry. Customers don't necessarily know if the mechanic's plan is motivated by the car really needing whatever it is, whether it's barely justifiable and mostly a scam to increase billing, or whatever else. Similarly, patients don't always know that sort of thing with doctors; they could also be concerned that a doctor is practicing defensive medicine rather than thinking about the patient's pocketbook and giving them only what they really need. These questions are probably near impossible to estimate; I would like to believe that doctors are actually equal to or better than mechanics (the median doctor is almost certainly better than the 25th percentile mechanic if I had to guess, unlike with price transparency). In both cases, the most common solutions are to just diversify your sources of knowledge. I gave an example of how diverse those sources of knowledge can be here, but an extremely common suggestion in both domains is to just get a second opinion.

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ControlsFreak 7mo ago

This is the data he offered to support his claim the last time. I pointed out that Figures 1, 3, and Table 5 might tell a different story to some folks. This time, he apparently didn't use this citation to support his claim; he only picked out the one statistic from it that sounds like it supports his position, preventing others from seeing the rest of the context.

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ControlsFreak 7mo ago

It doesn't translate to anything directly, and if I have no cash fee schedule you can't even squint and go "it's 100 right?" No, it's a billing code, it doesn't relate to what's "fair" or what is "cost" it is all negotiation. State Medicaid pays me 20 bucks an hour for that billing code. We still take state medicaid even though that's less than the cost to run the front desk because my hospital gets a grant from the state government. Private insurance pays me between 40 and 140 dollars for that billing code depending on the insurance.

Good news, since you pointed out that physicians are employed now and aren't in charge of anything! Your employer signed agreements for all those things, so your employer has all of those numbers. Your employer also knows which category the patient falls in (they took the patient's insurance information when they came in the door), so they know which number was negotiated for that patient. This is a solved problem with a computer even in an auto parts store in [current year]. It's a solved problem in every other industry. I've very occasionally had medical providers look it up for me; I have even seen what was on the screen on their computer; it's a solved problem.

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ControlsFreak 7mo ago

nobody replaces them

There are many times where they're not allowed to. Or they're prevented from entering the market prior to failure, whereas if they had been allowed, it might have been more robust to individual failures.

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ControlsFreak 7mo ago

This is viable for some services

Awesome. Start doing it.

What do you do when the surgery is a bit more complicated and expensive and the bill is 15k. What do you do when you have a major complication and the price is 1.5 million dollars? People would be furious!

How does the current system prevent this problem?

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ControlsFreak 7mo ago

Are Christians morally obligated to forgive someone if God has forgiven them?

What would I forgive her for? She has done me no wrong. She may have sinned against God and her own body; she can forgive her own conscience and God can forgive her sins. I cannot forgive her sins even if I wanted to.

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ControlsFreak 7mo ago

So glad to hear your little bun buns is doing well!

[consumers] are not aware of what is efficient use of resources

The great part about the price system is that this is never true, but it's totally fine. Consumers are not aware of what is efficient use of food resources. Or resources in automotive services. Or... or... or... In fact, believe it or not, many people even disagree as to whether something is an efficient use of resources! My wife absolutely loves bunnies, but if we had one as a pet, I think she would be willing to do even less veterinary care for it. She grew up in poor farm country, where there were a variety of animals around, both stray and productive. In her mind, animals exist, they're nice, it's good to be nice to them, but many just have short lifespans which aren't worth dumping much money into to extend. Even though we have more resources now, she still has similar views.

What we'd need is hireable healthcare negociators who work solely for the patients, to maximise utility for ressources.

I don't see why that wouldn't be a plausible service. I know that there are all sorts of different medical-related services out there that aren't traditional practice of medicine. I heard a podcast once about a person who has enough knowledge of medicine to make a business out of just connecting individual patients to possible clinical trials for whatever condition they have, because the "system" for this is more broken than you could possibly imagine.

The sources of knowledge that patients can get are diffuse and wildly varied. They don't fit neatly into technocratic boxes. When my mom was going through cancer treatment, she joined an online support group, basically just a group of folks who got together on zoom or whatever and talked about stuff. She could have had all the written disclosures or explanations from doctors in the world about the side effects of certain drugs, and it would have paled in comparison to just looking at a variety of actual people who were taking those drugs and hearing them talk about their life. (...and different people could have disagreed with her assessment!)

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ControlsFreak 7mo ago · Edited 7mo ago

it's moved around a bit

Just for a check, I counted nine comments where I asked for the same specific numbers and zero comments where I asked for any other specific numbers.

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ControlsFreak 7mo ago