ControlsFreak
No bio...
User ID: 1422
ControlsFreak
7mo ago
Hold your horses. I'm hoping for incremental change. I ain't nearly that hopeful, either. More likely, we'll get some bomb of other confused regulation, which might have some incidental pro-consumer stuff.
That's one of the rules I've already mentioned, and I've already discussed why it didn't really accomplish anything. Moreover, it didn't even attempt to do what you just proposed.
EDIT: Also, that report shows that 63% did comply entirely within that timeframe. At least from the standpoint of "can you do this", the answer seemed to be "yes" for the thing that rule wanted. They're reporting failure as failing in any component, so I'm sure that'll be cleaned up in a few more years.
ControlsFreak
7mo ago
Citation needed.
Let's say you passed a law that says "a patient is required to get a sheet of paper with the cost, price, insurance charge, and so on for the median procedure of that type, and if you don't provide this accurately you get fined." Do you have any idea how expensive that would be to do because of how frequently these things change?
Good faith estimate. Details of what needs to go on the sheet of paper can be haggled over. I'm sure we can come to a compromise. I bet you can do that pretty easily. Sounds a lot more efficient than a lecture. Glad you're starting to come up with better ideas than having the head of billing personally show up and manually do every single estimate and talk to every single patient (but I do remember the prior catastrophization, which is why I'm feeling pretty good right now).
The funny thing is, if this sort of law actually got passed, I'm pretty confident you'd figure it out pretty quick. It's actually pretty simple compared to a lot of other things that happen in your industry and others. You'd stop swearing that it would take 24/7 365 bullshit (which is Obvious Nonsense) and just do the damn thing. Shit, I am intimately familiar with the scramble to implement EHRs. Sucked for a while, probably still some lingering unintended consequences. But you figured out a process and did it. Bottom line: I absolutely do not believe your catastrophization of what it would take. It's Obvious Nonsense.
EDIT: BTW, you don't actually have to convince me. You have to convince the people who are willing to shoot CEOs dead in the streets of New York City and those who are cheering for them.
ControlsFreak
7mo ago
Possibly so. I don't know what mess we're gonna get, but in the linked comment, I read the tea leaves that might be pointing toward at least something happening, even if it's a mess and not terribly coherent:
This is an industry that just had two different bills passed by two different congresses and signed by the last two presidents (one of whom is coming back in and may be interested in taking another bite at the apple) specifically because this stuff is a problem. The purpose of this entire thread is because a notable CEO was shot dead in the streets of NYC, possibly because of frustration with these problems; news outlets are reporting people cheering this.
Public outrage can quickly boil to the point that "something must be done". Once it gets there, Sagan only knows what mess of a "something" we're going to get. Maybe the medical industry can consider banking on their regulatory capture enough that they can shape the output to at least not hurt them too much, or even to benefit them. But again, looking at how it's gone in other industries, I don't know that I'd count on it. I doubt it would be pure pro-consumer, but there's a good chance we'll get some mess of "something", which they might not super like. I bet the IoT industry wishes now that they had figured out a way to eliminate default passwords from the industry before, for example.
ControlsFreak
7mo ago
The charge we submit to the insurance and the negotiated rate with the insurance are generally but not always completely made up numbers.
Don't care. Inform your patient.
Sometimes the insurance neglects to the pay the negotiated rate. Sometimes that changes with phone calls and appears. Sometimes it doesn't.
Don't care. Inform your patient of what you've agreed to and what you will be charging.
The charge to the insurance for a roughly 5k dollar procedure might be 50k. The insurance might pay 5.5k. Medicare pays 4.5k. If you pay cash you get to pay 5k, assuming nothing goes wrong.
Inform your patient of these things. You have the numbers. Just tell them.
If you have a cardiac event mid procedure and end up on ECMO the cost is suddenly 5 million dollars.
We've already discussed unknown unknowns. Not an excuse for not informing your patient of the known knowns and known unknowns.
What number do you tell the patient?
You tell them the information that you have. Preferably, "Here is what we charge, and here is the negotiated rate." You can add, "Things don't always go perfectly with the insurance company, but that is our information." You can add nice answers like you gave two days ago if you have some known unknowns.
am I supposed to go through all of this with a patient in my 15 minute appointment?
I don't care who does it or when, except that it should be before a procedure occurs, because you need to get informed consent first.
Is the average person going to follow this? What if they are medically unwell?
Don't care. Do it anyway. The average/unwell person might not follow some of the things you say when you're informing them of the medical costs/benefits in order to get informed consent. If they're unwell enough (or for example, unconscious) that you would feel it is acceptable under the ethics of informed consent to not inform them of the medical costs/benefits, you can apply the same analysis here.
You have to be exhaustingly specific about much of this.
I just have.
The insurance company may authorize something and decline it later. Certain aspects of the care (like a consulted specialist who is the only person in the hospital for that thing) may not be covered.
Inform your patient to the best of your ability. Tell them your plan, expectations, and what that entails. Things happen, just like how medical things happen on the table. That's not an excuse to refuse to even try.
ControlsFreak
7mo ago
Total price opacity almost certainly is a benefit to the medical industry currently. As you mention, from the rest of the conversation, it's pretty clear that they have chosen this path, and it's likely because they think that it is in their own financial interest. I am extremely sympathetic to game theory arguments, and it is completely legitimate to ask why they would ever willingly give up their grip on the market.
The first, most obvious answer, is that it is the right thing to do. Doctors claim to hold themselves to high standards when it comes to informed consent. They are clearly failing miserably on that score when it comes to informing their patients about the financial parts of the costs and benefits.
Of course, one can easily observe that those sorts of considerations often get ground into dust upon first contact with the raw ability of a cartel to enrich themselves. So, a second possible reason would be if enough cultural argumentation is built up to force the conversation about informed consent and prices at a high enough level. Embarrass them, as they talk in circles. They will have to weigh the monetary gain against the loss in status as more and more people realize that they're lying and violating their stated principles in order to enrich themselves.
A third possible reason could be lawsuits to change the regulatory landscape. I've seen some lawsuits going on against hospitals who are using their boilerplate "consent to treat" forms that they use at intake to justify absolutely every charge that they choose to make, regardless of whether the patient actually agreed to that particular thing. We'll see if they go anywhere.
I described some additional possibilities here. One of the most likely possibilities is just that they are forced to change via regulation. This is not preferred, as the regulatory process is often a total mess, and it's not super likely that it will result in a truly coherent way of doing things, but when there is this much pent-up outrage at how things are currently done, it is entirely plausible that the government will just drop a bomb on them and force them to make some set of changes, regardless of whether it's in their interest, or whether those changes even make much sense.
As I argue in the linked comment, I personally think that the probabilities are trending in a way such that if they don't clean up their act, something is going to happen that is going to blow up the whole thing, with potentially highly unpredictable results. I mentioned similarly seeing the writing on the wall for the real estate and IoT industries. From a pure self-interest point of view, they have to weigh the value they would lose by voluntarily cleaning up their act in smaller ways now (in an attempt to reduce the probability of a regulatory bomb or something like that being dropped) against the expected value they'd get from a period of sticking with their guns until a bomb gets dropped plus whatever mess they get after.
If the question is "what does this thing truly cost the hospital"
The question is, "What charge will you be submitting to my insurance, and what is your negotiated rate for that service with my insurance?" If there is further discussion to be had about the chance of coverage for the service being denied altogether, you should have that discussion. And potentially involve the insurance company if it could be a big deal; you know full well what a pre-auth is and when it might be useful if there is significant uncertainty about the insurance company. You're being intentionally obtuse by going on about the hospital's cost. (EDIT: You obviously know what I'm talking about, given your other answers. You already gave an example of how you can answer. You already said that you do answer sometimes. Stop being ridiculous.)
why is this the physicians job
I don't care whose job it is.
ControlsFreak
7mo ago
Ok, I am glad that we have come to agreement that you can, indeed, actually give price information. It is not impossible, despite your previous protests. We have made progress. We should celebrate this moment.
What the thing costs, what the mark-up is, what the charge is, what the insurance pays, and what the patient ultimately pay are all different numbers.
Yes, indeed. Give them the information you have. Inform your patient. Stop hiding behind the false claim (that we have now agreed is false) that you are unable to inform your patient. Different costs and different insurance parameters will result in it not mattering sometimes. It will result in it mattering sometimes. This is no different to how you inform your patient about medical costs/benefits. You certainly try to inform them and provide information, even in cases where some piece of that information may not end up mattering for some specific cases. There are other cases where it will matter. "Live not by lies," they say. Stop with the lie that it is impossible for you to inform your patient. Just inform them. Sometimes, it won't change anything. Do it anyway. You know you can, and have now said as much.
ControlsFreak
7mo ago
You're forgetting your own answer again. You gave a perfectly fine answer. It contains the information that you know. You know that it typically costs about $5k, but about 1% of the time, it costs $1.5M. You know this. You "plan around" this. You just choose to not let your patient know anything about the costs part of your plan. You choose to keep your patient in the dark. You choose not to inform your patient.
Look, we know that you don't know everything with deterministic precision. That's fine. We also know there's a knowledge gap between you and the patient, both in terms of medical costs/benefits and in terms of financial costs/benefits. You understand that part of your job is to at least try to inform your patient, to the extent you can, about the medical costs/benefits, as you understand them. This will not always be perfect. Moreover, there will be unknown unknowns. Some might even say that some of the medical costs/benefits are "fundamentally unknowable". But you don't just throw up your hands and say, "Therefore, we never bother informing the patient at all." It's that your story changes 180 degrees when it comes to the financial side. You don't even try.
the patient isn't paying it.
"The first step is admitting that you have a problem." Please please please don't let it take more assassinations or new slapdash regulations before you get this.
ControlsFreak
7mo ago
I'm not sure we can proceed much further. You have a highly unorthodox definition of "fundamentally unknowable". You seem to apply it to a thing that I view as incredibly knowable. Perhaps we just have different levels of background in probability and decision theory. Perhaps I should wave my degrees and/or publications around (they do happen to be highly relevant) and say that if you can't answer highly technical questions about probability and decision theory, you don't know anything about what you're talking about? How should I think about how you might feel about that form of argumentation?
healthcare workers are often prohibited by law from making decisions based off of cost
We're talking about patient decisions.
Patients almost never pay cost and are rarely charged it.
This is obviously not true, as evidenced by the constant uproar about medical billing. To repeat myself:
This is an industry that just had two different bills passed by two different congresses and signed by the last two presidents (one of whom is coming back in and may be interested in taking another bite at the apple) specifically because this stuff is a problem. The purpose of this entire thread is because a notable CEO was shot dead in the streets of NYC, possibly because of frustration with these problems; news outlets are reporting people cheering this.
The old saying just happened to pop up in my mind: "The first step is admitting that you have a problem." I'm not quite sure what else it will take for you to realize that your industry has a problem. I hope it's not more assassinations or slap-dash regulations.
ControlsFreak
7mo ago
If you had a lottery-type game as an option that you could consider playing, and they said, "The payout is $5k with about probability p, and the payout is $1.5M with probability 1-p," would you say that the payout is "fundamentally unknowable"?
ControlsFreak
7mo ago
Can you remember what your answer was two days ago?
ControlsFreak
7mo ago
You appear to have forgotten your answer from two days ago. I suggest you go back and re-read your prior comments.
The important point is the conceptual realization that patients cannot consent without being informed. It's called informed consent. Part of being informed is being informed about the costs. Obviously, there is going to be a knowledge gap both in terms of the medical and financial costs/benefits. When it comes to medical cost/benefits, people mostly acknowledge the knowledge gap and say that it's important for doctors to find a way to explain the situation as they can to the patient. There is obviously a range of quality here, but the answer is that you have to try. When it comes to the financial side, they instead just say that it's impossible. They give up. They don't even try. (It's just a coincidence that doing this is in their interest.)
His prior answer gave a probability attached to a known unknown, conveying the information known by the doctor in a way that is very representative of the doctor's knowledge. First, it is obvious that they can do this sort of thing.
Second, as to the question of comparing the quality of the answers, suppose you were considering playing a lottery-style game. One just told you, "The range of payouts is between $5k and $1.5M." A second told you, "The payout is about $5k with about probability p, and the payout is about $1.5M with probability 1-p." Which of these answers do you think is better quality information? Which of these answers do you think is more helpful in analyzing whether you would like to play?
Third, the lingering question is whether/when it matters. It will obviously depend. It will depend on the dollar figures; it will depend on the probabilities; it can also obviously depend on how the individual's personal insurance is structured (common factors would be deductible, co-insurance, and out-of-pocket max). From there, we have a several-dimensional parameter sweep. We could sit down and generate plots. I'm sure we would see tons of regimes where having the information is basically useless. But I'm also confident that we would see tons of regimes where having the information is useful. I'm sure the good doctor we are talking to can come up with plenty of individual examples off the top of his head that are in the regime where it doesn't matter. Don't care. There are almost certainly also plenty of examples where it does matter; I would venture to guess that, actually, for the vast majority of regular, routine decisions, it can, in fact, matter. The standard party line is to just not even try, in any case, because there might be other cases where it doesn't matter. That's absurd. Moreover, it betrays a lack of understanding of economic thinking. There are always non-marginal cases. In no other area of economics do we say, "There are some extremely high/low value producers/consumers, and since their behavior won't be changed by [alteration to the price system], we should just completely blow up the price system and abandon it." Economists push back on this shoddy reasoning constantly. Sure, there might be someone who just loves eating exactly one apple every day so much that even if we blow up and get rid of the price system for apples, just don't tell anyone how much apples cost, and have them paid for via some complicated mechanism, they'll still buy exactly seven apples every week. Who cares? The price system is there for all of the other cases.
The challenge to someone saying that we should never talk about prices because they never matter is to actually show that they never matter, not that there are some cases in which they might not matter. I think they probably do matter to a hell of a lot more cases than they're willing to admit.
ControlsFreak
7mo ago
Let's go back to basics. You already gave a vastly better answer. Did you forget what you said two days ago?
To emphasize: name another business that is forced to work for free and is prohibited by law from closing unprofitable businesses segments
Don't need to. That does not in any way prevent you from giving a price. You know that it doesn't. You know that you can do it. You've basically admitted such by your responses and non-responses.
You are right of course that people will attempt to solve the problem by increasing regulations
You have an opportunity in front of you. Perhaps you'd like to respond to the questions I asked rather than not responding.
where else in modern America do you see costs kept down by using indentured servants? The closet thing to Residency
This is hilarious, given that you were just defending a claim about residency slots that looked extremely poor upon even a cursory look at the entire data you linked to. Maybe your industry is like other industries from an economic point of view when it comes to cartel behavior restricting supply. Like, economists know how systems like this lead to abuse, and perhaps if we stopped restricting supply and truly opened it up to competition, where if one hospital was known for abusing their residents or even paying them poorly or whatever, they would likely have other competing options. You might not be such a unique industry, impervious to literally all traditional analysis, as you think.
But yeah, you know there are atrocious problems. You can keep making bad arguments, pointing to data that you know doesn't show what you say, avoiding answering questions, choosing to be less helpful than we know you can be, etc. And one set of results will flow from that. There is another way, and hopefully another set of results to go with it.
EDIT: There are indeed many different dysfunctions in the medical industry, and one can always say, "Well, we can't spend time focusing on X, because there's also A, B, C, D, E, F that cause weird problems, too." That results in just spinning wheels and nothing ever gets done. When someone later suggests, "Here's an idea that can improve D," you will again say, "But we can't spend time on D, because there is also A, B, C, X, E, and F."
For IoT, I had originally suggested that people just focus on one thing, a little thing. You had to figure out a way to get default passwords out of the industry. It had to be done. It absolutely could be done. But it had to be done. Instead, we got the same distraction tactics, the same Obvious Nonsense claims that it was actually impossible, etc. We saw the results that followed.
I think it is plausible to start with one thing (I suggest just providing prices), especially one that we all know is actually, totally possible. There is no real reason why it cannot be done. If you adopt the mindset that it must be done, it must be the first step to changing the mindset of the rest of the culture, you at least have a chance of success. It requires admitting that there is dysfunction, admitting that the mindset needs to change, admitting that the old mindset and the old dysfunction was fundamentally built on lies, and here is one very straightforward, very easy way to demonstrate that it was built on lies and that we're going to have to call out those lies if we're going to have any hope at broader change.
Giving prices is possible. It will not break other things. It will not make other problems any worse. In some cases, it might not matter much; in other cases, it will. But it is an easy first thing that you can do to break the cycle of lies built upon lies and give us any hope of an alternative solution to something like the haphazard, chaotic mess of additional regulation. Not doing something like this is simply resigning to whatever other, possibly incoherent, change will come. The same dysfunctional mindset will persist, and I, for one, would have little hope that anything will be fixed anytime soon if we can't even do one little thing.
Look, I get it. You want it to be one way. You want to just keep everything the same; just stop all the change; just go into work, do a good job at doing your job, close your eyes to any dysfunction and make no changes to your mindset concerning the entire conceptual schema of the industry. That's fine. That's natural. Parts of it may even be commendable.
...but as the old saying goes, things that cannot possibly keep going the way they're going, won't. Change gon' come. I've seen this in industry after industry after industry. This is an industry that just had two different bills passed by two different congresses and signed by the last two presidents (one of whom is coming back in and may be interested in taking another bite at the apple) specifically because this stuff is a problem. The purpose of this entire thread is because a notable CEO was shot dead in the streets of NYC, possibly because of frustration with these problems; news outlets are reporting people cheering this. It's not always regulation; sometimes it's in other forms. Sometimes, the industry cleans itself up. Sometimes, there's just a shift in the case law. Sometimes, there's a disrupter. Sometimes, new regulations get dropped like bombs. And I get it, that last category is scary. I don't like a lot of new regulation. You know full well that I'm aware that it is often done shoddily, with all sorts of unintended consequences. This is the least-preferred solution in my mind. But everyone knows the medical industry is broken. Everyone knows that it can't keep going on forever without change. You know that it's broken when you say:
the prices are made up, they don't matter
I've heard industry after industry swear up and down about how unique they are, how they have to do things differently, how they can't possibly change things. A silly little example from the last few months is real estate. Oh Sagan, the kicking at the goads, even after the details of the settlement became clear. You should have seen the levels of broken people's minds were; how they were constantly talking about ways to try to get around the new rules, how they simply could not conceptually wrap their minds around the fact that they couldn't just operate the same way that they always had, how their industry is a special snowflake and their special needs will always shine through. You saw some of the smart ones figure it out reasonably quickly, and sure enough, they started doing the obvious things to follow the new incentives and improve their business. I'm sure some of the folks who kicked too hard or weren't smart enough to figure it out or were simply broken by the conceptual change are struggling right now; some might already be out of business.
Change will come, no matter how unique you think you are. You really have an opportunity now. You can change your conceptual schema, evangelize the change in mindset, and begin to fix what you can in your corner of the big problem. Maybe it'll be a lost cause for the purpose of avoiding some dumb regulation, but that's your opportunity. I'm just sounding the warning, like I did long ago for IoT. We saw how that worked out when they didn't heed the warning, banking on swearing up and down about how unique they were and how things had to be different for them. They probably liked the regulation they got less than they would have liked the alternative opportunities they previously had in front of them.
So, in the spirit of helping you get a head start, a leg up on your competition for when change comes, so that you can adapt, optimize, and make bank, rather then ending up broken, conceptually lost, and possibly out of business, let's really think about what you can do. You gave an answer yesterday about the cost of a gallblatter removal. Perhaps you forgot that answer today, but I'm guessing you didn't. Think about your previous answer; what was wrong with it? I liked it; I thought it was pretty good. If you didn't forget it, I sort of have to believe that you consciously or unconsciously chose to change your answer to a less good answer. Perhaps reflect on why you might have done so. What were your motivations in trying to be less helpful? How do you think it will affect people's (possibly including potential customers') impression of you as a person or as a possible topic expert when they see that you are choosing to be less helpful than they know you can be? How do you think the mindset of choosing to be less helpful will affect your business if/when change is imposed on your business or industry?
Additionally, I suggest you seriously study how other industries manage to solve this problem. All of them do it. There are a variety of solutions. Can you think of any? If the only one that you honestly can think of is to have the head of the billing department personally perform every single estimate for every single procedure for every single patient, how do you think that will affect your business's ability to adapt to changes? If regulation comes, could your lack of insight into how these problems are typically solved leave you lagging behind the competition in adapting to the new environment? Could it even pose an existential threat to your business?
I suggest you consider these things, because some of your competitors will. They will not only survive and make money; they will thrive and eat your lunch. You have a great opportunity now.
ControlsFreak
7mo ago
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C'mon man, you did better in the linked comment. You already gave a vastly better answer. Did you forget what you said yesterday?
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You cannot seriously think that every other industry that has solved this problem requires the head of their billing department to generate every price. How do you think other industries solve this problem?
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I'm not blaming you. I'm just asking you to do basic business practices in a decent way, just like how everyone else does. You can do this. You really can.
ControlsFreak
7mo ago
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This is false, as we've already discussed.
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I don't care whose job it is. Every single other industry has figured out how to do this basic business practice in a decent way, and many times, there is division of labor.
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This is the most pernicious, absolutely atrocious lie that is the core reason we have such a disaster of a medical industry. You cannot believe that anyone will read this entire thread branching from the OP and think that this a remotely reasonable response. Sure, if we just accept that everything is broken with insane prices that don't mean anything, then nothing means anything and we're doomed to dysfunction. We can do better.
ControlsFreak
7mo ago
If you're not capable of doing it, then you need to figure out a workflow so that someone who is capable provides a price. This is a part of basically every other service in every other industry; it is not impossible.
To go to the auto shop example, you could equally imagine a mechanic-head praising the beauty and sanctity of the Art of Motorcycle Automotive Maintenance, and how carefully he considers the non-monetary risks/benefits of a given intervention, saying that in his view, the price is entirely orthogonal to providing good automotive care. He could be so educated and experienced that he thinks it would be an utter waste of his time to even put together estimates. I would say that perhaps he is right on all those points. I still want a price. I want it as a routine matter. Maybe he will have some customers who literally don't care, who have a unique, historical vehicle and a fat bank account, and they just want the artistic approach, damn the costs. But as a routine matter, I don't care how beautiful you think your orthogonal things are; you are running a service business where the customer needs to know the costs/benefits. It is doubly important in the medical domain for them to be informed of the costs/benefits if they're going to give informed consent.
If you need to structure your workflow so that a different employee is up front assembling the estimate while the genius mechanic is spending every minute of his time on his craft, so be it. You have people that do that stuff anyway. Do it up front, not after-the-fact. Keep your patient informed. Just give him the damn price.
ControlsFreak
7mo ago
Tyler Cowen and Alex Tabarrok just had a great discussion about this at the propeller-head level. You're pretty close to what I think their ultimate prediction is. They think crypto will be paired with a few major currencies, and that will be attractive to a bunch of minor countries who want the benefits of access to a more major currency, but without the regulatory strings the originators of those currencies would like to attach. They think that this will drive out more minor currencies, but that crypto can't completely do it on its own; it will still need to be sort of attached to one of a few more major currencies. With the speed of calculation managing arbitrage against poor management of one of these major currencies, I guess the hope is that it will help enforce better management of the handful of major currencies (also perhaps taking away some of the value a major currency supplier could typically try to get by doing any number of the typical 'poor management' things they typically otherwise do).
ControlsFreak
7mo ago
We actually just had a minor development that is sort of on this front in the DC Circuit with the TikTok divestiture case. I haven't yet actually read the case, just some excerpts from Volokh, but it's likely to be influential.
A gallbladder removal can cost say roughly 5,000 dollars or 1.5 million. Sure the latter is 1% of the time, but you need to plan around it because it's a regular occurrence with the numbers involved.
This seems to be like something you can tell the patient. I mean, you just told me. Why can't you tell them? Why can't you plan around it?
There's clearly a category of unknown unknowns, but you're telling me that you have extremely known unknowns, such that you can spout the dollar figure and the percentage incidence off the top of your head. All I'm asking for is that when you have such a well-known unknown (such that you already have to "plan around it"), you should discuss it with the patient.
insurance
It's like you didn't even read my comment.
Nah, man. They didn't ask for anything like you suggested. And two thirds complied fully within a pretty short time frame, because what they asked for obviously could be done. I'm sure in a couple more years, that number will be higher.
Just do it. Just do what you know you can already do. What you already admitted that you can do; it was a lie before when you said you couldn't. You already admitted that you do do from time to time. We've been through every objection, in detail. I've responded, in detail. You're all out of excuses at this point and are just resting on speculative claims that it could possibly take a modicum of effort. Boo hoo. Grow up. They're literally shooting your people on the streets of New York City. Others are cheering. Stop lying to yourself and to others. Actually inform your patients and actually get informed consent. You probably will like the haphazard results that will follow if you don't clean up your act less.
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