ControlsFreak
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User ID: 1422
Getting close to a year ago, I talked about GOLO, a weight loss program that I heard about from an ad in a podcast I was listening to. I found it oddly satisfying, because they were trying to launder the standard science on CICO through explicit anti-CICO messaging; truly a beauty of capitalism. Their biggest tag line for what they think is going wrong with a lot of people was insulin resistance. Whelp, while I was at the gym this morning, what popped up in my podcast list? A two hour long Peter Attia podcast specifically on insulin resistance with MD/PhD Gerald Shulman, an academic researcher on the topic.
They talked about the prevalence of insulin resistance in the population. No, it is not obscure. Obesity basically causes it directly, and yeah, the population obesity numbers are high. They also talked about diabetes, both Type I and Type II, as well as some studies on healthy, lean young adults who had two parents with Type II diabetes and who displayed insulin resistance (i.e., at high risk of developing Type II diabetes). But yeah, lots of people do have insulin resistance, so things like GOLO are at least capturing a slice of reality, even though it's clear that they're not really specially targeting insulin resistant individuals. They're not testing people for insulin resistance and then tailoring their program accordingly; they're again just laundering the standard advice and giving it to all comers, whether they're actually insulin resistant or not.
They talked a lot about molecular mechanisms, evolutionary explanations, etc., in great gory detail, far more than I could do justice trying to reproduce here. I'll hopefully suffice by describing one concept; they distinguish between insulin resistance in muscle versus what happens in the liver down the chain (which can cause fatty liver disease, which is now working its way up to being one of the leading causes of death or other conditions that cause death). Apparently, many folks develop muscle insulin resistance, so glucose is not able to be deposited in muscle as glycogen, so it ends up in the liver, and all sorts of problems follow.
What can we do about this? "Exercise reverses this muscle insulin resistance ... exercise in muscle actually will prevent fatty liver and liver insulin resistance". [EDIT: They talked about a couple different studies, but Upon further review in the comments below; I think this part was just one study. They did talk about other studies generally, but I had interpreted this section as referring to two different studies, but now I think it refers to just one] remember that population of otherwise healthy, lean, young adults with parents who have Type II diabetes? They had them do a single bout session of exercise (45min 3 sets of 15min at 65% VO2Max), and that was sufficient to open up the necessary translocation pathway, resulting in "more glucose deposition as muscle glycogen and significant reductions in [something too technical for me to try to explain in this comment] and significant reductions in liver triglyceride."
What about beyond that population, thinking about just other obese people? "What can we do about this? If we can get our patients to lose weight; this of course is the best. Diet and exercise of course is the best thing, and that's the first thing I tell my patients. We really drill into them how we can really fix everything that's wrong with them through this process. [Emphasis added; italics felt true to the audio; bold is my own focus]"
We know a lot about how this works. We know how to fix it. Exercise still is the single most effective medical intervention we know of. If exercise were a pill being prescribed, it would be hands down the most effective thing for all-cause mortality. Paired with diet, it's basically a superpower against a vast swath of modern maladies. Doctors know this, they know how it works and why, they've known this for a long time now, and they'll say it in public. Some, like this guy, will even say it so bluntly to patients. But many doctors know that patients don't want to hear it. They don't want to hear the science; they don't want to "follow the science" (i.e., actually do the thing). He also mentions that even though they try to drill this into patients, many of them still just don't do it. Patients get annoyed with doctors telling them the truth, and this results in a lot of doctors giving up and not even telling them anymore. Just avoid the topic. I had one obese friend tell me that she practically begged her doctor for advice with her weight, and he said, "You know, you're just getting older..."
You don't have to believe the GOLOs of the world. You don't have to believe the sign on the gym swearing that they'll help you lose 20lbs in 30 days. They're grifting, and they're helping to confuse many many people about how their bodies work. But the evidence is pretty solid that basically whatever the excuse is, in this case insulin resistance, the most well-documented and scientifically-supported solution is still diet and exercise.
From time to time, people discuss prohibitions here. The general zeitgeist is often that one particular interpretation of the the US's experience with alcohol prohibition in the 1920s is conclusive for all prohibitions of any type everywhere and always. Nevermind that there are alternative interpretations of the US's experience with alcohol prohibition in the 1920s. Nevermind that different prohibitions are different. We now have one data set from South Africa.
In 2020, the South African government banned alcohol sales as part of their COVID measures. Then they lifted the ban, and then brought it back unexpectedly, and then did that again
Every ban saw murders decline, and every reprieve saw them return. Stunningly, prohibition worked:
Perhaps they just didn't keep the prohibition long enough over any time period for the data to show that murders would have really gone up massively over time. Perhaps murders aren't the right measure. (EDIT: Perhaps there were other restrictions that happened concurrent to the alcohol prohibition; one might be interested to see if there are any differences in start/end dates for other restrictions and see if there is something like a DiD.) Lots of interpretations, but only one limited data set. I'm not a huge fan of alcohol prohibition, personally, but I wonder if that is, to some extent, a luxury belief of mine.
ControlsFreak
6mo ago
There was a wild post on r/RealEstate yesterday. It's already been deleted.
Hello,
I'm a young owner of a few rentals - I got lucky young starting a marketing business that worked.
We've been having some wind here lately and it partly ripped off some siding on the side of my house that's way to high for me to reach with a ladder. I look online and call a dude with good reviews - I think he's a solo gig. He pulls up within an hour of calling him and he's like "Oh, no big deal!". I watch him get out his ladder, get up there, screw these screws into the siding that are literally going into nothing (i think he did it so it looked like he was doing something), he pushed the siding back into the trim, and got down. Literally up there for 2 minutes. He said "Okay I'll go to my truck and get a quote"
He ends up coming back to my door like a half hour later and he claims his service call is $3000 and the screws were $5.
I kind of just look at him and I'm like "hahaha how much do I owe ya?"
Him: "$3005. I accept all forms of payment"
Me: "You're joking right? You told me on the phone your service call was $75."
Him: "We never talked sir. You must have talked to some other siding guy"
Me: "If I talked to someone else, how would you have known to come over right away and do my siding?"
Him: "Uhhh.. I mean.. Like I use a contracting app that gave me this job. My rate is $3000"
Me: "I'll give you $100 just to leave. I'm not doing this, that's crazy"
Him: "Maybe I should call the police. Should we do that?"
Me: "Go right ahead but it's a civil manner"
Him: "This is theft of services. If you don't pay, I'm pressing charges and you're going to jail"
Me: "I can promise you if you keep up this immoral scam like behavior you're going to end up in jail"
Him: "I just got out of prison, no sweat off my brow"
Me: "Doesn't surprise me with that prison tat on your neck"
Him: "Look kid you gonna pay me or not"
Me: "No"
Him: "You'll be hearing from my lawyer kid. Hope mommy and daddy can pay for it"
Me: See ya later!
I'm 25 but look 20. I've had people try to charge me crazy prices for things or take advantage of me but this was nuts and criminal (not literally but you know what i mean - just not right). Why are there people out there like this?
There's obviously a good chance that it's a totally fake story. I'd basically assume that it is. I don't even really care if there's even a 0.1% chance that it's actually true; it doesn't really matter.
Part of the reason why people likely believe that it's fake is that it sounds like absolutely outrageous behavior by the contractor. Something that no one would put up with. Something that would shock the conscience if it actually happened and there was a recording of the interaction or something.
So what's weird is that this is the standard modus operandi in the medical industry. It's just the way things are done. Yes, if you have insurance, then instead of telling you to your face that they're charging a ridiculous made up number after the fact, they tell your insurance provider the same thing. But the basic fact pattern is absolutely the same.
I'm definitely not going to go all Kulak and say that since this routinized obscenity shocks the conscious, everyone needs to start going around murderin'. But it absolutely is a routinized obscenity that should shock the conscience. Perhaps my crazy pills are significantly less potent than his, but they appear to still be crazy pills.
Lawyers can debate the legalese of "consent to treat" forms and what they do and do not allow, but it simply cannot be plausible that we will have a functional medical industry when it is the one and only industry that is allowed to simply refuse to provide you a price prior to authorizing work and then go on to just make up whatever the hell inflated price they want after the fact.
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
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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
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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.
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.
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.
ControlsFreak
6mo 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?
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?
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.
ControlsFreak
7mo ago
Can you remember what your answer was two days ago?
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
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
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
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.
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
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.
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
Citation needed.
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.
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.
they are shooting people who work for insurance. The people who are the problem.
First, hilariously naive that you think you'll be spared if the anger boils over into something like regulation. Second, if you're going to claim that they're the problem, tell me how you're going to fix it. I don't want to hear you just complaining and finger pointing; I want solutions. How are you going to start cleaning up this mess?
Informed consent has nothing to do with price
Price is part of the costs/benefits. You are practicing medicine unethically if you are not properly informing your patients of the costs/benefits.
I also can't promise you a price or cost or charge before hand.
Not a strict promise. We've been through this. You know this. You know that you can do better.
You have yet to explain how providing more detail on cost, price, or charges adds any value to the system.
It is unethical to perform a procedure on a patient before acquiring informed consent. It's basic decency in business practice. It's good to stop lying to people and telling them that you can't do something that you know you can. I'd think in recent years, you'd be a bit in tune with the idea that if your profession is being seen as lying to the public, it can cause a significant reduction in your status and credibility. Conversely, if you start doing the basic thing, patients will have more faith in the medical system, believing that the market is operating more fairly and that they are not being overcharged for services. This fosters greater societal trust in the medical system and encourages broader participation in preventive and other health measures. Price transparency is an important component of many properties of markets. It can affect people's decision-making and allocate resources more efficiently. It reduces information asymmetry. It reduces surprises and the anger they generate. When patients know the cost of their treatment options, they can plan financially, leading to higher adherence to prescribed treatments. For example, patients who know they can afford the cost of necessary medications or follow-up procedures are more likely to stick with the treatment regimen, leading to better health outcomes. It speeds up price discovery, increases consumer welfare, and it can also be linked to encouraging innovation. The Nobel prize that Stigler got for this sort of stuff was looooooong ago.
You have yet to explain how doing everything you can to hide prices, lying to people, telling them it's impossible adds any value to the system.
Not giving prices is more misleading and confusing. Hence the legislation efforts and assassinations. Stop acting like people are so stupid that they can't understand costs/benefits. Inform your patients, just like you do with medical costs/benefits, even though there is also a knowledge gap there, too. Stop practicing unethically.
Regulations impair things.
I'm hoping we don't go there, but you need to fix things. Ask the techies in the IoT space how just stomping their feet, refusing to do anything, and resting on, "Regulation is bad, m-kay," worked for them.
Increased price awareness does not help patients make decisions.
This is utterly false and is completely unsupportable. You couldn't imagine saying such a thing for any other industry, because it's nonsensical.
I'm glad that you had no problem with the entire rest of my list of benefits. Given that the only benefit you gave on your side rests on the assumption that everyone else is too stupid (a bad assumption) that you need to be appointed to keep them in the dark and make all their choices for them (which isn't likely to help, anyway; how are you currently preventing them from going to the hospital where they happen to end up with the bill for $300k?), I think it's pretty clear that your approach is not helping. It's hurting. It unethical. It's bad business practice. It's bad economics. There is nothing good about what you are doing.
NYT had a doctor apologist op-ed this morning. Hilariously skewed, of course, but they also disagreed with you.
As a young doctor, I struggled with this. Studies show this drug is the most effective treatment, I would say. Of course, the insurer will cover it. My more seasoned colleague gently chided me that if I practiced this way, then my patients wouldn’t fill their prescriptions at all. And he was right.
Costs matter. Inform your patients. Stop lying and saying that they don't. I've given you a long list of reasons; compared to your one, extremely terrible reason for doing what you're doing, the choice is clear.
Various threads lately have had me thinking about how incredibly wealthy we are as a country, and how it definitely was not always so. For example, I made this comment a couple days ago about how everyone was just flat super poor back in 1900, and we're literally at least 10x richer now. I had likewise told the following story in the old place, in context of wealth to afford vast quantities of food (and how that may interplay with societal obesity):
I didn't completely spell it out, but that was my wife's father's story when he was a child in Canada. (I also hedged on the number; my best memory was that it was precisely one 50lb bag and one 5lb chunk). That was not that long ago.
Yesterday, I read an obituary for a 95 year old who was born in a homestead dugout in New Mexico. Literally born in a hole in the ground.
Perspective on how utterly ridiculously quickly we went from basically universal poverty to nearly universal wealth is often lacking in many conversations where it could be quite beneficial. Sure, some in the capitalism/communism debates (or more generally the sources/causes of wealth and how it interacts with society's choices/governance), but also in obesity conversations (as mentioned) and even fertility conversations. Born in a homestead dugout. And you don't want to have a kid because of a car seat?!
I still don't properly know how exactly to craft an argument that comes to a clean conclusion, but I really feel like this historical perspective is seriously lacking in a country where the median age is under 40 and many folks no longer have communal contexts where they get exposed to at least a slice of history from their elders.
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