Throwaway05
6mo ago
I don't think you understand that the numbers you are asking for in the situation you are asking for them are untethered from your financial responsibility because of the presence of insurance.
Throwaway05
6mo ago
You argument is that its worth putting the effort into delivering some numbers to you (which numbers don't matter!) because none of those numbers have any impact on you. You claim they do, but when I say "what impact" you don't provide an impact.
Let's try: "because I want to choose the cheaper option." Not necessarily unwise, but those numbers don't help you do that.
What else?
Throwaway05
6mo ago
You are asking for a number that has no impact on you. It does not impact how much you pay. It does not impact how much society pays. It does not impact how much your insurance pays. It does indicate quality of a given procedure.
As with the bonus it is unrelated to the issue at hand, since it does not impact you clinically or financially.
"Because" is not a reason to make things more complicated and more expensive, especially if it is at best irrelevant and at worst confuses people into make decisions using irrelevant information.
You have not indicated any value behind what you are asking for despite me repeatedly asking.
I think you need to admit that what you are asking for is for idle curiosity or provide a reason. Informed consent is not a reason because the information does not inform any consent!
Throwaway05
6mo ago
The number you are asking for has nothing to do with you. If it impacts your decision you are looking at the surface of the moon to decide what sandwich to buy. It doesn't make sense.
When you go to the mechanic do you have the right to barge into the manager's office and ask him what his bonus was last year? That has nothing to do with your oil change. And you certainly shouldn't call the manager evil for not telling you about his bonus.
Throwaway05
6mo ago
"It informs me as to the likely costs of various options, allowing me to proceed in deliberation and/or discussion about priorities and tradeoffs. This is straightforward stuff."
It does not allow you to do any of this. Explain the mechanism in which it allows you to do this.
Throwaway05
6mo ago
likely costs of various options
You cannot save money with this information. The higher number may be cheaper. Your insurance company cannot save money with this information (for you). I don't know how many times I can tell you this. This number doesn't mean what you think it means.
Throwaway05
6mo ago
I'm telling you that it has relevance to me
What relevance?
Throwaway05
6mo ago
What makes going under the knife qualitatively different when it comes to nigh universal desires to change or improve one's body? Getting rid of burn scars? Removing a mole? Does wanting to get a haircut or go to the gym count as body dysmorphia?
All yes per them.
(and therefore the dysmorphia isn't necessarily a bad thing).
Throwaway05
6mo ago
diagnosis of severe body dysmorphia
If you catch a plastic surgeon drunk they'll often argue that ANY desire for plastic surgery is body dysmorphia. Any at all.
Throwaway05
6mo ago
It has no relevance to you, I can only tell you that so many times.
Throwaway05
6mo ago
What are you doing with the information in the EOB? How does it alter your decision making?
Throwaway05
6mo ago
I tried to use the technical terms and you didn't seem to understand with those. Abstract labels seemed to be a more appropriate tack.
Why aren't you satisfied with the EOB? It's a bunch of random number that has no association with what you actually pay, that seems to be to your liking.
Throwaway05
6mo ago
Yes, we did.
I said it mattered for apples. We are talking about oranges.
Your EOB has pineapples, guava, and pasta on it, but not oranges.
Throwaway05
6mo ago
It can matter, as you have already agreed.
We have not agreed on this.
Throwaway05
6mo ago
Let me make it simple again. You are asking for a number in dollars that has no meaning to the patient. The number in dollars that has meaning to the patient is something else. Why do you want a number in dollars that has no meaning instead of a number in dollars that has meaning?
Throwaway05
6mo ago
My hospital charges three oranges, a second hospital charges two oranges, a third hospital charges four oranges. Your insurance gives all three hospitals a single banana. Regardless of which hospital you go to, your insurance makes you pay three sticks of whole wheat pasta.
Why then is it valuable to know how many oranges my hospital vs. the other two charges?
It has no impact on your pasta. It has no impact on your pasta. It has no impact on your pasta.
If you just want to know so you can know...that's fine. Curiosity is reasonable. Spending money to figure out things for your curiosity is not necessarily reasonable however.
The only proposed use for the orange you've given me is for "informed consent," but informed consent would be the pasta, not the orange. The orange has no impact on the patient.
If it has one please provide it.
Throwaway05
6mo ago
The information a patient needs to make a decision is whole wheat pasta, but you are demanding that I give them information about oranges.
This is the problem.
Patients want to know what they will pay. This is whole wheat pasta. Insurance is in charge of whole wheat pasta. Whole wheat pasta is what the patient gets.
Oranges are what you are asking for. Oranges have little relationship with whole wheat pasta other than they are food. What the insurance company does to turn oranges into whole wheat pasta is mostly nonsense and depending on the thing may be literally 100% unrelated. Knowing about oranges tells you little to nothing about whole wheat pasta.
For this reason oranges are not my job. I do know about some oranges, there are other oranges I know nothing about, because oranges are never relevant to the patient.
Informed consent implies information, information about oranges does not enhance knowledge of whole wheat pasta. Patients are getting whole wheat pasta, not oranges.
Furthermore, gathering information about oranges (which are not whole wheat pasta) is not free. You are asking me to spend time and money on oranges while the patient is getting whole wheat pasta.
This would have the impact of increasing the price of whole wheat pasta without improving its quality. The patient would still not get oranges.
Now the patient is confused! Why did you tell me about oranges? I got whole wheat pasta instead.
Because some random person on the internet insisted I tell you about oranges despite the fact that you were getting whole wheat pasta.
Throwaway05
6mo ago
I said the price of apples has value.
The prices of oranges has no value, especially when you are actually buying whole wheat pasta.
You want me to hire an orange consultant to teach someone about oranges but we are giving them pasta.
Hiring an orange consultant isn't free, and will lead to people being confused when they end up eating sauceless pasta instead of an orange.
Throwaway05
6mo ago
I don't in principle have any issue with modifying our system to more resemble a market, I suspect that would potentially have efficiency gains but may not be feasible given the amount of money involved and the inherent variability issues (as previously mentioned 5k for a surgery is a reasonable amount for someone to self-insure and so on, millions of dollars thought?). Also a million other questions would need to be answered (do we keep having healthy young people subsidize the sick?).
As is the prices have nothing to do with the patient the price is whatever their insurance's rules are (premiums, copays and so on).
Any information released by the hospital is unrelated to the patient's experience. A cheaper list price may be cost the patient 50,000 dollars, a more expensive list price may be literally free (if that's the way the coverage breaks down).
You can squint and try and figure out places where price transparency might help. I may see that my competitor across the river offers the same surgery for 500 dollars less and go "ooh wait maybe I could be saving money here" but when you shake those out practically they don't work out. Maybe the cost savings are because they average out their anesthetic gas charges over all procedures, they have more volume, or the people on my side of the river are fatter so cases take longer.
If you've got one I'll listen though.
Throwaway05
6mo ago
The prices have no relationship with what the patient pays. Why do you not understand this? What is so hard to understand about that?
See above.
I didn't answer your other statement because it was incorrect and misunderstands how this works.
Throwaway05
6mo ago
I think cost disease in general teaches me we aren't going to improve the cost side of the system with M4A. Too many bad actors and hands reaching into the till. If I was god, or failing that a dictator, I could probably do it (with appropriate subject matter experts obviously). But nobody is, so zero chance of that happening.
A good example is physician salaries. Obviously I care about this because I'm a doctor and want to get paid, but a lot of people want to crash MD salaries as much as possible, it will be one of the first things that happens when M4A inevitably happens. It also doesn't do much to help costs because MD salaries aren't a major driving factor. However you'll get a dramatic reduction in quality and shortages as people flee the field. A lot of nurses retired from bedside nursing because of a lawsuit result that was totally justified and wouldn't negatively impact nurses at all, they just didn't like the vibes. The jobs are so miserable that people are champing at the bit to leave and cutting salaries drastically is only going to hasten that.
And that's just one specific line item in the many catastrophes that would inevitably happen.
There are plenty of things we can do to improve things without crashing the system however. Tort reform is the obvious example. You don't even need to remove the ability to sue, just put in expert juries (and that doesn't need to be all doctors) instead. As it is now you can follow the standard of care and still be sued for all that you are worth. The protection isn't to never make a mistake, because you can still get sued for not making a mistake, instead its to provide the "safest" care possible which is super expensive and can actually be a negative for patients (unnecessary imaging leads to increase in lifetime cancer risk but is hard to sue over thirty years later).
Fix the things that are actually fixable first and see how stuff looks.
Make all insurance functionally non-profits, cap administrative salaries, etc as another example
Throwaway05
6mo ago
This is definitely a lie.
The prices have no relationship with what the patient pays. Why do you not understand this? What is so hard to understand about that?
Throwaway05
6mo ago
Oooh! Wait! One more, one more!
The insurance landscape in Hawaii is famously bad, they'd rather fly patients to another island and put them in a hotel room for multiple days than pay a fair wage to specialists on whichever island the patient was coming from. Now I'm sure the negotiating math makes sense such that this is ultimately the better decision. It is also insane.
The insurance industry lobby is extremely profitable and has excellent PR, they are very good at turning people against doctors for instance. See this discussion on Meddit for example: https://old.reddit.com/r/medicine/comments/1h9lli9/the_vast_majority_of_us_excess_healthcare/
They have a large number of loop holes they can use "we aren't practicing medicine, you are practicing medicine, you recommend what you feel the patient needs, we just won't pay for it" is the most famous example. Another common one is using the reviewers as liability sponges. I haven't worked in this environment so I don't know how it works exactly (and nobody is willing to admit to it haha) but I suspect they make it understood somehow that you need to deny a certain number of claims, and then fire you if you don't, then if regulators look they fire the reviewers and claim they were bad actors. Proving systemic malfeasance is challenging.
Pharma and insurance are absurdly profitable and influential, and again they both are very adroit at blaming other aspects of the system. See me banging my drum every time someone complains about physician salaries or the "AMA cartel" those are distracters from the real villains and not really part of the problem.
Medicare and Medicaid are both also awful but generally for different reasons. They are government entities so you can imagine how pleasant they are to work with. They still have deals with manufacturers that are almost always to the manufacturers benefit and very confusing but are more above board more or less because it's directly from the government. You also get weird stuff like instead of prior-authorization you may get an audit afterwards that decides if what you actually did was justified and then you get paid or not paid accordingly. Miss a new rule that requires you to document X required thing? Guess your practice or department is in the red. With private insurance you can at least try and adjust in advance.
The bigger problem is that they are often below cost. You'll have to forgive me on the numbers because it's been a few years since I looked this up, but it's something like Medicaid pays .8, Medicare pays .85, and private pays 1.1-1.2 times cost.
If you have a payor mix of mostly public insurance, you go out of business or require bailouts. Hahnemann University Hospital went under a few years ago mostly because of this and that caused huge problems (it had the most residents of any health system).
This also results in some services flat out not being offered anymore in a non-emergency setting, or things like public insurance not being taken.
If you see a doctor who is willingly taking Medicaid/Medicare (usually they are taking it because they are employees of a health system and the system takes it, often because of government funding or legal requirements) that means they are deliberately taking a pay cut to help people (which happens a lot because of martyr complexes) or have some way they are abusing the system (which can actually be legal and fairly harmless but isn't always).
Throwaway05
6mo ago
The cost for prescription drugs is reasonably knowable and often knowable with respect to how your insurance covers them. We choose with this information in mind and generally involve patients in shared decision making if such a thing is applicable for that clinical situation.
When you come to my office for an office visit I do not know in advance what I will bill for, because that depends on what you tell me. I can't tell you that in advance. No information is available beforehand. It is also not relevant because I will either have a cash pay fee schedule or you will pay a copay or other fee depending on your insurance. Both the cash pay fee schedule and copay/coinsurance exist independent of whatever billing codes I use and what value is being assigned to them.
For hospital based care, which is what we spent most of this conversation talking about, PATIENTS CANNOT MAKE DECISIONS BASED OFF OF PRICES.
The price and cost are not what the patient pays.
Thank you for affirming my belief that Americans cannot be trusted to reform healthcare in a sensible way.
Over the course of this conversation it's moved around a bit, it's been both price as in cost and price as in charge, although he also added reimbursed rate at some point. In the situation we are talking about (planned procedures covered by insurance) neither of those numbers matter to the patient and the price as in charge is pretty firmly unrelated to the reimbursed rate as well as the price as in cost (since determining the actual cost is hideously complicated in the hospital and rarely relevant given it poorly related to what private and public insurers actually pay). The numbers are pretty much all made up as part of some weird dance between the hospital, government, and insurance. This is suboptimal but is the current state.
Hospital finances typically involve extracting as much money from the few parts of healthcare delivery that are actually profitable so that you can fund unprofitable portions of the hospital. Naively this sounds bad but when you consider things like the fact that the ED loses money because a sizable portion of the care it delivers is functionally free (the uninsured who can't pay)...well the alternative is worse because it involves people with no insurance or unknown insurance status just dying instead.
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