Throwaway05
6mo ago
Yep.
Healthcare in the U.S. is comically complicated, expensive, and frustrating - with an intense human cost in what we do to the people who work in it.
In return we get best in the world access to care, immense human capital investment, the highest quality of care in the world (both for the poor and even more so for the rich - outcome problems are driven by our poor health in the country aka obesity). In addition because of the amount of profit available we do a huge portion of the world's research.
When people talk reforming the system they almost always propose things that are sure to break one of those pillars (like introducing rationing) with much more questionable ability to actually decrease costs.
Throwaway05
6mo ago
...did you listen to what I said at all?
Throwaway05
6mo ago
I did not.
Throwaway05
6mo ago
You are providing information to your patients.
This information has no value to patients. You cannot use this information to make more informed decisions. You cannot use this information to find cheaper care. Or more expensive care. You can give them false certainty, that's about it.
In situations where the information has value (like prescriptions)....we give this information to patients and there are a number of robust tools to facilitate this, even apps.
You are asking for something that has no value and has costs. Stop doing that. This is why healthcare is expensive. If you want to improve something please do! I'll support you. Don't make things more expensive for no reasons for fucks sake.
Throwaway05
6mo ago
Again, the only group that actually gains anything from maximally clear information is insurance companies since it improves their bargaining position. This information has no practical value to consumers and as is self-evident at this point, is confusing and misleading.
So is your goal to improve profits and rent-seeking for insurance?
If your goal is improve consumer choice or spending, or decrease healthcare costs...pick something that does that.
Throwaway05
6mo ago
What value does a posted price of a gallbladder removal provide for a patient if:
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That number is incorrect the majority of the time due to clinical circumstances.
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That price is not what anybody involved (either the insurance or the patient) actually pays.
Remember, if they make decisions off of this information they may spend more money.
The cheaper sticker price can be more expensive by hundreds of thousands of dollars.
At this point I think you make a compelling argument for why this information should not be delivered to patients. I'm sure many people would understand the problem here, but you post here and are therefore presumably reasonably intelligent and educated and you don't seem to get it.
What you are asking for is anti-information, in the sense that is intrinsically inaccurate, unhelpful, unrelated, and may lead people to make the wrong decision.
If you want to know how much something costs a patient, ask the person who is actually paying for it...the insurance. Why are we involved when it's the insurance who decides what things costs and how much to pay. You want patients not to be surprised by uncovered stuff? Ask the person who decides what is covered.
We are not in charge of this for gods sake.
Throwaway05
6mo ago
This is utterly false and is completely unsupportable. You couldn't imagine saying such a thing for any other industry, because it's nonsensical.
Costs matter for some things, you gave a good example which is drugs. We will set people up with GoodRx, use generics, inform people of choices they can make amongst similar options and so on.
That is not what you are talking about though, you are suggesting that hospital services provide information on some combination of cost/price/charges.....but those things don't matter to patients.
What your insurance does with that service at that hospital is not something the hospital is in charge of and therefore completely untethers this information from decision making.
The more expensive option is very often cheaper for the patient.
You couldn't imagine saying such a thing for any other industry, because it's nonsensical.
Medicine is not like other industries. I don't know how many times I can tell you this. We are often legally prohibited from considering cost or making less expensive choices. Your intuitions are wrong and do not apply.
If you would like to make medicine like other fields then propose that. It may even be a better state, but most people have decided that the drawbacks are unacceptable.
Medical care in the U.S. does not function as a market. If you assume it will function as a market you will be wrong about your conclusions.
If you would like it to function as a market....don't push it further away from a market by adding on more regulatory burden and unnecessary complexity.
Throwaway05
6mo 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.
I have explained repeatedly that explaining prices is misleading and confusing for that reason it adds no value. It also has costs because these things are confusing and constantly shifting. You want to make healthcare more expensive and confusing.....for why? Idle curiosity?
The benefits and risks of a procedure are clinical thing, the costs are not part of informed consent, because the costs are unknowable, because even if we knew with 100% surety what our costs are, we don't know what the insurance company is going to do. That is fundamental.
Great so you admit that you think that increased price transparency will have financial benefits - that's a good bet in a market system. Healthcare is not a market. It does not function like a market. Supply and demand curves are totally fucked. Regulations impair things.
If two hospitals post a price for a gallbladder removal and one is 5,000 dollars, and the other is 2,500 dollars, and the patient goes to the latter they could end up with a bill for 300,000 dollars when the more expensive surgery would have been free. Increased price awareness does not help patients make decisions.
If it does anything at all except add administrative burden then it results in a financial transfer from hospitals to insurance companies, which is not ideal.
Throwaway05
6mo ago
They're literally shooting your people on the streets of New York City.
No they are shooting people who work for insurance. The people who are the problem. Hospitals, patients, and physicians all get screwed by insurance.
Informed consent has nothing to do with price, because the price doesn't matter. We discuss the risks and benefits of a given medical treatment. The cost is between you and your insurance and/or the government. This is to some extent by law (for instance emergency care).
I also can't promise you a price or cost or charge before hand. That remains unchanged. I can get you rough estimates maybe, depending on the thing. That's not the same.
You have yet to explain how providing more detail on cost, price, or charges adds any value to the system.
Throwaway05
6mo ago
The government said "publish price transparency" and a third of hospitals just said "no." The remaining 2/3s published random nonsense. And there were penalties for this!
Because the price doesn't matter.
It's pure cost disease. Zero value.
Everyone has one or more ideas like this that don't do anything useful at all and increase costs and complexity.
And then they get mad when shit is expensive or the doctor can't spend time with you and explain things but they have tons of nonsensical administrative work.
If you are going to make things more expensive do it in a way that provides some value, but better yet don't make things more expensive for no reason especially if you are going to complain about costs.
This is (and you are proposing additional) regulation that adds nothing of value and increases the administrative burden that is already a third of healthcare spending.
Throwaway05
6mo ago
Throwaway05
6mo ago
The funny thing is, if this sort of law actually got passed, I'm pretty confident you'd figure it out pretty quick.
Actually no. A rule very much like this was passed a few years ago. Guess what happened? The information was inaccurate in the places that attempted to follow it and many hospitals chose to just be out of compliance and ignore it.
Throwaway05
6mo ago
So you want to increase the shortages in healthcare by requiring every service to involve a 15-30 minute lecture in billing paradigms and want every physician to receive additional training in multiple other people's jobs so that they can talk about this in a maximally fluent fashion?
This is why healthcare is so expensive "great, tell me how much it costs or I get charged or whatever" starts off reasonable but turns into thousands of hours of unpaid administrative labor a year and hundreds of salaried employees who are required to manage what is ultimately unnecessary and adds minimal value while creating a tremendous amount of expense.
Nobody needs to be on a receiving end of a lecture that explains that their insurance is paying 110% of the number that medicare randomly decided is an appropriate amount to pay for their diagnosis and that that number has absolutely nothing to do with the actual amount of money that the hospital is paying to provide that service or is charging the insurance company for it or would ask the patient to pay if they were financially on the hook.
The solution to government regulation and insurance making healthcare expenditures stupidly complicated to understand is not to subject everyone to a lecture about it, and it's certainly not to increase the cost of healthcare by adding unnecessary complexity that adds zero value.
Since these numbers are all made up and mostly unrelated to each other and de-tethered from reality and changing on a frequent basis, would you just accept us creating a new category of pricing which is "whenever a patient asks how much we give this answer" and then we can just call it a million dollars and call it a day?
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? You'd have to hire an extra department which works 24/7 365 and has a multiple staff in the hospital at all times or hospitals would have to just eat the fine.
Throwaway05
6mo ago
The charge we submit to the insurance and the negotiated rate with the insurance are generally but not always completely made up numbers.
Sometimes the insurance neglects to the pay the negotiated rate. Sometimes that changes with phone calls and appears. Sometimes it doesn't.
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. If you have a cardiac event mid procedure and end up on ECMO the cost is suddenly 5 million dollars.
What number do you tell the patient? We've been arguing about this for literally days and you still don't seem to get it - am I supposed to go through all of this with a patient in my 15 minute appointment? Is the average person going to follow this? What if they are medically unwell?
You have to be exhaustingly specific about much of this. Yes I know what a prior authorization is. You can't always do them. 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. Etc. Etc.
Throwaway05
6mo ago
You refuse to answer the question.
But the question is the point. When patients ask "what does this cost" they usually mean "what does it cost me."
We don't know. Because who the fuck knows what your insurance company is going to do. Usually we ask in advance and the answer is supposed to be nothing but insurance companies do whatever they want and we don't lie to accidentally lie to you.
Price is not cost and you need to commit to what you are talking about.
If the question is "what does this thing truly cost the hospital" the answer is "it is not your business" and "we don't truly know." Patients are not entitled to what has the potential to be business critical information. Nor is it simple to explain how much things cost. What if the case goes late because the patient is obese and requires thousands of dollars in overtime? Does that count as part of the cost? Do the administrative staff count as part of the cost? Potentially hundreds of individual people are involved in a surgery in some way or another. Do we count these? I can check my professional fees and the supply etc cost easily but I don't necessarily know how the hospital business team handles the rest of this.
Hospitals have entire departments whose job it is to figure this stuff out and deal with insurance. We also bundle things frequently to simplify this, but if you are asking for the true financial cost to the hospital you have to unbundle!
I have asked repeatedly, why is this the physicians job and why do you need to know specifically the cost?
Throwaway05
6mo ago
I mean patients ask sometime. We answer. Depending on the thing I can give hard numbers and explain that would be misleading, depending on the thing I cannot.
Ultimately it doesn't matter. 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.
You have to yet to explain what the relevance and importance of this number is, despite me repeatedly asking.
Throwaway05
6mo ago
What information do you deliver to the patient. The maximum? The median? The average?
These are all wildly different, would potentially impact patient decisions, and do not matter because the patient isn't paying it.
What, if anything, a patient gets stuck paying after insurance has nothing to do with the cost or the charge.
Throwaway05
6mo ago
Yes.
Expected payout does not equal pay out.
In car repair your estimate may be off by a few hundred to a few thousand dollars. Maybe more than a few thousand dollars at maximum.
In healthcare your estimate can be off by hundreds of thousands of dollars or more.
This impacts the wisdom of giving estimates and the validity of the practical validity of those estimates.
And AGAIN you have yet to establish why cost matters. As previously stated repeatedly healthcare workers are often prohibited by law from making decisions based off of cost and often by necessary convention when not prohibited by law. Patients almost never pay cost and are rarely charged it. Why does it matter?
Engage with the substantive and relevant portions of the discussion.
Throwaway05
6mo ago
If you think you "got me" in some way you will need to clarify.
Yes. Please see above. Thank you.
Throwaway05
6mo ago
You have made this accusation multiple times, I have consistently maintained that it is fundamentally unknowable (because it is) if you loosen your definitions of knowable you can know some things about it. Additionally, it ultimately is not relevant and not our job, but we do know some things about it anyway.
If you think you "got me" in some way you will need to clarify.
This tack is not helpful, unlike last time I've tried to give examples of things you don't know and would need to know in order to understand the complexity at hand, but you need to actually engage with them. Every example I've given you about how healthcare is not like a car repair shop has been ignored.
Throwaway05
6mo ago
Dawg I have no idea what you are saying, I've been consistent in my messaging with you which is that this stuff is hard and complicated.
You don't seem to want to engage with any of the most important details here which include things like "medicine is not like other fields, maybe it could be but it is not allowed to be - and we have evidence of this!" and "the specific cost is not relevant in any practical sense."
Throwaway05
6mo ago
Yes sorry, I though you were focusing on the doctor side of things which is what the rest of this mess is on about.
If you want to laser focus on that we still have problems, even as an insurance critically person I admit it's fair for them to go "okay I'll pay for it but you have to justify it correctly" because that prevents various bad actors in healthcare provision (including doctors) from doing sketchy stuff.
It's pretty fair for them to ask us to put into our note our medical decision making and only pay if it is justified.
But then they play games with what is required to justify it.
Mandate legally binding answers and you get "yes we will pay for this service if it is documented correctly." That is necessary but has chasm wide potential for abuse (and is generally what they do now).
Even if you were to hand wave away those problems that doesn't address after hours approval, delays in approval, surprise billing concerns and so on.
Throwaway05
6mo ago
Let's go back to basics. We can estimate the price of a given surgery prior to providing it but that estimate is misleading due to the frequency with which it is wrong, often to the degree of orders of magnitude. You might say "yes you can give me an average that's an estimate" another person might say "an estimate is only meaningful if it is reasonably correct."
In my experience people get pissed if they ask how much it is going to cost to renovate their kitchen and they get a bill for 3 million dollars instead of the initially stated 30,000.
So
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Estimates cannot be provided in the same way they can be in most other industries due to an intrinsic excess in variability secondary to the complications involved in human health.
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Giving estimates reduces bargaining power with insurance companies and is therefore disincentivized.
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Estimates have no value to patients because your insurance is going to be paying not you.
Please pick one or more of these you disagree with and explain why.
Throwaway05
6mo ago
So the way this works is that for things that are planned (like a routine surgery or an office visit) you will give your insurance card to the team that works with that physician and they will figure out if the planned services are covered. If they are? Great. Easy.
Immediately this runs into some problems.
What if you go to the office and the doctor wants to perform an unplanned mild procedure? Do you want to come back a week later after insurance has been worked out or just get it done? I have literally seen patients been given this option and then forget about it when the bill comes.
What if you didn't plan going to the doctor? Your anesthesiologist for your emergency surgery may not be in network, but this is not planned you get what is available. The insurance should be forced to pay for this, but they are lobbying to not.
Healthcare delivery is a 24 hour problem. Insurances are not generally open 24 hours. This limits the ability to contact the insurance and ask if something is covered. Plenty of practice environments are open outside of insurance hours even for routine things. Sometimes patients spend extra days in a hospital waiting for insurance to approve the next phase of care.
Now you might say "well listen, just tell me if this DOCTOR is covered." Some places will have a website that will tell you if a doctor is in network or not. Sounds great right?
Well no, just because a doctor is in principle in network doesn't mean they actually cover anything that doctor does. They might be in network for emergency care, but not routine care, or reimburse less than cost for a given procedure so performing it is not financially sustainable. It's not uncommon for certain types of procedures to just not be done in non-emergency settings because insurances won't pay more than it costs to do the thing.
Lastly even if you get something done that is covered, with a doctor that is covered, and you checked in advance with your insurance to make sure that it was covered...sometimes they just won't cover it anyway. They have all kinds of random excuses and often this can be addressed by some combination of patient and physician appeals, but:
We don't know if something is covered by insurance because 5% of the time they decide not to cover what they said they said they would.
*I don't know the true number here it is probably wildly variable on region, insurance, and specialty. United being notoriously bad about this.
I'm willing to infuriate my colleagues by supporting insurance companies at times. For instance insurance companies increase documentation burden on us to make sure we don't over bill. It's annoying trying to keep track of the constant web of changing requirements here...but they do it because there are unethical doctors who would take advantage and up code everything. Every year medicare finds someone who does this and comes down on them.
However a lot of what happens is comically unethical, with united being one of the worst.
Dr. Glaucomflecken, (the one good medfluencer) has a story of how he died at home (cardiac arrest), and had to spend nearly a year after his resuscitation trying to get United to pay for the hospital stay because he didn't take the right ambulance. While he was dead with his wife manually pumping his heart.
Another common thing that happens is that insurance companies will randomly deny things. If I bother to schedule an appeal they will usaully decide to cover, but they know we are busy so if they randomly deny a good number of things will be dropped. Especially cheap drugs - sometimes it's easier to send the patient to Walmart and cash pay than fight the insurance company. I have a limited amount of time. They abuse this. When they do decide to fight your "peer to peer" review is generally with someone in another specialty who retired 40 years ago and has no idea what the actual standard of care is.
They effectively practice medicine by controlling the purse strings but are able to avoid the scrutiny that should come with that by claiming they are not in charge.
If you go on meddit you'll see weekly threads complaining with horrifying examples. Not all of it seems to make sense, for instance they'll refuse to cover rehab stay for a patient and suggest they stay in the hospital instead, hoping that the person will improve enough to be sent home instead. This is a risky gamble that I'm sure works actuarially, but the human cost is somebody's grandma getting a hospital acquired infection and dying and because the rehab stay wasn't covered in time and she wasn't safe to go home with a broken hip.
You'll see asinine stuff like "get an x-ray" "we already have a CT that shows the finding, and is more reliable" "my algorithm says you need an X-ray" "so you want to expose the patient to more radiation for now reason" "it says I have to."
"You said the patient is sick, according to my documentation you need to edit the note to say the patient is ill" (in this example replace sick/ill with specific interchangeable technical terms).
Another classic is that their exists a number of inhaler products for disease like asthma. They are all mostly equivalent and very expensive. Each year, or quarter, the insurance changes what they cover (some have speculated kickbacks are involved). They don't make this obvious. So suddenly the patient goes for a refill and has a massive bill and then we have to spend a bunch of time switching agents and hopefully getting good clinical effect...
Now everybody does this stuff but somehow United is appreciably worse.
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