Throwaway05
1mo ago
Some important things to note here:
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The majority of the average patient's interaction with healthcare are the type of thing where this has some element of technical feasibility. You are likely thinking "okay what's the cash price for a relatively constrained activity like an allergy shot, elective MRI, even a basic procedure like a colonoscopy" the whole system (I'll come back to this) has some possibility of delivering this to you. However the system is designed around the more important and more complicated activities like a hospital stay. If you show up the ED with diverticulitis you could be seen in the ED and sent home with conservative management. You could be put in obs for a day and started on Zosyn and fluids and kept NPO, you could have a perf leading to surgical management, necrosis, and a 3 month hospital stay. Nobody knows any of the numbers associated with this visit until it's done. It's extremely hard to legislate for one but not capture the other, so it's easy to end up with meaningless bullshit numbers if you put a law down. In a healthy system the people involved will try and give you numbers when it's possible. Your doctor will usually be able to estimate what the professional fee for his visit with you will be, but:
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Physicians aren't in control of this. Usually when this comes up people demand the burden be on the doctor. I have other shit to do....like clinical work? Keeping up with the changes in billing is a full-time job for sometimes something like hundreds of staff. Elsewhere in this thread we have someone who used to work in insurance passing around misinformation - it's hard to keep track of this stuff and estimates are usually considered binding if not legally then in someone's mind. We can't feasible deliver this. Often the billing department can't deliver this until after we do our job because they aren't clinical. You'd need to have a meeting with your insurance, the billing department, and the physician in advance to have something with any accuracy for anything remotely complicated (and again we can get in a spitball distance but people get pissed at healthcare if you are wrong at all it'd be worse than not trying). On a more micro level it's worth keeping in mind that working for a health system these days usually involves surrendering lots of control, including often over billing. I can't control the billing department and what they put down, but:
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Health systems aren't in control of this. Most importantly we can't control insurance. Insurance decides how much you get stuck with. Usually we get a feel for what common plans and what common charges will end up resulting in but an insurance company can essentially decide to randomly say "no I'm not paying for that" which may or may not get addressed. While I've been rightly smacked on the nose for forgetting about coinsurance and other things like that, ultimately the person who decides what to do with the bill is not me or my hospital and I have no control over them and they are famously awful.
Throwaway05
1mo ago
My only nitpick would be that I don't see it as a "vulnerability". I just see it as a constitutive part of being human.
I mean the more objective style we generally see here is extremely valuable most of the time and is usually "better," but it's important to remember that the average person doesn't really think or act like us and that has implications for explanatory power of most of our thinking.
Throwaway05
1mo ago
You know it's funny what makes connections in your brain and gives you the eureka moment.
Here I am taking my morning shit, reading this, and my instant response to the conversation here is:
"Oh yeah of course people don't care if this one is 'the story' it just captures the emotions just right, exactly like BLM..."
Oh.
OHHHHHHHHHHH.
Obviously I know intellectually that BLM is an emotional movement about frustration in response to perceived injustice. But I've never really felt it. Until now.
Good reminder that most of us are reasonably good at being objective and decoupling, but those things have vulnerabilities and have chasm sized holes with respect to predicting populations and people.
Throwaway05
1mo ago
Physical books or kindle + libgen. I find reading on the phone to be terrible, and really, kindle isn't great either.
Some of this is different strokes for different folks - I would never in a million years ago back to a separate music player.
I will say that I have a kindle and used it over my phone for a long time until I got an oversized phone and then suddenly reading on the phone didn't bother me.
Throwaway05
1mo ago
I'd really rather stay focused, because you made a very specific claim, and whether or not healthcare "functions as a market" is not even relevant to it.
My claim was that the price, charge, and cost are all highly different from each other, often have minimal relationship to each other, have little value to the patient, and are highly misleading and hard to understand.
You noted "but I don't see how this is any different from any other industry that faces uncertainty (which is all of them)."
Well yes healthcare is different. That's important. It's inherently obvious in many ways. One of those is that "price, charge, and cost are all highly different..." the other is the problem with the supply and demand curves, the level of governmental intervention...... I provided several examples.
Furthermore -
Two posters in this thread neatly outlined the problem with what you are talking about.
If you charge people for what they use and only what they use and try and give them an answer in advance they get pissed when their hot dog costs 1 million dollars instead of 5.
If you add up the total costs of the ED and do some math to throw out the people who won't or can't pay and then charge people something that more resembles the true cost of the service on a per capita basis they then come on the motte and complain that they sat in a busy ED for 6 hours and got an ultrasound and it costs them how many thousands of dollars? (Sorry dev, but it's a good example).
Ugh we are back to healthcare doesn't function like anything else.
Few if any other lines of business are required by law to provide services to someone who walks in and says they will refuse to pay. Add on the fact that sometimes but not always you can get it covered by the government and the accounting is ferociously hard.
Obviously you can generate numbers like total revenue but turning that into useful information at the patient level is an ethical and political problem long before it becomes a practical one.
Throwaway05
1mo ago
It's worth noting that specific market segments in the U.S. can and do do things like this but while that stuff can be a large fraction of the profit it isn't a large percentage of the overall activity.
A large part of the problem is that insurance companies will deliberately provide poor service because their clients are usually unrelated institutions and not the individual patient or anyone on the healthcare side (remember we mostly get our insurance from our employer).
When they do fuckery like the examples I'll provide below nobody has any recourse unless they randomly manage to fuck up the CEO's healthcare or something.
Right now one of the world's most prestigious health systems (Johns Hopkins) is threatening to punt United from their health system. One of the two will blink but the service insurance provides to everybody is awful as hell.
A few classic examples: -My patient has been stable on an inhaler for 20 years. They get new insurance company which is one of the ones that has some kinda of complicated kickback program where they rotate the covered inhaler every year. My patient might die if they change inhalers and switch to one that doesn't work for them, so I can spend 5-10 hours on the phone fighting insurance or just cross my fingers and switch. FUCK THIS.
-Patient is sitting in the hospital and needs rehab placement after discharge. The insurance company refuses to approve rehab. The patient sits in the hospital getting hospital level care for an extra 3-5 days before going to rehab. The insurance company pays for that care. Why did they do this? WE DON'T KNOW.
-Psych patient in the ED, clearly needs involuntary care. Insurance refuses to approve, likely hoping that the patient calms down enough to be sent home with suboptimal care or the ED gets frustrated enough to roll the dice on sending the guy home and hope he doesnt kill anybody. THIS WORKS DAMNIT.
Also the "Hawaii" example: You provide a service, you are the only one on your island who does it. Insurance offers you a deal that's barely over cost for your services. You say no. The insurance company spends the next five years flying patients to one of the other islands for their care until you break or go out of business.
The more charitable explanation for what is going on is that when the private insurance is functionally the whole system (Medicare/Medicaid aside) it has to work for all parts of the system not just the ones where you can make things simple and offer a boutique product like your UK elective stuff.
Throwaway05
1mo ago
How old are you?
My life before smart phones was so different. I love that I can pull out and read any book I want, I love that I don't need a separate device for music, I love that I can research anything anytime instead of writing it down and searching through my encyclopedia at home.
Have you ever tried a long road trip with a physical map?
Yeah they ruin a lot of stuff and may not be worth it but don't forget what they've added.
Throwaway05
1mo ago
I don't think you are wrong, and at the same time if you look at the NFL the majority of the coaches are quite obviously awful.
Is giving advice just that hard?
Throwaway05
1mo ago
Uhhhhhh what? You know animal and human medicine are different right?
The difficulty in the ED is rolling out training to everyone because the modality wasn't as common when most people went through Medical School and Residency.
Throwaway05
1mo ago
This is probably the best summary I've ever seen on this topic. Thank you.
Throwaway05
1mo ago
Usually (and especially here) my angst is generated by people's frustration with physician salaries, as it's an easy target for frustration but is A (but not the) load bearing feature of the U.S. health system and angry people don't care.
Throwaway05
1mo ago
I can tell you that in my personal practice I try and be cost aware when possible but that a number of practical concerns come first. For one my job is to get people better, not spare their wallet, the threat of litigation makes it extremely hard to deviate from that even when both the patient and myself want to.
In some situations it appropriate (or required, most often with homeless people) to be more careful about this but I can't always do so. A classic example is inhalers, insurance change what they cover all the time, if I don't know your specific insurance plan well....it's just going to be wrong some of the time, even if I do know the insurance. Hospitals have invested in tools like e-prescribing which help with this.....but all kinds of negative effects of those things have also been generated.
One of those is that I am highly limited in what I can do. The hospital owns most physicians right now because of increased costs like EMRs we do what they say. Some times that involves practicing on our license essentially. It also frequently means things like me signing away my right to bill the hospital just does it for me based off of what I charted.
When it comes to inpatient medicine ultimately I'm going to be like "I'm sorry you are going to get a fuck off huge bill and I have no control over it and depending on your insurance that may or may not be a problem." I am also incentivized to not think about it too much to avoid burn out.
For outpatient medicine usually it's a stripped down professional fee that I have no influence over and a medication bill that I can try and save you money on.
I don't really know what percent of patients have co-insurance, and as you demonstrated and like I said I don't think about co-insurance at all most of the time. This is because legally and practically it has nothing to do with me, that's what the regulatory and legal environment have decided.
Usually when this kind of thing comes up it's "put the doctors on it" but the hospital and insurance company are in charge!
Throwaway05
1mo ago
You know, the American edge of this kinda stuff runs into a few issues. One is our legitimate exceptionalism, we are the superpower, we don't usually need to make compromises. That's not a completely terrible approach and for long enough that most of the people alive in the country have only experienced that....it worked.
It limits our facility with actually going through this process however.
Part of it is that people know that something can be shaved off without impairing patient care. This is probably right but nobody knows (or agrees) what it is.
Then you have American specific attributes - we are pussies when it comes to pain for instance, we are more willing to seek and use care, we are too independent, and so on.
Low societal temperament to say "yeah let some mee-maws go down if it saves a few hundred million dollars."
But yes you are right that this conversation is happening just less transparently, and at the same time if you came over here I think you'd be shocked at how much we through at things.
Is it good that we'll code a clearly dead kid for 90 minutes? Is it good that we will give homeless crack cocaine Fred the standard of care 12 times a month when he presents with psychiatric issues caused by his recreational polypharmacy?
I don't know.
I am however at times horrified and at times proud.
Throwaway05
1mo ago
I try and keep in mind that (in the U.S. for sure) the PUBLIC HEALTH apparatus absolutely did some shady business and doctors were complicit. This killed a ton of trust.
MRNA vaccines had legit concerns when they were being forced on everyone and I knew plenty of docs (including liberals) who had concerns initially for politics came into it.
Vaccines have always been a tough topic as far back as the Salk/Sabin days lol.
Throwaway05
1mo ago
you will cause new cancers once you scale to hundreds of thousands of people.
Ugh this is one of the biggest issues with large scale medical interventions like vaccines. Yes your vaccine can be perfectly safe for plenty of sigma but if you give it billions of people some weird shit is going to happen!!!!
Throwaway05
1mo ago
Laziness or ineptitude is certainly a cause at times but "I don't want to lose my livelihood" is a potent motivator.
ED pan-scanning is functionally "standard of care" because using your training effectively is going to result in a few miss or near misses at some point and it is much safer to hide behind the donut of truth.
When laziness and safety line up it's really hard to alter behavior.
However there is something to be said for "we are the richest country why can't we have the most expensive care and avoid making certain kinds of mistakes."
I don't think people realize the trade offs we are making and it's certainly worth a discussion but we rarely do that.
Throwaway05
1mo ago
"Good surgeons know how to operate, better ones when to operate, and the best when not to operate."
Alternatively one of the rules of The House of God - "The delivery of good medical care is to do as much nothing as possible."
Both are far harder than they sound.
Throwaway05
1mo ago
Are we talking high co-insurance costs here? I've never been on or been offered a health plan with a significant co-insurance burden although I'm aware they could hypothetically exist.
Interestingly, google-gpt says about 20% of plans have co-insurance.
So they certainly exist but aren't common.
If you are paying co-insurance charges would matter more but that dovetails into the rest of the discussion on this topic.
Outside of co-insurance - am I brain farting on anything other than: premium, deductible, co-insurance, co-pay? I guess uncovered nonsense.*
*Out of network costs are a separate problem that I forgot to mention in the other line of questioning (which is why my point is that shit is stupidly complicated!). Health systems don't really control who is and is not in network, it's usually a insurance fucking the consumer and hospital mechanism since canceling a scheduled surgery because Phil is the only anesthesia provider networked and he's off today or because the thing is emergency. This is one of the reasons why the hospital "know" they usually know what they charge, rarely know what the price is, and have zero ability to control and generally predict what the insurance company will pass along to the patient especially in uncontrolled situations like a hospital stay.
But yes thank you for reminding me of some of the other insurance related expense elements that I don't think about as they aren't in my plan, I dont think this alters the thrust of my argument though which is that the insurance is in charge of how much a patient pays and they have lots of ways to change that number away from the "price" and "charge."
Throwaway05
1mo ago
I didn't mean your specific situation, apologies if it came across that way.
In this case, there is a pre-negotiated master charge list
Those numbers should still have been negotiated with some bullshit juju thought right?
One of the crazy things
Ahh shit, I meant to also blame providers in my post and may not have. Yes it's not uncommon to see someone and have them go "oh I can't handle that" and send you to the ED. A good chunk of that is absolutely to shift liability and is inappropriate but common. Biggest issue is when you say something unrelated to a specialist. Tell your endocrinologist that you checked your blood pressure at home and it was 160 over something and they'll send you to the ED even if that isn't quite appropriate. Another common problem is increasing specialization leading to specialists not knowing as much outside their field and PCPs being limited in what they can do and know (especially with midlevels). Lastly you have legitimately complicated shit, I don't really do peds at all IIRC from med school people are super fucking careful with kids that young. I think an urgent care would probably also sent you to the ED especially if ultrasound was standard of care.
Incidentally peds providers get paid way way way way way less than adult medicine.
If our child was on telemetry
It sounds like you were paying for hospital level of resources and in ye olden days your kid would have been admitted but now instead it can be managed conservatively outpatient - but you need inpatient level equipment (the ultrasound). One of those weird gaps.
Ultrasound is in a weird spot because it's evolving from a "nobody in the ED to can do this" to "we are starting to train everyone from day one to do this because its safe and cheap" but we are in the middle of that process. Wouldn't be shocked if in 5-10 years most PCP offices were doing it.
Throwaway05
1mo ago
Pretty normal to essentially charge for "doctor - seeing you, thinking about you, and documenting you" and "things doctor did to you."
However in this case you could alternatively summarize it as "random blender of shit put together in an attempt to get the insurance company to pay enough for the hospital to stay afloat."
Throwaway05
1mo ago
Agree with the other poster and - insurance companies practically practice medicine all the time by deciding what is covered and what isn't, they deny this is the case however "you can still get X thing we just won't pay for it" works very well as a legal smoke screen and in the case of things like malignancy they can absolutely drag their heels and turn your melanoma from a short procedure to life altering or death causing.
Throwaway05
1mo ago
Okay so two things going on here:
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The funny numbers bit. The system is designed around everyone having insurance. The numbers on a bill a not random but can essentially be thought of as random. The hospital negotiates with the insurance by saying X and the insurance says 1/4X and then the hospital says 1/2X and that's what the insurance decides to pay. It's stupid but it is the system, the numbers are funny on purpose. If you don't have insurance you get absolutely obliterated but you can usually negotiate with the hospital because they know the numbers are funny, but "you have insurance" and "this weird shit happens" is how society and government have decided to run this bullshit so that's the way it is.
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The ED is for if you are dying, if you are not dying you are not supposed to be there, and it is expensive in the way that you'd expect for "this is the place where you are dying."
Unpacking this is complicated and it results in a mix of things that are the fault of various patients and things that aren't, but for the most part the ED is more expensive, complicated, and a higher level of care than actually being in the hospital. On a hospital floor things happen slowly - you might have a handful of nurses on a step down floor, your doctor might see you once at the beginning of the day. In the ED nurses have few patients, numerous types of staff you might not even think about are running around constantly (like the lady whose only job is to get people's insurance), people are in and out of your room, labs come back stat, people are constantly checking if you are dying or not. Most patients in the ED are on telemetry, most patients admitted to the hospital aren't. All these things are extremely expensive and a lot of them happen outside of patient understanding and line of sight. The ED is more like an ICU. This is part of why patients being boarded in the ED is such a catastrophe.
In any case the ED is designed such the majority of patient's are pre-triaged. You are "supposed" to go to your PCP first, or people to call your PCP's answering service. Most people used to do that while the modern model was being developed but they don't anymore. Many people use the ED as a PCP, go get obvious "wait and see" things checked out, don't use common sense, and so on. Other people can't really be blamed because they have a sensible complaint and don't triage because they aren't medical people, or because it's hard to get a PCP these days or one with a good answering service. But the system isn't designed for this. Add in other things like homeless and illegal immigrants don't or can't pay and you've got a mess.
Part of this is specifically American - in other countries people use PCP as designed more, or are more comfortable with waiting, but that isn't how we are. Step-down EDs or the equivalent have been triaged but they hard because if you fuck it up you'll get sued to hell (another American problem).
Additionally emergency care doesn't reimburse well from private or government insurance so one has an incentive to build out and staff EDs to match the volume they are getting.
The last piece is the professional fee aspect - you are paying for someone with a lot of training to figure out how safely they can do the minimum on you. Ideally we diagnose without any testing, give you the minimum of interventions, and use our brain power to rule everything that could kill you or be going wrong with your body.
Because we are on the hook if anything goes wrong! But we also don't want to give you an expensive full body scan that will give you cancer in thirty years.
NPs have much lower professional fees but they also scan and test people much more and cause more bad outcomes and unnecessary complications.
You pay ED physicians so much for them to safely do nothing, which is weird as hell but is what the ED is designed for.
Throwaway05
1mo ago
I think we need to go back to basics - it seems trivial to me that healthcare doesn't function as a market and doesn't work like other non-governmental activities. I provided a few examples of this in my replies.
If we can't get on the same page about that I'm not sure we'll be able to talk productively.
Throwaway05
1mo ago
Oh yeah I see - yes we are in an area where you run into two problems "this should have a billing code and doesn't" (classic example again - insurance fuckery) and as in this case "even if this had a billing code it would be unwise to use."
If you use "low priority - don't need to see patient" billing code on someone and they have an adverse outcome you are going to get eviscerated on the stand "you could have saved her life if you just went to see her!" and going to straight to bankruptcy.
I don't know what the right solution is to this but I am pro-tort reform.
It's true that I under emphasize coinsurance and deductibles in these conversations but the deductible is going to end up used fully if anything significant happens in most insurance plans and should be considered a sunk cost when evaluating plan choices.
Ultimately using hospital pricing information if it was available would be difficult since the hospital prices interact with your insurance in unpredictable way and a lower sticker price could end up being an order of magnitude higher when comparing after insurance costs.
You are right that I need to be more active at remembering that in some of the individual situations though, even if it doesn't impact the more structural issues.
A simple ED visit can cost <5k, 50 thousand dollars, 1 million dollars, or 5 million dollars.
An estimate for your kitchen getting redone is not like this.
The error bars around those are secondary to the fact that when people want an estimate in their mind that estimate is a commitment and being told a range from 500 dollars to 5 million is worthless information.
Yes plenty of healthcare interactions are simpler than that but if you are going to demand estimates for everything you have to capture this problem, if you are going to demand estimates when feasible we already do that.
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