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.
Throwaway05
1mo ago
Modern U.S. healthcare is probably more adversarial than you think because of the role of insurance companies that will try and refuse expensive things.
This doesn't work well for a million reasons (including Pharma basically paying the insurance company to only accept certain med requests). But supposedly we have these systems in place including with Medicare/Medicaid (sort of).
The problem is that nobody agrees what is an appropriate use of these things and in America that's going to be impossible.
Even if you can get agreement on what kinds of things are worth it........every last person is going to disagree when it's their turn to be told no, especially when it's no....you'll die now.
With respect to fraud it does happen but it's rarer than you think, calling out Medicare fraud is actually incredibly profitable for the whistleblower. Which is neat and stops a lot of bad stuff.
The government has also come under fire in the last few years for faking fraud because they had a quota system.
Throwaway05
1mo ago
For context I have Idiopathic Thrombocytopenia and I think my OB wanted to ask how to titrate Prednisone.
Yeah my suspicion is this is one of those weird situations where the OB legitimately needed help and wanted to make sure the hematologist got paid for their expertise. They may even have done you a solid by not making you go to a random doctor's office unnecessarily since this was OP.
What was supposed to happen was that the doctor was supposed to review your chart (probably did), see you (clearly no), and write a note (maybe?).
Not seeing you and saying they did is fraud but it's also okay sometimes. Does the delirious or sedated patient really need to see the psychiatrist to give an agitation rec? No.
Unfortunately physicians do a lot of unreimbursed work (like providing education to colleagues) and attempts to get some credit for this can be sketchy or fraudulent without actually being bad behavior.
Obviously in your case you may have appreciated the chance to ask the doc questions but most people would be excited if offered "hey let me just call this guy instead of scheduling you an extra appointment somewhere else" but it's technically not allowed.
Sometimes what we can vs cant bill for is stupid as hell (for instance: dealing with insurance!).
Since the hematologist would have accepted legal liability they def wanted to make sure they got paid and because most people's bill turn into a 20 dollar copay it doesn't get looked at closely.
Personally I think this is sketchy but fair, for those who think otherwise consider the side effects of formalizing things and reducing flexibility.
Throwaway05
1mo ago
Insurance is already calculating the relevant numbers, they can just show them to their customers / the public.
I don't think this is accurate. Insurance knows how much it costs to insure someone in aggregate and where to set their premiums.
They do not know how much stuff actually costs a hospital in aggregate (they attempt to guess and knowledge of this is extremely valuable to the insurance company and extremely detrimental to the hospital). They know what the hospital claims the stuff costs them in aggregate. Often the hospital doesn't know how much it really costs because even though they can add up everything they spent money on it is incredibly difficult to breakout what was spent on what because how do you account for things like admin costs. Do you spread them equally over all departments? Do you try and track what department those admin were spent working on (expensive, hard). How do you account for all the salaried people taking on extra work for no additional pay like physician committee work. Hospital employee a lot of people, a lot of types of people, many places will account for things differently than each other.
All of that is the aggregate stuff.
Nobody knows how much many types of individual things are going to cost a specific patient because the error bars are so large. You also have stuff like "this patient is ready for a downgrade to rehab but the insurance company isn't approving the prior auth because it is Labor Day. Does that suck? Yes. Does it need to get paid for by somebody? Yes. Is the insurance going to pay for it? Usually. Is that hard to calculate when giving cost estimates? Yep.
Sometimes the insurance company is increasing the costs for no reason other than their own inefficiency!
In short medical billing is hideously complicated and doesn't work like anything else and that should be trivially obvious because of what healthcare is necessitates that it not function like other economic activity.
Attempts to criticize or change it should necessitate some Chesterton's fence type thinking.
Throwaway05
1mo ago
You do see this kind of behavior sometimes and it can be extremely sketchy/represent illegal behavior or it can be ".....fine" or outright "okay."
Be curious if the hematologist dropped a note on you.
Examples of each:
-A kickback program of some kind. They are rare but they still (theoretically) exist.* Typically in shady for-profit health systems. Hematologist didn't do anything useful and didn't see you.
-An annoying consult or weird consult interaction. OB asks the hematologist something. Maybe it was a stupid question, maybe it wasn't. Maybe they dropped a note on your chart maybe they didn't. Now it gets weird. Do they go see you? They might be doing coverage in another city. Did the OB say they talked to you even though they were supposed to just ask a non patient specific question? Did they actually review your chart?
Probably they reviewed your chart and provided legitimate advice but didn't want to see you because it didn't alter management or was grossly inconvenient. Now they've done something and have legal liability so the hospital will insist they bill and it is somewhat legit. Radiologist and pathologist don't come to see you.
-They did actually see you. This is most common (we inpatient at least). Stop by at 4am and make a token effort to make you up? Oh you are in the bathroom, I'll come back later? These are obviously annoying as hell as a patient but depending on the interaction it may meet standard of care (especially for consultants that may not need to see your or talk to you). I promise you whoever did this is actually doing work somewhere or otherwise engaged in fruitful activity.
Of course it could be total nonsense and someone actually scheduled an appointment accidentally.
*I've worked/trained at some places where I've had concerns but never been approached or had any actual evidence.
Throwaway05
1mo ago
Ask them the most ridiculous thing they couldn't get covered or documentation change they had to make to get coverage.
Should get some good stories.
Throwaway05
1mo ago
The cost-benefit landscape is high-dimensional, fuzzy, and rapidly branching with time-delayed consequences. "Informed" consent is a complete misnomer and I have to wonder if given complete price transparency whether healthcare wouldn't completely devolve into a Market for Lemons.
Psychiatry is a great example of this. Do you prescribe the homeless schizophrenic the best drug or the cheapest one or the one that is easiest to take. These are very often all different medications and have different results.
In a different patient population you might ask the patient to decide what makes sense for them, but the schizophrenic has cognitive deficits from the disease (not counting any other factors like malnutrition and drug use). They can't adequately consent to to complicated cost benefit analysis.
Even highly educated, intelligent, frickin healthcare workers botch this when they are on the receiving end.
So then we have to wonder if the plan is to dictate patients get the cheapest medication not the most effective one....or vice versa.
As you mention it's complicated and ethically difficult.
Throwaway05
1mo ago
One of my attendings in training did an exercise with a patient where the patient was requesting something that was technically appropriate but would cause prior auth difficulties and could be avoided.
It was at the end of the day so he told the patient he would get it approved if the patient sat with us and if the patient left he would be discharged from the practice (deeply unethical but hilarious).
The three of us sat there for something in the 2-3 hour range while the attending argued with insurance, completely unpaid.
It worked.
Was it worth it? No.
Did the insurance win even after they approved the med? Yep.
Throwaway05
1mo ago
I mean I think that happens every time?
"Oh shit that looks bad" here are basic details "oh shit we were wrong."
This one was certainly "worse" (as in looked bad) than most of the others.
I think the dems blew a lot of juice in magnifying Floyd though, and as mentioned all kinds of other pressure cooker stuff was going on.
Throwaway05
1mo ago
Accepting the fixed costs of a quality insurance plan is obviously the best idea.
After that it depends on risk tolerance. A hospital is required to treat you if you show up even if you clearly won't pay you can then deal with medical debt. This is how homeless people function. Obviously not a great idea but you pay nothing (and also get no preventative care).
Speaking of which if you have any medical complexity you need a real plan.
That said if you are otherwise healthy you can try and get a catastrophic plan or other high deductible plan and realize the risks. Again recurring expenses cause problems.
I will draw your attention to direct primary care however which may be viable - you basically pay for a subscription to your PCP. Obviously this has recurring costs but it means you cut out insurance and therefore it can be much cheaper (because dealing with insurance is expensive for your doctor also) and if your PCP is good you won't need much in terms of specialists.
However you need to pay for other types of costs somehow (like hospital care).
Throwaway05
1mo ago
As long as these are reasonably predictable, you can calculate a price. The specific issue you're talking about might mean that the price is higher, not that it's impossible to give an accurate number.
Doing these necessitates a bunch of complicated questions. Do you refund people if they "use" less? Can you charge them more if they "use" more? Is it fair to charge someone 4k instead of 100 dollars because of an alcholic? If we are going to make everyone pay in and pay out according to who uses it why not just simplify it and make it socialized medicine which is the logical solution?
Developing accurate numbers is complicated, time consuming, and expensive and puts hospitals at financial risk due to insurance shenanigans. If you make it voluntary they'll do it where it makes sense like they do now. If you make it mandatory you need to put a number on how much you are willing to increase healthcare costs to do that and answer some of the questions above with respect to what to do about it when it fucks up.
Throwaway05
1mo ago
I wrote up a response a few different ways but ultimately I couldn't write something satisfying without a lot of follow-up questions so I'll just point out that usually the reason why things are weird and complicated is because the insurance company refused to pay for something common sense so the hospital had to do some equally weird shit in response.
Throwaway05
1mo ago
Fuck. That. Noise. So, an army of functionaries use their best judgement to try to translate a doctor's notes into one or more of a series of codes to reconstruct the exact service provided? I
Depending on your perspective it's either far better or worse than you imagine.
The physician's note was historically designed as a record of medical decision making on a patient and we are still primarily trained in this task. However they are now used as a record for billing, a record for legal ass covering, delivered to patients, used for cross staff communication, and as repository of information for research purposes.
As there is the greatest financial interest in doing so you more often see time and effort spent on maximizing billing but it's totally reasonable.
If I see a patient with high blood pressure I'm going to write something like "yo this patient has hypertension get some amlodipine in here stat."
Then the insurance goes oh we aren't going to pay because you didn't establish this patient has hypertension. What do you mean their blood pressure is high and its been high for 20 years and the last doctor had them on amlodipine.
Nope no hypertension.
(Billing staff: psst doc write primary hypertension)
.....Primary hypertension.
OH WHY DIDNT YOU SAY SO HERE HAVE SOME MONEY.
The classic for a long time was the Review of Systems which is sort of deprecated now but had resulted in tens of thousands of doctors being trained that if they didnt ask about renal, dermatologic and reproductive symptoms they couldn't get paid for this trauma patient whose arm fell off.
"The patient was anesthetized!!!!!" "Well just write 'patient declined to answer seven times.'"
It's not charging you for every 15 minutes of time like a lawyer its struggling to get paid for stuff we clearly did.
Yes some fraud and abused exists but essentially every physician has to be constantly thinking "what humps do I jump through to get paid for the basic standard of care thing I did."
Throwaway05
1mo ago
Many don't like this but you can't really function in our system without having insurance and this has been attempted to be enshrined in law.
The reasons for this are many but some things to keep in mind:
-Medical care is one of the most inelastic things arounds. If you need something or you will die that's a pretty good thought experiment for what perfect inelasticity looks like. For things that are less inelastic (primary care appointments say) usually not doing it is the actuarially wrong decision and demand should be more inelastic.
-Patient's aren't the ones paying. Insurance pays. "Randomly" your insurance or the health system or some weird combination of laws and policies screws you. The government tries to close these but it turns out to be really hard to do for a variety of reasons.
-Insane fuck off cost overruns are more common and possible in medicine than in other areas. Compared with say car insurance - the number of cars on the road worth over a million dollars is incredible small. Your chance of crashing into one of those cars and somehow being on the hook is one in a million. Major complications of surgery are 1%-10% depending what we are talking about, certainly orders of magnitude more (yes I know I'm missing some things about car insurance for the sake of simplicity). You can just not drive. Everyone has health and the lack of it - and it can become phenomenally expensive to manage through no fault of your or own or fault of your own. Getting a liver transplant or ECMO is a multi-million dollar endeavor.
Between those three things healthcare does not resemble any other industry. It's probably most similar to national defense in its fundamentally "non-economic" nature and that's why both of those things are usually run by the government.
But We Don't Do That Here.
Also - now insurance companies can use fancy computers and actuarial tables to even things out and stay functional but if you tried to do this directly with health system you may end up with something like: "hey this thing should cost 100 dollars but instead it costs 4000 because that guy over their refuses to stop drinking soda and vodka instead of water." People get pissed by that in the U.S.
Throwaway05
1mo ago
I would advise people to be extremely careful about this because the rules are frequently revised, confusing, or impenetrable to patients.
Yeah you do see issues with straight up fraudulent charges at times (usually you see this in Medicare when someone gets caught and obliterated by a federal prosecutor) but usually it's completely by the book or mild but justified up-coding. Hospitals have entire departments whose job it is to comb through notes and make sure they extract every dollar from insurance.
Does talking to the patient about their relationship count as brief therapy? What if the psychiatrist uses CBT language you aren't familiar with? Does an ear lavage count as a procedure? Does time based billing refer to purely face to face time or does coordination of care, medication ordering, and documentation count? Can you use MDM as part of your E/M instead of or in addition to time based billing? When was the last time the answers to any of these questions changed?
Doctors often go to workshops that teach them how to bill correctly, yes to up-code but also to make sure they don't accidentally commit fraud by putting something in wrong. It's hard.
If you complain you may get some stuff knocked off but it's very possible you are making an accidental fraudulent complaint and they just don't want to fight about it.
Especially if your insurance is paying, help the health system out dawg.
The doctor is unlikely to find out you did complain but if it's an iterated relationship and you keep doing this you will end up with worse service because they'll get told to clean up their documentation and be careful and it will knock them out of their flow state and likely result in petty inconveniences (ex: more likely to rely to mychart with 'schedule an appointment'").
For OP specifically - I'm obviously a homer for the medical care side of things but you should consider that insurance companies are famous for incorrectly denying things that were provided and even things were provided and billed correctly.
Throwaway05
1mo ago
I mean I think the article is accidentally a great example - they didn't actually need to know and numbers, it got covered, no?
They did end up running around sweating because the insurance company decided to be an asshole, which is what they do. Physicians complain about prior auth abuse all the time, and United is one of the worst. Basically they just try and refuse enough and slow things down enough that at times patients and doctors will give up and go with sub optimal management.
Quality price transparency doesn't help in those sort of situations and will likely help insurance company's beat on health systems.
It's also extremely expensive, you'd have to hire a lot more staff, and since people always expect physicians to know these things you'd probably have to cut clinical supply.
You could certainly change the system via regulation but that has its own costs and there are easier targets to reduce patient angst like prior auth reform.
For a more paternalistic and therefore likely less popular take - the system is incredibly complicated and even people who are subject matter experts in it get shit wrong quite a bit. Injecting patients into the mix would just add to the confusion, expense, and angst.
Throwaway05
1mo ago
So uhhh that's me. Intent here is to provide context not inflame drama so mods tell me if you think I should just delete that portion or just the whole comment.
Background - got in a loooooong argument with this guy which to my recollection involved neither of us covering ourselves in glory and involved me feeling my interlocutor was being deliberately obtuse and getting highly annoyed so I doubt the essential thrust of my point comes across well. Also not sure if it's appropriate for me to participate in this discussion since I blocked the guy for what I perceived to be him following me around complaining after the discussion stopped becoming productive.
That said, here's a summary of the argument: "the number is fake anyway, so you don't need to see it," (as you say!).
But yeah healthcare demand is typically excruciatingly inelastic which is a large part of it. Supply is also often inelastic in the short term. Add in all the usual complexities of the U.S. healthcare system and shit is a mess. It doesn't need to be, but it is.
The problem is that the cost to provide the healthcare, the price the hospital wants to charge the insurance company (and therefore you), the price the hospital actually charges the insurance company, the price the insurance company actually pays, and how much you are on the hook for are all totally different, often completely unrelated to each other, and involve information that other parties don't have. Your health system can usually functionally guess how much your insurance will want you to pay for something but it's a guess and insurance companies deviate frequently and quite substantially. If the insurance company knows exactly how much something costs they'll low ball the hospital and the hospital will go out of business (we have a huge issue with hospitals going out of business right now).
Even if the hospital knew with perfect information how much the average procedure "costs" the hospital, and could predict how much the procedure will "cost" you (they can't) it still has no relationship to how much the patient actually pays because their insurance company decides that and they do whatever the hell they want.
You can choose to socialize things and make everyone pay an average for a given thing but Americans typically don't like that so it usually only happens with "safe" stuff.
Smuggled into here is the expectation that the doctor specifically and the healthcare system in general provide information about what another actor (the insurance company) will do. Hospitals already spend a ton of time and salary costs on trying not to lose a war with insurance. Adding more expectations to this will not help anyone and have a low degree of accuracy because fundamentally insurance companies will do the shit they usually do like randomly change which inhaler they'll cover with no warning.
Physicians themselves having awareness of some of the specific numbers is possible in an environment like one guy only doing total knees with a few major insurance companies but that doesn't usually happen. Asking us to know quickly balloons into a time consuming, pointless, inaccurate mess. We'll usually try and keep track of some things that can be leveraged into value for a patient (like which beta blocker is cheapest for your insurance) but this has the risk of becoming rapidly inaccurate and is questionable when you are considering giving someone something less effective to save them money. Is the patient equipped to truly understand the tradeoff? Do you have time to consent and document this in a way that doesn't create risk of later lawsuit?
Messy.
As a practical matter I assume most people want this so they can say spend less money on their colonoscopy, but again their is a lot of inaccuracy and false sense of security that can be driven by this.
Let's say you try three GIs and you get a quote of 5k, 10k, 15k being charged to your insurance or you. The 15k guy says he knows your insurance and they are in network and will for sure only charge you a 20 dollar copay.
What are some possible outcomes?
Maybe you take up 15k guy, go in for your procedure and he has to do a stat case and he offers his partner. You are exhausted from the bowel prep and don't want to spend another day shitting yourself so you say sure. Wait this guy isn't in network! Full bill. If you are lucky they'll notice this in advance and tell you but you might not notice because at this point you are sick, but realistically some random intraop nurse saying "hey do you want this done today or nah" isn't going to catch that problem.
Maybe you want to self-insure and pay the 5k guy. It's a colonscopy the pricing std is going to be pretty favorable. Okay but you have a cardiac event during the procedure and are now on the hook for millions of dollars (wouldn't quite work this way but I'm trying to keep the examples constrained). Maybe your insurance covers 5k guy and you go with that but it doesn't cover the replacement anesthesia because they aren't in network or the cost of your adverse event.
Ultimately the problem is that it's hard to give numbers in general, it's harder to make them accurate, nothing the hospital can do can guarantee the numbers are accurate, they are therefore not very useful in the vast majority of situations and also have a very real cost to deliver to a patient (in the form of literal costs in staffing to generate the numbers and in negotiating costs with other actors).
Throwaway05
1mo ago
I know this isn't popular but I quite disagree, I think Floyd was exactly as bad a martyr as everyone else, he just stuck a lot better because of the circumstances and that makes it harder for people to have awareness of that.
Throwaway05
1mo ago
I mean it seems to be clearly multifactorial and a perfect storm situation - lock everyone up with a lot of fear and guilt, have this roiling social justice/woke thing that's been fermenting increasingly unquietly for years, and have a lot of money and power and propaganda trying to aim itself at Trump and anything that seems Trump related. Boom.
A number of non-conspiracy conspiracy theories over the years have commented on this like foreign funding trying to divide America and Democrat aligned sources trying to create division to make Trump bad.
Throwaway05
1mo ago
Thank you for sharing.
The subset of these types of people who end up requiring medical attention is of course not representative of the true population but I've Noticed Some Things that are of course not captured in the literature even when they are hinted at so it is useful to collect more N.
Throwaway05
1mo ago
I can only speak to the first season as I mentioned, but it's one of the best seasons of television of the last ten years. Full stop.
Now admittedly it's not to everyone's taste, it's a slow and deliberate Cold War spy thriller living in the most Star Wars feeling Star Wars since the original trilogy.
If you are the kind of person who liked Better Call Saul as much or more than Breaking Bad you are 100% going to love it, but I don't fault people for needing a faster pace etc.
Put another way it reminds me of Winter Soldier which duct taped an excellent non Marvel script to Marvel IP and kept the advantages of both.
It does have some woke elements but they are chiefly background casting stuff that isn't too annoying when it's drowned in quality. It is also explicitly anti-fascist and anti-authoritarian but not in the childish modern politics way so it shouldn't chafe too much.
It's much less Wolfenstein haha kill the nazis and much more Das Leben der Anderen this is the reality of these systems. Sure the woke end up liking it but that's by accident.
Throwaway05
1mo ago
I still haven't seen the last one, and should be surprised if I ever do.
I feel so seen haha. I also refused to watch the last one. Can't even remember its name if I'm being honest. Total fundamental drop off of interest.
You know I also thought Rogue One scratched the itch - interesting. Lots of the more traditional non-woke critics hated it.
Andor was actively incredible though (although I have yet to see the second season, just timing issues).
Throwaway05
1mo ago
Why have I never seen this word before this week, and yet like eighteen references in the last few days, each of which is presented in such a way as to help normalize it? Is this a psyop?
It's popping up because it is slang and then it got picked up in the tech-sphere (which is highly adjacent to here) as the term of choice for the behavior of LLMs being overly supportive in chats.
It's all over the place right now because of people complaining about LLMs and then a bunch people picking up and using a youth term because "neat new" and "how do you do fellow kids."
Throwaway05
1mo ago
The thing to remember here is that the show was conceptualized much closer to the Floyd/BLM time period.
Yeah I've always heard the writing was done quite proximal to Floyd events so it has zero moderation or sense.
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.
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