site banner
PaperclipPerfector  6hr ago (text post)   738 thread views

Culture War Roundup for the week of August 25, 2025

This weekly roundup thread is intended for all culture war posts. 'Culture war' is vaguely defined, but it basically means controversial issues that fall along set tribal lines. Arguments over culture war issues generate a lot of heat and little light, and few deeply entrenched people ever change their minds. This thread is for voicing opinions and analyzing the state of the discussion while trying to optimize for light over heat.

Optimistically, we think that engaging with people you disagree with is worth your time, and so is being nice! Pessimistically, there are many dynamics that can lead discussions on Culture War topics to become unproductive. There's a human tendency to divide along tribal lines, praising your ingroup and vilifying your outgroup - and if you think you find it easy to criticize your ingroup, then it may be that your outgroup is not who you think it is. Extremists with opposing positions can feed off each other, highlighting each other's worst points to justify their own angry rhetoric, which becomes in turn a new example of bad behavior for the other side to highlight.

We would like to avoid these negative dynamics. Accordingly, we ask that you do not use this thread for waging the Culture War. Examples of waging the Culture War:

  • Shaming.

  • Attempting to 'build consensus' or enforce ideological conformity.

  • Making sweeping generalizations to vilify a group you dislike.

  • Recruiting for a cause.

  • Posting links that could be summarized as 'Boo outgroup!' Basically, if your content is 'Can you believe what Those People did this week?' then you should either refrain from posting, or do some very patient work to contextualize and/or steel-man the relevant viewpoint.

In general, you should argue to understand, not to win. This thread is not territory to be claimed by one group or another; indeed, the aim is to have many different viewpoints represented here. Thus, we also ask that you follow some guidelines:

  • Speak plainly. Avoid sarcasm and mockery. When disagreeing with someone, state your objections explicitly.

  • Be as precise and charitable as you can. Don't paraphrase unflatteringly.

  • Don't imply that someone said something they did not say, even if you think it follows from what they said.

  • Write like everyone is reading and you want them to be included in the discussion.

On an ad hoc basis, the mods will try to compile a list of the best posts/comments from the previous week, posted in Quality Contribution threads and archived at /r/TheThread. You may nominate a comment for this list by clicking on 'report' at the bottom of the post and typing 'Actually a quality contribution' as the report reason.

Top Bottom Old Controversial Comments
Jump in the discussion.

No email address required.

Reading an article on why Britain should settle Antarctica from Palladium got me thinking: are there any major, visionary projects happening at the moment that have a plausible chance of success?

I'm still hopeful for SpaceX to at least make operations on the moon more feasible, though I'm skeptical of making a real go at Mars colonization, especially as Elon's star has fallen so far recently.

China seems a likely contender, but I don't know what they have going on. I know that AGI is the thing on everyone's mind, but I'm thinking more about a physical, non-software based major visionary project that's happening in the physical world.

To quote some from the article:

These apparently radical measures will look less radical by the year, but would nevertheless represent a dramatic break from the Westminster status quo. Declining nations can resort to many sensible technocratic reforms that are easy to explain, but they find it hard to come up with compelling political or bureaucratic motives for those reforms. That can only be done with national visions—visions that are not only suited to the capabilities a country could realistically develop, but also a congruent continuation of its history, or at least the best of its history. We can see that these two conditions have been fulfilled with nearly every successful national founding or refounding. Britain’s overlooked Antarctic legacy, and the vast frozen territory it still retains, then, offer us the opportunity for such a vision.

If such a project is pursued with enough vigor, it will make Britain’s claim to Antarctica inarguable. It is easy to draw peremptory lines on an empty map, but it is much harder and more admirable to people that map and to rescue its land from barrenness. For a stagnant or declining nation, it is easy to find this or that technocratic intervention that can solve this or that economic, social, or political issue. What is more difficult is finding a vision that gives the nation reason to carry out such reforms. These visions must be inspiring, but they must also be within reach. Most importantly, they must match the legacy and history of the country.

This is culture war because, well, the decline of nations is extremely political, and from my view the Trumpian Right, for all it's many and varied flaws, is the only party at least nominally pursuing a future vision of greatness, instead of simply ignoring or managing a decline.

Also, this is a very sassy quote from the article I loved:

This unworldly modern Britain is hardly the “perfidious Albion” depicted in the propaganda of its 19th century geopolitical rivals. Not wholly unflatteringly, contemporary Russian state media still portrays the country as the shadowy orchestrator of coups and death squads. A truer depiction, though, is that of the “cash-poor, asset-rich elderly woman who has somehow inherited a portfolio of scattered, high-value properties she doesn’t know what to do with.”

The UK's claim to a slice of Antarctica is worth about as much as if they claimed a crater of the moon instead.

Nobody wants to live in Antarctica. I would rather raise kids on a container ship.

This means that the normal process of the rule-based international order, where local polities organize however they like and get recognized as states (which is already flimsy in the case of Greenland with its 0.028 persons per square kilometer) will not have a good solution to this.

The traditional solution to solve conflicting territorial claims is, of course, war. Happily, Antarctica, being south of the Tropic of Cancer, is far outside NATO territory. So if the Brits want to wage war against China or Argentina in some god-forsaken desert of ice and desolation, let them.

Alternatively, the nations of Earth might jointly decide to exploit the resources of Antarctica, but in that case I would expect a reshuffling of territories. China is not going to accept that it does not get a slice based on some claims frozen by a treaty 60 years ago. Nor is the US, certainly not under 47.

China seems a likely contender, but I don't know what they have going on.

In space, China's performance these days (whether measured by launches or satellites put in orbit or upmass) beats out the entire rest of the world (excepting SpaceX) combined. SpaceX outdoes them by somewhere between 200% and 900% depending on how you measure, though whether that means "the West is fine" or just "the West got really lucky" is less quantifiable. China's shooting for their first manned lunar landing around 2030, which doesn't seem likely but does seem possible; if Blue Origin continues to move glacially (though they've reached orbit now, good for them) and if Starship continues to have teething problems (the v2 ships have been tragedies so far, though catching two boosters and reusing one already was impressive) then China might beat Artemis 3 (still supposedly 2027? that is not going to happen).

China's current lunar plans are basically Apollo-style "flag and footprints" missions, vs US designs that ought to be more sustainably affordable and carry more cargo (or "much more", if Starship gets working smoothly), but China has 3 companies with Falcon-9-scale partially reusable launch vehicles currently in testing, which puts them way ahead of most of the competition. China's Starship-scale fully reusable plans are currently at the "Powerpoint slides of what we say we'll do in the 2030s" stage, so may never happen, but even that feels like a step up from e.g. the UK (current motto: "The sun will never stop setting on the British Empire") or continental Europe (also armed with 2030s-target Powerpoint slides, but for a mere Falcon 9 competitor).

I'm skeptical of making a real go at Mars colonization, especially as Elon's star has fallen so far recently.

Starlink is up to 6 million subscribers now, so even if Elon's irrevocably pissed off both parties at this point they've still got enough non-federal revenue to keep going. If he goes full Howard Hughes and starts trying to redesign Starship from birch or something then all bets are off, of course.

Their next Starship flight test (scrubbed yesterday with a ground systems issue) is going to be attempted this evening. No exciting booster catch attempt this time (this flight and the last are trying different angle-of-attack flyback trajectories, to get data and push out the envelope on that, and they don't want to come back near the tower in case they push too far), but it should still be tense. Everybody's waiting on pins and needles to see whether they've fixed the last of the new v2 ship problems or whether Turks and Caicos are about to get another unintended fireworks show.

"At 660,000 square miles, the territory is about eight times the size of Great Britain"

Huh! That's interesting. I had no idea the UK had that much territory in Antarctica.

Still, I can't imagine them actually going through with such an ambitious plan, or that all the other countries would stand by and allow them to do it.

For your original question, it seems like Saudi Arabia is still working on the line. I'm not sure it will actually get finished, or whether it'll be any good... but there's a decent chance it will amount to something big.

Well, it is claimed territory. In fact, much of it is also claimed by Argentina and Chile. And China and the US do not have any claims and are unlikely to just play along.

For all practical purposes, the British claim is as valuable as if North Korea claimed half of the Pacific as their territorial waters.

OK yeah. Looking into it more, it sounds the makings for a hilariously old school imperialist land squabble. Going by this: https://en.wikipedia.org/wiki/Australian_Antarctic_Territory: "Only four other countries accept Australia's claim to sovereignty, being New Zealand, the United Kingdom, France, and Norway, all of which have territorial claims in Antarctica and mutually accept each other’s claims"

So it's the British Commonwealth, Frand, and Norway vs the entire rest of the world!

Britain already has history of shipping various prisoners and undesirables to inhospitable places in name of expansion. Who knows, history could repeat itself.

hmm, are you suggesting that Britain could ship away all of its undesirable white males to Antarctica...? (just a joke)

Unity of people will reinforce any vision that captures it. A deracinated, divided people are capable of following no vision but force.

This is a GPS unit in search of a vehicle. The car broke down a century ago. The UK is now a mirror on the vehicle that is the US empire.

Yeah a shared group identity is pretty crucial. Which do you think are still the most potent in the current era?

There's only two international ones, Islam and globohomo. Everything else is politically captured religion, ethnic division and nationalisms.

You don’t think Islam is riven with a ton of internal ethnic division? Huh that was my impression.

Of course it is. And with competing nationalisms and versions of the religion. Point is, they all happen within Islam. When Europe was "Christendom", they had thousands of heretical sects, competing secular governments, nobles, clerics, etc. They still had some more powerful ideology serving as the tent under which all that was "united". Neither Islam nor globohomo is any different. We're all in globohomo, whether we like it or not in the same way Iran is part of Islam, even though they are hated heretics by the rest of Islam.

I appreciate your framing, sincerely.

What's your take on the other abrahamic "hard" religious groups; Rad Trad catholics / Orthodox "ortho-Bros", and actual zionist and/or messianic Jews?

NYT Continues Medical Pricing Beat

They're starting to get closer.

It is well-known that the NYT will plan out long-term foci for sustained coverage, taking their own perspective, keeping it in their pages in a variety of ways. I've covered a few in recent months; this one is in the "Your Money" section.

The piece focuses on the author's experience with his wife's mastectomy for breast cancer plus reconstructive surgery and the role that prior authorization played in it. What's that?

prior authorization, where doctors must get approval from health insurance companies before performing big procedures or prescribing certain medications.

About half of Americans with insurance have needed their insurer’s blessing for services or treatments in the last two years, according to a poll from KFF, a health research group.

Why? The only reason they describe comes from their characterization of the insurance industry's response:

The insurance industry defends prior authorizations as a step to keep people safe — say, by preventing unnecessary procedures — and make sure they are getting cost-effective care.

I'd like to steelman the idea of prior authorization by rolling it into my own perspective that I've been trying to sustain over time.

The fundamental principle is that prices matter to patients. This statement simultaneously seems trivial and is also quite profound in context of the medical industry. There are doctors even here on The Motte who have sworn up and down that prices don't matter, but frankly, they're just wrong about this. This NYT piece reinforces this basic principle, though it does not state it quite so forthrightly.

That is, the story of the article is that, two days before the planned surgery, the author and his wife

found a letter in the mailbox from UnitedHealthcare stating that prior authorization for the operation was partially denied.

This was disconcerting to them, which is somewhat strange if one thinks that prices don't matter. It seemed to matter to them. He writes:

Our minds raced: If the denial stood, the cost could upend our financial lives and years of careful planning. Good luck to us, trying to sort this out on Sunday before we were supposed to show up at the hospital in the predawn hours on Monday. Should we even show up at all?

Contrary to what you might have heard doctors say, that prices don't matter because patients can't possibly make choices with price information, they actually can. Here are actual people, considering making the choice to skip a possibly life-saving surgery, because they have uncertainty concerning the price. I've pointed before to another, doctor-written op-ed in NYT that acknowledges this reality:

One of my first lessons as a new attending physician in a hospital serving a working-class community was in insurance. I saw my colleagues prescribing suboptimal drugs and thought they weren’t practicing evidence-based medicine. In reality, they were doing something better — practicing patient-based medicine. When people said they couldn’t afford a medication that their insurance didn’t cover, they would prescribe an alternative, even if it wasn’t the best available option.

As a young doctor, I struggled with this. Studies show this drug is the most effective treatment, I would say. Of course, the insurer will cover it. My more seasoned colleague gently chided me that if I practiced this way, then my patients wouldn’t fill their prescriptions at all. And he was right.

It also tells the story of an emergency room patient, in quite bad condition, that the author really felt should be admitted as an inpatient. The patient was concerned about the possible cost. No one could tell him anything. He chose to go home that evening.

Prices matter. Patients will make choices based on prices. Patients will make choices based on uncertainty about prices. This week's NYT piece drives this home with yet another example, this time concerning a surgical procedure.

They ultimately decided to go through with it, and it turns out that the author managed to talk to a billing specialist from the surgery provider while his wife was under the knife. What he learned:

Turns out MSK had known about the prior authorization problem about a week earlier, when UnitedHealthcare rendered its judgment. So the insurance company told MSK immediately — but not us.

The billing specialist told me that the partial denial was related to some minor procedure codes, not the most important ones. If big money trouble had been brewing, she said, someone would have told my wife not to come that day. Moreover, MSK would have eaten any out-of-pocket charges related to the prior authorization issue if it couldn’t get the insurance company to back off. After all, it had greenlit the surgery that day knowing that there was a lingering insurance issue.

Let's ignore the whackiness (and the veracity) of the claim that the provider would eat any uncovered charges for now. The article makes a fair amount of hash over the issue that they hadn't opted-in for electronic communications from their insurance company, so they only received a delayed snail mail, but the provider was notified earlier and didn't tell them either! Why not?

“MSK does not communicate secondary denials to patients because they are often resolved the day of or postsurgery,” said Robyn Walsh, MSK’s vice president of patient financial services, in an emailed statement. “MSK is committed to ensuring we are only communicating clinically necessary information to a patient prior to their procedure.”

They are just sooo addicted to price opacity; it's ridiculous. The author is not buying it:

This is a pretty clinical definition of clinical. Given that presurgery mental health is surely part of the institution’s concern, it could have sent out a note saying: “Hey, you’re about to get a scarygram. Don’t worry, we’ve got you. Here’s why.”

Prices matter. Prices matter. Prices matter. Get it through your thick skulls, providers and insurers. Just tell your patients. Tell them. They need to know. They're currently making decisions under uncertainty, and you can just tell them. The author closes with basically this exact plea:

As for the doctors, ask them a number of questions: Will there be a need for prior authorization for this procedure? How quickly are you requesting it, so there isn’t any last-minute scramble or fear? Will you or your institution call me immediately if the insurance company informs you of any trouble? If that’s not your normal practice, how about changing that? And if you won’t change your policy, will you please just do it for me? Who in your office should I call or email if I hear about a problem?

But for all of the opt-ins, app notifications and checklists, there doesn’t seem to be anything stopping all insurance companies from doing the simple and obvious thing right now: If there’s a problem, just alert everyone, always — as many ways as you can and as quickly as possible.

Just tell the patient what's going on. Just tell them the price. Do it before services are rendered.

Ok, with the basics out of the way, I should probably get around to that steelman of prior authorization that I promised. The fact of the matter is that there are going to be some drugs/procedures that insurance won't cover, at least under some circumstances. There's probably not a reasonable way out of this with a rule like, "Insurance must just cover literally anything all the time, no matter what." Obviously, there's going to be a spectrum, with some routine things being covered ~100% of the time, with others having significantly more variance. The useful idea behind prior authorization is that the provider and the insurance company should get together... get their shit together... and figure out what the price is going to be for the patient. And, frankly, that makes sense, especially for items that often have significant variance. It's hard to make hard and fast rules here, but my sense that many insurance companies have a list of items where there is significant variance and so they require prior authorization.

It is good for them to get their shit together. It would be even better for them to get their shit together more routinely and then to tell the patient what things are going to cost. It is a pox on both their houses that they haven't gotten their shit together. The old NYT op-ed was written by a doctor, so it's no surprise that they wanted to put all the blame on the insurance companies. This week's was written by just a guy, one of the journalists on staff, talking about his own experience, and he more rightfully pointed out that both providers and insurers are failing.

NYT is getting closer, but they're not quite there yet. They've given multiple examples of why giving patients prices matters, but they haven't quite figured out that they just need to beat that drum directly.

Based on the linked article I read, the couple was unsure about going forward with the surgery because it was unclear how much of the bill their insurance would cover. They got surprised with this last minute because their insurance dropped the ball.

None of the problems in this article are described as being caused by the healthcare provider and the author himself seems to think that these problems were at best only tangentially MSK's responsibility, including the following right after his criticism of them:

That said, MSK, like my wife and me, was downstream of UnitedHealthcare’s prior authorization system. The insurance company was the decider here, which puts the responsibility for quick and clear communication primarily on UnitedHealthcare.

Despite this, you spent most of your comment about prices in healthcare talking about doctors and providers. Why? How was this your takeaway from an article which almost entirely blames the insurance company?

I read the article as criticizing both the provider and the insurance company, rightfully. They never once put the blame for "dropping the ball" solely on one party or the other. I don't either. Both parts of the industry need to get over the ridiculous idea that prices don't matter to patients and do better at informing them prior to decisions. It is mostly the gestalt sense that prices don't matter and that there's no point in informing patients that causes both of these players to fail so miserably.

It is unfortunate that the author didn't tell us much more about UHC's perspective on the matter. That might have given some choice quotes to make my point further that they're not getting it, either. But we did get choice quotes from MSK which very clearly and directly make my point.

A brief tangent on medical billing that US-based Mottizens may find useful.

So back in college I worked for an insurance company for a short amount of time. While there I received a crash course in medical billing, and what I learned ended up being pretty helpful in disputing a bill I received a few years later. All doctor's offices, hospitals, and clinics across the country (the US) use a standardized billing method. While the actual paper bill may look different, each and every one will provide you with a list of common codes for the services you received. These are called Current Procedural Terminology Codes, or CPT Codes. These codes are published by the American Medical Association (AMA) and get very, very, granular. When you receive a bill, it is to your benefit to look up these five-digit codes to make sure that they match the treatment you received. Hospitals have a perverse incentive to "upcode" your bill, that is to put down a code for a higher tier/cost, of treatment that you received. This is illegal, but it happens with shocking regularity.

Consider code 97161, "pt eval low complex 20 min." That is, a healthcare provider spent between 0 and 20 minutes in the room with the patient, providing an evaluation of a low complexity issue. An unethical hospital might "upcode" this to 97163, "pt eval high complex 45 min." Or you might have gone in for a G2251, "brief chkin, 5-10, non-e/m." That is a brief check-in for 5-10 minutes for a non-emergency issue, which got up-coded to a 97161.

You will rarely, if ever, know the exact proper code for what you went in for. You're not supposed to. This is arcane back-end stuff the patient is not supposed to ever really understand. But the list is public information, and you can very easily check the codes you were billed against the list of treatments. Being able to respond to a bill with specific questions, such as "why was I billed for an hour-long patient interaction when the doctor was only in the room for 20 minutes?" is a very effective way of disputing a medical bill.

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.

Firstly, prices only reliably influence decision making if you have skin in the game.

If I am at a bar and paying for my own drinks, I will carefully consider the trade-offs between different options. If some corporation is paying for drinks, different things could happen. Perhaps I am indifferent to the company spending money, then I might use high prices as Bayesian evidence for "is a good drink". Or I like the corporation and do not want them to spend money needlessly, then I might still consider the trade-offs. Or I hate them and want to try my best to bankrupt them through my liver, then I might simply drink the fanciest drinks I can find even if they taste like horse piss to me.

For major surgeries, patients typically do not have skin in the game, their health insurance is paying for them. Price transparency is nice for society, but not crucial for patients.

Secondly, the health insurer and the hospital already have a pre-existing agreement on a price list. What they are negotiating about is which medical procedures (and line items) are indicated.

In a borderline sane medical system (e.g. what we have in Germany), that should be wholly between the health insurer and the clinic. The doctors use whatever procedures they see medically indicated, and then their billing department will settle with the health insurer. Sometimes the health insurer will dispute the charges. If dispute resolution favors the insurer, the hospital will just eat the charges. Running a hospital is a mixed calculation, you can afford to lose money on a few cases if you make some money on average. The patient would only be on the hook if they had lied about having health insurance.

Of course, the US health care system was lovingly hand-crafted by Moloch himself. Take competing health insurers, but then let the employer -- who cares very little about coverage but a whole lot about costs -- pick the health insurance company for their employees. Then pass a lot of regulations forcing Dog Butcher Healthcare to actually cover anything. Let every insurer build their own network based on secretly negotiated prices so that people will have to change their therapist when the change jobs. Sprinkle in some socialized healthcare for the poor. Have juries award excessive malpractice damages to keep everything expensive. Also link in the Molochian university and student loan system for the same reason.

I agree that there are plenty of situations where the patient doesn't really have much skin in the game or where price mostly doesn't matter for whatever reason. I wrote about an example of the former here.

The latter are probably quite routine, too. This is sort of unsurprising in economics. Demand curves slope downward, and everyone to the left of the equilibrium point gets consumer surplus. The further left you go, the more surplus they get. If I'm a customer who would buy an apple for $2, and prices usually vary a bit around $1, but maybe if there's a bad harvest, they're like $1.50, then yeah, for the most part, the price doesn't matter to me. That doesn't really imply that the price doesn't matter in general. So, riffing of what you say:

Price transparency is nice for society, but not crucial for patients.

Price transparency of apples is not crucial for a bunch of people whose willingness to pay isn't somewhat close to what the price actually is. But it's actually pretty important for society and for a bunch of people whose willingness to pay is much closer to the actual price.

Many people are discovering the headline-grabbing version of the problem, too. Imagine if apples usually cost about a dollar. It varied from day to day, but they didn't tell you up front. Some times, incomprehensibly to the individual, they suddenly cost $1k. But they also didn't tell you this until after you'd eaten it (after services were rendered). Everyone knows it's kind of sketch, but no one can bring themselves to just make the grocery stores give people a price up front. This is how a lot of people view the current lack of transparency. Memes abound about how you got a papercut, spun the roulette wheel of the American Medical Industry, and found out later whether it cost you $1 or $100k.

Secondly, the health insurer and the hospital already have a pre-existing agreement on a price list. What they are negotiating about is which medical procedures (and line items) are indicated.

Yup. This cuts out most of the arguments for why patients shouldn't get prices. At the very least, providers can provide an estimate of what procedures (and line items) they're planning to bill. They can look at the pre-existing, agreed upon price list, that they have, and give you the relevant information. Of course there will be cases where 'something happens', and it turns out to not be correct. The classic example is that you're going in for a relatively routine surgery, and there's like a 1% chance they're going to find something that 100x's the price. Well guess what? There's a good chance that the doctor already told the patient that there was something like a 1% chance of finding something that significantly changed the nature of the procedure. That's just good informed consent. That same informed consent should at least include some form of, "...and yeah, if that happens, it'll 100x the price." (Now, that may not meaningfully matter for some insurance cases, but just inform them, people!)

For the most part, providers and insurance know where the line items are that typically get argued over. Sometimes, a pre-auth is actually good to do. Providers can at least tell the patient what their plan is, but it would also be nice if they gave their perspective on whether the planned billing was likely to run into difficulties or not. As the linked article puts it:

Given that presurgery mental health is surely part of the institution’s concern, it could have sent out a note saying: “Hey, you’re about to get a scarygram. Don’t worry, we’ve got you. Here’s why.”

Just communicate. If there's likely to be some sort of issues with haggling over line items, inform your patient the best you can.

Let’s also add EMTALA- hospitals get left on the hook for care for genuinely uninsured patients.

When have people argued that customers don't want to see price in healthcare? Seems insane to me. I also have no clue why you wouldn't want to price things out up front. Does it benefit the medical industry?

This is one of those issues that are prone to a gish gallop. There are a bunch of different argument variants, and folks often slip back and forth between them, often not letting a response to one form become the actual topic of discussion, deflecting to a different form, and then swinging back later, as if the initial response was never made. I will try to cover a few variants, of course trying to steelman some where I can.

There is some historical sense of medicine as charity. Historically, many hospitals were, indeed, primarily charities. Medicine is often considered an unalloyed good, and of course, when it's being provided as a charity, doctors and patients should only be thinking about the medical decision, itself.

Robin Hanson talks about how this historical sense has lingered, even as it has transformed significantly into one of the largest industries in modern society. He thinks that medicine is 'sacred' in his terminology. He believes that money is 'profane', and one of the primary rules of the sacred is that is shall not be mixed with the profane.

This makes a bit of sense, and we can sort of steelman it. Medical decisions can, indeed, be life/death sorts of things. (Not all of them, of course.) Plenty of folks have a generic sense that when it comes to such life/death decisions, money shouldn't come into it. They may think so from a personal perspective ("It could save your life; you have to do it; you can figure out the financial stuff later; if you're dead, the financial stuff won't matter anyway") or from a societal perspective ("Society shouldn't allow anyone to have to decide to not get a life-saving treatment just because of the price"). There are pieces of this in @quiet_NaN's comment:

In a borderline sane medical system (e.g. what we have in Germany), that should be wholly between the health insurer and the clinic. The doctors use whatever procedures they see medically indicated, and then their billing department will settle with the health insurer.

Or, as I quoted above, the way the NYT journalist's surgery provider put it:

“MSK is committed to ensuring we are only communicating clinically necessary information to a patient prior to their procedure.”

Or, part of the quote I had above from the old doctor-written NYT Op-Ed:

I saw my colleagues prescribing suboptimal drugs and thought they weren’t practicing evidence-based medicine. In reality, they were doing something better — practicing patient-based medicine. When people said they couldn’t afford a medication that their insurance didn’t cover, they would prescribe an alternative, even if it wasn’t the best available option.

As a young doctor, I struggled with this. Studies show this drug is the most effective treatment, I would say.

There really is a sense for a variety of people that prices are simply conceptually divorced from what the Objective Right Medical Choice is. That there is a simple and sharp divide between the one true optimal thing, which is the Platonic Ideal of Evidence-Based Medicine, and every other possible consideration, which is pure bollocks. That anything else is, or should be, someone else's problem. That patients and doctors should only talk about direct medical costs/benefits. That price 'costs' just aren't even costs, and some other magic either will or should take care of it. And of course, if some other magic doesn't, well, then, you'll be fine figuring out how to manage your gigantic bill; you should just be happy that you got the best care.

Of course, while I get where this is coming from, I don't really buy it. There are plenty of situations where there isn't necessarily an Objectively Right Medical Choice that is conceptually divorced from price. The silly example I use to illustrate this is to imagine having some minor pain in your wrist. For a lot of people, it's probably just fine to take some painkiller and just wait to see if it goes away in a few weeks. The chance of it going away is decently high, and the cost of doing a whole lot more often isn't worth it. However, suppose that same minor wrist pain presents in a superstar NFL quarterback. Say it's in their throwing arm. There may be a ton of value in doing a whole lot more, gathering information, possibly trying an intervention, deciding whether they should sit out for a week or two before the playoffs to have a better chance then, etc. In this situation, the price is much much more worth it.

Obviously, this is an extreme example to make a point, but again, many many people don't think this way. They want prices to not matter. It's probably part of the impetus for many people to support government-run healthcare, because then no patient has to directly make decisions based on price. For many people, just the idea that a patient might "have to" consider price in their medical decisions is an affront to their sense of what medicine "should" be about.

Equally obviously, the medical industry would prefer if no patients ever thought about prices. You don't even need to jump to a nefarious provider who is sneakily deciding to perform procedures for the purpose of making more money rather than the patient's best interest. For one, it contributes to their status image. Their expertise is so valuable that you can't even put a number on it. Obviously, they know best, way way better than you do, and you really ought to mostly defer to them. Dovetailing with this, their expertise is in the medicine; that's what they want to focus on; there's a half-decent chance they don't know anything about the prices anyway. So you should really just acknowledge their status and expertise and view things the way they do, leaving any petty concerns about money out of it.

Second, very related, they don't want to bother. The other thing that the doctor who kept trying to argue here that prices don't matter would slip to is, "Why should that be the doctor's job?" I get it. I do. They're very busy. They have many, many things that they need to know. Prices are complicated. This isn't really along the lines of "customers don't want to see prices in healthcare", but trust me, when doctors get going on this topic, they will slip into this one.

On this front, I just say that I don't care who actually does it, so long as it gets done. Most healthcare providers have plenty of non-doctor staff. Insurance companies likely deserve blame, too. Neither the providers or insurance really cares to inform patients much, and they're more than happy to point the finger and say it should be someone else's job.

This is why I have mostly defaulted into just saying that it should be a requirement. That a patient cannot consent to a procedure (or the corresponding billing) unless they've been provided a price. Legislation can mayyybe even be a bit coy as to who actually hands it over; so long as the outcome is required to happen, let them figure out how to do it.

I suppose, since @ArjinFerman mentioned another variant, I should give a sentence to it. The "all the numbers are fake, so nothing matters" argument. Sigh? Get your shit together and make not fake numbers? When the patient actually gets a bill, it's not going to be a 'fake' number. It's going to be a number that they're expected to pay. With potential threats of collections/bankruptcy, etc. Sure, some providers may make some allowances sometimes, but that's hardly here nor there. If you can provide actual bills with actual numbers that patients are expected to pay (and you do), then you can do a lot better to inform your patient. At least a lot better than the current default, which is 'not at all'.

We had a guy arguing that, I remember ControlsFreak getting into a rather long fight with him over this. I believe the argument is something like "the number is fake anyway, so you don't need to see it".

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).

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.

Adding to @ArjinFerman's response, most of these don't matter.

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.

You know what you're planning to bill, right? You know what the list price and the negotiated price are, right? You can give that to the patient. If you're doing something where you think there's a substantial chance of a substantial deviation, perhaps inform your patient and consider asking them if they'd like to do a pre-auth to help reduce the uncertainty?

If the insurance company knows exactly how much something costs they'll low ball the hospital

You're slipping back to one of the numbers that aren't relevant and that no one is asking for. We just want what you're going to bill and what you've already negotiated with the insurance company. The insurance company already knows these things. You already know these things.

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.

You don't need that to provide what you're planning to bill and what your negotiated price are. Sure, if you're significantly worried about what this other actor will do, then see above.

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

Yup. The "Why should that be the doctor's job?" argument. You know full well that I don't care whose job it is.

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.

I might be a simpleton (it is very likely, in fact), but I don't see how this is any different from any other industry that faces uncertainty (which is all of them), where the prospect of telling the end customer "you don't need to know the price" is typically seen as absurd.

For your case to be persuasive, you'd need to do some comparative analysis, and show how the kinds of uncertainty faced by the medical field is much larger or fundamentally different from, say, car manufacturing or agriculture.

If making the numbers accurate being impossible / comes with costs, how can insurance companies function to begin with? Their existence hinges on having reasonably accurate numbers for these things. If they do have accurate numbers, I don't see how passing them to the customer would generate edtra costs - we have computers these days!

And if it's all really so arbitrary, is there any point to this system? Would anyone really notice if the whole healthcare system got nationalized, with Stalin's reanimated corpse in charge?

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.

If people won't and can't use the prices, how exactly do we get the situation in the OP where the NYT writers specifically wanted and could have used price information?

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.

Hopefully it's more coherent than that! Though healthcare does seem to make people go crazy for one reason or other.

I just noticed he actually linked to the conversation, so you can judge for yourself.

What is this place?

This website is a place for people who want to move past shady thinking and test their ideas in a court of people who don't all share the same biases. Our goal is to optimize for light, not heat; this is a group effort, and all commentators are asked to do their part.

The weekly Culture War threads host the most controversial topics and are the most visible aspect of The Motte. However, many other topics are appropriate here. We encourage people to post anything related to science, politics, or philosophy; if in doubt, post!

Check out The Vault for an archive of old quality posts. You are encouraged to crosspost these elsewhere.


Why are you called The Motte?

A motte is a stone keep on a raised earthwork common in early medieval fortifications. More pertinently, it's an element in a rhetorical move called a "Motte-and-Bailey", originally identified by philosopher Nicholas Shackel. It describes the tendency in discourse for people to move from a controversial but high value claim to a defensible but less exciting one upon any resistance to the former. He likens this to the medieval fortification, where a desirable land (the bailey) is abandoned when in danger for the more easily defended motte. In Shackel's words, "The Motte represents the defensible but undesired propositions to which one retreats when hard pressed."

On The Motte, always attempt to remain inside your defensible territory, even if you are not being pressed.


New post guidelines

If you're posting something that isn't related to the culture war, we encourage you to post a thread for it. A submission statement is highly appreciated, but isn't necessary for text posts or links to largely-text posts such as blogs or news articles; if we're unsure of the value of your post, we might remove it until you add a submission statement. A submission statement is required for non-text sources (videos, podcasts, images).

Culture war posts go in the culture war thread; all links must either include a submission statement or significant commentary. Bare links without those will be removed.

If in doubt, please post it!


Rules


Recommended Posts And Communities

Recommended Realtime Chats