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PaperclipPerfector  3mo ago (text post)   27023 thread views

Culture War Roundup for the week of August 25, 2025

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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.

Well off people who don’t have any real relations to the lower and middle classes believe prices don’t matter.

Price is how the majority of decisions are made.

And then we go blow 120$ at the bar.

Human condition and all that.

I have used private healthcare in the UK, both as a cash-paying patient and as an insured patient. The following are basic expectations that the system does, in fact, deliver on.

  1. For simple out-patient procedures like scans, the price-list is available on the provider's website. As a cash-paying patient, you will pay the price on the website. As an insured patient treated in-network, your insurer will pay the price on the website less a small negotiated discount (and your deductible/co-insurance if applicable).
  2. The price for elective surgery (including urgent elective surgery like cancer treatment) will be reasonably predictable. You will receive a written estimate before admission if you want one. If nothing untoward happens, the bill will be within 10% of the estimate.
  3. If you are cash-paying, you can get a "fixed-price" quote for standard procedures. Even if something untoward does happen, your hospital bill will match the quote plus the possible upcharges that were clearly explained on the quote letter. The standard case is that you pay the basic room rate (but nothing else) for an extended hospital stay, and the surgeon's and anaesthetist's bills (but no hospital charges) for any unplanned follow-up surgery.
  4. The up-to-date, accurate list of in-network providers is available on your insurance company's website. Any doctor's secretary knows which insurance companies they are in-network for. Any private hospital or clinic receptionist knows which insurance companies their employer is in-network for.
  5. Pre-authorisations are turned around quickly if the doctor co-operates. 48 hours for simple stuff, a week for complex surgery. The pre-authorisation letter states clearly and in language comprehensible to the average adult what your deductible/co-pay/whatever will be, and the rules are simple enough that this explanation is at most one paragraph.
  6. Pre-authorisations are honoured. You end up paying the deductible/co-pay/whatever that was explained on the pre-authorisation letter, and no more.

The private system in the UK doesn't really touch actual emergencies (there are a few private A&E departments, but they are effectively providing an overpriced out-of-hours GP service), and I understand why they are difficult. But I don't see why the insurance-based system in the US can't deliver the same level of service in non-emergency cases as the insurance-based private system in the UK, particularly given how much more money the US system has to play around with.

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.

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.

Or if they manage to fuck of the CEO of healthcare.

The US has a very peculiar arrangement where you don't buy healthcare. Your insurance provider buys healthcare on your behalf from healthcare providers, (except when they don't). But at least you buy health insurance, so if you get bad service from your insurance provider you can switch Your health insurance, in turn, is bought for you by your employer. Basically everyone in the system has terrible incentives.

  • Healthcare providers are incentivized to overtreat because it mitigates risk (less likely to get sued for malpractice), allows them to charge more, and the patient (usually) isn't footing most of the bill, so they're often price insensitive. (Also, the patients are clueless so they have no real ability to argue with the doctors about treatment plans)
  • Health Insurers are generally trying to sell the cheapest product possible to employers and pay out as little as possible to providers. They're not terribly worried about customer service quality beyond an absolute bare minimum, because their customers have limited ability to leave. So they stiff patients and deny coverage whenever they can get away with it.
  • Employers are generally trying to conform to their legal obligations and need to retain employees as cheaply as possible. Fortunately for them, your employees aren't sick most of the time, so you can actually get away with buying them fairly low quality health insurance.
  • The patient wants treatment, but lacks the information and expertise to make an informed decision. Almost as importantly, they want to avoid being left holding the bag. If the doctor recommends it and insurance approves it, they'll probably agree to it, because better safe than sorry. After all, it's (mostly) not their money (until it is).

The result is that the consumer (i.e. patient) is marooned in an incredibly capricious system which is only tenuously interested in his welfare and which may saddle him with a colossal bill as a result of processes completely opaque to him.

The one thing missing is that the people inside a business who select the Health Insurer also usually is subject to the choice they make. I have watched a company switch to a cheap horrid plan, then switch back after two years when the chief HR lady had a cancer scare.

This is probably the best summary I've ever seen on this topic. Thank you.

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.

Price matters, but it’s really hard to put a price on survival. And even with transparency in pricing, there’s no way to know the difference between “cheaper but just as good” and “cheaper because it’s dangerously substandard care/medicine.” And it’s likewise difficult to tell when something that sounds trivial isn’t. It’s a lot of information asymmetry that the patient can have a really hard time understanding. And in some cases a high price can be taken for a sign of quality.

I always assumed that life-saving care must be rendered unconditionally, but that the insurance company can still refuse to cover certain elective procedures, in which the hospital is under no obligation to perform them.

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.

But what's considered life saving? Say a person has a condition that is chronic and deteriorates their heart over time. Untreated, it will lead to heart failure but this could take years. Treatment is an insanely expensive medication or some kind of invasive procedure that has to be done periodically. Insurance, in its arcane wisdom, decides they don't want to pay for it. Eventually the person ends up in the ER with a heart attack. The heart attack is treated but not the underlying condition. The patient is just sent home. This is a fake example because I'm not a doctor but very easy to imagine something similar playing out. The medication treatment is not "life saving" because the patient was able to live for years without it, therefore it clearly was not that vital, right?

When you think about it, it's similar to the debate about covering "preventative" measures, including counseling on diet and exercise. Some people think it's absurd, but I would argue that by not covering preventative and maintenance types of treatments early on, they're creating much more serious problems down the road.

This is a fake example because I'm not a doctor but very easy to imagine something similar playing out.

Oh no, you're bang on target. I'd know, both because I'm a doctor and because my dad has a heart condition that behaves more or less exactly like this. It would likely be cheaper to get a brand new heart (secondhand) than attempt to cure it with medication.

Some people think it's absurd, but I would argue that by not covering preventative and maintenance types of treatments early on, they're creating much more serious problems down the road.

Depends a great deal on the costs and benefits of the prevention and maintenance! Screening not only costs money, but if it involves, say, ionizing radiation, you will cause new cancers once you scale to hundreds of thousands of people. NICE in the UK does painstaking evaluations, and insurance companies definitely have their own systems, if not nearly as open to scrutiny. It is difficult to make a blanket statement, in some cases, it genuinely is better to wait for a disease to manifest before acting on it.

NICE in the UK

I would've thought Parliament had enough C.S. Lewis fans to avoid this name.

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!!!!

I am regularly dismayed by the Motte's average epistemics when it comes to things like vaccination. Some of the takes I've seen post-covid had me pulling at my hair.

The mRNA vaccines? The ongoing moratorium on government funds for the same? Where does the stupidity end?

The rest of the world is not devoid of competent doctors or statisticians, the COVID vaccines are highly imperfect and not that important for young, healthy adults or children. There is no concerted effort to suppress a spree of cardiac myopathies or weird clotting/autoimmune disorders that needs buy-in from the governments of the other 7.5 billion people on this globe. When promising cures for things like aggressive pancreatic cancers are caught in the cross-fire, I am tempted to order a gun, or, in this country, a sharp gardening implement.

the COVID vaccines are highly imperfect and not that important for young, healthy adults or children

And yet public health officials keep pressing for COVID vaccines for young, healthy adults and children.

There is no concerted effort to suppress a spree of cardiac myopathies

Maybe there isn't such an effort ANY MORE.

When promising cures for things like aggressive pancreatic cancers are caught in the cross-fire

Are they? Or is that just marketing, because the mRNA producers are looking for applications that sound really good? What I find when searching for that is particularly unpromising -- it's a personalized mRNA vaccine to be used after surgery. Even it works, it'll be eleventy-billion dollars a dose, and you still have to have the surgery.

And yet public health officials keep pressing for COVID vaccines for young, healthy adults and children.

Sure, but what do I have to do with that? As it stands, the side effect profile from the jab is so minimal that the harm is negligible, even if that's the case for the benefits in that age group. If the government was mandating that every human alive take a dose of a single spoonful of sugar, it wouldn't be the best for diabetics, but it wouldn't kill them either.

Maybe there isn't such an effort ANY MORE.

Sigh. If there was a concerted effort at any point in time, it would have to have been a pan-national cover up of frankly astonishing proportions. If civilization was that good at organization, we'd have a Dyson sphere by now.

I have worked in two countries adding up to probably 1.5 billion people and change. There was no coverup there, you can take it from someone who worked in a COVID ICU and ran the vaccination programs. The UK grabbed onto the same Moderna and Pfizer vaccines used in the US at about the same time, India opted to use a different mRNA made by Gennova, but AstraZeneca's and another indigenous "normal" vaccine came first.

The sheer scale it would take to run cover for significant mRNA vaccine related adverse effects.. In that many countries, over such a long period of time. It's ludicrous.

Are they? Or is that just marketing, because the mRNA producers are looking for applications that sound really good?

  1. The whole point of the FDA is to hold manufacturers accountable and to ensure that their drugs *work, . If it doesn't pass every single trial phase, it won't make it to consumers.
  2. Pancreatic cancer is one of many potential treatments mRNA-based care provides. You can Google that yourself. At the absolute bare minimum, it allows for a velocity of gene therapy development that is staggering compared to previous options.

What I find when searching for that is particularly unpromising -- it's a personalized mRNA vaccine to be used after surgery. Even it works, it'll be eleventy-billion dollars a dose, and you still have to have the surgery.

https://www.mskcc.org/news/can-mrna-vaccines-fight-pancreatic-cancer-msk-clinical-researchers-are-trying-find-out

Pancreatic cancer consistently gets a podium finish in World's Worst Cancer To Get competition. A cousin of mine, now long gone, proves that. Every patient I saw admitted with it in the Oncology ward weren't there to bid me goodbye when I quit my job. Even the best existing treatment only ensures a 13% five-year survival rate. You die very badly, in a lot of agony.

So fucking what if it's expensive? Drugs tend to get cheaper over time. It is not an intrinsic property of mRNA vaccines that they must be expensive and personalized, they can be spammed by the shipload when circumstances demand.

I only raise this as a specific example of a highly promising treatment that is now derailed by the sheer stupidity of US politics. There are more, and there would be even more if funding wasn't cut. This isn't merely eating your seed corn, it's using it as fuel for the fire during a heatwave.

If there was a concerted effort at any point in time, it would have to have been a pan-national cover up of frankly astonishing proportions

Steelman: the mistake is the assumption that you need a coordinated coverup. What about uncoordinated one?

Scientific literature has no shortage of results that don't hold up. If you take proponents of Bayesian statistics seriously, vast majority of statistical methods in all published literature use subpar methodology (NHST p-values) which is often misinterpreted. Does this need coordinated malice? No, incentives are sufficient to yield uncoordinated malice. I see similar stuff everyday at my work.

What is the one largest possible incentive? Find out that the institutions made a mistake, nearly everyone was pushed vaccine that has harmful side-effect, young adult males most at risk.

It is only a steelman however. Personally, my problem is that no anti-COVID-vaccine skeptic has ever pushed a study that attempts to there is prominent rise of side-effects and they can be attributed to vaccine, not COVID itself. Secondly, when vaccines really do cause notable increase of major side effects, people have previously noticed relatively quickly.

(Anti-anti-steelman, which makes me nervous: Swedish-Finnish pandemrix-narcolepsy case is about as well established as such causal relationship can be. It is notable that publications by anglosphere institutions like CDC and NICE and WHO seem to downplay it, presumably due to risk of fueling perceived fake vaccine scares?)

If there was a concerted effort at any point in time, it would have to have been a pan-national cover up of frankly astonishing proportions.

What do you think the consequences would be, if the populations of the countries that were forced to take this stuff (and strongly encouraged to give it to their children) were to find out that it was even somewhat harmful?

Rivers of blood my man -- this is not a game.

And if that is not worth covering up (on an individual prospiracy type basis; not overarching organization is needed because the incentives are the same everywhere), I don't know what would be.

More comments

And yet public health officials keep pressing for COVID vaccines for young, healthy adults and children.

Sure, but what do I have to do with that? As it stands, the side effect profile from the jab is no minimal that the harm is negligible, even if that's the case for the benefits in that age group.

You're still defending it, that's what you have to do with that. And I disagree; the typical flu-like symptoms from the COVID vaccines are already not "negligible".

Sigh. If there was a concerted effort at any point in time, it would have to have been a pan-national cover up of frankly astonishing proportions. If civilization was that good at organization, we'd have a Dyson sphere by now.

We had a pan-national shutdown of a vast array of normal activity. Civilization is clearly that good at organization; Dyson spheres are just harder. That said, the myocarditis coverup was clumsy by comparison and mostly consisted of public health officials lying a lot.

Pancreatic cancer consistently gets a podium finish in World's Worst Cancer To Get competition.

Yes, which is why it's good marketing for boosters to claim any given new technology has a chance of curing it.

So fucking what if it's expensive?

Yeah, that's the attitude that's making health care costs rise.

Drugs tend to get cheaper over time.

This isn't a single drug, it's a specific new drug for each patient.

It is not an intrinsic property of mRNA vaccines that they must be expensive and personalized, they can be spammed by the shipload when circumstances demand.

It IS an intrinsic property of this pancreatic cancer treatment that they must be personalized.

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.

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.

This is fine for a steelman. But in real life the insurance company likes to treat prior authorization like a negotiation. That is, they'll start by just saying "no" regardless of whether the policy covers the thing or not. Then either the provider will argue with them, or the provider will say that the insurance company said "no" and leave the patient to argue with them if they care to.

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.

I have long thought that modern medicine could use a bit of an adversarial model on whether specific treatments are strictly necessary. Briefly, doctors are incentivized, at least slightly, to treat patients that may or may not benefit from the treatment. As examples, I'd point to the occasional fraud charges brought on accounting of billing Medicare or Medicaid for unnecessary services, and occasional horror stories of long chains of medications for symptoms of other medications for an original prescription from three doctors ago that has never been reconsidered.

As a weak contrast, I've heard stories from more centrally run health systems where "have tried seeing if it gets better on its own?" was a much more common question. Not for all situations, but "wait 12 weeks to see a doctor" comes across similarly, if not direct medical advice.

That said, I don't think modern health insurance is a good adversarial system. But maybe we do save a few unnecessary procedures (and presumably put hurdles on ones that are necessary).

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.

I don't think I'm being naive enough to say that the providers and insurers will sing kumbaya and everything will get happily approved perfectly as it should be. As evidenced by the doctor's comments elsewhere in this thread, both parties take every single interaction as a chance to negotiate and improve their take. If anyone has an idea to fix this, I'm all ears. But I'm certainly not counting on it.

Consider the case without the pre-auth. Services are rendered, a bill exists that shall be paid, one way or another. Nothing really stops the insurance company from just saying "no" regardless of whether the policy covers the thing or not... at which point, either the provider will argue with them, or the provider will say that the insurance company said "no" and leave the patient to argue with them if they care to. (Otherwise, of course, they must pay the bill themselves.) But now, all of this happens after the fact. What have we improved?

Instead, the only choice I think we have much hope of making is whether they have to hash out their beef before or after patients have to make decisions that could bankrupt themselves because of the crossfire. I'm certainly open to ideas for reforming pre-auths, so that they get that hashed out before patients have to make these decisions. Time limits, whatever. Any ideas for how to do any better?

I mean, you can always cartelize healthcare providers and insurance companies and leave them aligned, together against the patient.

Consider the case without the pre-auth. Services are rendered, a bill exists that shall be paid, one way or another. Nothing really stops the insurance company from just saying "no" regardless of whether the policy covers the thing or not... at which point, either the provider will argue with them, or the provider will say that the insurance company said "no" and leave the patient to argue with them if they care to. (Otherwise, of course, they must pay the bill themselves.) But now, all of this happens after the fact. What have we improved?

Without pre-auth, the patient has gotten the treatment and now "someone" is going to get stuck with the bill. With pre-auth, the patient can be denied treatment. Both of these are bad outcomes of course, but which is worse depends on the urgency of the treatment. When the insurance company lodges a (specious) objection to cancer surgery, their negotiation tactic could literally kill the patient. Also without pre-auth, the patient has more leverage; it's the provider who is on the hook if nothing is done, and the provider has lots more skill dealing with the insurance company. With pre-auth, the patient is just stuck it the provider won't dispute it and they can't deal with the company themselves. They have zero leverage dealing with the insurance company, since they're not the customer.

You could make a state-funded lender of last resort for such cases.

If you're denied then the state advances the funds at the same cost that would have been charged to the insurance company. The loan becomes non-dischargeable and the state is able to garnish wages and seize assets should it become necessary.

They also assume the right to represent the patient to the insurance company and demand payment. Should the treatment have actually been approved according to the insurance policy, the insurer has some penalty big enough to incentivize them not to play denial games and to keep the lender solvent.

This could lead to interest rates being a function of insurer denial accuracy. If it's very likely the state will recover from insurers, interest rates could be very low. If insurers are exceptionally accurate and you're very unlikely to recover, then insurance rates could approach the same as any unsecured loan for a person of your creditworthiness.

I mean, the patient likely can get the treatment regardless (see also the main NYT article). Doing so with a not-yet-settled pre-auth battle is approximately equivalent to doing so without a pre-auth battle at all.

Also without pre-auth, the patient has more leverage; it's the provider who is on the hook if nothing is done

This isn't really true, though. If they get the treatment without the pre-auth completed and agreed (or none done at all), and the insurer ultimately denies it after-the-fact, the patient still owes the bill. There's still a whole range of things that can occur with the resulting cluster of a negotiation after-the-fact. The only thing that I see that has changed is that services have already been rendered, the patient is now potentially liable for a gigantic bill, and the negotiation for who actually pays what just hasn't happened yet. The patient has even less leverage, because they've already agreed to buy the thing. They almost certainly can't un-buy the thing. They're purely at the mercy of the other parties to decide how much they're going to get stuck paying.

I mean, the patient likely can get the treatment regardless (see also the main NYT article). Doing so with a not-yet-settled pre-auth battle is approximately equivalent to doing so without a pre-auth battle at all.

If you do it without pre-auth, the insurance company's next move will be to say you violated their pre-auth policy so they're not obligated to pay in any case. They may or may not get away with that, but it's another line of defense between the provider and the insurance money.

This isn't really true, though. If they get the treatment without the pre-auth completed and agreed (or none done at all), and the insurer ultimately denies it after-the-fact, the patient still owes the bill.

Yes, the patient owes it. But they can simply... not pay it. Especially true if they can't pay it. Then the provider is stuck with the bill, or sells it to some shady medical debt collector for rather less than face value.

They may send it to a collector. They may also just sue you directly, which is apparently a thing that has been happening more often. One of those things where, sure, if you're flat broke and judgment proof, then perhaps you can 'get away with something'. I was under the impression that you were inclined to disfavor systems that inherently gave free stuff to broke, judgment proof folks and crushed upstanding citizens with assets to lose.

The health care payment system is screwed up in all sorts of ways. But even if we're going to bite the the bullet and say "If your insurance doesn't cover this operation and you can't pay, you die", it shouldn't allow the insurance companies to moot the issue by stonewalling until you die, which is exactly the sort of thing I'd expect them to do if they get away with it.

I mean, sure? Got any suggestions for how to do that? I don't think, "Do everything you can to make sure patients never get prices," is particularly helpful for that problem.

I remember having to get an X-ray for an injury a few years ago and not a single person from the hospital or insurance company could give me a straight answer on how much it would cost me out of pocket. This was a procedure with extremely predictable costs and no potential for complications and still, after hours of navigating the insurance company's websites and phone trees, I had to give up. I'm sympathetic to the concept of price transparency generally but when it comes to healthcare I do have some concerns.

I've always wanted to ask those most ardently supportive of socialized healthcare: we have finite resources, where will you draw the line for what medical services we do and do not provide? Does grandma get a $300,000 chemotherapy course for a 60% chance at 2 months of vomiting and brain-fog? In a single payer system, the government has to make those decisions.

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.

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. For those who want complete price transparency: do you think the populace is equipped to make those decisions for themselves? We have enough snake oil products as is. How long before a price transparent but information asymmetric free market devolves into the same? The current system seems to eliminate the principal-agent problem, giving doctors less incentive to stray from optimizing for standard of care (hopefully one of our resident doctors can comment on whether this is at all an accurate assessment or a complete misinterpretation). The downside is this price-opaque mess. I'm not sure if the alternative is better or worse for society at large. Do you really want hospitals cutting corners and trying to undercut competitors on prices? A/B testing in medicine takes years of expensive and coordinated clinical trials. It's not something as quickly self-correcting as a restaurant going back to more costly ingredients because their customers notice the decline in quality and the consequences aren't as trivial as a bad meal.

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.

Does grandma get a three hundred thousand dollar chemotherapy course for a sixty percent chance at two months of vomiting and brain-fog?

This is a powerful objection because it feels like an unanswerable dilemma. It conjures the image of a cold, centralized bureaucracy, a "death panel," weighing a beloved grandmother's life against a line item in a budget. The implication is that any system forced to make such a choice is morally monstrous, and that your current system, for all its faults, avoids this grim calculus.

But this assumes the alternative to an explicit line is no line at all. In reality, the American system draws lines constantly. The line is your FICO score. It is the fine print of your employer’s chosen insurance plan. It is the difference between an in-network and out-of-network hospital. You don't get to avoid the decision about grandma’s chemo, you simply outsource it to an opaque web/distributed network of insurance adjusters, hospital billing departments, and personal bankruptcy lawyers. I presume that, at some point, someone with an MD will have opinions on the matter.

The interesting thing is that the dreaded explicit system is not a hypothetical construct from a dystopian novel. It is a real, functioning, and remarkably mundane bureaucracy in places like the United Kingdom. The NHS confronts the line-drawing problem head on, not with a panel of grim-faced commissars, but with a legion of actuaries and medical ethicists, and yes, actual medical doctors at an institution called NICE, the National Institute for Health and Care Excellence.

NICE's primary tool is something called the Quality-Adjusted Life Year, or QALY. It is a straightforward, if necessarily imperfect, metric. One year of perfect health is one QALY. A year lived with a condition that reduces your quality of life by half is half a QALY. NICE then calculates the cost of a given treatment per QALY gained. As a general rule, a treatment that costs between twenty and thirty thousand pounds per QALY is considered cost-effective.

I'll run the numbers on grandma, even if I already know the answer. A $300,000 treatment (roughly £240,000) for a 60% chance at two months (0.16 years) of very low-quality life (let's generously say 0.2 QALYs) results in a cost per QALY that is astronomically high. The answer from the system is a clear, predictable no. Conversely, a treatment with the same price tag for a teenager that offers a high chance of fifty more years of healthy life would be approved without a second thought. The system is explicitly utilitarian. It prioritizes maximizing the total amount of healthy life across the population. It can and will spend millions on a child, but it will counsel a family against a futile and painful intervention for a demented octogenarian. This isn't some big secret either. I have had such discussions with dozens of families, and not a single one has had a problem with it, or withdrawn their relative to go elsewhere, as they are at full liberty to do.

For those who find this calculus unsettling (I do not know why the standard approach to handling scarce resources unsettles anyone) the system provides an escape hatch. The existence of the NHS does not preclude private medicine. The wealthy, or anyone with good private insurance, can opt out of the public queue and pay for the treatment the state has denied. You can, in effect, disagree with the state’s valuation of a life year and substitute your own. The state provides a robust, free baseline for ninety-nine percent of situations, while allowing a private market for those who want more. A similar model exists in India, a country with far fewer resources than the United States (citation available on request) which manages to provide basic care for free while supporting a thriving private sector.

The American conversation on this topic often seems stuck in a state of arrested development, terrified by the philosophical specter of a problem that other Anglosphere nations have long since downgraded to a matter of accounting. The "death panel" is not a uniquely socialist horror. It is an inescapable feature of any system that deals with scarce resources, which is to say, any system in the real world. Not even the most charitably inclined soul will spend the entirety of their nation's GDP on the cancer treatment of even the most photogenic child. Their parents might empty their bank account and go into debt to do so, but that's simultaneously their right while also not entitling them to demand infinite resources from the rest of us. The Pope might claim that all lives are priceless, but you don't see him pawning off the Vatican's paintings or his Pope Mobile to do so.

I mean, it’s a news story every few years that the pope(or secular Italian government) offers to pay for medical treatment for some very sick baby thé NHS is pulling the plug on and the organs of the British state won’t let the parents take him to it.

I keep saying I've reached the point in my Motte career where I've discussed every topic under the sun. That's true for this one.

In this specific case, assuming it's the incident from a year or two back, the child was almost guaranteed to die regardless of where they were taken. The main objection of the doctors and the government against them being taken was both that transfer would be highly expensive, and that it wouldn't make a single jot of difference other than prolonging the anguish. If you know any paediatricians, you'll know that they're the kind of people who love kids and will move heaven and earth to help them. If they're saying it's a write off, I am highly inclined to believe them.

From my own, liberatarianish position, I would have preferred the family got to try nonetheless. But there is no clear cut answer, and it was a decision made in good faith.

It seems very likely that everything you’re saying is true but thé limited NHS budget wasn’t getting stuck with the bill(thé Italian government and the pope were gonna take care of it). What this actually looks like is petty bureaucrats being thin skinned self important control freaks- again, thé NHS wasn’t being forced to treat them, wasn’t being asked to pay to treat them, was merely being asked not to prevent seeking treatment in a foreign hospital.

Charlie Gard and other related cases had nothing to do with resource allocation.

English law (and this isn't an English weirdness - for example it is the same as the Florida law the courts applied in the Terri Schiavo case) is that once there is a legitimate dispute about whether a patient with no capacity to consent should be treated or not, the courts get to determine the best interests of the patient rather than automatically deferring to the next of kin. I am not a legal historian, but my understanding is that the law ended up in this state in order to stop parents who are Jehovah's Witnesses declining blood transfusions on behalf of their kids - the whole point is the parents' religious beliefs are not imputed to the child, so the Catholic parents' belief that they should prolong life for religious reasons is irrelevant. From a secular perspective, it is not in the child's best interests to keep a moribund child alive in horrible pain in order to attempt treatments with a negligible chance of success.

This isn't a libertarian rule, but it is a perfectly reasonable one. Gard-type cases (resources available to pay for the Hail Mary treatment but the current treating doctors object sufficiently on avoidable-suffering grounds to go to court over it) are rare compared to Jehovah's Witnesses etc, so the rule is life-preserving relative to "go with the parents". And "always try to preserve life" gives the wrong answer in a large fraction of the normal run of cases where resource allocation is an issue.

The "death panel" is not a uniquely socialist horror. It is an inescapable feature of any system that deals with scarce resources, which is to say, any system in the real world.

I think you've put it perfectly here. I wasn't intending to use it as a counterpoint, instead I was just interested in how they might respond. I think a QALY-based calculation is a transparent and reasonable approach, at the very least moreso than the convoluted mess we have now, but I find a lot of people will, as you say, find the calculus unsettling.

This isn't some big secret either. I have had such discussions with dozens of families, and not a single one has had a problem with it, or withdrawn their relative to go elsewhere, as they are at full liberty to do.

I find this particularly interesting. I suppose there are significant UK/US cultural differences in this regard, because I cannot imagine such a thing going well over here (My doctor friends told me once about Daughter from California Syndrome. I don't suppose you have an equivalent over there?).

My doctor friends told me once about Daughter from California Syndrome. I don't suppose you have an equivalent over there?

Sadly, we do. It is a human universal, including back in India. On the contrary, the fact that there's no financial incentivefor us to "do everything" means that it's easier to say no, though I have sufficient respect for my American brethren to assume they usually manage something in the end.

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.

Better men than me have tried to grapple with cost-disease in the American healthcare system. From my perspective, it is a 'good' problem to have, if only because it proves you guys have so much fucking money that you can piss away such large sums of it without causing the system to go up in flames. Everyone gripes and kvetches, nobody seems happy, but happiness is a tall ask when lives and money are on the line.

For all the flaws of the system, it is clearly adequate, in the sense that the majority of the country is unwilling to set the rest of it on fire in a bid to fix it. I don't mean to damn with faint praise, it's not like medical systems elsewhere don't have their flaws. The "good/quick/cheap, pick two" problem has never been solved anywhere that I know of. America is like a whale, so huge that even the most aggressive cancer doesn't amount to more than a pimple.

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.

Given that presurgery mental health is surely part of the institution’s concern

Tangent here.

Not only no, but fuck no. To this.

The quick little slip of "mental health" here is an exemplar of how insidious current perspectives are on the topic.

When (normie) people hear the term "mental health" they automatically connect it to images of depression, bipolar, maybe even schizorphrenia, along with PTSD etc. A "mental health crisis" might even conjure desperate scenes of attempted suicide or some full blown panic attack that necessitates the men in white coats arriving.

Whatever the specific circumstance, we're dealing with a disorder of some kind. Perhaps mood related, perhaps cognitively related, perhaps something more broadly endocrine (note: there are some cases of neurological issues, but I always roll my eyes when people use the term "brain chemistry" as it is both horribly imprecise and, more to the point, they're usually talking about the endocrine system as opposed to a brain (as in the grey matter, not the concept of mind) specific neurological problem")

These things are called disorders because they represent an unexpected and maladaptive response to normal life circumstances. Depression; "I have a good job, an active social life, stay in shape, and don't abuse any substances. I'm horribly sad all of the time. What do?", Bipolar disorder: "I have a good job, an active social life, stay in shape, and don't abuse any substances. But these mood swings are causing me to drink, miss work, not go to the gym, and alienate myself from people. What do?", Schizophrenia: "The Jew Aliens keep reading my brainwaves without my permission. What do?" (Okay, I had fun with that last one).

What the NYT author describes is categorically not a "mental health" issue. Getting an unexpected and alarming piece of mail should cause some level of distress. If you're totally incapable of dealing with that distress, my first response would be to question general maturity and life capability. A second would be to look at your specific life circumstances at the time to see if there's a charitable reason why you might be in a bad position to deal with such an occurrence. Only much, much later would I start to think, "Well, maybe this guy has an awful mental health disorder which makes it hard for him to deal with ... things happening and mail."

"Mental health" is not a species wide mission to prevent bad feelings from happening. Especially when the given circumstances would naturally provoke negative feelings. But this is yet another wonderful biproduct of the culture war; bad feelings have become pathologized as a) horribly disturbing and never to be expected b) worthy of full and unquestioning accommodation by ALL others and c) probably both someone else's fault and responsibility to deal with.

The author slips all of this in, easy as you please, by asserting that of course his health care provider obviously considers "mental health" to be as high a priority as sterile operating room conditions and well trained staff.

How many run-ins with HR must a man have
before he recognizes the pattern?

The answer my friend
Is blowing in the wind

I think the author is making a somewhat more reasonable point than "we shouldn't have to worry about the bill" - it's that they shouldn't be having such a worry added on last-minute to the existing worries of a surgery! Maybe it shouldn't be called "mental health", but what would you prefer for such a reasonable ask?

Maybe it shouldn't be called "mental health", but what would you prefer for such a reasonable ask?

Not who you're talking to, but I believe a good word for this is "stress", which most people recognise as something that can play a part in adverse health outcomes. The possibility that the medical system might just saddle you with a gigantic, life-ruining debt by surprise and with no recourse would make absolutely be a significant source of stress.

Maybe it shouldn't be called "mental health"

That's my point, and that's why I caveated my post with "Tangent"

but what would you prefer for such a reasonable ask?

Nothing. It is, in fact, a reasonable ask. It's not a mental health question. "Patient comfort" sure, "procedural professionalism" whatever.

I don't think it was your intention, but please try to avoid conflating the points I'm making.

Your comment suggested to me that the provider shouldn't be concerned about what you're calling "patient comfort" here - that "bad feelings happen" and who cares if it's before your surgery. The author of the NYT piece is communicating that the provider SHOULD be (and probably is) concerned about that emotional state, and that having scary financial concerns get dropped on you the day before a surgery is something that ought to be avoided.

And not to get too linguistic-descriptivist, but I'm afraid it's too late to be too prescriptive about the expansion of the meaning of "mental health" for the wider world.

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.

EDIT: This comment, while written to the best of my knowledge, appears to have some factual inaccuracies. Please see this comment here detailing them.

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 might get 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.

This is excellent information, thank you!

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.

There is also the converse problem -- I am friendly with a lot of doctors and they are all beyond frustrated that they will get an appointment for visit A and patients will expect them to also cover B,C,D and E. This is especially bad at the level of preventative visits turning into issue visits".

They have different approaches. Some will bill higher codes if patients want to talk about something outside the scope. Others will ask them to come back (or do a Telehealth followup). Sometimes they'll just eat it if the patient is quick about it. None of them have an objection to doing those visits, it's just that they aren't reflected in their scheduling or billing.

I expect upcoding is more of a problem than scope-creep, but I wanted to mention it because the symmetry is there.

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.

Oh, I have. The interesting thing is that they are pissed they get insurance consults on patients they want to send to surgery, but they freely admit that there are some of their colleagues (and it's a "everyone knows who it is" kind of thing) that propose surgery for literally anyone that comes through the door.

Can't have nice things ...

"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.

I remember once being billed for a 1 hour visit with a hematologist I never saw in person - my OB consulted with them. When I asked billing they replied, "That's because you saw the hematologist." No matter what I said, they kept insisting I had an in person visit with a hematologist, even had a specific date/time I supposedly saw him (though the visit did not show up in OneChart, hmmm?.) Eventually gave up because it was "only" 200 or so after insurance and I was dealing with the other hospital billing issues of being billed by the visiting hospitalist OB in a completely different system and it going to collections before I got a whiff of the charge.

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.

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.

This is probably what happened but shouldn't there be an ICD code for that? It just seemed sketchy that they insisted I saw the Hematologist in person, as described it sounded like a office visit (this wasn't in an in-patient context, charge was a few weeks before admission for delivery). Hematologist should be paid if my OB asked a question, and I trust my OB to only ask good questions, but presumably the cost is less for a phone call vs. going into an office, paying office staff, paying for the examination room, etc?

For context I have Idiopathic Thrombocytopenia and I think my OB wanted to ask how to titrate Prednisone.

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.

I don't know if I'm being clear but my specific and very minor gripe is that ICD has codes for everything under the sun but not a code for a physician phone consult (which would cover the time and hassle?) Or is there one and it wasn't used here?

Edit for clarity: This wasn't Out of Pocket, I had insurance. Not every insurance has a Co Pay system, even when you do have a "Co Pay" on the card you still get billed for more than the co pay later on, I've noticed this on your comments a few times over the years but you seem to have always had really good insurance and don't know what the average experience is like.

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.

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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.

So, in an unexpected instance of "the system works" would this imply that the frequent flyer hypochondriac who asks the doctor dozens of follow up questions, thereby turning a 15 min consultation into a 45 minute one, will actually end up paying (either directly, or via their insurer) more?

Hospitals have entire departments whose job it is to comb through notes.

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 thought lawyers billing me in 15 minute increments was bullshit. After the fact reconstruction of what happened layered with overly hierarchical categorization is a new level of theft.

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."

I mean, that's the problem. The system can be issue-based or it can be time-based. But it can't be both.

I thought lawyers billing me in 15 minute increments was bullshit

Bruh, we're at 0.1 hr (6min) increments. And I'm happy enough about it because they do good work and don't waste time. Remember you are paying a professional to deal with arbitrary issues.

Your best bet when dealing with medical bills Act Like a Dot Indian. 'I'm not paying that, it is too much'. They'll knock it down eventually.

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.

Okay so two things going on here:

  1. 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.

  2. 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.

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.

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OK, but then you charged us separately for the ultrasound and the doctor's time, so you are essentially double-counting.

What about the nurses’ time? What about the time spent in the facilities? What about liability risk? The time spent by the doctor is not the only institutional decision-makinng cost that the hospital incurred.

It doesn’t seem obviously retarded to me to have both a per-patient complexity-weighted administrative charge, and also a per procedure/per doctor-hour charge. Invoices for complex professional services are incredibly dense like this in many industries.

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."

The answer is that the guidelines say that level 4 is when "more complex decision making is required" or a diagnostic test like an ultrasound is required, which is what they did. OK, but then you charged us separately for the ultrasound and the doctor's time, so you are essentially double-counting.

I haven't seen your details, but the complex issue could be the ED physician and the extra doctor's time was probably the radiologist. It's not double counting.

Yup. I mean, it’s bad alright.

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.

Many don't like this but you can't really function in our system without having insurance

If you were to attempt to function in the system without insurance, how would you go about it? Asking for myself.

When I was younger I went uninsured for a few years, and a few more on a catastrophic plan, and happily didn't have any issues. Now I'm older and married and my wife has a lot of worries about not being insured (I currently have full health care coverage from my job but I'm about to leave that career). Conceptually I think 'health insurance' is a misnomer the way it's typically used, that only high cap catastrophic plans actually constitute insurance, and frankly that I'd much prefer saving and investing my money instead of giving it to an insurance company.

However, anecdotally I've heard it's a real pain to get medical care if you show up and say you don't have insurance, and that you'll just pay for everything yourself. So, do you have any advice on how to do that effectively?

Health care sharing is a thing. It's worse than real insurance but you're just getting what you pay for there. The one that's solidarity something is better than the one that's samaritan's something. I am not the expert on these things or how they work but there's plenty of people who's main medical expenses are child-related who are very happy with them.

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).

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.

Those sound like arguments for price transparency, not arguments for the impossibility of determining pricing to the end consumer.

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)

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.

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.

That could be an argument against price transparency, but not an argument for the impossibility of providing accurate numbers. Even then, this point can be argued against, it's not like it's unheard of for regulators to tell companies which factors they're allowed to take into account when making their calculations.

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.

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?

That's just a restatement of your third argument, and it does not show how calculating the price is impossible. These sort of calculations take place in most industries all the time.

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?

That was my original question, if you remember, and you asking it makes no sense. For one, socialized healthcare is the opposite of "pay in and pay out according to who uses it". For another, how is the government supposed to allocate the healthcare budget, if calculating the prices is so impossible?

Developing accurate numbers is complicated, time consuming, and expensive and puts hospitals at financial risk due to insurance shenanigans.

Insurance is already calculating the relevant numbers, they can just show them to their customers / the public.

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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)

As long as these are reasonably predictable, you can calculate a price.

I don't think that's true at all. You can calculate an expected value, but 90%+ of patients won't understand that. If you tell them the price of a procedure is $2000 dollars, but the typical/median price is $1000 and the max is a million, how are they supposed to use that information?

My insurance charges all policyholders enough to pay on average $2000 for this procedure, or a copay of $2000 if we are imagining patient out of pocket. I’d say that’s rather the point of insurance. There’s some tiny chance of true financial disaster and they charge all of us a bearable portion of that small chance.

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If these numbers are well understood, I wonder if you could buy "procedure insurance" instead of general insurance.

As long as these are reasonably predictable, you can calculate a price.

I don't think that's true at all.

I'm sorry for being pedantic, but how does that mean what I said is "not true at all"? You literally just gave an example of a calculated price. Someone might not now a median from their ass, but you can tell them "just look at the expected value, bro". They can then use that information to compare with other providers.

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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.

prior auth reform

I am sad that you won't see this, because I am genuinely curious to find out what you mean by this. Like, it could mean anything. We could reform it in a way that is even pretty painful for insurers. Could make it basically mandatory for many of the things (at least anything that has some minimal level of denials happening), and require insurers to respond within certain timelines, electronically or whatever. Then, you'd have less uncertainty about what they'll want to do, and you'll have good information to give to your patients. I kiiiinda think that this isn't what you have in mind, and yeah, am just super curious.

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.

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