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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?
Why? The only reason they describe comes from their characterization of the insurance industry's response:
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
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:
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:
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:
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?
They are just sooo addicted to price opacity; it's ridiculous. The author is not buying it:
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:
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.
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:
Or, as I quoted above, the way the NYT journalist's surgery provider put it:
Or, part of the quote I had above from the old doctor-written NYT Op-Ed:
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'.
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