This weekly roundup thread is intended for all culture war posts. 'Culture war' is vaguely defined, but it basically means controversial issues that fall along set tribal lines. Arguments over culture war issues generate a lot of heat and little light, and few deeply entrenched people ever change their minds. This thread is for voicing opinions and analyzing the state of the discussion while trying to optimize for light over heat.
Optimistically, we think that engaging with people you disagree with is worth your time, and so is being nice! Pessimistically, there are many dynamics that can lead discussions on Culture War topics to become unproductive. There's a human tendency to divide along tribal lines, praising your ingroup and vilifying your outgroup - and if you think you find it easy to criticize your ingroup, then it may be that your outgroup is not who you think it is. Extremists with opposing positions can feed off each other, highlighting each other's worst points to justify their own angry rhetoric, which becomes in turn a new example of bad behavior for the other side to highlight.
We would like to avoid these negative dynamics. Accordingly, we ask that you do not use this thread for waging the Culture War. Examples of waging the Culture War:
-
Shaming.
-
Attempting to 'build consensus' or enforce ideological conformity.
-
Making sweeping generalizations to vilify a group you dislike.
-
Recruiting for a cause.
-
Posting links that could be summarized as 'Boo outgroup!' Basically, if your content is 'Can you believe what Those People did this week?' then you should either refrain from posting, or do some very patient work to contextualize and/or steel-man the relevant viewpoint.
In general, you should argue to understand, not to win. This thread is not territory to be claimed by one group or another; indeed, the aim is to have many different viewpoints represented here. Thus, we also ask that you follow some guidelines:
-
Speak plainly. Avoid sarcasm and mockery. When disagreeing with someone, state your objections explicitly.
-
Be as precise and charitable as you can. Don't paraphrase unflatteringly.
-
Don't imply that someone said something they did not say, even if you think it follows from what they said.
-
Write like everyone is reading and you want them to be included in the discussion.
On an ad hoc basis, the mods will try to compile a list of the best posts/comments from the previous week, posted in Quality Contribution threads and archived at /r/TheThread. You may nominate a comment for this list by clicking on 'report' at the bottom of the post and typing 'Actually a quality contribution' as the report reason.
Jump in the discussion.
No email address required.
Notes -
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?
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).
Adding to @ArjinFerman's response, most of these don't matter.
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?
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.
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.
Yup. The "Why should that be the doctor's job?" argument. You know full well that I don't care whose job it is.
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link