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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.
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.
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.
An issue that made be angry recently was that my kid's emergency room stay was upcoded from level 2 to level 4 because they wanted to take an ultrasound, which meant an extra $2k in charge, but then they charged be separately $3k for the ultrasound and $1k for the doctor's time. I asked, why is it level 4 when we weren't urgent, it took us 6 hours to be admitted? 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. The bot-like tier 1 billing support person did not understand this argument though, and since I already had paid the bill I had no leverage.
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.
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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.
I didn't see anything the insurance denied. Altogether, our insurance and ourselves paid
$8,500$9k for an ER visit that involved a six hour wait in a crowded waiting room, then a brief consultation with the doctor, a catheter insertion and lab tests, and an ultrasound. The bill seems totally unreasonable to me, there is no way I can get that amount by calculating their costs from first principles. They had to be overcharging me above costs in order to pad their overall revenue.Okay so two things going on here:
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.
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.
In this case, there is a pre-negotiated master charge list with a million cells in by code and by insurer. There must have been negotiation in agreeing to that list, but what we paid was the list price, the insurer did not do any negotiation to lower the chargers. I think this is a newer development, I remember ten years ago or so getting bills where it would say one charge, and then have a lower "this is what your insurer negotiated." But that is not how it worked for this bill. At this point, it looks like the cash pay rates are generally lower than the insurance negotiated rates.
One of the crazy things is that for a 3mo infant this is not actually how it works. We went to our PCP first, in fact, spent almost 5 hours there before finally getting diagnosed with a UTI...and then they sent us to the ER because our PCP wanted a catheter sample and she did not feel comfortable doing that, so she said we had to go to the ER, that was the only option. Our child did not have a fever, but did have a UTI that needed antibiotics, but the only way to get those antibiotics was an ER visit. From what I have read since then, the type of antibiotics they will prescribe depends on if the UTI is deep in the kidneys, which is why they want to do an ultrasound. We could have easily gone to an urgent care facility during business hours if that was an option, but that was not an option, so instead we spent 6 hours in a packed waiting room which was a hot-box of germy kids.
If our child was on telemetry and had people checking in on him constantly that may have justified and expensive level 4 or level 5 charge, but he was not. He was clearly fine and low priority. We were just waiting hours for admission and then after that many hours for for the ultrasound so we could get the antibiotics prescription.
I didn't mean your specific situation, apologies if it came across that way.
Those numbers should still have been negotiated with some bullshit juju thought right?
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.
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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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.
I'm not objecting to base charge for a level 2 emergency room visit ($700) which should have covered the facilities and the nurse time (which was very little). I'm objecting that they upcoded that to a $2400 charge while then itemizing and also charging for the things that supposedly triggered the upcoding (the doctor's time and the ultrasound).
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."
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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.
Just looked over my bills. We got itemized $600 for the radiologist, $800 for the emergency room doc. Then on top of that was the $3,300 for the ultrasound itself. Then on top of that was the up-coding of the ER visit from level 2 (which would have been $700) to level 4 which was $2,400. And then there was also another $900 for catheter insertion and $940 for labs. Everything feels over charged ($900 for a two minute catheter insertion..?) but it particularly galls me that they up-coded me from 2 to 4 because of the ultrasound and decision making and then charged us separately for those things.
Yup. I mean, it’s bad alright.
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