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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.
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.
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