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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.
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.
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.
Oh no, you're bang on target. I'd know, being 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 than attempt to cure it with medication.
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.
I would've thought Parliament had enough C.S. Lewis fans to avoid this name.
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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.
And yet public health officials keep pressing for COVID vaccines for young, healthy adults and children.
Maybe there isn't such an effort ANY MORE.
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.
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.
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.
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.
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".
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.
Yes, which is why it's good marketing for boosters to claim any given new technology has a chance of curing it.
Yeah, that's the attitude that's making health care costs rise.
This isn't a single drug, it's a specific new drug for each patient.
It IS an intrinsic property of this pancreatic cancer treatment that they must be personalized.
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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.
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