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At least hospital administrators pay attention to how much things cost.
In many cases, doctors literally do not know how much the treatments they provide cost. This means that they simply don’t do any cost-benefit analysis. They will prescribe an expensive brand-name drug instead of a generic drug that does basically the same thing for no reason other than because they heard about it more recently.
Why is it the physicians job to know what things cost? A hospital will literally have hundreds of employees whose full-time job it is to figure out what things cost and deal with insurance companies, who are always changing things constantly. Even a small practice will usually have 2-3 employees minimum who spend most of their day figuring that stuff out.
It's entirely orthogonal to providing good medical care.
We do cost benefit analysis all the time, but it is in terms of the risks and benefits of a given intervention, wouldn't you rather us be focusing on that?
I don’t know at what point this went off the rails, but you both eventually end up sounding like assholes. @ControlsFreak, you’ve been specifically warned for arguing with this exact poster! One or both of you needs to make use of the block feature.
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If you're not capable of doing it, then you need to figure out a workflow so that someone who is capable provides a price. This is a part of basically every other service in every other industry; it is not impossible.
To go to the auto shop example, you could equally imagine a mechanic-head praising the beauty and sanctity of the Art of
MotorcycleAutomotive Maintenance, and how carefully he considers the non-monetary risks/benefits of a given intervention, saying that in his view, the price is entirely orthogonal to providing good automotive care. He could be so educated and experienced that he thinks it would be an utter waste of his time to even put together estimates. I would say that perhaps he is right on all those points. I still want a price. I want it as a routine matter. Maybe he will have some customers who literally don't care, who have a unique, historical vehicle and a fat bank account, and they just want the artistic approach, damn the costs. But as a routine matter, I don't care how beautiful you think your orthogonal things are; you are running a service business where the customer needs to know the costs/benefits. It is doubly important in the medical domain for them to be informed of the costs/benefits if they're going to give informed consent.If you need to structure your workflow so that a different employee is up front assembling the estimate while the genius mechanic is spending every minute of his time on his craft, so be it. You have people that do that stuff anyway. Do it up front, not after-the-fact. Keep your patient informed. Just give him the damn price.
I'm curious as to why you think it would ever be in the best interests of the medical industry to provide price transparency.
Like, obviously they could develop ways to formalize price estimates and communicate them to customers. If anything, that's confirmed by the poor quality of the countervailing arguments in the thread below. But why would they ever want to?
Having the ability to inflate prices without reducing demand, because nobody at the point of consumption has any idea what anything costs, seems like a pretty sweet situation. Likewise, high salaries and various other forms of grift and waste across healthcare are made possible by the broader cultural perception that the industry provides priceless, sanctified Human Care Through Science rather than some mere grubby service like your hairdresser or auto mechanic. Giving patients the power to participate in rational cost-benefit analysis about their healthcare seems like it'd work out worse for every single level of the industry.
Total price opacity almost certainly is a benefit to the medical industry currently. As you mention, from the rest of the conversation, it's pretty clear that they have chosen this path, and it's likely because they think that it is in their own financial interest. I am extremely sympathetic to game theory arguments, and it is completely legitimate to ask why they would ever willingly give up their grip on the market.
The first, most obvious answer, is that it is the right thing to do. Doctors claim to hold themselves to high standards when it comes to informed consent. They are clearly failing miserably on that score when it comes to informing their patients about the financial parts of the costs and benefits.
Of course, one can easily observe that those sorts of considerations often get ground into dust upon first contact with the raw ability of a cartel to enrich themselves. So, a second possible reason would be if enough cultural argumentation is built up to force the conversation about informed consent and prices at a high enough level. Embarrass them, as they talk in circles. They will have to weigh the monetary gain against the loss in status as more and more people realize that they're lying and violating their stated principles in order to enrich themselves.
A third possible reason could be lawsuits to change the regulatory landscape. I've seen some lawsuits going on against hospitals who are using their boilerplate "consent to treat" forms that they use at intake to justify absolutely every charge that they choose to make, regardless of whether the patient actually agreed to that particular thing. We'll see if they go anywhere.
I described some additional possibilities here. One of the most likely possibilities is just that they are forced to change via regulation. This is not preferred, as the regulatory process is often a total mess, and it's not super likely that it will result in a truly coherent way of doing things, but when there is this much pent-up outrage at how things are currently done, it is entirely plausible that the government will just drop a bomb on them and force them to make some set of changes, regardless of whether it's in their interest, or whether those changes even make much sense.
As I argue in the linked comment, I personally think that the probabilities are trending in a way such that if they don't clean up their act, something is going to happen that is going to blow up the whole thing, with potentially highly unpredictable results. I mentioned similarly seeing the writing on the wall for the real estate and IoT industries. From a pure self-interest point of view, they have to weigh the value they would lose by voluntarily cleaning up their act in smaller ways now (in an attempt to reduce the probability of a regulatory bomb or something like that being dropped) against the expected value they'd get from a period of sticking with their guns until a bomb gets dropped plus whatever mess they get after.
Maybe I'm just a pessimist, but most of the industry-facing benefits of price opacity seem to entail a parallel set of benefits for regulators, legislators and nonprofits. If the meme that Healthcare is Priceless signs blank checks for producers in the industry, it presumably works the same way for bureaucrats and lawmakers, who get a free pass to accumulate power, expand surveillance, reward cronies and promote pet causes through selective disbursement of all that funding. And that's leaving out the large proportion of regulators/ lawmakers who are just literally in bed with parts of the industry, like the FDA folks who retire to take plum positions with Pharma.
I'm sure you could get that class to happily support selected instances of price-limiting legislation where it might hurt their political adversaries, but who's the constituency for plain consumer empowerment, beyond just Joe Q. Public?
Possibly so. I don't know what mess we're gonna get, but in the linked comment, I read the tea leaves that might be pointing toward at least something happening, even if it's a mess and not terribly coherent:
Public outrage can quickly boil to the point that "something must be done". Once it gets there, Sagan only knows what mess of a "something" we're going to get. Maybe the medical industry can consider banking on their regulatory capture enough that they can shape the output to at least not hurt them too much, or even to benefit them. But again, looking at how it's gone in other industries, I don't know that I'd count on it. I doubt it would be pure pro-consumer, but there's a good chance we'll get some mess of "something", which they might not super like. I bet the IoT industry wishes now that they had figured out a way to eliminate default passwords from the industry before, for example.
I sure hope you're right. But does there exist a historical precedent for any industry ever moving from "heavily bureaucratized, intensively regulated, ideologically freighted, opaque, inefficient and expensive" toward "lean, simple, transparent and consumer-oriented" in any meaningful way under a modern state? If so, I'd genuinely love to hear about it.
Hold your horses. I'm hoping for incremental change. I ain't nearly that hopeful, either. More likely, we'll get some bomb of other confused regulation, which might have some incidental pro-consumer stuff.
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There are multiple parallel problems here.
The cost is fundamentally unknown. It is reasonable to determine what the average cost of a thing is, but that is not helpful information because when we leave the average the costs can become profoundly immense. More people are upset with an estimate that is off by multiple orders of magnitude than by no estimate at all, and that will happen.
To torture your mechanic analogy, it's like if you go to buy a car and ask for a Corolla, but 5% of the time you get a Bentley whether you want it or not.
The average cost is not necessarily known to your doctor. If I'm your surgeon I know what my professional fees are and how long my average case takes. I probably know the billing codes used, if I'm business minded I may know something about the average cost of supplies, instruments, and equipment. However a run of the mill routine surgery requires a team of 40+ people between the office visit, PAT, pre-op, intra-op, PACU, and post-op. It is unbelievable how many hands are involved and it is incredibly difficult to keep track. You immediately start running into problems like "cleaning staff are a critical part of the OR and are a cost to the hospital but are not usually considered a part of the surgery, is that a cost or is it not a cost?" or "does this facility charge by the minute for anesthetic gases or use a flat fee" both options are viable, your anesthesiologist probably knows, your surgeon probably doesn't. Keep track of "costs" is a full time job with an entire department just for the OR. Your surgeon might be able to say "your surgery probably costs 10k" because they asked someone in a billing meeting what all the averages on the spreadsheets said, but nobody wants to have a 20 minute conversation about how much of an oversimplification that is.
Additionally that is fundamentally not the surgeons job and does nothing to improve the surgeons provision of medical care. We evaluate whether to perform a case or not based off of the medical risks and benefits, not the cost. This is part of why healthcare is expensive in the U.S. but most people prefer that to the alternative.
Doctors wear a lot of hats. Things like increased regulatory burden and the dance with insurance below mean that you have of multiple departments involved in figuring out how to deal with the above. We already do a lot of things like that slow us down and prevent us from actually spending time with patients. Making it worse is not desirable to us or our patients.
The cost is irrelevant, which disincentivizes processes involved in streamlining all these things and makes it useless for your doctor to know and be able to relay to you. Almost all procedures are paid for by insurance or involuntary charity care by the hospital, with a small rarity of actual self-pay. Getting insurance to pay for something involves complicated negotiations where they try and pay you less than "cost" so you exaggerate cost as much as possible in hopes you don't actually lose money. It is not uncommon for the payment mix to end up being something like medicaid reimbursing 80% of cost, medicare 85% and private insurance 110%. If you mostly care for medicare and medicaid patients you go out of business (which has happened a lot lately) or require government bailouts. This is why the sticker price is so insane, and hospitals will almost always drop 90% of the bill if you end up being cash pay. You have to negotiate with the insurance company and that involves the "official cost" of a gallbladder removal being 100k instead of 5k or whatever.
A surgery has more in common with a government procurement and bidding process than getting a car repaired.
Even more simple things like an office visit are a pain in the ass to figure out. Unless you are doing very specific types of PCP practice or outpatient cash Psychiatry you are taking insurance. Therefore I don't know what the visit costs. I know what my billing team will try and charge for my time, they'll use the specific office visit billing code, I'm told to make sure to put X and Y thing in my note so they actually cover the work I did, but then I know that even the insurance company is supposed to pay for that code they'll make a big stink about it and require hours of the billing teams time going back and forth to make sure that its not worth it to actually get paid for that, even though the other insurance company always takes it if I put in X and Y, so my office staff will adjust the coding and bill you for the down coded visit even though that's not what I did and that's somewhat illegal, and your sister will get billed the actual billing code because she has "better" insurance.
All kinds of asinine shit like that happens for the most routine interaction with healthcare.
This is why psychiatrists are like "dude just pay me 100 an hour and we are good" and why there are now multiple forms of primary care that avoid working with insurance.
"What's my rate for a visit" is never a viable question because every insurance company pays me differently and its constantly changing year to year and I'm effectively only paid for by insurance.
As minimum they should be obligated to answer yes/no questions like "is consulting with this specific doctor covered by my health insurance"
If that is too risky to answer I guess they can insure themselves.
Or force health insurance companies to make legally binding answers.
So the way this works is that for things that are planned (like a routine surgery or an office visit) you will give your insurance card to the team that works with that physician and they will figure out if the planned services are covered. If they are? Great. Easy.
Immediately this runs into some problems.
What if you go to the office and the doctor wants to perform an unplanned mild procedure? Do you want to come back a week later after insurance has been worked out or just get it done? I have literally seen patients been given this option and then forget about it when the bill comes.
What if you didn't plan going to the doctor? Your anesthesiologist for your emergency surgery may not be in network, but this is not planned you get what is available. The insurance should be forced to pay for this, but they are lobbying to not.
Healthcare delivery is a 24 hour problem. Insurances are not generally open 24 hours. This limits the ability to contact the insurance and ask if something is covered. Plenty of practice environments are open outside of insurance hours even for routine things. Sometimes patients spend extra days in a hospital waiting for insurance to approve the next phase of care.
Now you might say "well listen, just tell me if this DOCTOR is covered." Some places will have a website that will tell you if a doctor is in network or not. Sounds great right?
Well no, just because a doctor is in principle in network doesn't mean they actually cover anything that doctor does. They might be in network for emergency care, but not routine care, or reimburse less than cost for a given procedure so performing it is not financially sustainable. It's not uncommon for certain types of procedures to just not be done in non-emergency settings because insurances won't pay more than it costs to do the thing.
Lastly even if you get something done that is covered, with a doctor that is covered, and you checked in advance with your insurance to make sure that it was covered...sometimes they just won't cover it anyway. They have all kinds of random excuses and often this can be addressed by some combination of patient and physician appeals, but:
We don't know if something is covered by insurance because 5% of the time they decide not to cover what they said they said they would.
*I don't know the true number here it is probably wildly variable on region, insurance, and specialty. United being notoriously bad about this.
You are replying to short post that included "force health insurance companies to make legally binding answers".
Yes sorry, I though you were focusing on the doctor side of things which is what the rest of this mess is on about.
If you want to laser focus on that we still have problems, even as an insurance critically person I admit it's fair for them to go "okay I'll pay for it but you have to justify it correctly" because that prevents various bad actors in healthcare provision (including doctors) from doing sketchy stuff.
It's pretty fair for them to ask us to put into our note our medical decision making and only pay if it is justified.
But then they play games with what is required to justify it.
Mandate legally binding answers and you get "yes we will pay for this service if it is documented correctly." That is necessary but has chasm wide potential for abuse (and is generally what they do now).
Even if you were to hand wave away those problems that doesn't address after hours approval, delays in approval, surprise billing concerns and so on.
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This is false, as we've already discussed.
I don't care whose job it is. Every single other industry has figured out how to do this basic business practice in a decent way, and many times, there is division of labor.
This is the most pernicious, absolutely atrocious lie that is the core reason we have such a disaster of a medical industry. You cannot believe that anyone will read this entire thread branching from the OP and think that this a remotely reasonable response. Sure, if we just accept that everything is broken with insane prices that don't mean anything, then nothing means anything and we're doomed to dysfunction. We can do better.
"Your surgery will cost anything between 4,000 and 5 million dollars, as those are the minimum and maximum recorded prices we have charged in the last ten years." Is not a satisfactory answer. "The median price for the surgery is 5,000 dollars" is not viable either because patients will sue if it's wildly off that. Either way the cost doesn't matter, it's almost entirely removed from how much the hospital gets paid or collects.
This like a governmental procurement process. The person who has knowledge of everything is the head of the OR or billing department, not the person who is on the ground doing the thing. You can't have the head of the FBI come down every time and explain what the cost of an investigation is, the individual agents sure as hell don't know, why would they need to?
Healthcare systems (including doctors) are the victims here, victims of a predatory insurance industry and unhelpful overregulation that needs to be replaced with functional regulation or needs to be understood to be reducing the amount of and increasing the price of care. Don't blame us doctors and nurses are leaving the field and hospitals are shutting down because insurance companies are winning the battle. Blaming us helps them collapse the system faster.
C'mon man, you did better in the linked comment. You already gave a vastly better answer. Did you forget what you said yesterday?
You cannot seriously think that every other industry that has solved this problem requires the head of their billing department to generate every price. How do you think other industries solve this problem?
I'm not blaming you. I'm just asking you to do basic business practices in a decent way, just like how everyone else does. You can do this. You really can.
I'm confused as to how you see his earlier estimate as better at all, much less vastly better. Are you saying you'd be happy with a price tag which consists of the range $4000 to $1500000?
The chance of hitting the $1.5m upper end makes this price tag functionally identical to "idk, could be anything" for most people. Unless you have millions in assets then 1.5 million is already enough to ruin your life and put you in a place where you're probably staring down bankruptcy. Whether the cost caps out at 1.5 million or 1.5 billion is irrelevant to people who can pay neither of those numbers.
The important point is the conceptual realization that patients cannot consent without being informed. It's called informed consent. Part of being informed is being informed about the costs. Obviously, there is going to be a knowledge gap both in terms of the medical and financial costs/benefits. When it comes to medical cost/benefits, people mostly acknowledge the knowledge gap and say that it's important for doctors to find a way to explain the situation as they can to the patient. There is obviously a range of quality here, but the answer is that you have to try. When it comes to the financial side, they instead just say that it's impossible. They give up. They don't even try. (It's just a coincidence that doing this is in their interest.)
His prior answer gave a probability attached to a known unknown, conveying the information known by the doctor in a way that is very representative of the doctor's knowledge. First, it is obvious that they can do this sort of thing.
Second, as to the question of comparing the quality of the answers, suppose you were considering playing a lottery-style game. One just told you, "The range of payouts is between $5k and $1.5M." A second told you, "The payout is about $5k with about probability p, and the payout is about $1.5M with probability 1-p." Which of these answers do you think is better quality information? Which of these answers do you think is more helpful in analyzing whether you would like to play?
Third, the lingering question is whether/when it matters. It will obviously depend. It will depend on the dollar figures; it will depend on the probabilities; it can also obviously depend on how the individual's personal insurance is structured (common factors would be deductible, co-insurance, and out-of-pocket max). From there, we have a several-dimensional parameter sweep. We could sit down and generate plots. I'm sure we would see tons of regimes where having the information is basically useless. But I'm also confident that we would see tons of regimes where having the information is useful. I'm sure the good doctor we are talking to can come up with plenty of individual examples off the top of his head that are in the regime where it doesn't matter. Don't care. There are almost certainly also plenty of examples where it does matter; I would venture to guess that, actually, for the vast majority of regular, routine decisions, it can, in fact, matter. The standard party line is to just not even try, in any case, because there might be other cases where it doesn't matter. That's absurd. Moreover, it betrays a lack of understanding of economic thinking. There are always non-marginal cases. In no other area of economics do we say, "There are some extremely high/low value producers/consumers, and since their behavior won't be changed by [alteration to the price system], we should just completely blow up the price system and abandon it." Economists push back on this shoddy reasoning constantly. Sure, there might be someone who just loves eating exactly one apple every day so much that even if we blow up and get rid of the price system for apples, just don't tell anyone how much apples cost, and have them paid for via some complicated mechanism, they'll still buy exactly seven apples every week. Who cares? The price system is there for all of the other cases.
The challenge to someone saying that we should never talk about prices because they never matter is to actually show that they never matter, not that there are some cases in which they might not matter. I think they probably do matter to a hell of a lot more cases than they're willing to admit.
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Healthcare is like aviation and nuclear in that bad outcomes are considered unacceptable, therefore there is a ton of regulation and complexity that does not exist in other industries, there is also more variation in health care than aviation and nuclear because people's bodies are variable and much of the more complicated stuff cannot easily be standardized.
It is its own entity not like other economic segments and intuitions brought in from elsewhere have a tendency to be incorrect. This is why companies like Amazon, Google, and Apple all tried to start healthcare projects and bailed out. This is why PE firms buy hospitals, crash them and then just sell the land. This is why Theranos happened. Healthcare doesn't work the same way as everyone else. Maybe it should but it doesn't.
Part of that, and something you really need to simply address is "who the fuck cares about the prices" the prices are made up, they don't matter, insurance pays and insurance NEVER actually pays the price. There is no value to you in knowing what the price is, and as given in an example in my last post sometimes the prices DOESN'T EXIST.
There is no cash value for my professional time if I don't see cash patients and what the insurance company will give me for my time is a big fat question mark.
Look, I get it. You want it to be one way. You want to just keep everything the same; just stop all the change; just go into work, do a good job at doing your job, close your eyes to any dysfunction and make no changes to your mindset concerning the entire conceptual schema of the industry. That's fine. That's natural. Parts of it may even be commendable.
...but as the old saying goes, things that cannot possibly keep going the way they're going, won't. Change gon' come. I've seen this in industry after industry after industry. This is an industry that just had two different bills passed by two different congresses and signed by the last two presidents (one of whom is coming back in and may be interested in taking another bite at the apple) specifically because this stuff is a problem. The purpose of this entire thread is because a notable CEO was shot dead in the streets of NYC, possibly because of frustration with these problems; news outlets are reporting people cheering this. It's not always regulation; sometimes it's in other forms. Sometimes, the industry cleans itself up. Sometimes, there's just a shift in the case law. Sometimes, there's a disrupter. Sometimes, new regulations get dropped like bombs. And I get it, that last category is scary. I don't like a lot of new regulation. You know full well that I'm aware that it is often done shoddily, with all sorts of unintended consequences. This is the least-preferred solution in my mind. But everyone knows the medical industry is broken. Everyone knows that it can't keep going on forever without change. You know that it's broken when you say:
I've heard industry after industry swear up and down about how unique they are, how they have to do things differently, how they can't possibly change things. A silly little example from the last few months is real estate. Oh Sagan, the kicking at the goads, even after the details of the settlement became clear. You should have seen the levels of broken people's minds were; how they were constantly talking about ways to try to get around the new rules, how they simply could not conceptually wrap their minds around the fact that they couldn't just operate the same way that they always had, how their industry is a special snowflake and their special needs will always shine through. You saw some of the smart ones figure it out reasonably quickly, and sure enough, they started doing the obvious things to follow the new incentives and improve their business. I'm sure some of the folks who kicked too hard or weren't smart enough to figure it out or were simply broken by the conceptual change are struggling right now; some might already be out of business.
Change will come, no matter how unique you think you are. You really have an opportunity now. You can change your conceptual schema, evangelize the change in mindset, and begin to fix what you can in your corner of the big problem. Maybe it'll be a lost cause for the purpose of avoiding some dumb regulation, but that's your opportunity. I'm just sounding the warning, like I did long ago for IoT. We saw how that worked out when they didn't heed the warning, banking on swearing up and down about how unique they were and how things had to be different for them. They probably liked the regulation they got less than they would have liked the alternative opportunities they previously had in front of them.
So, in the spirit of helping you get a head start, a leg up on your competition for when change comes, so that you can adapt, optimize, and make bank, rather then ending up broken, conceptually lost, and possibly out of business, let's really think about what you can do. You gave an answer yesterday about the cost of a gallblatter removal. Perhaps you forgot that answer today, but I'm guessing you didn't. Think about your previous answer; what was wrong with it? I liked it; I thought it was pretty good. If you didn't forget it, I sort of have to believe that you consciously or unconsciously chose to change your answer to a less good answer. Perhaps reflect on why you might have done so. What were your motivations in trying to be less helpful? How do you think it will affect people's (possibly including potential customers') impression of you as a person or as a possible topic expert when they see that you are choosing to be less helpful than they know you can be? How do you think the mindset of choosing to be less helpful will affect your business if/when change is imposed on your business or industry?
Additionally, I suggest you seriously study how other industries manage to solve this problem. All of them do it. There are a variety of solutions. Can you think of any? If the only one that you honestly can think of is to have the head of the billing department personally perform every single estimate for every single procedure for every single patient, how do you think that will affect your business's ability to adapt to changes? If regulation comes, could your lack of insight into how these problems are typically solved leave you lagging behind the competition in adapting to the new environment? Could it even pose an existential threat to your business?
I suggest you consider these things, because some of your competitors will. They will not only survive and make money; they will thrive and eat your lunch. You have a great opportunity now.
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It seems like the natural control group is veterinary medicine, which is fairly cost conscious by nature. Veterinarians have similar education requirements. What's the difference between veterinary medical costs and human medical costs for routine things(let's exclude end of life care for obvious reasons).
That should be a natural ceiling to how much of healthcare costs are inflated by cost-insensitivity.
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Doctors will also just blithely lie to you and make stuff up. They'll tell you to your face, in the exam room, that something is totally covered, but as you say, they have no idea whatsoever. You have to either force them to have someone actually verify it (which will annoy them, as they'll view it as just a waste of their precious time), or roll the dice and hope to not get slapped with a huge bill after the fact (that could be literally anything, could be gigantic enough to make whatever the service is completely not worth it to you).
I've said it before, and I'm becoming more obstinate about it; the entire medical industry is absolutely addicted to complete and total price opacity. This is only one of the many dysfunctions, but it's a big one. Forcing them to put their prices up on some website, in a way that would require you writing your own JSON or whatever parser, make your own interface, and still not be able to figure out what the price is because the doctor can't even tell you what the procedure code is... has simply failed as a "price transparency" law. I would be open to literally any other solution that anyone can think of, but I can't think of any other than simply forcing them to give you a price. Could declare that patients cannot exercise legally-valid informed consent to a procedure unless they've already been provided a price, in writing, for example.
EDIT: Forgot to add that when you call up the billing department to ask, "What the hell? I thought this was supposed to be covered?" they'll just bluntly tell you that the doctors don't have a clue and that "they probably just guessedsorrybut not sorry enough to have you not pay this".
I'm not sure I fully understand this, even a car mechanic won't give you a price up front, they'll give you an estimate, and sometimes, even with a machine, a repair doesn't go the way they expect, and your bill is higher than the estimate. Are you asking for medical care to have set, up-front pricing unlike car repair, or are you saying their estimates are significantly worse / harder to get?
This bit. They won't even give you an estimate (or they might just lie to you). Sometimes, they'll claim that it's "impossible for them to know" (that's a fun one to get into; they try to hide behind the fact that an insurance company will be involved; just wait, I'm sure someone will try to jump in here and claim this). And this will be the case even for many procedures that are pretty standard, without much likelihood of something happening.
I'd be perfectly fine with the same sort of, "Looks like you've got a bad CV joint; we're gonna replace that, and it'll cost this much," with an always-implied, "...and if we get in there and see something else, we'll let you know." Just tell us what you plan to do, what you plan for it to entail, and what the price will be for your plan.
I mean it is impossible to know. You know how much an average thing costs more or less, but a bad outcome or routine complication can make the cost 10x or 50x, or more very very easily, and that's just with the planned treatment.
If you find something incidentally that needs management then you start getting into the territory of "oh yes, you could later make a case that not treating this immediately led to the patients death and lawsuit" or "anesthesia is bad for you and has excessive risks, doing it now while the patient is under will improve recovery time and decrease overall costs." Costs are way more complicated than is typical in medicine because people have more variety than manufactured products.
And that says nothing about charges, your insurance company can approve everything or nothing for a variety of reasons that are constantly changing and may be appealable or not appealable.
Healthcare providers can't easily predict what the insurance company is going to do because of enemy action, and many things are not practical to be done via cash pay outside of sketchy situations because if anything goes wrong the patient is on the hook for a bill they can't pay and the hospital has burned a lot of resources.
Right on cue. Thank for the evidence, so others here can see.
This is all distraction, akin to a mechanic saying, "Yeah, it'll cost you $X to replace the CV joint, but when we get in there, we might see something super major that we didn't know about that could be $10X," but instead saying, "It's impossible to know." Sure, but you can still tell me how much it costs for your plan to replace the CV joint. That's not impossible to know. If it's a "routine" complication, this can be pretty easily estimated; it's routine, after all. I've had a grand total of one provider do exactly that for me, up front ("Here's the base charge for our planned procedure, but we see X a fair number of times when we get in there, and if we see that for you, we'll do Y, and it'll cost $Z.")
Certainly, issues can arise while a patient is under anesthesia, when it is impossible to consult with them and get further consent for further charges. I see nothing wrong with that. But when a patient is conscious and coherent prior to a procedure and you have a planned course of action, you can provide a price for the planned course of action.
Oh well. Don't really care. You can still give a price. You have both a list price and a negotiated price. You have my insurance; you made me give it to you when I walked in the building. You know which list to look at to find my plan's negotiated price. Honestly, if you're at all worried about it being denied (and even if you're not), you probably should just provide the patient both prices. They should be informed about both what it will cost if their insurance accepts the charge and what it will cost if the insurance denies the charge. That is all important information that could perhaps lead to a conversation about whether the procedure in question typically has much risk of being denied and why or whether they'd like to get a pre-auth, etc. Things that are relevant once you realize that patients can't really have informed consent1 to the costs/benefits of a procedure if they have literally no clue whatsoever as to one of the significant aspects of "costs". This is an excuse for choosing to not give them the prices, not a reason why you can't.
(Disclosure, I used to work at a shop long ago, and I would literally call, with a phone, different parts stores to get quotes for parts in order to give the customer an estimate. It's much easier for you, because you've already negotiated an agreement with the insurance company; you've already signed a copy of the list of prices that you've agreed to.)
1 - On the theme of informed consent and anesthesia, the considerations here are very similar to any other costs/benefits of any procedure. Yes, if they're under or unconscious for some other reason, they can't really consent to the price of an additional procedure that might need to happen once you discover something, but they couldn't have regularly consented to the non-price costs/benefits either. So yes, we have special considerations for those cases. In literally all the other cases (most of them, TBH), just give them the price.
I don't know how many times I can tell people that medicine isn't like other fields.
A gallbladder removal can cost say roughly 5,000 dollars or 1.5 million. Sure the latter is 1% of the time, but you need to plan around it because it's a regular occurrence with the numbers involved.
We don't know what is going to happen, and if we told patient before they went under that they'd be paying 5k and woke up to a million dollar bill....that's not better.
Magnifying this is the fact that nobody knows what your insurance will pay because your insurance breaks the rules and makes shit up all the time. Regulate them better, most things are getting paid for by insurance anyway.
This seems to be like something you can tell the patient. I mean, you just told me. Why can't you tell them? Why can't you plan around it?
There's clearly a category of unknown unknowns, but you're telling me that you have extremely known unknowns, such that you can spout the dollar figure and the percentage incidence off the top of your head. All I'm asking for is that when you have such a well-known unknown (such that you already have to "plan around it"), you should discuss it with the patient.
It's like you didn't even read my comment.
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What mechanic are you going to? Every mechanic I've seen has standard prices based on hours worked and cost of parts. I mean if I bring in a car without knowing what's wrong with it, yeah the cost of "Make this car work again" is unknown. But with a known problem the cost is fixed and they can tell you the exact price to replace a transmission, change the breaks, swap out a strut, you name it.
They might have fixed prices but things don't always go to plan. Maybe something goes wrong and it takes them four hours to get at some part of the car, instead of one. Maybe they find (once they get in there) that the problem isn't just with part A, but also part B. It isn't typical that the final bill exceeds the estimate, but it isn't unheard of either. Diagnostics and repair are not an exact science and shit goes wrong sometimes.
I'll also chime in here that this is not how most auto shops work. Probably not all of them; who knows what Jim-Bob is doing up in the hills. But most places are "flat rate" shops. They list their labor charge as $X/hr, but the way they figure out the amount of the actual charge is not by setting a stopwatch for when the mechanic starts/finishes the job. The history here is that many mechanics would get paid a direct portion of the shop rate (say, P% of the $X/hr that is billed). A lot of places still do this to incentivize the mechanic to get more stuff done and make the business more money (usually the final pay being determined as the minimum of either their labor charges for the pay period or a different hourly rate for on-the-clock time; e.g., they could get paid $20/hr for on-the-clock time or $45/hr of billable labor).
But obviously, it would be dumb incentives for them to be able to start a job, lollygag, take an extra few hours getting it done, and rack up the money. Instead, what the majority of shops do is just use a "book" (a computer these days, for sure) that estimates how long it would take an average mechanic to do that procedure on that car. That determines how much they quote/bill the customer... and how much the mechanic will get paid for that billable labor. This is extra incentive for the mechanic to work hard. If he can be more productive than the average book rate (e.g., he can get a three hour job done in two and a half, then start another job and rack up more billable labor hours), he can make even more money.
I will admit I have no insight into the inner workings of auto mechanics, as I experience it only from the customer side. I was speculating as to what might happen, but I can say that I have had auto shop bills come in higher than the estimate. So whatever the cause might be, it does happen.
Of course it happens. Most people are mostly okay with it happening sometimes, because they got an estimate, were told what the plan was and what the estimate was based on, were able to make an informed decision, and then were told what happened and why the charge was higher. Often times, we would call people when we ran into something that we saw would increase the price and tell them what was going on and if they had options. Many customers are price conscious, and you had to be communicative. If you were, and you made sense in your communication, they're mostly okay with it.
Contrast with the medical industry. Most consumers aren't nearly as price conscious, probably in part because they hardly feel like it's even an option to be1. (There are other reasons, more cultural, but one would have to get off on a tangent about Robin Hanson's terminology of the sacred/profane.) They just go to the doctor, do what he says, and magically a bill goes through their insurance company... and maybe they have to pay some of it. If they bother to inquire, there's a half decent chance they'll be told that it's impossible to know anyway. Every part of it is completely the opposite of the pro-active, communicative pricing information that even only half-decent auto shops provide. If we could get the median medical provider to have price transparency resembling the 25th percentile auto shop (with similar allowances for some situations to happen sometimes where final bills are higher than the estimate, but with similar communication), I'd be super happy. I think this is pretty possible to do.
1 - Yes, and some patients are in situations where they really really really aren't price conscious at all
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Fine, but don't pretend that an edge case in car repair being the norm in health care makes them equivalent.
I mean, it's not the norm in healthcare. It's uncommon to have the kind of issues @ControlsFreak describes - I've never had it happen, and if I think to my wider social circle I can think of perhaps once that someone I know has run into that. I think it's perfectly fair to compare an edge case in healthcare to an edge case in auto repair.
You've always had them provide a price up front? You've never been hit by a surprise? This seems unlikely, especially because this is one of the most common complaints. We've had multiple laws passed in recent years specifically attempting to go after this problem in response to public dissatisfaction, but they've been kind of half-measures (the surprise billing law about out-of-network providers at in-network facilities/emergency care and the price transparency law that only resulted in some incomprehensible websites).
This comes up a lot on reddit, because a lot of people are frustrated with how often it keeps constantly going on. A lot of those times, you have doctors showing up claiming that folks just don't understand; that they don't even know the price of things; some say it's basically impossible to know.
I haven't gotten prices up front (but I don't ask either). I have never been surprised by "oh actually this isn't covered, sorry". My insurance gets billed, either they pay the charge or (if I haven't met my yearly deductible yet), I do. Everything works smoothly.
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