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Ultimately the lack of price transparency is not something that should be relevant to patients, you functionally need insurance in the US and every having to do with payment outside of your insurance fees is a total nonsense dance between various entities. If your ultrasound costs 300 dollars or 350 dollars shouldn't be relevant if you are paying 0, 5, or 20 for the thing.
It's certainly annoying not to know stuff if you are a curious person, but I'm not really sure it is ever relevant.
You really cannot be serious. You do not get to decide that it is never relevant. There are many many many stories of it being relevant (some on the storied pages of the Times). You may be in a narrow slice of a specialty where it happens to be rarely relevant, but across the entire swath of healthcare services, with the entire swath of different patients, with different insurance terms and different financial situations, it's going to be relevant often enough. At times, you've even admitted that it "is viable for some services". It beggars belief that you can say with a straight face that you think it is never relevant.
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The problem is for example, me going for a colonoscopy, I contacted my insurance company to ask how much would be covered. They said if my doctor coded it as preventative (i.e. I was just being screened due to my age) it would be essentially entirely covered, however if it was because the doctor was trying to find a diagnosis it would be 50% co-pay. So I asked well how much would that be, and they said depends on your doctor and their facility but somewhere between 3 and 10,000 dollars, perhaps more.
Now the problem is I was having symptoms, which is why my GP referred me to a GE (the only GE I can get into see inside 3 months in the area as it happens) in the first place. So I ask the GE how they are going to code it and he says, no idea, you'll have to ask the front desk staff who do my billing. So I ask them and they say, depends on what the doctor puts in his notes. If he mentions pre-existing symptoms we'll code it as exploratory. So I ask how much that will cost and they say, we have no idea, so I ask how much does it usually cost OOP on average and they mumble around a lot and eventually say 2-4000 dollars.
So I get the colonoscopy because I am feeling pretty bad, and I get diagnosed with ulcerative colitis, they code it as exploratory and I end up having to pay about 4 and half grand out of pocket (most of which as it happened went to the facility and the anesthetist and the lab that analyzed the removed polyps and tissue, it appears). Now luckily I can afford that, because I am a responsible person with a decent paying job. But I asked my doctor what would have been different if it was just a routine screening and he said nothing at all. He would still have checked polyps in the lab, he would still have done everything he did, except I wouldn't have had to pay more than 50 bucks. And of course he is recommending I get a colonoscopy every 6 months because I am at elevated risk of bowel cancer. Now my GE doctor says he does 5 or 6 colonoscopies a day. It is essentially the main thing he does, and my insurance company is the biggest in the state. There has to be a better way than telling me, well it can be somewhere between zero and unknown but probably between zero and 10K, for a procedure which is pretty well defined.
Reminds me of "How to Do Health Care Right" by The Dreaded Jim:
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Thank you for providing a good example, last pile on about this nobody gave me anything to work with. I'm assuming in this case that your plan is a high deductible one and once that runs out you no longer pay co-insurance right? (If not... I didn't think that was legal anymore?).
My mental model of the deductibles is that if anything remotely complicated happens you'll burn them instantly but it appears that isn't the expectation for most people. Probably because in hospital medicine if you so much as sniff a patient they've been charged an arm and a leg but our population on this board is mostly young people who aren't utilizing medicine too much with related expectations.
That said 25% your doctor is being lazy asshole for not trying to work with you, but 75% he's employed and not in charge which is pretty common these days. He can write his note however the hell he wants but the backend people are just going to do something else. He doesn't want to promise you anything because you'll take it at face value (because doctor!) but then somebody he never talks to in a building he's never been to changes some shit and you go form 0 to thousands of dollars.
Your story smells a little more lazy asshole doctor and I'm sorry that happened to you, during my training most of the attendings I worked with would try and save patients time and money, even when a little tiny bit fraud was involved to make that happen. I tried and remember that and encourage the people I train to remember that. I don't do any fraud though. Obviously.
Asking the doctor to know what somebody else is going to do (in this case, sometimes it's for knowledge he doesn't have) isn't super reasonable but that's a lot of this stuff at times.
The whole system is arranged around insurance plans where this kinda stuff never really applies but it hurts those in edge cases.
Also your plan sounds shitty.
Also also: shit. UC sucks. Follow the screening recs they give you. Seriously.
I don't really blame a doctor for not being willing to commit fraud for me. I also don't really blame him for the musical chairs of billing. He is just a cog in the system (an important one, but a cog nonetheless), but the system is just pretty terrible for people who don't have great insurance plans (which is a lot of people) and it is also pretty terrible at being really clear about what things are likely to cost for those people, and to decide about trade offs.
As an example my dentist has a hook up straight to my dental insurer, so once he does my check up and decides I need a filling or a crown or a root canal or whatever (or all my old NHS fillings replaced as he thinks they are causing my teeth to crack). He can put in various treatments and get an exact OOP price for each option, right on his tablet. "I recommend a root canal and a crown but we can make do with a filling if you cannot afford it." He still has to tell me that if something goes wrong, it might cost more, and he can't for emergency treatments, but he can tell me the exact expected cost of routine treatments that he does every single day.
Because like it or not cost should be part of the treatment discussion. You want to put me on X but it will cost me 500 dollars a month I don't have or Y which is less effective but I can afford. I will have to make a choice, and I cannot do that without someone going through both the benefits of each medication or surgery and the costs, whether that is risks, side effects but also actual dollar amounts are likely to be.
To be clear Doctor's cannot fix that alone. These are systemic problems caused by interactions of insurance companies, hospitals, laws, regulations and yes doctors. But I do think doctors SHOULD be trained to look at costs as one part of the treatment model. If you want your patient to get a scan, preferably an MRI but a CAT scan would be 50% cheaper (in cost to the patient) and 14% less useful, then patients should be having input into those choices. Even if you can't tell me the exact difference , proactively giving advice on better vs cheaper options is helpful.
Now of course, the patient will probably need to sign off on something to protect you as the doctor ,so they don't come back and sue you for using a cheaper less effective option. But that is solvable.
As for me, well my insurance company refused to cover the first two drugs my GE prescribed anyway because they are new and not on their coverage list, and they will only consider covering them once the older (and cheaper) drugs that are on the list have shown to be ineffective first. Which objectively is an entirely understandable choice on their part. But then it takes another 2 weeks of back and forth to establish what drug they could put me on.
But again an interface with the insurance company where it will immediately tell you what is automatically covered and what is not, is not rocket science. My dentist can tell me what material I am or am not covered for in a crown in 30 seconds. Some of these problems are systemically solvable, even if more complex and emergent costs could not be. My doctor says there are 6 drugs he commonly prescribes for UC and Crohn's and the majority of his patients (who have private insurance) are on one of three insurance providers. Even if all you cover is those 3 providers and those 6 drugs X will cover 1, 2, and 4, Y will cover 2, 3, 5, 6 and so on, you're not only going to save your patients time, you will save yourself time, because now I don't have to keep coming back until we find a drug you want to use that is covered. You'll know for United Healthcare to not bother with 1 and 2 until you have tried 3 and 4.
Doctor's can't do it on their own, but maybe a bit more awareness that pressuring for more transparent costs and the systems that would allow common treatments and insurers to be checked to be Doctor facing (rather than handled entirely separately) would be helpful to both patient and doctor would be useful. Cost is an integral part of treatment decisions, for many, many people, and the current system is simply not set up to facilitate informed choices on that.
That isn't your fault or any doctor's fault. But as a patient advocate, I don't think it is something they perhaps consider enough.
Fundamentally I'm not against greater cost transparency if you don't break something else in the process, but some of the difficulty serves a purpose (mostly in the hospital vs insurance war).
The other piece to keep in mind is that this is pretty much how a bunch of the expense of our system came to be. Someone had a great idea for how to improve the system. The idea had uncertain benefits and costs. It got thrown out there and ended up costing more than it benefited. I'm not convinced the costs associated with cost transparency (one poster elsewhere suggested that hospitals eat the loss of cost overruns in a surgery for instance) end up being better once you add everything up. You should be damn sure.
I quoted the above part because fundamentally the rest of the system prevents us from being too cost conscious. "Here are the benefits and risks of your gyn surgery written on a paper. A routine complication is the ureter being severed. It happens. Nobody necessarily makes a mistake but it happens. Actuarially it will happen. Please don't sue us. In fact this paper says you can't sue us." Result: lawsuit. "You could die if you leave the hospital. No really your arm is literally falling off and you will die from infection within 48 hours I can fucking see the pus oozing out of you Jesus Christ. Fine sign this form saying you are leaving against medical advice and won't sue us." Result: lawsuit. (both of these examples are making fun of specific things I've seen and aren't really real).
More centrally you see things like "meemaw is a fighter, use enough resources to build a jet fighter to try and save her life even though she is 97 or we are going to sue the shit out of you."
You have to revise a lot of other things before that becomes viable.
We try and do things where we can like offering a slightly less effective but much cheaper medication.
Sure, I think that most doctors probably do what they can within the system as it is. But a lot of patients are unhappy with the system as it is. And by the sound of it many doctors are unhappy with the way it is as well.
And while extrapolating from a single act is not a good idea, the number of people who were somewhat or actually supportive of the out and out murder of an Insurance CEO may indicate that something needs to change.
So I suppose the question is, from someone within the system if you were told: "The people are about to rebel and start executing insurance CEOs, hospital CEOs, doctors and more, and we must change to make the system more transparent and cheaper and to not make Drs work insane hours, we don't have a choice" what would you recommend? You have been endowed with decision making power and insurance CEOs are so scared they will follow your decisions. What would you do?
Previously I've advocated for tort reform as a way to reduce defensive medicine and cost of care, but elsewhere in one of these threads it was pointed out to me the complexity of addressing that (fixing things is hard, who knew haha).
There should be a way to reduce administrative burden - capping profits more diligently and reducing overhead /forcing institutions to be lean should be feasible. Health insurance companies and healthcare admin are both hideously bloated and didn't use to be that way, and I'm sure well intentioned regulation is what caused the problem.
In my mind it is fundamentally the same question as "lets make college cheaper again" similarly hard to fix but what works for one will probably work for the other.
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I'm not SSCReader, but for a different example:
I have the low-deductible buy-up plan. Deductible is 1500 per person or 4500 over the whole family, for in-network providers. This is not the same as an Out of Pocket Maximum. When the deductible is hit, insurance starts paying 50% of the costs until the Out of Pocket Maximum is hit. Individual Out of Pocket maximum is $6,850, over the whole family it is 12,000.
I had the ill fortune of reaching my family's Out of Pocket Maximum a couple years back. Three young kids hospitalized with complications from a bad combo of RSV and Parainfluenza. Two of the kids spend 2 days in the ICU, the third spent 9 days in the ICU. Each day in the ICU was $8,140.00 charged to insurance, and that is leaving out all other services that were provided while they were in the ICU. In the end, about $300,000 was billed to insurance and I paid only $12,000 of that. (That doesn't count the hundreds of dollars we spent on the Starbucks in the hospital over the three weeks we were swapping kids in and out, but you can only expect so much from insurance.)
Naturally, when I was sitting in the Emergency room with an unresponsive kid I had no way of knowing how much would get charged to insurance. I think by the time I was bringing my second child we assumed we were hitting our Maximum.
Also, my husband has annual colonoscopies and SSCReader's experience is also our own.
Thank you for sharing your experience.
I definitely did not realize that most people don't just view the deductible as a sunk cost with any significant utilization.
RSV sucks but kids bounce back thank god.
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