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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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