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I'll once again note that various excuses about how a treating physician probably can't really know what things cost ring hollow for anyone with a decent veterinarian. That end of things is admittedly a newish experience for me, but when I take my dog to the vet and he presents treatment options, I can inquire what they cost and his reply is, "about [$X], but I can get the exact number for you if you want". That physicians cannot do this for much narrower ranges of practice indicates an incentive structure for not knowing what things cost.
I genuinely believe this is the part that triggers so many people to feel the way they do about Luigi. Guys like Brian Thompson make tens of millions of dollars and if anyone has a problem with it, they can get their lawyers to take it up with his lawyers, who will all make a shitload of money arguing with each other, lying for hire and making arguments that no one actually believes and that most laymen can't even understand. I'm surprised that others are surprised that profitable Kafka rituals occasionally trigger rage.
Here is an idea: simply allow veterinarians to treat humans.
The human has to be competent and sign a waver that they are aware that the vet's malpractice insurance will only cover a certain amount, so the patient is SOOL if something goes wrong big time.
TMK while canine and feline(the vast majority of veterinarians are trained for these two things and not other animals) biochemistry is pretty similar to people's, with slight differences(eg allergies, dietary requirements), their anatomy is... not.
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Or Dick the Butcher from Henry VI, Part 2, who spoke the famous line "The first thing we do, let's kill all the lawyers." in Act IV, Scene 2.
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To me, the complaint is very clearly with the doctor (or practice/hospital -whatever), not the executive! So I'm not sure why this would make people admire Luigi.
The doctor doesn't want to fuck you over, neither does the hospital or practice. The health insurance executive however, wants nothing else but to fuck you over.
In my experience, hospitals are more than happy to screw over patients in billing as long as they don't complain too much after the fact. Surprise out-of-network anaesthesiologists used to be common (now prohibited), and I've seen hospitals try to tack on not-covered-by-insurance fees that show up much later and weren't disclosed in advance (not that they ever give straightforward billing answers in advance). Yeah, they'll "kindly" remove or waive those if you call and complain a bunch (probably marking it down as "charity"), but it's really annoying and not always worth my billing rate.
IME you are significantly overstating how much of a hassle it is to get your hospital bill adjusted.
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There are scum bags everywhere, for sure, but the perverse incentives start with the insurance companies. You can't pull a surprise out of network anaesthesiologist out of your pocket if there aren't any networks. It's the insurance companies who ban pharmacies and doctors from talking about the price of medication and offering cheaper alternatives. And it was insurance companies who instituted the policy of denying every claim first and forcing patients to pull teeth getting their claim covered.
This claim simply does not pass the smell test.
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Can you provide citation/further reading on this? A brief search actually turned up basically the opposite complaint (in multiple articles that were clearly founded on pro-doctor
propagandaadvocacy), so I'm definitely interested if the surface internet has it all wrong and no one has been talking about these secret bans.You're right (well, the opposite complaint would be that doctors and pharmacies are banning insurance companies from offering cheaper alternatives, but I think I get what you mean) I merged two problems in my head - the three big pbms (all owned by insurance companies) refusing to stock certain brands making it either expensive or impossible for doctors to prescribe them and insurance companies banning doctors from telling patients they could get their meds cheaper without using insurance.
I chuckled. But anyway, what I meant (as you probably know) is the insurance company banning doctors/pharmacies from using more expensive alternatives. Dubbed "step therapy" or "fail first", the insurance companies were saying that you had to have the patient try a cheaper alternative first, and only if/when that didn't work would they cover the more expensive drug. I'm sure there are nuanced arguments on both sides of this, and I don't have a dog in that fight. Probably sometimes one approach is good; probably sometimes the other approach is good. Not worth getting involved from the outside.
I agree that lack of price transparency here was a problem. At a cursory look, I would agree with the goals of the Patient Right to Know Drug Prices Act that they cite, which fixed this problem. All we need to do is take that same name, swap in "Medical Services" for "Drug" in the title, and perhaps we can work out a text that can fix more of this price transparency nightmare.
I was kidding, but I appreciate the clarification anyway. But man the prkdpa didn't fix this problem any more than the anti kickbacks statute fixed the problem of doctors taking kickbacks for prescribing certain medications.
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The insurance companies want cheap alternatives. It's doctors and pharma companies who run advertising for big pharma, patients then demand treatments that are extremely expensive, then insurance has to pay for it.
Hold up, are you saying doctors want patients to spend more money on meds?
I'm saying that doctors often appear in drug advertising, sure.
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I've expressed before that veterinary care has a lot of medicine, especially the business side, figured out better than humans.
Insurance, for the most part, really is for the big stuff that can't be anticipated, and is priced as such. It's $60 a month to insure my 14 year old beagle with 50% coinsurance. It doesn't cover the cost of exams or checkups. It does cover things like surgeries and cancer treatment.
I once used it for a spine surgery. The total cost was about $7,000, quoted upfront. I paid about $3,500 and the insurance covered the other half. This would have been well into hundreds of thousands of dollars if performed on a human.
I was able to have conversations via email, not through some dumb HIPAA compliant portal.
That most dogs are uninsured probably keeps costs down, as does that typically pet insurance has a higher coinsurance figure than human insurance. There's an unavoidable principal-agent problem that we exacerbate with regulations that practically remove all incentive for people to price shop.
Why did you get insurance with a co-pay of 50%?
Insurance is good if it prevents improbable but huge payments. It has a negative expectation value on your net worth, but should have a positive expectation value on the logarithm of your net worth (presumably defined inclusive enough that the case of going negative does not appear), which is closer to actual utility. LW recently had an article on this, here.
A fixed co-pay seems reasonable enough, the case you want to avoid with insurance is paying hundreds of thousands of dollars, and if you co-pay is a few thousand, then that limits your risk exposure.
But an insurance with a proportional co-pay feels different. I mean, if it is 1% co-pay, one could still argue that it scales the treatment options one can afford by orders of magnitudes. By contrast, a 99% co-pay would not be worth it for anyone, because if you can afford 99%, you can also pay 100%.
I would argue that 50% co-pay is more like 99% co-pay than 1%. If X is the maximum loss you could absorb, it will only be helpful for losses between X and 2X. For example, say you could absorb losses of 5k$ without insurance. Then for any treatment which ends up costing up to 5k$, you would have been better off to just absorb the losses in case they appear without paying a middle man. And for everything which costs more than 10k$, you could not afford your co-pay and thus would not benefit from insurance. Now, if it happens that most vet bills are in that range, then it could still make sense to buy it, but from my priors, they are likely much wider in distribution.
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Which is certainly what it should be for healthy people. A high deductible catastrophic plan. But the ACA outlawed that and instead young healthy people have to buy expensive insurance that they largely don't use.
It's called a health sharing plan. They exist mostly as religious exemptions to ACA requirements to cover the morning after pill, but nobody actually checks whether you go to church or not.
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Your rate sounds not to far off from what a cash pay health sharing or a ultra high deductible plan would be- and that’s basically what you have.
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How much has your pet insurance paid out? Seems that unless you're having major procedures regularly, self insurance is the way to go.
Roughly $5,000, dog had another surgery later on to remove a bunch of tumors.
Got the dog in 2018, at about $60 per month since then, I'm still ahead, but that's very luck of the draw. I'd prefer not to have some other incident that would make the insurance pay out and deliver more value for my premiums, I'd rather he just die in his sleep when the time comes.
These products are regulated and competetive, I expect the rates to be actuarily fair and the median customer to have been better of self insured.
That doesn't make any sense. For an insurance to exist as a business, they have to take more then they're giving to the average customer. They have to pay for offices, ads and personnel. Maybe you got lucky and are temporarily ahead financially, but long-term insurance will always result in a net negative for the customer.
I think we agree.
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I’m curious if survival rates are similar? That is, if the margin for error is much smaller when operating on humans it makes sense to me the cost may be orders of magnitude higher
Even if survival rates are similar, a dog's life is worth less than a human's in court.
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Bingo. It's been a while since I went to the vet, but when I was a kid we had our dog neutered and they asked us to put a budget on lifesaving efforts if things went south for some reason (they didn't, everything turned out fine).
Anyway, yes, I think doctors could do this and it might help everyone involved think a lot more clearly about treatment plans. In fact, because people are so leery of hidden fees, I would not be surprised if it would save lives if doctors were required to post consultation prices and then notify patients of the cost of treatment beforehand. Nobody wants to get a surprise $1000 bill in the mail, if people knew that going to the doctor to check out that weird lump or whatever was only gonna cost them $50 it might be more effective than all the work Obamacare put into making annual visits free.
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