This weekly roundup thread is intended for all culture war posts. 'Culture war' is vaguely defined, but it basically means controversial issues that fall along set tribal lines. Arguments over culture war issues generate a lot of heat and little light, and few deeply entrenched people ever change their minds. This thread is for voicing opinions and analyzing the state of the discussion while trying to optimize for light over heat.
Optimistically, we think that engaging with people you disagree with is worth your time, and so is being nice! Pessimistically, there are many dynamics that can lead discussions on Culture War topics to become unproductive. There's a human tendency to divide along tribal lines, praising your ingroup and vilifying your outgroup - and if you think you find it easy to criticize your ingroup, then it may be that your outgroup is not who you think it is. Extremists with opposing positions can feed off each other, highlighting each other's worst points to justify their own angry rhetoric, which becomes in turn a new example of bad behavior for the other side to highlight.
We would like to avoid these negative dynamics. Accordingly, we ask that you do not use this thread for waging the Culture War. Examples of waging the Culture War:
-
Shaming.
-
Attempting to 'build consensus' or enforce ideological conformity.
-
Making sweeping generalizations to vilify a group you dislike.
-
Recruiting for a cause.
-
Posting links that could be summarized as 'Boo outgroup!' Basically, if your content is 'Can you believe what Those People did this week?' then you should either refrain from posting, or do some very patient work to contextualize and/or steel-man the relevant viewpoint.
In general, you should argue to understand, not to win. This thread is not territory to be claimed by one group or another; indeed, the aim is to have many different viewpoints represented here. Thus, we also ask that you follow some guidelines:
-
Speak plainly. Avoid sarcasm and mockery. When disagreeing with someone, state your objections explicitly.
-
Be as precise and charitable as you can. Don't paraphrase unflatteringly.
-
Don't imply that someone said something they did not say, even if you think it follows from what they said.
-
Write like everyone is reading and you want them to be included in the discussion.
On an ad hoc basis, the mods will try to compile a list of the best posts/comments from the previous week, posted in Quality Contribution threads and archived at /r/TheThread. You may nominate a comment for this list by clicking on 'report' at the bottom of the post and typing 'Actually a quality contribution' as the report reason.
Jump in the discussion.
No email address required.
Notes -
A big problem with medicine, along with other notoriously expensive professional services like law, is that knowing which specific actions to take is part of the service. One can't provide a remotely accurate quote without having already performed the services requested. A checkup for a 10-year-old boy with no medical conditions is a very different service from a checkup for a 58-year-old woman with twelve medications and diabetes.
It's also true for contractors and mechanics as well.
True story, I had a leak above my kitchen, called a plumber who told me that the pan under our utility closet (yay for 2nd floor HVAC/water heater), quoted to replace it. Gets halfway through replacing it, find a bunch of rotted boards underneath and says we really should do those too and that will be whatever-extra$. Dude was 100% honest and his price was, while not cheap, near enough the median charged in the area for that kind of thing.
It happens -- I don't understand why people would expect medicine to be any different. There are a lot of things where both knowing specifically what to do and encountering wild variations in the actual scope of work are routine. A surgery could go well or the patient could crump and be in the ICU for 3 days recovering.
You had said:
The medical industry currently is different. They refuse to do this part. At all. You can make it not any different. You just have to start giving some quotes/estimates. It's not all that hard; even a plumber can do it. Why can't you? Do we need to tack on some plumber school at the end of medical school or something?
There is a world of difference between a quote and an estimate.
Both can be used in the appropriate time/place. Your plumber didn't seem to have any problems with a quote and then a revision for additional work.
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
I think that the original poster would be satisfied with a rough estimate for a checkup of the demographic of their kid, with the understanding that this is the money they are committing to pay, not the money it will cost to cure the kid of all ills. If at some point the checkup discovers the need for additional medical procedures, the doctor can simply quote their prices and ask if he should perform them, or if they would like to shop around more.
I mean, there can be procedures where they go "we cut you open, check what is wrong and try to fix it, and depending on what is wrong, this is going to cost you more or less", but even then they could state the costs of the hypothetical treatment options beforehand, with the patient opting in or out of specific treatments.
This works for a basic "checkup" type thing which is bounded, but in a "cut you open" situation, the higher end of the spectrum is "your vitals suddenly collapse and you have to be taken to the ICU for a week, that will be $300K". Nearly every surgery would have to have this as one of the possibilities.
Moreover, that's not one a patient could be realistically given an opt-out from -- they can't just leave you to die.
Absolutely correct. The correct lens to look at this through is informed consent. Patients must be reasonably informed of the known costs/risks/benefits of medical procedures at the point when they give consent. Prices are part of costs, so they need to be reasonably informed of them when they give consent.
Of course, when they're lights out and cut open and something happens, there is no opportunity to inform them of the medical costs/risks/benefits, so we reasonably say that in such situations, it is acceptable to proceed anyway. All you need to do is import the exact same considerations to the question of when you can skip informing them of pricing information. If you feel ethically comfortable not getting informed consent for the medical costs/risks/benefits, sure, go ahead. Otherwise, when you're informing them to a reasonable extent about the medical costs/risks/benefits, you also need to inform them to a reasonable extent about prices. Just tell them what you're planning and what you know about that plan.
Oh definitely. I think that's fine.
I think the other bit is that up-front, the estimate for any surgery with anesthesia is going to be "it's unlikely but as we discussed there are risks in anesthesia and so in the worst case you nearly die and it's gonna be $300K".
Sounds fine to me! Maybe not even strictly necessary to put numbers to all the things. Again, it's just informed consent, just like medical costs/risks/benefits. You can say that there are risks in anesthesia, that unknown complications can happen, and if they do, you'll do what you can (where the actions and price are yet unknown). However, in some cases, where it's a "routine" complication, you can advise a little better. One doctor in these forums suggested that there are some procedures where they know that something happens about 1% of the time, that they plan for it, that they know what they're going to do if that happens (e.g., "If we see X, we're going to remove Y also"). In those cases where you have reasonably known specifics with reasonably known, planned actions, what you do is inform the patient. You can likewise inform them with reasonable information about likely costs of that relatively-known event and following actions. I think people would be perfectly happy with that.
All of this is getting into what is a common situation in hospitals, but is relatively rare for individual patients and in terms of total patient interactions with medical billing. It's kind of an edge case, though it is important to put some thought into. I think people would be pretty fine with a variety of practices concerning informed consent in these edge cases if the industry started getting the basics done on the much more vast world of much more numerous, much simpler services.
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
This is also true for HVAC work and plumbing. Estimates are a normal part of dealing with these trades.
I think the example cuts the other way -- those trades will give you an estimate but it's by no means binding if unexpected things come up.
To some extent you can just tell the guy to leave in the middle of the job, but that would leave you with a non-functional system, not really an option in medicine.
Literally no one is asking for this. They still give you the estimate, anyway, with what they do know. You can do at least that much, too. You can be better than a shitty, druggy, probably criminal contractor.
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
The checkup itself is pretty routine. If they get referred to a specialist or have to take a test or a vaccine that incurs a separate charge. But surely a base rate for the visit is easy to figure and most added services should be easy to look up as well.
More options
Context Copy link
It seems that every time people complain about medicine or law, someone (usually in the industry) will say something like "No, you see it is very very complicated. Our current system is perfect, or, barring that, it's literally impossible to change".
But I don't believe that change is impossible. I believe that there is a lack of political will and that entrenched interest groups have rigged the system for their benefit.
Price transparency is not impossible. But the medical industry won't do it unless they are forced to.
Insurance companies are working on this - ie I've seen presentations about trying to build variable copays into an app so someone trying to go to an urgent care or ER can go to one the company has contracted with at a cheaper rate.
More options
Context Copy link
More options
Context Copy link
Do those differences show up with different billing codes when you send them over to insurance? If so, how is that difference expressed in the content of the billing codes?
More options
Context Copy link
Mechanics have no trouble telling you what it will cost to take a look at your car. They'll post their hourly rate and let you know that if it's just [X] they'll figure it out pretty quick, but it might take [Y] hours if it winds up being the transmission instead. Ask a physician what their hourly rate is for diagnostic services and you will be likely to receive much less transparency and possibly a look of indignance that you'd be so gauche as to reduce their priestly actions to mere labor.
More options
Context Copy link
More options
Context Copy link