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PaperclipPerfector  1yr ago (text post)   31304 thread views

Culture War Roundup for the week of May 15, 2023

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Let's exclude from the analysis, for the most part, the emergency scenario. I'd like to think if I had my leg blown off I'd ask my wife to bring me to Hospital A that would be a $500 ER visit instead of B at $5,000 but she'd really just panic and get me wherever showed up closest in google maps. I understand people can't shop around in every instance.

However, saying this is just giving up:

I could've shopped around for a "ENT visit + CT scan" combo in advance, but how can a patient know in advance what kind of tests and treatments they will require?

People believe healthcare is an intensely customized and personal process. It's not. Your doctor and the hospital just think of you as a wallet identified by a GUID. They do the same treatment for you as the next guy with congestion, and it costs the same. Saying they can't tell you how much it costs beforehand is bullshit. Saying they won't be able to tell you how much a CT or MRI will cost is BULLSHIT. They can caveat it with "any unique treatments may result in additional costs" sure, but they already sell certificates for all these things at sites like https://www.mdsave.com/ . Which, btw, the billing admins fucking love. These sort of pay upfront services are simpler to handle, won't have to go to collections, anything.

We've tried nothing and we're all out of ideas. That's what comes to mind whenever we discuss medical price transparency.

This just all sounds so bizarre, working as a medical professional outside the US.

Absolutely no argument there at all. We are in the maximally awful valley between the free market and government run healthcare. It's hell.

Republicans knew the Affordable Care Act (Obamacare) was always a system designed to drive up the demand for single-payer government-run healthcare. That’s why it was passed without a single Republican vote.

(…except I now see it was always virtue signaling for votes by the institution of a minority party which wanted to be in the minority.)

And I don't have a problem with elective treatments being excluded from insurance. After all, I paid for my visit out of pocket. It's the emergencies and other life-threatening conditions that bankrupt people.

And I don't have a problem with elective treatments being excluded from insurance.

Electives are a very wide set of treatments, it doesn't mean plastic surgery. It is pretty much anything that you schedule in advance.

It's the emergencies and other life-threatening conditions that bankrupt people.

I thought about this for a minute, couldn't actually reason from first principles whether or not it should be true. For example, I'm not sure why the modal medical bankruptcy isn't more of the type, "I got cancer or whatever, so that blew my out-of-pocket max for a couple years. I'd have been okay financially even with just my out-of-pocket-max, but I also couldn't work anymore, so I lost my income. That's what really tipped me over into bankruptcy." One could plausibly categorize this in the "life-threatening" bucket (one could quibble by type of cancer, as some may be curable/treatable but still prevent you from working for a long time), but even then, it's not clear that the medical cost side is the long pole in the tent.

So then I went to see if I could find some data in the literature. Unfortunately, while I didn't spend hours and hours doing a complete literature survey, my sense is that this data is not readily available. Medical expenses/debt relating to bankruptcy became a political football, so there was a flurry of papers on the general topic. As expected, many of them feel like they're picking/choosing their metrics specifically to try to get a splashy number/talking point to support this political position or that political position. But even given those limitations, I got a little bit of a sense for what I think is available.

Turns out that even figuring out the connection between general "medical expenses/debt" and bankruptcy is difficult. Publicly-available bankruptcy documents don't come pre-packaged with a nice conclusion, "This bankruptcy was because of medical expenses." Even when you can tell from the bankruptcy filings that some of the debt was medical, it doesn't often contain information that allows a categorization of whether or not it's specifically emergency-related. Nor whether it's life-threatening. One example is that folks just try to put some measure on the amount of debt at bankruptcy (like, the medical debt needs to be some percentage of total debt and some percentage of income), which obviously has benefits/drawbacks as a measure. There are some more clever attempts. Consider one study, which

reported that the bankruptcy rate for drivers who were admitted to an emergency room after a crash (“EDA Admit”) was 45% higher than the rate among drivers who did not seek medical care (“Not EDA Admit”). Although this may show a correlation, the authors found that it did not establish causation because bankruptcy rates were “thirty to fifty percent” higher for EDA Admit drivers in every pre-crash year. Thus, the authors conclude that households whose financial characteristics make them more likely to file for bankruptcy are also more likely to have severe auto accidents, but that health shocks (as represented by auto accidents) are not a causal factor on bankruptcy filing rates.

This attempt is really nice and clever, because we can access pretty good data on auto accidents, knowing that they at least reflect a sudden, unexpected event, though some could quibble over whether all the folks who go to the ER after a wreck are actually in "emergency" condition or are just being cautious given the circumstances (I say this without judgment; this is a very unexpected event where caution may be appropriate; the circumstances are much more likely to rapidly develop into a true emergency situation, even if the instant symptoms are minor). It has some obvious drawbacks, too, as auto accidents aren't necessarily reflective of all types of medical emergencies, and they may correlate with other behavior more than other types of emergencies or life-threatening conditions.

In sum, I'm just not sure I have data that swings one way or the other on this question, and I'm sort of leaning toward the position that measurement issues push me toward, "We just aren't going to be able to conclude something here," at least until someone is able to be extraordinarily clever in overcoming the limitations in the data. I also think that "emergency" and "life-threatening" sometimes go together, but sometimes don't. Car crashes are unlikely to permit much shopping around for most people. Cancer does moreso.

Thank you for writing this. I really enjoyed the deep dive.

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