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How would price transparency even look if it's not just "Medicare for all, you pay taxes, we provide healthcare"?
And even that might not work. As an example, a few weeks ago I finally decided to do something about my nasal congestion.
I went to a private ENT doctor my wife had heard good things about.
The price was communicated up front, but how could I choose a different ENT?
There could be a big-ass site where all the doctors would be listed and I could sort and filter them
What would I sort them by? Price? Rating?
If it's rating, how can I trust it?
If it's price, how can doctors who have this cool expensive video probe explain to customers that their diagnostic tools warrant a higher price?
The ENT took a look at my cavities with his cool expensive video probe and said he needed a CT scan
Now I had two options: pay for this visit, shop for the cheapest CT, pay for another visit or do the CT in the same clinic right now and continue.
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?
The ENT took a look at my CT, gave me a list of tests and a recommendation to see an allergologist.
Tests are easy, since they are standardized by definition
Shopping for an allergologist is basically another repetition of step 1.
And I was not in a real hurry doing all that. If you're hospitalized with a medical emergency, there's simply no time to shop around. It's not like you can go, "you know what, thank you for stemming the blood flow, but I've taken a look at the total price you're suggesting, and Google says there's a hospital two counties over that can do the rest for $1200 less. Even if I hire an ambulance for $600 to take me there, it's still worth it. Will the stitches hold?" And then you go to hospital B, spend a few days there, and the doc says, "actually, the tests show you'll need another surgery, that'll be $5000 more".
In India there's mostly free market health care. Here's how it works:
Patient: "Hey person taking my appointment? How much does it cost?"
Person on the phone: "500 rupees."
After paying my 500 rs for the doctor visit:
Patient: "Dr, you say I need XYZ surgery. How much does it cost?"
Doctor: "I believe it is about a lac, but the finance department will tell you exactly."
Finance department: "It is 1.1 lac."
Me calling up other hospitals: "The surgery is 1.2 lac."
Doctor: "You need an MRI."
Patient: "Hey star MRI, how much for an MRI?"
Star MRI: "8000 rupees."
Other MRI place: "9000 rupees."
This is such an irrelevant fraction of medicine that it's not even worth discussing.
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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:
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.)
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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.
Electives are a very wide set of treatments, it doesn't mean plastic surgery. It is pretty much anything that you schedule in advance.
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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
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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This seems like it would actually be the opposite of price transparency, at least from the perspective of consumers. Each item of healthcare would still have a price, but they would be totally and completely oblivious to it. It would be entirely up to bureaucrats to look through the prices and decide what procedures seem to be worth it.
Concerning (1), selection of a doctor is approximately as difficult as any other selection of a good or service. There are a variety of solutions other industries have used. Branding, reviews, spec sheets, etc. Compare your ENT to very similar services that don't get to play the "insurance made me do it" shell game, like lasik or cosmetic surgery. Since they have to actually convince you to pay a real sticker price, they're vastly more open about it. They usually have free consultations; they tell you on their website what cool expensive tech they use; if you're the type of person who wants to shop around, ask questions, and figure out who you're comfortable with, you can do it. Some people are still going to view it as, "Well, you just go, do the thing, and pay whatever price," but if you want to be more informed, you at least can. You can at least usually get them to not lie to you and say that it's impossible to know what the price will be.
Concerning (2), this is obviously a more difficult one. Let's scope out a bit and consider a comparison with a hypothetical ENT who doesn't have access to their own CT. My experience has been that with someone like this, they send you out with orders to get a CT from somewhere and have the results sent to them. But then, when you come back, usually, you don't pay for an "additional" visit. Instead, it's treated as an extension of the original visit, which needed to be interrupted because of the need for a test. There is a true tension here that is hard to resolve. For legacy reasons, we don't just pay doctors by the hour, we pay them by the service. If we paid them by the hour, it wouldn't matter whether we got the CT there or somewhere else; that doctor is still just spending the time of "make recommendation for CT + evaluate result of CT", and those things are just more or less stretched out across different days.
The fundamental thing happening here is some sort of bundling. Bundling often makes sense. I had a dental implant, and there were multiple visits. Several were just, "Let's follow-up in two weeks; I want to see how it's healing to make sure there aren't any issues." Every one of those was bundled with the price of the original service, not charged as an "additional visit". Honestly, I was naive at the time, didn't ask a lot of questions, and sort of didn't know that they were bundled until after the follow-up appointment was finished, asked if I needed to pay anything, and they said no. This sort of bundling makes tons of sense. Other times, people don't bundle. I got stitches for a cut one time, and when I went to get them taken out, I had no idea whether this <5min followup was going to be bundled or not. Turns out it wasn't. Honestly, if I had known that it wasn't bundled, I probably wouldn't have spent the money for them to use scissors for 10 seconds. Again, we can compare to lasik. I haven't had it yet, but I've looked at websites. They often publicly state that certain follow-ups are bundled, because that is valuable price information for consumers.
In any event, the extent to which a service is bundled/unbundled is also usually not transparent. Are you sure you'd have had to pay for an additional visit if you had the CT done elsewhere? Did you ask? I'm not 100% against the idea that they might want to essentially give you a discount on the evaluation of the CT if you have them do the CT, but I want them to have to tell you this explicitly. "If you get the CT done here, we will bundle the price of the next step where we evaluate the result of the CT and decide what to do next. Alternatively, if you get a CT done somewhere else, we will not bundle it, and you'll have to pay extra for that." Most critically, I think this should not be a pressure tactic. It shouldn't be, "If you just sign on the dotted line RIGHT NOW, we'll give you a GREAT DEAL on this
new carCT follow-up!" Like, if they're bundling, they're probably not bundling strictly based on things happening right now. What if it's the end of the day; the guy in the office who actually runs the CT machine is about to go home; maybe it'll be better if you come back in the morning; "we'll do the CT first thing and then evaluate the results immediately after". Do they still bundle the follow-up? I'm guessing probably. So, there shouldn't be any difference between that and if you go home, shop around, then decide to have them still do the CT a few days later. If they're still going to bundle in this situation, I think we've gotten most of the benefits that we're going to get.So in sum on this point, I just want them to have to be more explicit about what is/isn't bundled. When they say, "We should do a CT; we can do it today," they should have to follow it up with, "Here is our price for a CT. That price includes the follow-up evaluation of the results. That price is good even if you shop around and then decide to have us do the same CT service tomorrow or next week. You can get a CT somewhere else if you want, but then we won't bundle the follow-up evaluation of the results, and it'll be an additional charge of $X." At least then, we can see what they're doing. We can see how their price is structured and make comparisons. It's still a bit anti-competitive to be integrated in this fashion and to have this type of preference for their own product. Honestly, anti-competition cases have been brought on less in other industries. I don't even think we need to get there now. Just get the prices and what is/isn't included out there in the open. Then, when people actually see what's happening under the hood, when they're actually seeing what games are played where and what things cost, they can decide which games they're willing to play and which prices they're willing to pay.
Finally, I also agree that true emergencies are tough. Sometimes, health situations naturally create their own pressure tactic. I don't have great solutions for this. I also think that true, really time-critical emergencies are far far more rare than most people think. Probably more than 90% of healthcare transactions simply won't matter that much if it waits a day or even a week. Don't stop us from putting good rules in place to improve the 90% just because those rules may not help the small minority. Even if we just exempt the small minority from the rules, we've made nothing worse (the small minority is in the same situation it was before), and we've made the 90% better. That's a pareto improvement.
But I do think that they should still have to be transparent if it's possible. Yeah, some people might take a risk in going to another hospital, hoping the stitches hold. Some people might even get burned by their choice (that's the nature of risk). Maybe they'd have needed the extra surgery a few days later at the first place, too. Lots of ways it could play out. I'm not saying my solution makes literally 100% of situations/choices turn out 100% optimal and that there is never a case where something bad/expensive happens. Literally no solution can accomplish that; again, that's the nature of risk. But I would rather be informed of the price and be able to make my own choices concerning my personal risk tolerance than not. Maybe the difference is $60, so I don't think the risk is worth it. Maybe the difference is $600, and I'm indifferent. Maybe the difference is $6000, and I think the risk is worth it. Someone else may be really risk averse and still pay the extra $6k. Yet someone else may estimate the risk differently and want to save the $600. Which of us made bad choices? Which of us got burned? Which of us came out ahead? Nature decides that, and no policy that either of us comes up with can possibly guarantee that no one will ever get burned. I just want people to be able to have the information and be able to make their own choice.
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