Cost-saving means more money to spend on other aspects of health care. It's not necessarily worse than "exploring new frontiers."
I'm with LB. Will no one think of the venture capitalists?
(I know that's an unfair dig, this is one you might have to listen to in order to really pick up the point-of-view. The road to effective cost controls with political opportunists ready to demagogue with "rationing" and "death panels"*, is fraught.)
*Not that there are not real, thorny issues that arise.
... patients actively want to consume less health care resources, because if they're consuming health care resources, that means they're sick, and they'd prefer not to be sick.
It depends on how you look at it. It also means they are alive.
...people making the purchasing decisions don't have the expertise to evaluate what they're buying.
They also don't typically have accurate price information or the ability to shop around for the best price. The only time I've had an accurate up-front price for a medical procedure was at the vet. I've had sort of hand-wavey estimates that turned out to be wrong on a couple of occasions, but more often than not I simply don't have a meaningful choice. I suppose I could have hobbled from on surgeon to the next to find the best price for a laminectomy, spending valuable time away from work, suffering horrible pain, and wasting a bunch of my partner's time as she shuttled me around. In practice I did what most people would do - find a surgeon who was well rated by his peers and just get the damn thing done.
I'm currently shopping around for a colonoscopy, but again it's turning out to be hard to get pricing information over the phone and I can't get an assurance about how they'll do the billing. If they do the billing wrong I could be on the hook for additional thousands of dollars due to perversity on the part of my insurance company.
4: I think that plastic surgeons are upfront, sometimes, but that's obviously not a medically necessary procedure. (Most of the time, anyway.)
I'm currently shopping around for a colonoscopy
I'll do it for twenty bucks.
A big part of the problem is that "how much would you charge for this if I were completely uninsured?" is usually not helpful information, and "how much will I actually have to pay for this, out of pocket?" isn't something you doctor can easily answer. They can tell you what they'll bill for the procedure based on the agreement with your insurance company (or in theory they could tell you this, although it might be something they need first to calculate themselves, which they'll be reluctant to do just to answer a general inquiry), and even then your personal out of pocket might depend a lot on your personal plan design, which your doctor may not even know. And also there's the fact that, especially with more complex procedures, it's not at all unusual for what exactly needs to be done to change during the course of the procedure, which might again make the numbers they tell you upfront wrong. E.g., will this patient need full anesthesia or not? Or, more relevant, w/r/t your colonoscopy, if they find any polyps, they'll probably remove them. This will both add something to the cost of the procedure in and of itself, but also for your insurance purposes will probably reclassify the entire from "preventative" to "treatment" (which of course impacts how much it will cost you).
I could be on the hook for additional thousands of dollars due to perversity on the part of my insurance company
"It's hotter when you have to pay full price, baby."
9: That you still owe me twenty bucks?
4, 7: The system really is set up to make it impossible to shop for medical care on price. Which suggests to me that the health care industry doesn't think patients are indifferent to cost: if they thought patients were indifferent to cost, they wouldn't be hiding the ball.
7.last_bit: Exactly. I ought to be able to bill the time spent actually doing surgery independently of the bit that would have been done regardless, at least in a sane world. The difference is several grand if I actually needed the procedure vs nothing out of pocket if I didn't. This pisses me off quite badly.
11: Good point. I was hoping the ACA would force binding up front pricing and uniform billing codes, both of which would help bring those magical market forces to bear. It was painfully clear during that debate that the last thing the AMA wanted was patient empowerment.
Which suggests to me that the health care industry doesn't think patients are indifferent to cost
Of course patients aren't indifferent to cost. The problem is that patient sensitivity to cost runs in exactly the opposite of the direction we want healthcare to go. Cost-sensitive patients delay or avoid preventative procedures until things become crises and they find themselves with worse, more difficult to treat conditions (or in emergency care units (where they actually are fairly cost-insensitive)). Or they cut back on needed medications, which are too expensive, until they end up with the same result. It's a terrible approach, both from a health perspective and from a cost perspective.
The idea that making patients more cost-sensitive (by having high deductibles, etc.) will improve cost control (in any way other than by worsening health outcomes, and possibly not even then) seems to be based on absolutely nothing in reality. It's simplistic econ 101 assumptions all the way down.
That's fucked up, Togolosh. I'm Australian, I've lived in Australia, the UK and Japan. I've never had to shop around on price. You just go to your doctor and they do what has to be done and you pay the standard price (or nothing, in the UK) and it's done.
The alternatives are madness.
13: I don't disagree with that in its specifics -- encouraging patients to save money by forgoing necessary care is counterproductive and wasteful. Still, if it were possible to find out the prices of bigger-ticket expenditures, it's possible that in at least some circumstances, it would result in saner behavior: if you've got two possible treatments, one for 10K and one for 100K, most patients would get really interested in the evidence that one was or wasn't superior to the other. If they don't know what either costs, they'll take whichever is suggested.
14: Of course, you're in a system where there's a regulator doing the price shopping for you. Which would be great, if we could get that going here.
if you've got two possible treatments, one for 10K and one for 100K, most patients would get really interested in the evidence that one was or wasn't superior to the other. If they don't know what either costs, they'll take whichever is suggested.
This is going to often require a medical degree to navigate. How can you easily compare treatments, as a patient, if you're sick and scared? You take whichever is suggested by your doctor, same as the current system.
if you've got two possible treatments, one for 10K and one for 100K, most patients would get really interested in the evidence that one was or wasn't superior to the other.
No, if they're paying out of pocket, most patients would just have to forgo either. (In truly dire circumstances, they might liquidate their savings and go for the $10k procedure, but the $100k procedure wouldn't even be worth thinking about.)
If an insurance company is paying, then the consumer will basically just want to know which procedure is more effective. The insurance company will want to know if the more expensive procedure is really more effective, and if there isn't good evidence that it is, they probably won't cover it. They don't actually tend towards throwing away money needlessly. (And, in reality, if there's no good evidence that the $100,000 procedure is at least in some circumstances more effective than the $10,000 procedure, I doubt many practitioners would even offer it as an option.)
So I doubt there's any realistic circumstance in which most patients will get really interested in the evidence that one procedure was or wasn't superior to the other. Moreover, on the broader point, I think patients in general are going to be really extraordinarily unreliable decisonmakers w/r/t the comparative effectiveness of various medical procedures. Are you imaging them reading the relevant medical journals and carefully evaluating the evidence, or what?
17: Often, but not always. You hear about this with drugs: perfectly functional generic, slightly tweaked new version for ten times the price, and no one involved, including the prescribing doctor, has the information necessary to even think about price.
I'm not advocating that patients should have 'skin in the game' to cut costs. That's stupid for exactly the reasons you're giving. But we've got a system where no one (in a lot of circumstances) making medical decisions is considering both cost and the best interests of the patient: you've got insurance companies with no real interest in the best interests of the patient denying coverage where they can get away with, rather than where it makes medical sense, and doctor and patients largely isolated from even knowing what the costs are.
This is a job for regulators.
19: NOT IF YOU READ THE BROCHURE I GAVE YOU. WANT SOME SUSHI?
I'm currently shopping around for a colonoscopy, but again it's turning out to be hard to get pricing information over the phone and I can't get an assurance about how they'll do the billing. If they do the billing wrong I could be on the hook for additional thousands of dollars due to perversity on the part of my insurance company.
This is what George Orwell would write, were he writing today.
You hear about this with drugs: perfectly functional generic, slightly tweaked new version for ten times the price, and no one involved, including the prescribing doctor, has the information necessary to even think about price.
I would agree that this is a problem, but I don't see how putting the consumer in the position of being the person "thinking about price" is going to be helpful in the least. The consumer can't evaluate the effectiveness!
I understand that the theory behind high-deductible plans is roughly: doctor will prescibe ghastly expensive new medication, patient will say "doctor, please, I can't afford that! Isn't there any less expensive alternative?", and the doctor will say, "Oh, sure, there's a generic verison that does almost exactly the same thing. Some patients have [more significant side effects; no as good results, etc.] on the generic version, but I'll prescribe that instead if you want, and we can see how you do." It seems to me that (1) IME, the last part of that conversation is actually what basically happens most of the time, even if you're not on an HD plan, and (2) this interaction obviously describes such a small percentage of the healthcare landscape that it would be comical (if it weren't so sad) that people actually proposed this as a workable cost-control model (to apply to everything, NOT just to prescription drugs), and other people didn't laugh at them.
23 before seeing 20, which seems to retreat from 15/19. 20 is reasonable.
3: Yeah, there are plenty of people who run in to get checked or have their kids checked for every hangnail or knee scrape. What I don't know is the demographic, my examples don't come from the bottom of the economic ladder.
27: That's pretty small potatoes, though. Someone who's in a doctor's office once a week for something that shouldn't have needed medical care is wasting a couple of thousand dollars a year, not more than that. And once a week is pretty wildly extreme. Important waste shows up in terms of badly thought-out spending on people who are genuinely sick.
My impression is that 27 is basically a fantasy. No one runs to the doctor for a hangnail--even if you've got gold-plated insuance, there's a real time cost involved. To the extent we have a problem with trips to the doctor for minor ailments, it's that there are too few being taken, not too many. (And things that were minor therefore become more severe.)
This is a job for regulators.
Right, not for patients.
Actually, I don't even agree that it's a job for regulators. All insurance companies should be public entities. (Aside from non-essential things. Feel free to buy insurance on your second home.)
All insurance companies should be public entities.
You mean single payer? Sure, regulators or other bureaucrats.
I was being general to include things like home insurance and car insurance. There's no reason that government actually needs to rebuild your home or buy your new car, but I don't see how any insurance company should ever be profit-driven.
Huh. I'm professionally involved in insurance regulation, which means that I know enough about it to know that I am nowhere near knowing enough to have strong beliefs about good policy in insurance regulation generally. So, maybe.
Also, single-payer doesn't seem like insurance, exactly, the way the fire department doesn't seem like insurance. It's just available. As opposed to having a public option. (Or that situation where the county had the optional fire tax and the fire department let the house burn down when the guy had let it lapse for a few years.)
I'm professionally involved in insurance regulation, which means that I know enough about it to know that I am nowhere near knowing enough to have strong beliefs about good policy in insurance regulation generally. So, maybe.
It's true that I am so happily ignorant that I can spout off belligerently, without really knowing what I'm talking about.
I tried to get the doctors not to do what I knew was an unnecessary laryngascope, but there were three of them and a med student, and I was all alone, because they had kicked out my BF.
I know people who go to the doctor too much. I have a client who goes to all the specialists all the time when really she ought to be seeing her therapist more often, but she's not typical of the general population and doesn't have a job and has a huge trauma history and lost her father as a kid. Very few people who are willing to put up with her if they're not paid, so doctors are the best choice for her to feel cared for. Many trips to the ED.
Some people probably go to therapists more than they need to, but some of those people would be visiting their PCP all the time if they didn't.
29: It's not a fantasy for someone with tendencies towards hypochondria. (Yes, "hangnail" was hyperbole, but googling a transient symptom and finding it's part of Martian Red Dust Syndrome and immediate care is needed isn't all that uncommon).
24: You know, I think where 15/19 were puzzling is that I was arguing with the voices in my head, or in a prior thread anyway: the idea that the demand for health care is infinite and unconstrained by cost, which means that we're doomed to a spiral of ever-increasing health expenditures. What I was doing in 15/19 was arguing that the health care industry, in making it impossible to find out what anything costs, acts as though they believe their customers would be cost-sensitive if given the option.
I didn't literally mean that no person ever goes to the doctor needlessly. Of course they do. Just that those people basically aren't representative, and in any even really aren't the problem in our system. They're much less of a problem overall than the people who go too little.
37: Did I mention that the most singular thing about my recent hospitalization, from my perspective, was that I was expected to make fairly major healthcare decisions while intoxicated with large amounts of opiates? That just seems weird to me. I mean, sure, I wasn't as high as I would have been if I had been using the same drugs recreationally, with no serious pain, but damn, I was pretty spacy. Seems like there ought to be more provisions for that.
Hah. I remember being given a release to sign when I was in labor, and actually having a contraction. And I just barely restrained myself from saying "You know, I took the NYS Bar exam yesterday, and let me tell you that whatever I just signed, it has no legal effect whatsoever."
I don't see how any insurance company should ever be profit-driven.
I feel the same way about medical practices. (Whether general practices, hospitals, diagnostic labs, surgical centers, etc.)
Doctors should all be paid salaries. Highly skilled doctors would of course command higher salaries, but no doctors should be earning profits on the treatments they order for their patients.
I feel the same way about medical practices.
Yes, me too.
Some people consider that idea un-American.
- from back when everyone accepted profit wasn't a good way to organize medicine.
I'm linkingly-challenged today. "The conservatism that could have been" was how that was supposed to start.
45: What do you mean by profit exactly? I'm sure that my dentist gets more money from a dental cleaning than she pets her hygienist even after you figure in rent, the cost of capital equipment and the office manager. Does that count as profit?
Then there are other dentists who make a profit off of mouthguards.
48: That's profit, and at the moment it's unexceptional, but I'm pretty sure it's the system urple is arguing against: ideally, practitioners could simply practice without having to be small-business owners.
48: 49 is right. Medical professionals could easily be required to practice as employees of nonprofit coporations (even if they were practicing alone and so set the entity up themselves). They'd pay themselves a salary, but other than that any "profits" that were generated could only be put to use in furtherance of their charitable purpose of promoting health and wellnes--not put into someone's pocket. So if their practice ordered more xrays for you, it would be because they thought those xrays would be valuable diagnostic tools, not because that's how they earn their money.
Medical professionals could easily be required to practice as employees of nonprofit coporations
I basically agree with your point 100%, but note that a lot of actually existing health care in the USA is provided by theoretically "nonprofit" corporations and it still sucks.
note that a lot of actually existing health care in the USA is provided by theoretically "nonprofit" corporations and it still sucks
Well, yeah, it's not a cure-all. For that, we'll need the guillotines.
Sorry, shouldn't joke about guillotines.
No, you shouldn't. What if ferrets figured out how to use them?
Oops, I actually just saw 9/10. 9 was a half-written comment, and my phone rang and I thought I closed the page, but I must have accidentally pressed "post".
I don't really want to tell this now, because I've told enough awkward and embarrassing personal stories for the day, and also because I'm 99% sure its in the fucking archives somewhere. But, I don't want to be a tease, so in brief: I'd had colonoscopies in the past that were basically painless. My most recent, however, with a different provider: I woke up very, um, sore. And then I got an incredibly bizarre hand-written card in the mail a few days later, from the doctor, saying how much he enjoyed the procedure, and what a great pleasure it was, and how much he hopes I'll come again and see him any time I want another. It was really disconcerting.
Until quite recently Massachusetts was almost entirely free of for-profit hospitals. (The exception was in mental health.) It didn't keep Partners from being pretty rapacious.
On the other hand, community health centers can be pretty great.
Aaaaaand the doctor is a childhood friend that you had lost touch with.
Oh, urple.
Is it normal to be put out cold for a colonoscopy?
urple in 56: an incredibly bizarre hand-written card in the mail a few days later, from the doctor, saying how much he enjoyed the procedure, and what a great pleasure it was
Run, urple, run! If he had said that he enjoyed meeting you that might be different, but "enjoyed the procedure" is pretty strange. My dentist sent out cards when we started seeing her.
I mean, I don't actually think anything horrible happened. But it was very weird. And genuinely disconcerting.
56: Was the doctor either a ferret, or in any important way like a ferret?
Was the doctor either a ferret, or in any important way like a ferret?
The doctor was a mammal, just like birds are dinosaurs.
The Doctor Was a Mammal: The Urple Story.
I don't actually think anything horrible happened
It's hard not to be a sucker.
What Happened To Urple: After A Colon
66 is hilarious. I'm glad that I'm reading this in a waiting room and not at work.
51: So if their practice ordered more xrays for you, it would be because they thought those xrays would be valuable diagnostic tools, not because that's how they earn their money.
Or if they needed the money so that they could afford to treat an indigent patient.
48: Is it normal for a dentist to pet her hygienist?
48: I have no idea how "pets" got in there. I'm wondering how I misspelled "pays" to make autocorrect change it to "pets."
I don't actually think anything horrible happened
Define 'horrible'.
Or if they needed the money so that they could afford to treat an indigent patient.
"We're going to need to x-ray your arm one last time. Drape it around the shoulders of this homeless guy, please."
Most people don't understand what "non-profit" means. What it means, basically, is that the corporation shouldn't show a large profit year after year. The way most of them get around that is to pay the administrator and the board members huge salaries, which are deducted from revenue to figure profit or loss. That's why many mid-sized hospitals are started by groups of doctors who then have lots of time to spend playing golf and still get rich. This is called "working incredibly hard" by the 0.1%.
That's not actually what non-profit means, no. They can show boatloads of "surplus" year after year. ("Surplus"="profit".) They just can't distribute it out to anyone--it's got to be reinvested in supporting the valid nonprofit mission of the organization.
And at least in theory all salaries must be "reasonable". This is poorly policed, I agree--things must be egregious before the IRS will threaten enforcement action.
75.last: See for instance, UPMC and its seeming drive to deliver Pittsburgh health care as a virtual monopoly.
14: The alternatives are madness. SPARTA! USA, USA!
48,48,51: So if their practice ordered more xrays for you, it would be because they thought those xrays
would be valuable diagnostic tools, not because that's how they earn their money.
There are federal limits to self referral $. Limits not so tight as to cover "in-office" ancillary services, but limits, nonetheless.
http://www.kevinmd.com/blog/2011/04/physicians-referring-patients-diagnostic-facility.html
Self-referral was known as early as the 1920s, well before the advent of high-technology radiology [3], but observers generally agree its volume has increased in the last 20-30 years [4,5,6,7,8]. Reasons for this increase include the fact that new technologies such as sonography, CT, and MR imaging became available during the 1970s, providing new opportunities for self-referral [6]. Care in the nonhospital setting, where there is no privileging to restrict the services physicians perform, grew. In part, this was an unintended consequence of 1970s federal health planning laws that required hospitals--but not others--to acquire a certificate of need before making significant investments [9]. New possibilities for self-referral and a proliferation of joint ventures emerged from collaborations between medicine and industry, a growing environment of business-type competition, and acceptance of a for-profit orientation in the 1980s, which gave rise to questions about loyalty to patients [3, 4, 8, 10,11,12,13,14].
http://www.ajronline.org/content/179/4/843.full
From the link in 76:
The IRS information says UPMC reported $473.5 million -- or 9.2 percent of total expenses -- in charity care and other community benefits. That included not only free care to the poor, but the difference between what UPMC would normally charge and what Medicaid reimburses, as well as health education, research and contributions to community groups.
Medicaid does pay too little, but that's not free care. Free care is people who have no insurance and pay nothing. A couple of hospitals claimed that Medicare was charity care. Research (funded by grants!) is charity as well.
It seems like the smart think for UPMC to do would be to make a voluntary contribution to local governments in lieu of property taxes.
That included not only free care to the poor, but the difference between what UPMC would normally charge and what Medicaid reimburses, as well as health education, research and contributions to community groups.
That is especially evil if they're talking about "charges," the nominal price that virtually nobody pays.