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Price transparency in health care

Neomalthusian

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Quick anecdote. A few months back our 5-year old had white streaks and a very sore throat, and I suspected strep. I took him to the doctor ($35 copay) to find out if it was indeed strep, in which case he'd get antibiotics so that he could return to school sooner, or find out it was viral in which case he could return to school. Doctor swab tests on site and determine's it's not strep, but says by company policy they send swabs to a second round of testing just to be sure. I asked what the rate of false-negative for on-site testing was and he said significantly less than 1%. I asked how much this all costs and he said he had no idea, and that it depends on insurance. I didn't question him further and we left.

But on the way home I asked my wife to get onto the health system's website to find out the billable rate for the strep culture lab test, and found out it was either $280 or $560, depending on which was ordered. Being well within our deductible, that would be all our cost. I called back and demanded they cancel that order.

My reaction to all this was that, first of all, billing $280 to $560 to double-check a usually non-lethal childhood illness seems medically unnecessary to me. Second, doctors should know or be able to easily check the cost of what they're recommending so that the cost vs. benefit can be discussed with patients.

But then more recently I started thinking about health care price transparency in general and trying to understand why there isn't better transparency and what the arguments are for and against.

I ran across evidence (Characterizing Health Plan Price Estimator Tools: Findings From a National Survey) that not only to health plans and, in many cases, provider systems, make cost information available, but extremely few seem to be looking or caring. As few as 2% use web-based tools for determining health care costs.

This gets me thinking, there was really no reason why I couldn't have determined in advance the cost or potential costs of the strep testing before taking my kid to the doctor. If I had known, I might have gone in to the doctor and said "I want an on-site strep test but I do not consent to any additional follow-up or secondary testing." That might piss some doctors off to have patients coming in demanding specific things and refusing others, but that is what I should have done. I cannot abdicate all responsibility for situations like the one I encountered and "blame the system" when the system avails the information to me and I choose not to look.

If a vast majority of Americans aren't even interested in the cost of health care even when it's made available to them, then by default we are entrusting the entire responsibility for controlling health care costs onto a combination of government and insurance companies, because we refuse to take responsibility for ourselves as patients. Consumers determining exactly what they want and are willing to pay for is the most organic and effective form of cost control there is, and collectively we're refusing to do it.

I'd be interested to hear from people what they specifically think would be necessary and effective at incorporating more patient-driven cost control into our health care system.
 

Praxas

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I'd be interested to hear from people what they specifically think would be necessary and effective at incorporating more patient-driven cost control into our health care system.

I know there's many issues with the current healthcare, but one thing that really bugs me is that doctors can bill by the hour and can talk to you for 5 minutes. Now imagine if that doctor talked to 10 people for 5 minutes a piece and billed the insurance for 10 hours for a essentially a total of 1 hour of work. I'm not sure how that is even legal to be honest. At least when I go see a lawyer, they bill me by the minute. That's not even counting the cost of the visit, the nurse, equipment, ect. That is just what the doctor themselves charge.
 

Neomalthusian

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I know there's many issues with the current healthcare, but one thing that really bugs me is that doctors can bill by the hour and can talk to you for 5 minutes. Now imagine if that doctor talked to 10 people for 5 minutes a piece and billed the insurance for 10 hours for a essentially a total of 1 hour of work. I'm not sure how that is even legal to be honest. At least when I go see a lawyer, they bill me by the minute. That's not even counting the cost of the visit, the nurse, equipment, ect. That is just what the doctor themselves charge.

If a price is set based on a certain amount of time, this is insurance fraud.

Some services, on the other hand, are allowed to be performed by multiple individuals, so for example a CNA or other assistant role can spend most of the time gathering the necessary information, because there’s no real reason why a doctor has to be the one that gathers basic info that could be gathered by anyone. But despite multiple individuals being involved, there is one payment for that service, and it encompasses all of it.
 

Praxas

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If a price is set based on a certain amount of time, this is insurance fraud.

Some services, on the other hand, are allowed to be performed by multiple individuals, so for example a CNA or other assistant role can spend most of the time gathering the necessary information, because there’s no real reason why a doctor has to be the one that gathers basic info that could be gathered by anyone. But despite multiple individuals being involved, there is one payment for that service, and it encompasses all of it.

And that's just it, when I saw the breakdown of services, they went by individual and many were listed as 1 hour when at most I talked to all them for a total of maybe 15-20 minutes.

Now granted, I'm just one person but if this place is doing this for thousands of people that adds up quite quickly.
 

Neomalthusian

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And that's just it, when I saw the breakdown of services, they went by individual and many were listed as 1 hour when at most I talked to all them for a total of maybe 15-20 minutes.

Now granted, I'm just one person but if this place is doing this for thousands of people that adds up quite quickly.

Well that really should be an easy one, because regardless of who’s paying or managing care/payment, if the rate is based on a duration of time, the duration of time needs to be satisfied. It’s just inherently fraudulent to base a price on a period of time and then not satisfy the duration but be entitled to that rate.

That may be a problem in some cases, but I see that is a bit different from price transparency in general, especially the type of price transparency that would enable patient to control costs and reduce overutilization or over-billing.
 

Mach

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If a vast majority of Americans aren't even interested in the cost of health care even when it's made available to them, then by default we are entrusting the entire responsibility for controlling health care costs onto a combination of government and insurance companies, because we refuse to take responsibility for ourselves as patients. Consumers determining exactly what they want and are willing to pay for is the most organic and effective form of cost control there is, and collectively we're refusing to do it. interested to hear from people what they specifically think would be necessary and effective at incorporating more patient-driven cost control into our health care system.
And what about the patients who aren't as involved or as savvy as you? That's probably...giving you the benefit of the doubt, over 50% of the population..the elderly, etc. No, the idea that random people are going to be savvy enough to understand the risks and needs of the most complex system we have (health), is not the way to go. And the issue you mention (if it's even an issue), is something that can be solved in any number of ways.

We *do* need transparency and more rules and regulations, much of which should be dictated by the medical community, that governs health care. Big-data and a well-funded regulatory private/public oversight board that helps us manage it, is what I'd guess will help. A well-managed process *should* afford for feedback from patients. But I don't think they can give you a person to answer and still keep costs low. They would need to get this electronically and manage the millions of feedback using priorities and grouping, etc.

Countless lives are cut short and quality of life is reduced, because we have not come together as a society and admit we all need to address this collectively. You know who opposes it.
 

PirateMk1

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I know there's many issues with the current healthcare, but one thing that really bugs me is that doctors can bill by the hour and can talk to you for 5 minutes. Now imagine if that doctor talked to 10 people for 5 minutes a piece and billed the insurance for 10 hours for a essentially a total of 1 hour of work. I'm not sure how that is even legal to be honest. At least when I go see a lawyer, they bill me by the minute. That's not even counting the cost of the visit, the nurse, equipment, ect. That is just what the doctor themselves charge.

In my logistics company I have a four hour minimum charge, that does not include afterhours surcharges. It does not matter if I am done in four hours or a minute. I do that so if I am called out to move something I have an expectation of some bit of minimum compensation. Normally with what we do its normally about 2.5 to 3.5 hours to get a man to the where the material to be moved is located loaded moved and offloaded and then proceed to the next call or return to the shop. All my customers know this because I give them sales sheets every quarter and let them know at the time they order the material move.

Doctors when they see you for five minutes dont just see you. They also have to document and chart what they said to you and what they do. This takes time and probabley personal and is something patients do not normally see. This may or may not consume a full hour, but one can presume that is their minimum charge for the service to cover their expenses and compensate for their time and knowledge.


My lawyer charges on an hourly basis in half hour increments.
 

Neomalthusian

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And what about the patients who aren't as involved or as savvy as you? That's probably...giving you the benefit of the doubt, over 50% of the population..the elderly, etc. No, the idea that random people are going to be savvy enough to understand the risks and needs of the most complex system we have (health), is not the way to go. And the issue you mention (if it's even an issue), is something that can be solved in any number of ways.

I’m interested in those number of ways.

We *do* need transparency and more rules and regulations, much of which should be dictated by the medical community, that governs health care.

The medical community has a vested interest in NOT controlling the cost of healthcare, and instead presenting itself as the expert whose opinion should be what determines what turns the money spigot on and off.

Big-data and a well-funded regulatory private/public oversight board that helps us manage it, is what I’d guess will help. A well-managed process *should* afford for feedback from patients. But I don't think they can give you a person to answer and still keep costs low. They would need to get this electronically and manage the millions of feedback using priorities and grouping, etc.

I don’t think price transparency is ever really going to matter to people until they start sharing in more of the direct costs of their own care. This is what I like least about recent Medicare for all proposals, because they advertise themselves as eliminating all patient cost-sharing as well as eliminating insurance companies, which concentrates the cost containment responsibilities onto a federal bureaucracy. Relative to patients who stand to lose their own money, or insurance companies who stand to incur losses if they cover too much (or customers if they cover too little), a federal bureaucracy is always going to lack inherent cost controls incentives. It lacks the aversion to financial losses that a private individual or company does, and it also lacks the fear of losing customers because everyone is an involuntary participant.
 
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Greenbeard

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I know there's many issues with the current healthcare, but one thing that really bugs me is that doctors can bill by the hour and can talk to you for 5 minutes. Now imagine if that doctor talked to 10 people for 5 minutes a piece and billed the insurance for 10 hours for a essentially a total of 1 hour of work. I'm not sure how that is even legal to be honest. At least when I go see a lawyer, they bill me by the minute. That's not even counting the cost of the visit, the nurse, equipment, ect. That is just what the doctor themselves charge.

If you get face-to-face time with a provider in an office setting they're usually getting reimbursed via what are called evaluation and management codes. Those fall into one of five levels, scaling with the complexity of the visit and time spent with the patient. Obviously as you go up the ladder the reimbursement level increases.

ME091014_58_bfd0ed0c-72a0-4fe0-8291-df09c9475936.jpg


So they're not just billing you for an hour of their time regardless of the contents of the visit.

(A proposal by the Trump administration to reduce the number of possible levels Medicare pays for in exchange for reducing the documentation requirements for proving how complex the visit was turned into a whole thing earlier this year: https://www.debatepolitics.com/brea...overhaul-medicare-payment-angers-doctors.html).
 

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I'd be interested to hear from people what they specifically think would be necessary and effective at incorporating more patient-driven cost control into our health care system.

It's worth thinking through major reasons it doesn't happen now. I’d say the big ones are:

Consumer behavior and market structure. To date, people have resisted acting like consumers with respect to health care, even as cost-sharing has grown. The reasons seem to be a mix of the practical and the ideological. They've lacked the tools to even obtain comparative price information, though that's starting to change. Similarly, they've lacked the financial incentive to obtain and use such information, though that's starting to change.

But beyond that, pricing in health care has never really been designed for a real consumer market, which limits the utility of price comparison tools. (In part this may be because only a minority of health spending is on services that would be considered "shoppable".) Prices are often not individually rational because the focus is on an aggregate financial package negotiated at the level of organizations, not individual prices brought to the market for consumer consideration.

Equally important, providers aren't bringing distinct care bundles to market with easily comprehensible price tags. You’ve often got to figure out which CPT code(s) are relevant to your situation and try to work through which additional fees might get tacked on in various circumstances and settings. Sometimes that’s not too hard, sometimes it’s very hard. And even if you could easily do that, people tend not to view their provider relationships as strictly transactional relationships in the market, which means in practice you’re fighting a very strong sort of brand loyalty if you want people to start price shopping for providers. Which leads into the next one:

Clinical practice patterns. The health care provider landscape is a mishmash of provider relationships and clinical affiliations. Because of people's willingness to trust their providers' recommendations, their decisions will tend to follow the contours of existing referral patterns in their market. If the market continues its march toward making integrated provider systems financially accountable for their patient populations, then provider systems have ever more incentive to tighten up the referral patterns of their providers and prevent leakage outside their system. So unless people become more predisposed to disregard their provider's advice and clinical relationships, normal market dynamics will be pretty hard to achieve. Beyond the clinically valid reasons providers might guide or restrict choice, there are more self-serving ones:

Provider behavior. There are steps provider organizations take to intentionally stymy price transparency or its goals. They might impose contractual restrictions on payers sharing price information. Or, to the extent they can manipulate at the negotiating table the pricing methodology that payers use to compensate them, they could shift revenue from shoppable services to services behind the veil. So maybe they drop prices on low-end imaging services or even big-ticket shoppable services like knee replacements (e.g., if the payer institutes a reference pricing scheme for that service) but compensate by negotiating to spread that forgone revenue across a variety of inpatient services that aren't shoppable. Then people could act like the most perfect homo economicus imaginable, it still wouldn't hold down health spending.

Payer strategies. To the extent that payers keep moving in the direction of value-based reimbursement, you could get to a point where rewarding higher-performing providers with higher prices penalizes them in a consumer market. (We’re not quite there yet but it’s something to think about.)

Those are pretty strong headwinds working against the hope of creating a workable consumer market for health services.
 

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So where does the above leave us if we really wanted this to work? Health services would need to be commoditized for competition in a consumer market. Perhaps that would require doing for health care services what the ACA did for health insurance products: create standardized, comprehensible packages that allow for easy, meaningful price comparisons. Given the huge variation in care delivery patterns, even within a single organization, and the long way still to go on precision medicine, it’s hard to say how possible this is even at a conceptual level.

Once you get beyond the question of what providers are selling, you then probably need to simplify, rationalize, and standardize the pricing. Instead of prices and (even payment methodologies) varying payer-by-payer, you would probably need all-payer prices that reside with the provider. That would unravel the managed care paradigm under which the market currently operates. That could be good, until you remember that the majority of spending is on services that aren’t shoppable and thus aren’t going to be turned into commodities in a consumer-driven market. Which means that the only actors with the incentive and ability to hold down those prices are the payers—but what happens when those payers are defanged?

If we could figure out how to package and price care for consumers, we’d still need to reshape the way people think about care. They’d need to take on primary responsibility for identifying the course of treatment they want to pursue and the provider they want to get it from. That is, they’d need to be willing to potentially give up longitudinal relationships with providers and disregard the referral relationships of the providers they do choose. The delegation of decision-making to providers would need to be significantly curtailed, if not ended, if we wanted to really turn health care into a market like most others. Is that feasible and desirable? I’m not sure that it is. At least not at the scale required here.

The consumer-directed approach seems to me like it can work a little bit around the edges, and probably should be used where it can, but I don’t really view it as a realistic large-scale solution. It requires hugely revamping the structure and finances of the health care industry based on an assumption of consumer behavior that doesn’t really exist (and which, even if it did, probably couldn’t be applied to the majority of health spending anyway).
 

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Thanks for your thoughts on this.

Where's the most obvious direction to go from here (e.g., legislatively)?
 

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It's easier to say why stuff doesn't work than to identify what will.

I'm more-or-less where I've been for the past several years: robust exchanges/marketplaces are the best tool we've got going forward to retain any semblance of market dynamics in the health system. If people are voting with their feet and wallets and we've got ACA-era consumer protections forcing insurers to compete on price instead of creative risk-shifting/shedding, that downward pressure on premiums seeps into provider-insurer price negotiations, it adds urgency to the push for payment and delivery system reforms, and it incents insurers to get smarter about benefit design.

We're always going to need some degree of paternalism in the health system. With their clinical and financial knowledge, insurers are in a position to build products that can enable and harness informed consumer choice and decision-making without facing the impracticalities of directly exposing consumers to the labyrinth of provider prices.

And if in some markets we're going to have mega-provider-systems competing directly with each other and pricing access to their system with a premium (effectively usurping the insurer role), then they can bring that premium to the market by selling provider-sponsored plans in an exchange.

I view the ACA exchanges as a pilot of the concept. The results have been promising but the entire endeavor has been hamstrung by unforced errors made by bad political actors. I also would've liked to see more employers using the on-ramps into the exchanges in the law. The rise of parallel private exchanges for employers also complicates things--I applaud the spirit but I don't like the dicing up of the market.

Anyway, my immediate policy prescriptions would all be about shoring up the exchanges and making them more attractive to individuals and businesses (and thus, ultimately, to insurers as well). Frank Pallone's legislation is good, on net I like the current pending rule that would allow employers to fund HRAs for use in the individual market, and I'd like to see some creative efforts to nudge greater insurer participation.
 

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Thanks for your thoughts on this.

Where's the most obvious direction to go from here (e.g., legislatively)?

Pick up where the ACA left off and increase competition in the healthcare insurance market.

Move away from employer provided plans.. and move toward individual purchased plans with minimum coverages

Mandate everyone have insurance coverage.

Offer a federal public plan through a separate entity like the FHA. One that does not have investors.. but is not at the whim of legislators that are influenced by the insurance industry.
 

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But on the way home I asked my wife to get onto the health system's website to find out the billable rate for the strep culture lab test, and found out it was either $280 or $560, depending on which was ordered.

Another anecdote: I checked with insurance company and a billing manager at the the provider the cost for 2 Xrays under the plan. Result came back that provider would charge more than the allowed max of $150 copay and thus it would cost $150 * 2, or $300. Then I went and did the 2 Xrays. Final cost for both was $58 to me.

And yet another anecdote:
Date 1: went to pharmacy to get some drugs for a family member and the cost was unusually high. I declined getting the drugs. After various calls, figured out they are in the doughnut hole due to 1 expensive drug being filled on that date.
Date 2: Called insurance company and they started a process to get an exception to not charge for the drug. Went back to pharmacy and got 10 OTHER drugs. Since the person was not in the doughnut hole now (since we refused the meds on Date 1), all came through with pre-doughnut-hole pricing as expected.
Date 3: Insurance company process came through. Went to pharmacy and got the expensive drug (for free). Now the family member is in the doughnut hole (because insurance company paid a lot anyway).

Two months later got a bill from insurance company for underpayment for those 10 OTHER drugs on Date 2 saying we should have paid for them as if the person was already in the doughnut hole. Explained to many supervisors that on Date 2 they were NOT in the hole, since Date 1 transaction did not count. They understood. Pushed the appeals. Two more months of back-and-forth resulted in them sticking to their decision despite the fact that on Date 2 the person clearly was NOT in the hole.

Sometimes, it's almost impossible to find a price, even when you try. And even if you know the price, you may end up paying more anyway.
 

James972

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I'd be interested to hear from people what they specifically think would be necessary and effective at incorporating more patient-driven cost control into our health care system.

very very simple. we need a law that prices be published and that people shop with more of their own money. This would reduce prices 80%. Its called capitalism
 

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I know there's many issues with the current healthcare, but one thing that really bugs me is that doctors can bill by the hour and can talk to you for 5 minutes. Now imagine if that doctor talked to 10 people for 5 minutes a piece and billed the insurance for 10 hours for a essentially a total of 1 hour of work. I'm not sure how that is even legal to be honest. At least when I go see a lawyer, they bill me by the minute. That's not even counting the cost of the visit, the nurse, equipment, ect. That is just what the doctor themselves charge.


Thats actually routine in service based business. I am in the logistics industry and I charge a 4 hour minimum just to move my equipment. It doesn't matter if the job takes an hour or 4. The only time I dont is if I am hired for the day or other specified time period and negotiated that rate previously. My attorney charges on an hourly basis.
 

Neomalthusian

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very very simple. we need a law that prices be published and that people shop with more of their own money. This would reduce prices 80%. Its called capitalism

Greenbeard already very cogently pointed out with supporting evidence that most healthcare is not shopped or shoppable.

I’m not sure why you pull figures out of thin air like that.
 

James972

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Greenbeard already very cogently pointed out with supporting evidence that most healthcare is not shopped or shoppable.

not shopable?????? If an appendectomy costs 5000 at one place $55,000 at anothe quess which one a shopper would pick? See how easy that was??
 

Neomalthusian

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not shopable?????? If an appendectomy costs 5000 at one place $55,000 at anothe quess which one a shopper would pick? See how easy that was??

But in reality people don't shop for appendectomies.

Have you read the posts in this thread, including the links provided? Insurance companies have provided tools for checking prices and a vast majority of people don't use them. Greenbeard cited sources explaining why health care is not actually shopped for and a great deal of the expensive stuff basically cannot be shopped for (with explanations as to why that is).

You should read those posts.
 

Neomalthusian

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what figure would a liberal dare challenge?? Just coincidental you forgot to say??

I've seen you do this before. "Do (x) and the price will drop by (y)%. Source: me. Explanation: Just think about it!"

The claim that health care costs will drop by 80% if we passed a law requiring the price of health care to be readily available was plucked from thin air.
 

James972

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The claim that health care costs will drop by 80% if we passed a law requiring the price of health care to be readily available was plucked from thin air.

80% with published prices and people shopping with their own money. That would be called capitalism. Look at Cuba/Florida. People can buy everything in FLorida(capitalism) and almost nothing in Cuba( socialism) Was that simple enough for you?
 

Neomalthusian

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80% with published prices and people shopping with their own money. That would be called capitalism. Look at Cuba/Florida. People can buy everything in FLorida(capitalism) and almost nothing in Cuba( socialism) Was that simple enough for you?

Extremely simple. Too simple, really. As simple as just making stuff up. Which is what you’re doing.
 

James972

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Extremely simple. Too simple, really. As simple as just making stuff up. Which is what you’re doing.

who can buy more? People in Cuba or Florida? This teaches you that Republican capitalism makes stuff plentiful and cheap. NOw do you understand?
 
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