That actually sounds like the high deductible plan is functioning as it should though. Causing consumers to price-shop and avoid price-gouging providers.

I'll be sure to let the ambulance driver know after a car accident they should shop around :\ Maybe an Ayn Rand medicalert bracelet would help. Allergy: Socialism.

In our area, its becoming popular for the hospital (the only one in our area) to be in network, but the doctors who work in that hospital are NOT in our network.

#BAM!

Funny! Pointed too.

Getting the best dealz runs in basic conflict with needing to stay alive.

This is why markets do not work well for primary care. They can work well higher up the chain where life basics are not really in play.

That's why the out of pocket maximum exists. (I think?)

The out of pocket maximum can be a lie, too. I have an 'out of pocket maximum' on my ACA insurance plan, but there are medical services that are exempt.

Last year, I paid $4000 more than my $6500 out of pocket maximum, because I had a heart procedure and the heart rehab following the procedure was an exception to the out of pocket maximum, a fact I discovered only after incurring the costs. You see, if you clearly follow the asterisk and the footnote references in the policy, then it's very clear that these expenses would not have been covered.

if I understand correctly, the out of pocket maximum might only apply to in network providers. I think if you end up getting a non-covered procedure or get service from an out of network provider, you can be on the hook for way more than the out of pocket maximum. if so, it would be hard to ensure that this doesn't happen in an emergency.

That was fixed long ago by ACA. Emergency services are treated as in-network regardless of whether they were actually in-network.

Well yes, but you make it sound so easy. You'll have to go multiple rounds with the insurance and aca reps in many cases to get it approved after the fact.

Yes, and that is the biggest issue. Hospitals and insurance companies playing hot potato with each other while the hospital tries to pin whatever the insurance company doesn't pay for on the consumer. We need more punitive regulatory action for such situations.

Sure, in the case of a scan that isn't urgent. If you were in a car accident and have a piece of metal embedded in your kidney are you in a level, clear-minded state to price shop about which emergency room won't gouge you?

Health care is an inelastic good, we need it. So this is a market (much like having a military) that really benefits from the government stepping in and making things sane.

If you're in that dire an emergency you're going to max out your in-network limits anyway, so it doesn't really matter which emergency room you get taken to, you pay the same.

My in network max is around $13k, my out of network is $99,999,999.

EPO / HMO?

My card says PCP.

That’s what an advanced directive is for. We just need to extend it beyond CPR/no CPR and heroic measures vs no heroic measures, etc. Kinda how like insurance companies negotiate prices for everything in advance of you showing up.

Let users watch a series of videos and choose what kind of risk and benefit they tolerate/want and how much they’re willing to spend.

It’s morbid, but we do such assessments constantly. Do I come to a complete stop and waste a few seconds and ml of gas, or roll through it and be really careful about it?

Seriously?

The difference in your "every day" scenarios is recoverability. Your actual health put at risk means you die, unrecoverably.

Then there is always people not being able to spend. So they just die?

A poll on that policy would be instructive.

The every day scenarios can result in permanent effects. Not everyone going through a stop sign is in a protective cage.

Obviously the advanced directive solution is largely irrelevant in a 100% coverage/public system. The insurer then makes those decisions for you. But for as long as you have a system with uninsured, there’s value in having decisions made in advance as a “just in case”.

Real value is health care as human right. That we do not do it, and worse, can't even get a basic like water right is an embarrassment at the least, and rock solid cause for reform all day long.

In simpler times, a city able to provide clean water was a city of note. Worthy destination. This has been true for ages.

Flint fucked for how long now?

Our national priorities are insane! Bat shit wrong and health care, food, water, housing are all right at the top of reform agendas for damn good reason.

We can do better, and we need to.

The uninsured are uninsured because they are unable to spend. Put whatever the fuck anyone wants on that paper and it does not matter one lick.

Might as well write, "yeah, let me die, k?"

Frankly, there is zero value in the idea, and a lot of harm potential in the norms being changed for the worse: "but they consented..."

Anyone who wants to make a directive can do so today. Expecting people to do it because our system is fucked makes zero sense.

It is long past time we get our priorities in order so conversations like this are laughable, not morbid.

So now not only do I have to spend several days on the phone each year with my insurance company, on top of figuring out which plan I want every new job, but I also need to watch a bunch of videos about kidney-replacement options for when I get in a car accident? And what heart attack care is available? And how many $1000 Ti screws they should put in my leg when I shatter it rock climbing? And somehow the collective time-wasting is going to be somehow cheaper for all of us?

I always wonder if you libertarians are doing a bit, because it sure seems like it.

You get some agent to do the heavy lifting in agreement with your parameters.

It’s a solution to the problem of “I continued to choose to live in an environment without health insurance, how do I handle the situation of not being in a position to negotiate?”

The agent I choose it the government, which I am proposing becomes the common agent of all Americans and advocates for all of us - since the expertise to act as a rational agent in this setting is unavailable to most citizens.

This extreme libretarianism stuff is pure BS, health care services in an emergency cannot exist as a free market.

Oh, I agree. But most Americans actively vote against that system.

As for those uninsured that just broke their ____ and are not in a position to start calling around, having pre-negotiated rates for the best pricing against all hospitals within a reasonable time’s transport would save a pile of cash. There’s no shortage of hospitals or excess capacity in the US.

Not that I disagree, but the majority of health care expenses are not time-critical emergencies. I saw a statistic somewhere where it's around 15%?

IMO the biggest problem is that you're not really qualified to judge medical practitioners. How am I supposed to know if what they're recommending is actually necessary? The market price of an MRI? How do I know they're not skipping care I should have to offer a lower price? Or if they're offering unnecessary procedures?

The reality is you need an M.D. to make a reasonable evaluation. This is why at an HMO we have primary care physicians. Or in any other country, GPs. They decide if you need specialized care. However, how am I supposed to pick one of them? It's Russian nesting doctors.

It's probably the most complicated thing we have to deal with in our non-professional lives.

Same way you evaluate developers. Say you are a manager at a company who needs to hire somebody to develop an application for you. You aren't technical. You have no idea if you need the thing the consultant is saying you need. So you check completed works, existing client testimonials, educational history, recommendations from coworkers or friends, etc.

Just wait until you get a reference request on your last colonoscopy :P

Seriously though in general managers have worked in and around technical people before, and their role in the process is to evaluate qualitatively. Are they a good communicator? Do they seem like awful people? They use feedback from the engineers to estimate if they're good engineers. I don't have a deep bench of M.D.s to lean on to figure this stuff out.

Actually that raises an additional interesting point... if the market price is varying from doctor to doctor it could be for many factors - how am I supposed to judge the relative quality of an MRI that would be read by two different specialists. If the quality is different then how can I be informed as to the efficacy and truth of that difference?

With a bank, Bank of America has terrible service - so I just don't use them, with a doctor though... what if I'm paying a premium price but receiving substandard care, given how complex human bodies are most illnesses compound over time and only in very select circumstances could you get a doctor to come in post defacto look at an X-Ray and say "This doctor was terrible, that's totally a tumor" maybe the real issue is that a tingling in your finger tips when you sit down that you asked your doctor about went unnoticed and twelve years later your heart gave out over totally preventable causes.

The majority in terms of cost or volume? Also is this figure including oncology treatments - those drugs can run 1k/pill and while some are potentially cures many more are just pushing eventual death a bit further off. These drugs would quite possibly skew any statistic that isn't designed precisely to account for them.

Also I think it's not really fair to take full lifetime costs into consideration at once. As you get older you'll be looking at those much more expensive treatments and covered by expensive insurance but the insurance tends to be of a higher quality when it comes to reducing sudden costs - I am more concerned about younger people who generally have terrible insurance and may get hit with 4 months of 20k physio due to a sudden injury but generally have low "normal" costs.

What if the cheaper place is cheaper cause it's not as capable? How am I supposed to know? In what other scenario are we similarly encouraged to act on price alone? Price transparency is meaningless with quality transparency.

... and assessing quality in this space is way outside of what a normal consumer is capable of anyway.

The UK has periodically had a back and forth on whether the outcome ratio numbers which are collected for internal statistical measures should be published.

ie should we make it easy to get a number that says 4.6 for Mr Able, 5.2 for Ms Awesome and 3.8 for Mr Good?

At one extreme the reality may be that Mr Good isn't good and his numbers are low because he's a bad surgeon, he makes a lot of mistakes, his technique is not what it should be, he's using an approach that's outdated... that's a real problem, and maybe "patient choice" is a fix where colleagues may be reluctant to say "Fire Mr Good" because he's a good guy, he's not _terrible_ at his job, but yeah they would not themselves choose to be treated by him.

At the other extreme the reality may be that Mr Good is the only guy who'll take patients that Ms Awesome thinks are too high risk. She thinks it's better to say "No", he thinks if they seek medicine he should do his part. Maybe they're obese, or they won't stop smoking, or they won't stop doing the sport that's wrecking their body. And Ms Awesome is right that Mr Good's patients are higher risk, but that's not because he's doing a bad job, he's playing what was dealt.

Also don't forget that Mr. Good might have tougher customers because he's Mr. Good and his prices are low or because he's willing to take on the hardest jobs that are unlikely to leave customers satisfied no matter how good they turn out. If you're the guy that everyone goes to because nobody else is willing to try and fix what you will your success/failure ratio will by abysmal.

Measuring quality is also incredibly difficult, patient input is practically worthless.

Every time patients are asked to rate the quality of the care, they consistently rate simple feel-good care like massages, chiropractice, or just therapy as very good, but saved-your-lfe-operations get rated very badly, because the experience and recovery is often miserable. You live, but you don't feel good, so you rate the quality of the care after how you feel, even though you ought to rate it Five-star, A++++, would transplant a failed heart again!

So the rational person abandons subjective ratings and look at objective ratings, what's the medical outcome for a provider? Sure, that's better, but the quality of the outcome is incredibly dependent on the quality of the patients! It's a well-known fact that a positive attitude helps immensely with recovery, how do you measure that? How do you integrate that with an outcome measurement?

And quality transparency isn't that much help either - if you have cancer are you really going to shop around if chemo treatment drug group A is more effective then drug group B? A patient cant even begin to be able to shop around for something like that.

Price is the best mechanism for organically assessing quality at scale.

People in poor health are not consumers and getting medical help is not shopping.

No... the grandparent had it right. "Skin in the game" is just a colloquial restatement of the earlier point. The purpose isn't to make people needlessly suffer more by having to pay!

The principle idea is that because they have to pay some, they'll be more sensitive to pricing and more willing to shop for an affordable provider, which is exactly the efficiency argument.

And in this particular case I agree, even. Though the fact that this has to be done by individuals (who are sick!) sort of makes a hash of the moral notions of "the market" being the solution here. We're buying efficiency at the cost of individual grief, and that has value too.