Thank you. The wife is going for 6 hours of testing tomorrow having to do with her dry drusen that are nowhere near the macula. She’s 29 with perfect vision and narrow angle they just corrected with lasers.
The doctor wasn’t all that helpful with recommendations to halt drusen progression and the wife is a health nut (perfect blood lipids, weight, glucose And BP) type A personality. I was skeptical of the AREDs formulas since they were vitamins being marketed to seniors as a treatment.
I agree with you that market-forces won’t serve as the panacea that libertarians think theywill - however, I do think a lot of health care is amenable to cost-conscious shopping, which is why I support price transparency across the board. Then, whether the consumer is the patient, the insurer, or the government, the powers of competition are given a chance to work.
Best of luck to her. As one has to be 50+ and have changes in the macula to have a condition called age-related macular degeneration, it doesn’t take an ophthalmologist to recognize that your wife doesn’t have it. (Which is not to say she doesn’t have drusen; there are many ocular conditions that manifest them.)
Laser peripheral iridotomy, or (less commonly) iridoplasty.
For good reason. To my knowledge, there is no as-yet known method to halt or even slow drusen development. (Lots of things have been tried; none have worked.) Even the AREDS vitamins don’t affect drusen (they influence the risk of wet dz development in people who have significant macular drusen).
Competing on price is fine for some aspects of HC–DME, drugs, etc. But would you really want doctors to compete on price? I don’t see that as a good thing.
I think that’s accurate. One thing I would say–and I don’t have the answer to this–is that you would have to compare the expansion in Medicare treatment and cost vs the expansion in non-medicare treatment costs as a way to see which grew unwieldy faster. Naturally this is a nightmare to set parameters and control adequately, but an attempt at something like that would be the only thing I could see being reasonable for the purpose of determining what the outpacong growth of the economy is due to.
Well, while I largely agree with what you’re saying, allow me to state the opposing view: earlier today I finished a training session with a urologist, who saw 40 patients today, did 2 procedures and 1 emergency surgery. Do you really think someone who sees that many patients a day is capable of “knowing” and “detecting a change that would be impossible for someone not familiar with you to notice”?
Realizing of course that the number of patients varies doctor to doctor and field to field, and that physicians are often horrendously overworked through no fault of their own, I think that your statement above is increasingly optimistic–there is in many many places a decreasing amount of personal time and attention by doctors.
I do, understanding that some would see that as risky because cheaper will not necessarily mean better. When the dust settles, my hope would be that smart consumers would see a fee range, avoid the lowest and the highest and start choosing the middle priced doctors, who give the market signal of being competent but motivated by good service, not greed. And then, let competition do its work. With pressure to lower prices, the overpriced physicians might have to settle for a smaller second lake house 
, but the cost of seeing a physician would come down, a good thing for patients.
That is actually a great example of what I’m talking about. A good urologist (coupled with good record-keeping) has an amazing ability to detect changes in the size, consistency and surface contour of every prostate in his/her practice. If there’s any part of your body where continuity of care and a personal relationship is important, it’s your prostate!
This is true. As overhead increases and remuneration drops, physicians are forced to see more and more pts to maintain their income. An unfortunate development.
Tell you what–I’ll go along with this, but only so long as physicians are allowed to unionize. Deal?
Why would we want them to stop working?
This is an important point and one I have mentioned many times. Steven Brill’s Bitter Pill is one of the better articles I have ever read on the subject. Essentially hospitals vastly over charge for things but don’t really in Medicare when they have someone who can call them out on their BS. And most importantly a lot of people in hospitals have no idea why they charge what they do and it varies crazily from hospital to hospital. This (among a million other reasons) makes health care unlike any thing else.
Life and death decisions and zero knowledge have no comparison to shopping for something like a refrigerator. I would certainly be for mandated price transparency.
Single payer or not we don’t have anything like a free market so the benefits of market forces have no chance to work.
Well, it wouldn’t be subject to unionization, typically - since you’d have independent economic actors, any agreement to lock arms and hold the line to inflate prices would be a cartel and possible price collusion, not collective bargaining as a group to a payor.
I don’t see these as the same thing I see them as 2 different issues, albeit linked. The knowledge gap or asymmetry is one thing, but charging exorbitant fees for shit because nobody can tell you “no” is something that needs to be fixed.
No, you don’t usually get to pick when you are in the hospital, particularly the ER. This means that your fee for treatment is not something you can necessarily “choose” like in a free market (although it has zero to do with knowledge gap and everything to do with being in a wreck/physical mess).
But this also means the seller has enormous power–they can charge whatever they want (unless it’s Medicare as you pointed out) and you’re on the hook. That is completely screwed up, and I think can be ameliorated regardless of knowledge gap.
For example, some years ago I was in a motorcycle wreck in the middle of the night when I hit some sand in a turn, about 4 miles from the hospital. I went to the ER, but not in the back of a bus–i had a passenger that was messed up but conscious…more freaking out than anything (they’re fine btw). She rides in the back, I take a hop in the front seat to avoid being transported as a “patient”.
We get to a deserted ER. We go in, they usher us into different rooms. I wait about 2 hours to be seen, they’re checking her out. I clean my own wound because I am tired of waiting. Nobody in there, nurse doesn’t come back after she takes my information on the chart. They wrap my self cleaned road rash up and charge me $3000. Passenger has insurance, her treatment goes on her insurance not on my bill (I checked).
There’s no way in hell gauze and a “how’s your father” costs 3 grand but I didn’t have any say in the matter. I did my own fucking medical care for fucks sake!
Long and a few years old by now but amazing read. I believe it was and still is the longest article ever printed by time magazine. If I remember right it also explained why Obamacare wasn’t going to work
https://www.uta.edu/faculty/story/2311/Misc/2013,2,26,MedicalCostsDemandAndGreed.pdf
In fairness, one reason hospitals do this is cost shifting–covering the costs of uninsured pts by overcharging funded pts. Remember, hospitals are by law required to take all comers under EMTALA. This amounts to an unfunded mandate.
Who says you can’t say ‘no’? Assuming one is of sound mind, they can sign out of any hospital at any time (although you might be asked to sign a statement indicating your leaving against medical advice [AMA]).
Sure you did. You could have refused transport to the hospital. Or once there, you could have declined to be seen.
I certaibly understand that part of it, but as H Factor pointed out they DO lower costs in the face of enough oversight and bargaining power. I think that there is quite enough room to bring down consumer costs from their present level in many areas while still ensuring that EMTALA does not bankrupt the facility. Would it likely be as low as Medicare? No, for obvious reasons. But lower than at present? I think that could be achieved, and should be done.
The specific situation I am thinking about is one lying unconscious. Or nearly so–I should think that even if no life threatening physical trauma exists one could be in shock and therefore not of right mind. In any case, I think you understand quite well that much hospital treatment represents what business types might call a “captive market”, yielding extreme pricing power to the seller of services over the consumer.
My bill did not include transport; I was not charged for it as I explained. I was not hooked up to any machinery, given IVs, X-rays, or anything else. Considering you know the costs involved with visitation, I think you must admit that this is exorbitant for having the patient do his own medical care without even a doctor present in the room. And yes, I checked myself out as soon as I cleaned myself up and someone finally came in the room. I did not spend the night checked in, I spent it in the lobby waiting for people to wake up so I could call a ride.
In any case, my point is that I did not have a choice as to how they charged me once I was there, or what they charged me for (not that I could refuse being seen, which I knew). The costs were 100% opaque until bill time–THAT is what I mean when I say I didn’t have a choice. I think you must admit that there are some serious problems involved with price and billing at hospitals, even while the industry is indeed complex.
Incidentally, the price of that night was well above the national average for treatment of an open wound (roughly double), and they didn’t treat it…I did.
That’s fine by me. But note that you’re not talking about getting prices down via market forces, rather, you’re talking about price control via regulatory oversight. In other words, you’re proposing we essentially treat HC as a utility. Again, I think that makes much more sense that treating it like a mattress store.
If one is lying unconscious, it is an emergency, and EMTALA rules. So the hospital is in at least as unfair a position as the consumer; ie, the hospital is obliged to eval and treat whether or not the consumer has the ability to pay. I know of no other goods/services that are mandated in this manner; eg, I don’t care how hungry you are, a restaurant is not obliged to give you a meal for free. Advantage: Consumer.
While it might feel that way, this is in fact not the case–you can leave anytime (again, assuming one is of sound mind). But the fact that it feels like you have no choice is testament to what I’ve been arguing all along–that HC delivery is not a normal ‘market,’ and thus its costs cannot be governed by the same sorts of passive controls as other goods and services.
My point was, you didn’t have to go to the hospital at all.
As I was not there, I cannot comment on the care you received. Perhaps the person you thought was a nurse was a PA, or an NP. Perhaps their assessment was more thorough than you recall. If you truly didn’t see anyone but a non-NP nurse, then this amounts to fraud (assuming your bill includes a practitioner’s fee). Now, if you left AMA without being seen, they might still be able to bill you, depending on the laws in your state.
So, in addition to discussing your recommended plan of diagnostic and treatment procedures, you’d like the doc to also discuss how much each one is going to cost you? And then what–you’d pick what you want a la carte? Haggle over the price? Is the doctor obliged to follow your ‘plan’ if s/he thinks it is unwise, or can s/he refuse to ‘serve’ you? And what about the doctor’s liability? Suppose s/he wants an MVA victim to have a CT chest to rule out a cardiothoracic injury, but the pt balks at the cost–who is on the hook if the pt later dies from a ruptured aortic root? It’s easy to say ‘the pt made the choice,’ but his/her family is going to argue (in court) that the doc didn’t adequately explain the urgency of the procedure, or didn’t appropriately stress its importance, etc.
Again, pricing transparency cannot make up for the other obstacles inherent to treating HC delivery as just another good/service.
I honestly have no idea why you agreed to be seen at all.
I certainly don’t want to come off as anti doctor or anything. Sister is an obgyn at KU med and other sister a charge nurse at an Omaha cancer speciality place. Doctors nurses etc are probably underpaid in many respects when you look at what it takes to become one.
The article highlights the absurd salaries of some hospital Presidents as one factor and also notes the 400 percent markup in a drug at a “non profit” place.
I can fully admit health care is not something I have studied feverishly or anything. You know so much more about the topic not even sure if I should be posting!
Just an update for the good doctor. The docs suspect some sort of problem with the ABCA4 gene , but not Stargardt. She has 20/20 at age 29. Hence the ERG/VEP.
I guess there are dozens of different ways that gene can go wrong. So now we wait 10 weeks for the gene information to come back. Once they decide what it is then it is blood tests to see if I’m a carrier and if the kids have it so they can be monitored. Thanks for the bad genes ancestors. Lol
I think that one part of this that market forces simply can’t ameliorate is a situation like my friend. He was an anesthesiologist physician/professor at a university. I asked him about his billing rate and he honestly had no idea. It was not something he was ever involved or concerned with.
People aren’t going to be picking and choosing, thereby assembling surgical teams for things like multi organ transplants or emergency neo-natal procedures. Its not like “Oh, I heard about that Starzl guy. No way I’m paying for him…”.
I didn’t want to ask, but I was wondering what testing she was undergoing that took 6 hours. ERG/VEP answers that question.
The ATP-binding cassette (ABC) transporter protein is indeed implicated in a number of retinal diseases, and in ways we don’t fully understand. Some pts get very serious conditions (much worse that Stargardt, in fact), whereas others get phenotypic findings (eg, your wife’s ‘drusen’) without significant functional impairment.
Well, 5-10% of the population is believed to harbor an ABCA4 mutation, so don’t be too hard on your progenitors.
Hopefully if single-payer becomes a reality, dolts like you who would rather pay more money for potentially worse outcomes will have that choice.