Libertarian Diskanen

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Warren
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Re: Libertarian Diskanen

Post by Warren » 13 Jan 2019, 11:52

Mo wrote:
13 Jan 2019, 10:26
Warren wrote:But what is really needed put market forces to work in health care is to eliminate 3rd party payer. Even if you could stick it into some omnibus bill, I'm not sure how to craft it. I'm absolutely sure nobody wants to hear that. Any attempt to so much as mumble it out loud would be political suicide.
As long as their are medical treatments that cost multiples of people’s houses, you’ll need 3rd party payer.
For those situations, yes. But those are exceptional cases. There's a not insignificant number of people that don't think they should be inconvenienced with so much as a co-pay. The cost for medical services needs to be transparent. Comparative shopping needs to be a thing. Individually negotiated pricing should not be the norm. Without these things, I see no way for even routine healthcare costs to remain within reach of the middle class. And I see no way to get there from here.
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Re: Libertarian Diskanen

Post by Shem » 13 Jan 2019, 14:03

I'm not sure you can call "any cancer that requires more treatment than cutting it out" an exceptional case. Even the cheap chemo treatments will get you into midsized sedan territory within a few months.
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Re: Libertarian Diskanen

Post by lunchstealer » 13 Jan 2019, 14:40

Warren wrote:
Hugh Akston wrote:
12 Jan 2019, 15:01
I think eliminating employer-provided coverage would go a long way toward doing that. People will be much more aware of the cost/service curve when they have to shop for themselves. And I suspect that doctors would offer cash discounts for routine procedures, up to the point where the only time you deal with your insurance company is when you're facing an acute or debilitating condition.
No, that would represent a complete overhaul of the current regime. Even with high deductible plans, your care provider bills the insurance company, the insurance company says "No you can't charge $600 for an x-Ray" and you get a bill for 80 bucks. No doctor's office will tell you how much anything costs. They don't even know themselves. All they know how to interface with the bureaucracy. If you spent a thousand hours trying to get a straight answer on how much getting a mole removed is going to cost you, it would be a thousand hours wasted.

I really don't think it would even be possible for a doctor to offer "cash discounts" without scrapping medical regulations entire.
Doctors who do stuff that isn’t covered by insurance give fixed up front pricing all the time. Bariatric surgery, lasik, plastic surgery, any of that can be priced up front.
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Re: Libertarian Diskanen

Post by Warren » 13 Jan 2019, 14:43

Shem wrote:
13 Jan 2019, 14:03
I'm not sure you can call "any cancer that requires more treatment than cutting it out" an exceptional case. Even the cheap chemo treatments will get you into midsized sedan territory within a few months.
Which is considerably less than multiple houses. It's not like you have to pay up front. The doctors/hospital should collect from you. Insurance would preferably be Aflec style where you get a fixed amount for a given diagnosis.
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Re: Libertarian Diskanen

Post by Warren » 13 Jan 2019, 14:45

lunchstealer wrote:
13 Jan 2019, 14:40
Warren wrote:
Hugh Akston wrote:
12 Jan 2019, 15:01
I think eliminating employer-provided coverage would go a long way toward doing that. People will be much more aware of the cost/service curve when they have to shop for themselves. And I suspect that doctors would offer cash discounts for routine procedures, up to the point where the only time you deal with your insurance company is when you're facing an acute or debilitating condition.
No, that would represent a complete overhaul of the current regime. Even with high deductible plans, your care provider bills the insurance company, the insurance company says "No you can't charge $600 for an x-Ray" and you get a bill for 80 bucks. No doctor's office will tell you how much anything costs. They don't even know themselves. All they know how to interface with the bureaucracy. If you spent a thousand hours trying to get a straight answer on how much getting a mole removed is going to cost you, it would be a thousand hours wasted.

I really don't think it would even be possible for a doctor to offer "cash discounts" without scrapping medical regulations entire.
Doctors who do stuff that isn’t covered by insurance give fixed up front pricing all the time. Bariatric surgery, lasik, plastic surgery, any of that can be priced up front.
YES! The market on those things is working. I want to move all health care to that model.
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Re: Libertarian Diskanen

Post by Mo » 13 Jan 2019, 15:15

Between the emergency C and the hospitalization due to a fever under 3 months old, I was an M4 convertible in the hole 6 weeks in. While my situation was not typical, it’s not uncommon.
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Re: Libertarian Diskanen

Post by Warren » 13 Jan 2019, 15:52

Mo wrote:
13 Jan 2019, 15:15
Between the emergency C and the hospitalization due to a fever under 3 months old, I was an M4 convertible in the hole 6 weeks in. While my situation was not typical, it’s not uncommon.
And you should be able to pay that over time. There's no need for third party payer.
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Re: Libertarian Diskanen

Post by Mo » 13 Jan 2019, 16:25

If I was in a household where that represented 100% of my pretax income, and my credit was decent, who the fuck would approve that financing?
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Re: Libertarian Diskanen

Post by Jennifer » 13 Jan 2019, 16:34

Mo wrote:
13 Jan 2019, 16:25
If I was in a household where that represented 100% of my pretax income, and my credit was decent, who the fuck would approve that financing?
[Googles cost of M4 convertible] Yikes. In the ghetto-ey neighborhood where I live (and though mine and Jeff's financial situation is not remotely where it should be, by immediate-locality standards we are downright rich), that's more then twice the pretax annual income for a lot of households around here. Nobody would extend such credit to any local families.
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Re: Libertarian Diskanen

Post by Shem » 13 Jan 2019, 17:25

Warren wrote:
13 Jan 2019, 14:43
Shem wrote:
13 Jan 2019, 14:03
I'm not sure you can call "any cancer that requires more treatment than cutting it out" an exceptional case. Even the cheap chemo treatments will get you into midsized sedan territory within a few months.
Which is considerably less than multiple houses. It's not like you have to pay up front. The doctors/hospital should collect from you. Insurance would preferably be Aflec style where you get a fixed amount for a given diagnosis.
That's for generic drugs. For name-brand you're looking at 20-30k per month just for the meds, never mind the care. Good luck comparison shopping for that.

And your provider collection idea will make things more expensive, not less. Who do you think winds up paying for all the poor people who take care and then either never make enough to pay or drop dead before anyone can get to them? That gets passed on to you.
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Re: Libertarian Diskanen

Post by Warren » 13 Jan 2019, 18:43

So what then? I don't see any possible way to manage health care costs with third party payer.
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Re: Libertarian Diskanen

Post by D.A. Ridgely » 13 Jan 2019, 18:56

No one knows what medical services would cost in a less regulated market between patient and provider; therefore, no one knows whether third party payers would be required in many of the circumstances they currently cover. On balance, as soon as a hospital is required, yes, insurance is probably going to be required; but an increasing number of procedures are performed in clinics that are little more than slightly better equipped private offices, so who knows?

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Re: Libertarian Diskanen

Post by D.A. Ridgely » 13 Jan 2019, 18:57

By the way, my son is attempting to start a web service in which prospective patients can shop for elective 'surgeries' such as Lasik, hair transplants, etc.

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Re: Libertarian Diskanen

Post by JasonL » 13 Jan 2019, 18:59

If the third party has a) the market power and b) the incentives, you can triangulate provider costs. It fails now because providers are way more regionally powerful than insurers.

The other thing is end of life care and extreme cost events. Someone has to say no. One advantage of doing national provision for catastrophe is the ability to say no for things that cost a lot but add few to no quality years.

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Re: Libertarian Diskanen

Post by Warren » 13 Jan 2019, 19:05

JasonL wrote:
13 Jan 2019, 18:59
If the third party has a) the market power and b) the incentives, you can triangulate provider costs.
If that were true HMOs wouln'd be so fucking horrible.
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Re: Libertarian Diskanen

Post by JasonL » 13 Jan 2019, 22:04

They don't have the power after hospital groups formed. Also when they had the power everyone hated them for making people die by saying no sometimes.

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Re: Libertarian Diskanen

Post by Aresen » 13 Jan 2019, 22:38

JasonL wrote:
13 Jan 2019, 22:04
They don't have the power after hospital groups formed. Also when they had the power everyone hated them for making people die by saying no sometimes.
*Ponders ways of getting on the 'approval panels' for certain individuals*
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Re: Libertarian Diskanen

Post by Mo » 14 Jan 2019, 07:53

JasonL wrote:
13 Jan 2019, 18:59
If the third party has a) the market power and b) the incentives, you can triangulate provider costs. It fails now because providers are way more regionally powerful than insurers.
I don't see how that changes unless you start breaking up regional providers.
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Re: Libertarian Diskanen

Post by JasonL » 14 Jan 2019, 09:00

The first step has to be that they don't get to veto all competition in local markets. The second step is probably something that allows national insurer pools. I don't know that you get there with just those things though. It's one reason I'm increasingly convinced you might need a system that uses a large national entity to backstop catastrophic expenses. That entity would simply say - no, we aren't paying for that thing based on cost/effectiveness.

If you pull the most expensive cases out, our system looks way better all of a sudden, and you can see how many of these other things will help costs in those areas. It's the 6% of most expensive cases where there really is no hope for competition to do anything I think. I do worry that a universal catastrophic provision could take a dump on investment in cutting edge stuff that is expensive at first.

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Re: Libertarian Diskanen

Post by Warren » 14 Jan 2019, 10:52

JasonL wrote:
14 Jan 2019, 09:00
The first step has to be that they don't get to veto all competition in local markets.
Yes, good, fine.
JasonL wrote:
14 Jan 2019, 09:00
The second step is probably something that allows national insurer pools.
Okay.
JasonL wrote:
14 Jan 2019, 09:00
I'm increasingly convinced you might need a system that uses a large national entity to backstop catastrophic expenses. That entity would simply say - no, we aren't paying for that thing based on cost/effectiveness.
Oh hell no. Any "national entity" is necessarily a political entity. There's no fucking way anything good comes of that. What's more, I remain convinced that the actual patients that receive the actual benefit need to be engaged in comparative shopping or there's no hope for cost control. I don't see how you get transparent pricing and patient engagement without severely curtailing third party payer.

ETA
Your focus on eliminating expensive/marginal-benefit care is itself only marginally beneficial. Even were you to achieve your ideal version of it, you haven't introduced any market forces driving quality up and prices down. It's a good goal but it's not a solution to anything.
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Re: Libertarian Diskanen

Post by Shem » 14 Jan 2019, 12:13

Warren wrote:
14 Jan 2019, 10:52
What's more, I remain convinced that the actual patients that receive the actual benefit need to be engaged in comparative shopping or there's no hope for cost control.
"I understand you dislike the price we charge for massive trauma arising from a head-on collision. You're more than welcome to try the next hospital: it's a 75 minute drive away. Hope you can still give informed consent if your brain bleed gets worse on the way there."

"The drug patent means everyone gets this medication for a flat fee of $21,000/month non-negotiable, but we're more than happy to knock $250 off the $1500/week in clinic fees if your care is overseen by a PA rather than an MD."

If your solution involves putting people into price negotiations with an entity that can offer them a "pay me right now or you die" choice, your solution is going to be enacted in the morning, repealed after the first person dies that afternoon, and wholly discarded by the next morning, along with whatever other ideas you came up with. Even if they're good ones.
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Re: Libertarian Diskanen

Post by JasonL » 14 Jan 2019, 12:18

I'm basically trying to figure out how to address the 5% of patients creating 50% of healthcare dollars without saying "the only answer is for the other 95% of cases have to be governed by single payer mandates with price caps". I think you have to treat dramatic edge cases with some care and hold them distinct from "normal care" in some way. I'm doing that with catastrophic care under one model and regular care under another.

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Re: Libertarian Diskanen

Post by Mo » 14 Jan 2019, 18:35

JasonL wrote:The first step has to be that they don't get to veto all competition in local markets. The second step is probably something that allows national insurer pools. I don't know that you get there with just those things though. It's one reason I'm increasingly convinced you might need a system that uses a large national entity to backstop catastrophic expenses. That entity would simply say - no, we aren't paying for that thing based on cost/effectiveness.

If you pull the most expensive cases out, our system looks way better all of a sudden, and you can see how many of these other things will help costs in those areas. It's the 6% of most expensive cases where there really is no hope for competition to do anything I think. I do worry that a universal catastrophic provision could take a dump on investment in cutting edge stuff that is expensive at first.
Not sure how national insurer pools solves the local providers are bigger than the payers. California and Texas have the same issues, despite both being the size of a good sized country. You solve the single hemophiliac in Iowa killing the insurance market problem, but not lots of the other ones.
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Re: Libertarian Diskanen

Post by Jennifer » 14 Jan 2019, 20:16

On some level, I suppose, we'll have to accept that healthcare in general is going to run at an overall loss; it's just a matter of deciding how much loss is going to be acceptable (specifically, how much of a loss the collective "we" are willing to take on behalf of other people). Even on an individual level, most healthcare costs (with the arguable exceptions of maternity matters and certain elective/cosmetic surgeries) are a "loss," in that you are (in a manner of speaking) not "gaining" anything, so much as you are, at best, trying to avoid a loss.

Do y'all remember the time someone (IIRC Ellie) posted some idiotic twitter complaint a la "Prescription glasses prove capitalism is evil, because people with poor vision must pay money if they want to see"? Of course it's a stupid argument which among other things confuses cause and effect. But prescription glasses do indeed cost money, so anyone who needs them is automatically at a slight financial disadvantage compared to someone who does not need them. Speaking as someone who's needed glasses since age 14 and paid for them herself since 20: I've spent at least $4,000 in absolute dollars on prescription exams and glasses in my lifetime, more if you adjust earlier prices for inflation, and in exchange for this I'm not getting heat- or X-ray vision or other superpowers; I'm only regressing back to the visual norm rather than squinting somewhere below it. Same's true for every other non-dentist medical cost I've ever incurred.
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Re: Libertarian Diskanen

Post by Mo » 15 Jan 2019, 12:28

Jennifer wrote:
14 Jan 2019, 20:16
Do y'all remember the time someone (IIRC Ellie) posted some idiotic twitter complaint a la "Prescription glasses prove capitalism is evil, because people with poor vision must pay money if they want to see"? Of course it's a stupid argument which among other things confuses cause and effect.
This is close, but not right. Luxottica proves that capitalism is evil*. Those glasses should have cost you half as much.

* Kidding sorta.
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