Comment by travisp | Hacker News Reader

Comment by travisp | Hacker News Reader

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I hear this argument brought up a lot, but the majority of situations are not this type of situation, and those are also not the things that cost the most (which are more things like extending an unconscious, never-to-recover terminally ill patient's life another 2 months).

Even a large percentage of ER visits would likely see people acting with price sensitivity -- This is why in some places of the country you see Emergency Rooms advertising about how low their current wait time is. The wait time isn't really relevant to true emergencies (you get seen right away), but people without true emergencies don't want to wait. Financial cost is irrelevant (someone else is paying), but the cost to their time is relevant, and so people select emergency rooms (and urgent care clinics) where they will have to wait less. Hospitals are acting on the one thing that the patient cares about (sitting in a waiting room), since the other (price) doesn't matter.

For the really expensive things, like end of life care, governments with universal healthcare systems are the ones that act with price sensitivity and ration this care and refuse in some cases to pay for the most expensive treatments. For example, the UK has the National Institute for Health and Clinical Excellence (NICE), which set a maximum of about $47,000 per quality-adjusted year gained. What we refuse to do in the US is allow patients to make a choice like that (instead, we mandate that insurance cover far more in health care expenses, driving up the cost of that insurance). As a comparison, the US sets it supposedly to about $50,000 per QALY, but in practice it tends to be far more, with some regulation-required treatments requiring as much as $500,000 per quality adjusted year (some heart pumps, and kidney dialysis being another very expensive example).

I think you are taking his argument too literally. Using your own examples, someone who chooses a treatment with a $500k/QALY is probably suffering from the same sense of urgency/price insensitivity as the guy bleeding out on the street. Just because that person has some time to shop around, doesn't mean that they aren't getting price gouged. When someones health/life is on the line they are not going to act rationally.

Does the ACA address QALY? Seems like it might make sense to tie health insurance coverage to that metric. I would be more than happy to pay for coverage that covered the low end of the spectrum if it would mean lower premiums.

>someone who chooses a treatment with a $500k/QALY is probably suffering from the same sense of urgency/price insensitivity as the guy bleeding out on the street. Just because that person has some time to shop around, doesn't mean that they aren't getting price gouged. When someones health/life is on the line they are not going to act rationally.

What insurance lets you do is decide in advance what you think is reasonable, assuming no government rules about what must be covered (just like the UK does for its entire population).

Nobody (at least before preexisting conditions were not required to be covered) was buying insurance that would cover a $500k/QALY right when they needed it. Instead, they previously bought insurance that the government decided had to cover a $500k/QALY for certain treatments and weren't allowed to make any other decision.

And what if they choose the insurance that didn't cover a $500k/year heart pump and realize in a panic at the last minute that they actually did want to be able to be treated at that high level of expenditure, but can no longer afford it? They're in no worse condition than somebody in the UK who would never be given the option.

I think we are starting to dig into the weeds a bit too much. I am well aware of how insurance works, and how single payer systems contrast to the US system. What the OP was trying to point out was that free market economics can break down in certain situations, and health care is a prime example.

>What the OP was trying to point out was that free market economics can break down in certain situations, and health care is a prime example.

And my point was that such situations account for a very small percentage of situations in health care. Most situations and most medical care expenditures aren't of the type claimed by OP. In other words, it's really not a prime example and many of the highest costs are things that people could decide on. For example, the UK will probably not offer treatments that cost more than about $50,000/quality-adjusted year. It would be possible to offer insurance in the US for substantially less if insurance companies could sell a policy that would stick to that, and many people would take probably buy them (many people choose not to even buy insurance currently).

If I slice open my finger badly, I might get myself to the hospital of my choice. But if I fear I am dying in a rather immediate way, or worse, if the people who find my unconscious body think that I am dying, then there is no way in hell I would be acting with any sort of price sensitivity. The hospital doors I could get to the fastest is the ones I would be going to.

I think you're missing my point. My point isn't that those situations don't exist, my point is that they don't make up the majority of situations in healthcare, nor do they make up the majority of healthcare expenditures.

> my point is that they don't make up the majority of situations in healthcare

And I think that you are wrong, particularly when you consider this based on dollars billed by emergency rooms, not patients seen by emergency rooms.

> And I think that you are wrong, particularly when you consider this based on dollars billed by emergency rooms, not patients seen by emergency rooms.

The statistics are that all emergency care expenditures totaled accounts for about 2% of all medical expenditures, or in any case no more than 10% depending on who is reporting and calculating [1]. And, not all emergency room visits are emergencies by far [2] and many patients are swayed by things like advertisements for emergency rooms.

Sources:

1) http://www.politifact.com/truth-o-meter/statements/2013/oct/...

2) My ER doctor wife

> 2% of all medical expenditures

Who is talking about all medical expenditures? I am talking only about emergency room visits.

1) Ads for emergency rooms function as ads for hospitals in general. People in need of non-critical care will naturally be influenced by ads that depict a high quality of care for emergencies. The existence of ads for emergency rooms therefore tell us little.

2) "Real" emergencies will almost certainly be more expensive than "non"-emergencies. They are going to charge more to sew your hand back on than to give your kid some coughdrops.

3) "Non"-emergencies, as perceived by a doctor, are not the same as "non"-emergencies, as perceived by patients. The mother frantically driving her kid with a broken arm to the hospital is going to consider the situation far more urgent than a doctor would. In these cases, people are not going to act with price sensitivity, even though they could, strictly speaking.

Also, I get the impression that "emergency care" omits emergency-related care. If you receive "emergency care" its not unreasonable to assume you may well need follow up - and that follow up could easily end up costing a lot more than the original incidents "emergency care". But that later care is often closely tied to the initial incident. Moving patients around and/or switching doctors often isn't easy nor necessarily safe.

In short: Non-emergency care doesn't necessarily mean care where you can flexibly and easily choose your care provider.

> Who is talking about all medical expenditures? I am talking only about emergency room visits.

I said "my point is that [those situations] don't make up the majority of situations in healthcare" and you said "And I think that you are wrong, particularly when you consider this based on dollars billed by emergency rooms". I don't get the point of looking at a percentage of emergency-related dollars billed in emergency room visits. My point is that if less than ten percent of all medical expenditures are related to the type of emergencies where (to quote OP) you are "bleeding out in the middle of a street or who are delirious from fever [and] won't be acting with price sensitivity.", then that type of situation is not a primary driver of medical costs in the US, nor is it the most important factor to consider when deciding how our medical system should be run. A huge portion of health care expenditures are of the type where a person would act on price.

If your child's leg is broken at a soccer game after close of business, it is not a "true emergency" because she is not going to die. But you are not going to leave her in the most significant pain she has ever experienced with a bone poking out through her skin until the urgent care clinic opens tomorrow morning.

How long she should suffer before getting treatment definitely doesn't have anything to do with your disposable income. Some people might agree with you that poor adults deserve whatever the market gives them (I won't) but how are you going to hold people's kids responsible for having parents who are too price-sensitive to get them timely medical treatment?

A bone fracture that breaks the skin, known as an open or compound fracture, is a true emergency. You should go to the emergency room immediately. If you delay significantly you will almost certainly get an infection and risk the loss of limb or life.

I know this is a straw man for your argument but try and make it somewhat realistic. And no need to appeal to emotion by making it about a child.

There is a reasonable argument that an adult ought to be able to deal with the pain, also an argument that adults are responsible for their own financial predicaments. I chose a child because I didn't want to go down those routes. Also because every ER visit I've been involved with has been a children's sports issue.

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