Tuesday, May 27, 2014

Kidnapped at Needlepoint

Medicine is not euvoluntary. If you're sick and you don't get a doctor, the consequences could be severe. Single-payer/single-provider systems like the UK's NHS avoid  the implied rent extraction by fixing prices. Third-party-payer/multiple-provider systems as in the US purportedly rely instead on market competition to keep prices reasonable. Naturally, that isn't exactly what happens. Instead of a reasonable bill for services rendered like you'd get at the dry cleaner's, you get a massive laundry list of meticulously detailed line items, from blood panels to MRI scans to a dose of Advil for your achy breaky knee.

Of course, everyone who's either been a patient long enough, or who works in the medical services industry knows quite well that the first bill you get that you send along to your insurance provider is what negotiators call a highball: an obviously grossly overstated estimate of the actual cost of care. Whatever the reasons for treating a routine hospital stay the same way you would haggle over a rug in Marrakesh, the effect on the patient is the same: "good gravy, look at this crazy medical bill. Thank God I have a good insurance plan to take care of it. Could you even imagine having to pay this out of pocket?"

Of course, no hospital would even think of making a patient pay those ridiculous rates out of pocket.


"Against medical advice," aka AMA should be right below "we've had an ebola outbreak in med-surg" as the most terrifying thing you can hear as a patient. If you do anything your loving medical staff disapproves of (including undergoing superfluous tests, seeking a second opinion, or refusing medication you've deemed too risky to justify the alleged benefits), you will be acting against medical advice. And if you go AMA, your insurance company is no longer obliged to pick up the tab. That absurdist comedy of a bill you get at the end of a couple days' inpatient care is all yours, baby.

So here's my question for all my great friends out there: is this exploitation? Do hospitals and insurance companies effectively conspire to over-provide zero (or negative)-product care using the threat of AMA as a bludgeon in case patients do not cooperate? And if they do, are they morally justified in doing so? Why or why not?

And if they are not justified in doing so, what moral intuitions steer the median voter away from their ordinary skepticism of big business for health care provision, and instead towards beefing up the entire apparatus via Medicare, the AMA, the ACA, et al? Can the care ethic alone do all the heavy moral lifting here?

I think I'll devote the rest of the week at EE to exploring different possibilities for health care delivery in very broad strokes. Medicine is not euvoluntary, but some systems may be more not euvoluntary than others.

[Update] My old [AS] confederate Cepheus84 informs me that in his professional experience in the medical billing industry, it is (unruly) patients more often than service providers that end up rattling the AMA saber. This is consistent with the frequent tales told by Mrs. Spivonomist about some of the more desperate drug-seeking behavior she encounters at work. AMA, it seems, is a double-edged sword, as the hassle of dealing with an investigation is often more costly than just signing a prescription for some percocet. It's an information asymmetry problem, and patients who've learned how to game the system have an advantage.

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Do you have suggestions on where we could find more examples of this phenomenon?