Ricochet is the best place on the internet to discuss the issues of the day, either through commenting on posts or writing your own for our active and dynamic community in a fully moderated environment. In addition, the Ricochet Audio Network offers over 50 original podcasts with new episodes released every day.
Health Care Lights and Sirens
“If we want to make America great again, we’re gonna have to make healthcare well again.” — Katy Talento
Or, we can call it too hard to do, take two aspirin, and call Doctor Ocasio-Cortez in a year.
Katy Talento has talent. However busy you are, do listen to at least the last two minutes and thirty seconds of the Candice Owens Show November 24, 2019 episode, in which Katy Talento gives the Trump Administration’s two-minute pitch on real health care reform. Then go to PatientRightsAdvocate.org to submit a comment into the official federal regulatory comment process—because the Medical Industrial Swamp is loading up the system, once again seeking to stack the deck in their pecuniary and power interests. Would you prefer to read the proposed rule and comment directly in the Federal Register? There is a button to submit formal comments and guidance on that and other forms of commenting, along with the summary and details about the “Transparency in Coverage” proposed rule.
We are told:
To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on January 14, 2020.
…Or don’t, and shut up when the left rides single-payer to permanent power. These are the actual stakes, as news any month out of the UK shows.
Paul Ryan and the TruCon Grifters rode the lie “if you elect us we’ll repeal Obamacare” to eight profitable years of power, without the “policy wonks” and “experts” ever actually building support through hearings and placing real replacement solutions on the Senate and President Obama’s desk. Meanwhile, the grossly corrupt medical industry makes Hollywood studio movie accounting look transparent. Taken together, we are sliding towards an electoral majority throwing up their hands and taking the government-run “single-payer” system as the least dreadful option. President Trump, within the limits of his Article II constitutional authority, enhanced by the Congress and the Court ceding so much authority to the permanent bureaucracy, is doing everything he can to save America from that fate.
The latest move is one that strikes ordinary folk, not possessed of advanced “expert” credentials, as eminently sensible. We already are bombarded with the most gruesome details about the possible side effects of drugs. If pill pushers can be made to speak those warnings, as a condition of touting their latest miracle potion, then surely they can be made to fully reveal the real prices. Surely, if you must be given the prices before a meal is set before you, you can expect the real prices for medical services upfront. These proposals have been met with howls of outrage and full-on FUD campaigns (fear, uncertainty, and doubt). Somehow, the great free-market virtue of price transparency as a condition of free exchanges is supposed to not operate in the oh so special environment of Big Healthcare.
President Trump’s administration started down this path while Paul Ryan and crew were still in the majority. If Ryan’s Resistance was too busy with hamstringing and delaying the Great Big Ugly Man to keep almost a decade of pinky-swears, President Trump would be the adult in the room. In May of 2018, Seema Verma took the point:
Americans are active shoppers. Whether purchasing a car, a dishwasher, or a jar of salsa, we rarely buy anything without comparing the price and quality of available options. These days, shoppers have access to a wide array of tools online to inform our quest for value. Our demand for value is the engine that drives competition which, in turn, lowers prices and inspires innovation to improve the quality of the products we purchase.
Yet, when it comes to one of the most important services we receive — our health care — this consumer driven engine sputters.
Some might argue that health care is different. However, recent studies show that giving people tools to shop for health-care services by price reduces their costs without any evidence of a decrease in quality.
Health and Human Services has the lead on the American Patients First initiative, to lower costs to consumers through a wide range of reforms, centered on transparency and reducing the complex system, rigged to the advantage of those with the most well-funded lobbying arms.
For years, American patients have suffered under a drug-pricing system that provides generous incentives for innovation, while too often failing to deliver important medications at an affordable cost. We have access to the greatest medicines in the world, but access is meaningless without affordability.
In January of 2019, President Trump increased pressure, with the new Democratic House majority and increased Republican Senate majority having a chance to do something constructive on an issue both parties had made part of their campaigns. President Trump spoke on healthcare to the American people through live video coverage of a healthcare roundtable:
THE PRESIDENT: […] First time in over 50 years that prescription drug prices have declined — that’s in 2018.
But the seen and unseen costs of healthcare are still taking an enormous toll on millions of American families. And this is something that I inherited; unfortunately, you inherited it, and also the people inherited. And we’re doing a lot about it.
Half of all unpaid bills on consumer credit reports in America are for medical bills. One-fifth of credit reports include a past-due medical bill. And you think of so many other bills, but one-fifth — a big portion of what people are having trouble with right now are medical bills, and we’re doing a lot about that.
Nearly 40 percent of insured adults report receiving a surprise medical bill in the last year. Patients should know that the real price — and what’s going on with the real prices of procedures, because they don’t know. They go in, they have a procedure, and then all of a sudden they can’t afford it. They had no idea it was so bad — of procedures, treatments, and medicines before they receive them. And this is a big shock to a lot of people, patients and others.
When you go to a grocery store, or you go to see a mechanic, you know the prices upfront, and you get a receipt that shows the cost of every item. Every single item. You know exactly what you’re paying. You go and get your car fixed and you say, “How much?” But people don’t do that with the medical to the same extent, and they get some very unpleasant surprises.
And one of the things that happens is when you don’t make a deal upfront, then the doctor, or whoever it may it be, all of a sudden doubles and triples the price, because they figure you don’t care or you’re rich — you have plenty of money; you don’t have to worry about it. And we don’t want that happening.
That’s what we want to do with healthcare so that patients will know exactly what the cost is, what the quality is. And just think of it as a consumer. You’re really a consumer at a very high level, and you can get some great healthcare. We have some plans that are great. but you have to go in and price them.
As Congress, under Speaker Pelosi and Majority Leader McConnell, failed to act for six months, President Trump took the next step under Article II, signing an “Executive Order on Improving Price and Quality Transparency in American Healthcare to Put Patients First.” This executive order set 30/60/90 day deadlines for agencies to initiate the federal rule-making process to realize his stated objectives:
By the authority vested in me as President by the Constitution and the laws of the United States of America, it is hereby ordered as follows:
Section 1. Purpose. My Administration seeks to enhance the ability of patients to choose the healthcare that is best for them. To make fully informed decisions about their healthcare, patients must know the price and quality of a good or service in advance. With the predominant role that third-party payers and Government programs play in the American healthcare system, however, patients often lack both access to useful price and quality information and the incentives to find low-cost, high-quality care. Opaque pricing structures may benefit powerful special interest groups, such as large hospital systems and insurance companies, but they generally leave patients and taxpayers worse off than would a more transparent system.
[…]
Making meaningful price and quality information more broadly available to more Americans will protect patients and increase competition, innovation, and value in the healthcare system.
Sec. 2. Policy. It is the policy of the Federal Government to ensure that patients are engaged with their healthcare decisions and have the information requisite for choosing the healthcare they want and need. The Federal Government aims to eliminate unnecessary barriers to price and quality transparency; to increase the availability of meaningful price and quality information for patients; to enhance patients’ control over their own healthcare resources, including through tax-preferred medical accounts; and to protect patients from surprise medical bills.
As NPR reported, the industry push back was swift and consistent with earlier resistance to change that would force real price competition on Big Medicine:
Push back from various corners of the healthcare industry came quickly, with hospital and health plan lobbying organizations arguing this transparency requirement would have the unintended consequence of pushing prices up, rather than down.
“Publicly disclosing competitively negotiated, proprietary rates will reduce competition and push prices higher — not lower — for consumers, patients, and taxpayers,” said Matt Eyles, CEO of America’s Health Insurance Plans in a statement. He says it will perpetuate “the old days of the American health care system paying for volume over value. We know that is a formula for higher costs and worse care for everyone.”
…
This executive order is the latest in a series of moves from the Trump administration on health care price transparency recently. As NPR reported, just last month the White House announced its legislative priorities for ending surprise medical bills, which included patients receiving a “clear and honest bill upfront” before scheduled care. That same week, HHS announced a final rule requiring drugmakers to display list prices of their drugs in TV ads.
However, several of President Trump’s past health care announcements have gotten tied up before the promises to lower costs could be realized.
For instance, in May 2018, Trump rolled out a Blueprint To Lower Drug Prices which included a variety of proposals intended to reduce pharmaceutical costs to individuals, the industry and the economy as a whole, as NPR reported.
In October of last year, the Centers for Medicare and Medicaid Services proposed an international pricing model for setting what Medicare Part B would pay for certain drugs. This is the closest the Trump administration has come to Trump’s campaign promise to have Medicare negotiate with drug companies.
The proposal was put out for public comment with a December 2018 deadline. Thousands of comments came in, including a lot of pushback from the pharmaceutical industry and the proposed rule has not yet been finalized and it’s not clear it ever will be.
Well, President Trump’s political brand is “promises made, promises kept.” So, he has pushed even harder. Last month, November 2019, in the midst of all the Congressional and Deep State nonsense, the Trump administration pressed forward with the rule-making he had ordered this past summer. Seema Verma advocated for price transparency while warning against the impending disaster of “Medicare for All.” Katy Talento, operated outside the administration in a supporting role, making the argument in plain, persuasive language and urging citizen action. To establish Trump administration credibility for further reforms, the Council of Economic Advisors issued a statement on falling drug prices:
While the media continues to claim prescription drug prices are rising, a recent Council of Economic Advisers (CEA) paper shows the opposite: Under President Trump, prescription drug prices are decreasing at rates not seen since the 1960s.
In the eight years prior to President Trump’s inauguration, prescription drug prices increased by an average of 3.6 percent per year. Fast forward to today, and prescription drug prices have seen year-over-year declines in nine of the last ten months, with a 1.1 percent drop as of the most recent month. In June 2019, the United States saw the largest single-year drop (2.0 percent year-over-year decline) in prescription drug prices since 1967.
President Trump promoted broader healthcare transparency with another event, this time in the Roosevelt Room, in which he led with the great job and economic growth news and rolled into promoting two further actions under his June 2019 executive order [emphasis added]:
So I signed, as you know, an executive order — historic. And we’re requiring price transparency in healthcare, forcing companies to compete for your business. It’s a very important thing that we’ve done here. I don’t think it’ll be covered by you, but it will be in the years to come [aimed at the 90-95% hostile media represented behind the cameras and microphones].
Our goal was to give patients the knowledge they need about the real price of healthcare services. They’ll be able to check them, compare them, go to different locations, so they can shop for the highest-quality care at the lowest cost. And this is about high-quality care. You’re also looking at that. You’re looking at comparisons between talents, which is very important. And then, you’re also looking at cost. And, in some cases, you get the best doctor for the lowest cost. That’s a — that’s a good thing.
Today, I’m proud to announce two new actions implementing that order. First, we are finalizing a rule that will compel hospitals to publish prices publicly online for everyone to see and to compare. So you’re able to go online and compare all of the hospitals and the doctors and the prices, and, I assume, get résumés on doctors and see who you like.
And the good doctors — like, I assume these two guys are fantastic doctors, otherwise you wouldn’t be here. (Laughter.) And the bad doctors, I guess they have to go and hide someplace. I don’t know. Maybe they don’t do so well. I don’t know. But if they’re not good, we — we are more interested in the good ones. It’s called “rewarding talent.”
Second, we’re putting forward a proposed rule to require health insurance providers to disclose their pricing information to consumers. We’re giving American families control of their healthcare decisions. And the freedom to choose that care is right before them on the Internet and elsewhere, but on the Internet. Very, very open. Very transparent. That’s why it’s called transparency.
The alternative is not to continue tinkering around the edges. We could go the National Health Service route and have our elected “representatives” genuflect weekly from the floor of Congress towards NHS and strike supplicant poses for one more GP, one more specialist in their district. See most any Prime Minister’s Question Time, outside of a Brexit showdown session. We would swiftly find ourselves and our loved ones culled out for the greater good of cost savings, as cancer treatment delayed is cancer treatment denied. Just read the London Times:*
Cancer patients are being forced to endure the worst waiting times since records began, official figures reveal.
For all nine NHS cancer targets, between April and September the lowest percentage of patients were treated on time since the standards were introduced a decade ago.
In total, 168,390 patients were not seen or treated within the specified times. The figure is up 24 per cent on the same period in 2018-19. Staff shortages, lack of equipment and beds filled by patients needing social care were to blame.
[…]
Last year, for the first time, the NHS carried out more than 2m checks. It says cancer survival is at an all-time high, yet Britain is near the bottom of international league tables for cancer survival and is lagging years behind some countries for some types of the disease.
Motivated? Go, read, and comment. Or don’t, and don’t complain later. Hugh Hewitt wrote 15 years ago: If It Isn’t Close, They Can’t Cheat. He was writing about elections at every level of government, speaking evergreen truths. The same advice applies to commenting on proposed regulations. There is a small army of professional advocates stuffing the comment box with their clients’ self-interested views. There are far more of us, so if we have an interest and choose to shove our own views into the comment box, there will be much stronger support against hostile judges claiming a rule was not properly promulgated.
Or take two aspirin and call Doctor Ocasio-Cortez in a year.
* Hat tip to John Hinderaker, Power Line Blog, “Annals of Government Medicine.”
Published in Healthcare
God bless him.
He really is the Conservative president they told us we didn’t need. And could never have.
It seems the last few years the left has found ways to make winning happen even if it’s not close. If we don’t stop ballot harvesting, they won’t need two hundred ballots found in the trunk of someone’s car . . .
“Leave it for the states to figure out, with the Federal Government stepping in only to resolve cross-border disputes. ”
– My Answer To Everything
I’d be curious to learn what the target time to treatment actually is. Maybe that tidbit is reported in the part of the article that’s hidden behind the pay wall?
When or how does any of this actually go into effect? If the President can unilaterally effect price transparency, when will we see those prices? If the President cannot accomplish this unilaterally, why should we expect it to proceed?
I don’t know what Ryan, McConnell, and company were telling Trump behind closed doors in that first year of his presidency, but we heard diddly squat from him about repealing Obamacare after the election. He did not publicly pressure the Republican-dominated Congress and Senate for results.
Sounds familiar. We’ll see if Trump can actually get something done.
https://www.commonwealthfund.org/publications/newsletter-article/bush-hints-legislation-price-transparency
I think any efforts on price transparency should be focused on common, non-emergency procedures, like childbirth services. If we can’t get consumers shopping for that, then its hopeless to think they’ll do it for surgeries. Also need employers to change their plan designs to make it worth it to shop.
If free market surgery center in Oklahoma can post prices, it seems that hospitals full of MBA’s can figure out how to do it. https://surgerycenterok.com/pricing/
Russ Roberts interviewed the owner on Econtalk. It was a good program.
Great article on the health care fleecing of Americans.
It is no surprise to me when Candace Owens and Katie, her guest discuss how one out of every five American households is in collections due to the health care bills.
In 2017, when I had to max out my credit cards to pay health cost bills, I was overwhelmed over how billing is allowed in this day and age. The first time that a person gets a bill, it gives the date of service, and the provider and what the care was. (An X ray, or Cat Scan, or doctor visit.)
But the second time the bill is sent, there is no date, no info about what or who or how I was seen, it was now just an amount. You have to hope that the billing people did not make a mistake, and that you are now paying what you should be.
I have the leisure time as a semi retired person to spend lots of time on this. One thing that happened after I collated all my bills and invoices: one month, Invoice to me designated as 12ABC was for $ 484. And Invoice 34DEF was for $ 1,112.
The next month, Invoice 12ABC was now $ 1,112 and Invoice 34CDEF was now $ 484.
When I called the billing dept to tell them of the mix up – the supervisor just laughed at me. It was like, “So what?”
Because that is how sloppily this billing situation is handled!
Here is a clue about what Trump was told: Big Pharma and Big Medical now occupy the Number One spot in the economy. They are now ahead of Defense Contractors and the Military.
And it will stay this way. Vaccine mandates for children are just the beginning. Right now in many states, if you don’t vaccinate yr kid according to the new and insane schedule of vaccinations, the kid can’t go to day care or school. It will happen soon that if you don’t get the vaccines required, no Social Security or MediCare.
One single vaccination for a newborn – the hep vaccine – costs over $ 400. And think about it: if they can mandate a totally unnecesary and possibly the riskiest vaccine most normal people have ever had to have to brand spanking new newborns, who due to not swapping sex partners or sharing needles don’t get hepatitis, then Big Pharma can soon be telling people that due to the DNA record that Big Pharma has assembled, Citizen A must have a $ 12,000 a year anti-cancer genetic tinkering procedure, as that person’s genetic records determine it is absolutely necessary. (And the necessity is based on their arranging their studies and statistics to be able to convince doctors to tell citizens that these are totally necessary.)
The problem is, the state legislatures are totally owned by Big Medical and Big Pharma. So it won’t get done in the states, just as it has not gotten done in Washington.
Lobbyists rule.
It’s not hopeless at all but it does take courage and innovation. Check out the Oklahoma Surgery Center to see real price transparency. You can also hear a good explanation of how and why this is the correct approach on a recent Econtalk podcast where the OSC director is interviewed. The system is currently a mishmash of ways to hide real costs in order to inflate billing and scam patients as to costs and ‘savings’. Unscrupulous providers as well as insurance companies are the beneficiaries. Patients and taxpayers get the bill.
There’s a major element missing to this conversation: the primary reason we have such horrible opacity (and worse, huge discrepancies) in the pricing of patient-reimbursed medical care is due to the structure of our healthcare system. Over the decades, we have set up a convoluted, internally-contradictory Rube-Goldberg contraption that provides major incentives – one could even say requires – providers to be very secretive about their prices and to monkey with them in a seeming arbitrary and capricious manner.
In other words, the root cause of undesirable phenomena like price opacity is government policy, not private sector corruption. That corruption absolutely does exist, but it’s a natural and inevitable result of the incentives in place. It’s like leaving dirty dishes in a wet sink for a week and then blaming the bacteria for the fact that everything is slimy and putrid.
To provide but one of millions of examples: Medicare pricing. Medicare typically pays a fixed percent deduction from hospital’s list prices. So the obvious incentive is for hospitals to jack their list prices to astronomic levels, but then they also have an obvious disincentive to publishing those prices. So forcing them to publish their list prices could very well lead to fewer clinics accepting Medicare patients. That may be good or bad, but it’s certainly an unintended consequence that would likely have major political effects.
I’m fine with some sort of government-mandated price disclosure, so this isn’t an argument against the current efforts. My arguments are rather: a) there will definitely be unintended consequences which may be worse than the benefits of this change, and b) without changes to the underlying structure of our healthcare payment systems and the incentives it creates, changes like this won’t solve anything, they’ll just shift the problems from one place to another.
This sentiment gets to the root of my issue with conservative health care debates.
One unanimous (and correct) complaint from the right about Obamacare was that it was far too long and complicated for any one person to understand. “You have to pass the bill to find out what’s in the bill” was prophetically true and rightly criticized by every Republican voter as fundamentally undemocratic.
But here’s my problem: the same voters who acknowledge that our health care system is too complex for even the professionals to understand then turn around and become insulted when someone (like myself) says “there are no easy solutions to our health care mess.” There’s a huge inherent contradiction between saying the system is too complex for even the experts yet ordinary folk are capable of knowing what’s good and bad for the system. Same for those who think there are simple solutions to repairing our health care system.
The reason that neither Paul Ryan nor Donald Trump nor Ted “I shut down the government over Obamacare funding” Cruz made a full-throated call for comprehensive reform after the 2016 election is because Republican voters aren’t yet willing to accept the fact that any meaningful reform will be a) dreadfully complicated and in many ways only understandable to experts, b) require eliminating features of our current health care system that many voters (including Republican voters) like, and c) still probably end up with a fairly unsatisfying final product.
TL;DR: The primary reason why Republicans can’t enact meaningful health care reform isn’t because of our elected officials or lobbyists, it’s Republican voters.
Of course, those same teams of MBAs at big hospitals will also quickly find out a way to game the new price transparency regime just as well as they are gaming the current regulations.
Yeah that’s their job.
The same way that rich people hire accountants to minimize their tax liabilities.
The second one isn’t a bill, it’s a statement of your account. Every vendor I’ve ever dealt with in any industry does it the same exact way. It’s not their fault you didn’t look at your first bill. And you can call at any time and get the original detailed bill I’ve done it a million times.
It surprises me. If they have a bill they can’t pay, why don’t they call and make arrangements? I’ve done it. My grown daughter just recently had a bill from Children’s Hospital she couldn’t pay. I said “Call them, tell them you are out of work, and can you pay $25 a month until it is paid off.” She did, they said ok.
It’s tough when you can’t fit 10 pounds of manure in a 5 pound bag. I’ve been there. But you only go in to collections because you ignored the manure.
For the majority of people who have insurance through their employer there is something else to consider. YOU are not their customer, but the “end user”. Their customer is your employer, and that is whom they (hospital, doctors, etc.) need to satisfy. Your employer is who does the shopping, not you. You are confined, mostly, to the providers within the network specified by the insurance company chosen by your employer.
Shopping around is easier for those with a high-deductible health plan, but if you don’t know the actual cash price for a service, it’s pretty hard to shop around!
Economics is so simple until you complicate it with needless bureaucracy. Medical care and insurance is no different than any other industry and operates on the same principles – supply, demand and competition. I always like to refer to the LASIK eye surgery example. A procedure not covered by most insurance carriers, therefore it isn’t caught up in their Ponzi scheme. Doctors who perform this work need to be competitive. They also need to tell you how much it will cost. Surprise, surprise – prices for LASIK have dropped drastically in the past 20 years.
Every time an outside party forces its way into free market exchange, prices rise, regardless of what the product is.
Which is one antidote to the typical, “If a little government interference in society doesn’t work, then keep doubling it until the government has complete control.”
“The target relating to the first part of a patient’s journey states that following an urgent GP referral for suspected cancer, at least 93% of patients should be seen by a specialist within two weeks. The standard is the same for patients with breast symptoms (where cancer is not initially suspected).
Between 2009 and 2014, the percentage of people with suspected cancer having their first consultant appointment within two weeks of an urgent GP referral fluctuated at around 95%. After this, performance dropped slightly to about 94%, until the most recent year where it declined further. The two-week standard has been missed for the last five quarters. In quarter one (Q1) 2019/20, only 90.2% of patients had their first consultant appointment within two weeks.
Waiting times for patients with breast symptoms were similar to those with suspected cancer between 2010 and 2014. However, over the last four years performance has declined at a faster rate, especially in Q1 of each financial year (April to June). In Q1 2018/19, only 77.5% of patients with breast symptoms had their first consultant appointment within two weeks of an urgent GP referral.”
It’s not the providers. We almost never know what the charge or compensation for a procedure is going to be. The problem is insurance. Our employers ( and most of no longer work as individual practitioners) negotiate rates with all the insurance companies and it’s an incredibly arcane process. Commercial insurance usually pays on a percentage of the Medicare reimbursement rate. Thats based on averages across an area. Then Medicaid pays whatever the hell they want to pay.
It’s as stupid as the cost for drugs. When I have patients ask me what a drug is going to cost I have no idea. It’s all dependent on their insurance.
A) And they don’t rule in D.C.?
B) All it takes is one state to figure out something that works, and a few other states will start to emulate it. I mean, you’ve got 50 friggin’ states to choose from.
So that’s just the wait time until their first consultation, and not the wait time until their first actual treatment?
Wow.
To be fair to the NHS, the fact that wait times were so good up until 2014 suggests that something other than “public health care doesn’t work” happened in the meantime to make the wait times get so bad in 2019.
What other trends started to happen around 2014 that could have effected wait times?
It could be just the normal working of the Tragedy of the Commons. Some things that don’t work in the long term might work in the short term.
At least states have the fiscal restraint of having to balance their budgets. Thats the biggest limit on lobbyists going. The Feds otoh will always prefer runnning up more debt over upsetting a lobbyist or a voter. Which is why the Left won’t do single payer on a state level.
I would hope that everyone in the US is fine with price disclosure. The system we have now reeks of illegal price fixing.
One of the more popular graphics relating to US med pricing indicates what affluent people know & take advantage of all the time: medical tourism. A person can have a hip replacement procedure here, or travel to Madrid Spain, have a hip replacement procedure there, stay for six months & learn the language while there. All while enjoying a decent vacation. They will still save money.
The average American cannot do that as they don’t have a way to be insured for their medical excursion to Spain. Employer paid insurance keeps us inside the oppressive loop of local hospitals.
It is all insider trading done in a way most Americans do not understand. I watched a local Big Wig at one of the major insurance firm HQ in Marin County trade his position at the insurance firm for an Executive position at the local hospital. What came with him, and was probably the reason he received the new position at the hospital was that he brought with him an agreement that the insurance firms’ employees would now be exclusively treated at that hospital.
Yep, really good Econtalk episode about the Oklahoma surgery center and the sources of murky health care pricing. It touched on the fiction of the size of “discounts” on health care services that insurance plans/firms claim they can procure for employers and individuals.
What struck me most from the episode was the surgery center’s example of the synthesis of professional competence, integrity, and transparent pricing. The center expects its partner doctors to be competent at determining exactly the type of treatment required and thus estimating its cost, so it can spell out prices exactly to patients. If the surgery turned out to be more complicated later on, the center would expect the doctor (and itself) to swallow the extra costs of dealing with complications–and not charge the patient more than what was originally specified. The owner added that the center would simply stop working with doctors who had neither the honesty nor competence needed to be clear to patients how much their treatments cost.