The Economics of Health Insurance: Denials, Pre-Authorizations, and Cost Control

[MUSIC] Here's a question for the ages. Why does anyone outside of the doctor's office make decisions about treatment? Someone's got a control cost, and we leave that to the discretion of employers and insurers. And so, yeah, it's natural that doctors and patients feel like their ability to make their own decisions is being restrictive. Welcome to the pie. I'm your host, Tess Vigland. Economists are always talking about the pie, how it grows and shrinks, how it's sliced, who gets the biggest to share. In this show, we're talking about the most pressing matters of the day, seen through the lens of economics. The pie is a production of the University of Chicago's Becker-Free Min Institute for Economics. And in this episode, we're looking at some of the most intractable aspects of the US healthcare system, and how they could be, if not fixed, then at least made a bit better than they are now. Specifically, we're looking at the question of prior authorizations and insurance denials. It's a topic that's been debated for years, if not decades, but came into sharp relief late last year, with the assassination of the CEO of the Insurance Giant United Healthcare. So today, I'm joined by three University of Chicago scholars who have looked into the trade-offs involved in how the US healthcare system is managed. And the lessons they've learned from their research into the consequences of those trade-offs. Hi, I'm Maggie Shee. I'm an assistant professor at the Harris School of Public Policy. I'm Josh Gantleyb. I'm a professor in the University of Chicago's Harris School of Public Policy and co-director of the Becker-Free Min Institute's Health Economics Initiative. I'm Zarek Brott. Well, welcome to all of you. And Josh and Maggie, we've had you on the show before. So, Zarek, welcome to your Pi debut. Thank you. I'd like to begin by doing a quick review of your relevant research for each of you. Josh Gantleyb, let's start with you and with billing problems. I think anyone who has touched the US healthcare system as a patient probably has a story about billing issues I certainly do. But you looked at what effect those kinds of issues have on doctors, specifically related to Medicaid. Tell us about your research into the cost of incomplete payments and a bit about how it relates more broadly to the issue of insurance denials. Let me start by answering your second question. I'm going to take a step back and thinking about why are we talking about this at all. Why is insurance not just paying for everything? So the fundamental challenge in health insurance that economists have known about for decades and the insurance industry even longer is once somebody has insurance. They're inclined to use that insurance in the context of health insurance. That means if you have the government or a private insurer that's offering to pay for your healthcare, you suddenly don't have as much of an incentive as a patient to worry about the costs of that care, the quantity of that care, the getting all of the latest products, the latest innovations, the best specialists, you have every incentive to use that insurance. And that's what the insurance industry and an economist call moral hazard. So that's a fundamental challenge. We think insurance can do some good things for patients. It can smooth out fluctuations in consumption because of health shocks. It can potentially get people access to care. They couldn't otherwise afford. They could save their life or help them come out of a health shock and in a better health status. So it's got these benefits, but it has this fundamental challenge that once people are insured, they would want to very naturally would want to overuse the insurance. One way that's become particularly prominent recently for insurers to avoid that to try to limit costs while still providing some insurance value is by paying more attention to what claims doctors are submitting. And reviewing them more carefully for medical appropriateness, for fraud, for high costs, and potentially denying claims that don't meet some qualifying criteria. So that's the background. And my research said, so acknowledging that there may be some benefits from these denial processes and and Zerick and Maggie will get into that. I'm sure much more as the conversation goes on, but setting aside those benefits and those, of course, need to be quantified. How can we think about the flip side, the bureaucracy, the paperwork, the costs as we put it, the costs of incomplete payments. So what we did in our work was try to measure these costs across different insurers and different states. Once we came up with those estimates, we then said, what do they do to doctors willingness to engage with this health insurance system. And we found that much like probably everyone else who's listening to this show, doctors don't like paperwork. There's a lot of it. And we found to our surprise, there was more of this paperwork and Medicaid than in other insurance programs. So Medicaid, right, which is the program for lower to middle income Americans, especially for pregnant mothers and children. This program, you might think should operate really smoothly because the payment rates are pretty low, much lower than private insurance or Medicare. It's trying to serve a safety net function and yet the denials and the costs for doctors of interacting with Medicaid are much higher, at least as a proportion of the revenue. And we find that when doctors face these costs, they turn away Medicaid patients. They say if they move to a state where the Medicaid costs of incomplete payments are higher, they're less likely to accept Medicaid patients. So these costs are operating in perhaps in the way that they're intended to discourage use, but it goes even farther and makes people opt out of the system entirely. And it has deleterious effects down the line for patients because they don't potentially have as many choices for a doctor. We don't look specifically at that word. Our data don't allow us to look at health outcomes are setting doesn't really allow us to look at health outcomes from these denials. Presumably you want patients to have access to doctors. Yeah, I think patients value having doctors who they can see and see faster and having a choice of doctors. And so the more doctors that are driven out of the system by these hassles or by low payment rates, which Medicaid also features, the less choice patients will have. And likely the less access to care. Well, Derek brought your research is into the effects of pre-authorization on decisions around prescription drugs. And you looked through the lens of the Medicare program. But I think most of us can relate to this if you've ever gotten a prescription. You are at the mercy of your insurance company regarding how much of that cost will be covered or even with if it will be covered and authorized. Walk us through the basic conclusion of your research into how prior authorization can be a tool for reducing overall health care costs, which would be beneficial for all of us. Yeah, so I think following onto what Josh said, it's usually lay the ground record. But so if you think about insurers who face this moral hazard concern, they face sort of like a trilemma, right, they could do one of three things. So one is they can impose prior authorization. We'll talk about that in a second. The other is they which was sort of a more common strategy in the early odds after the Medicare modernization act is you could instead shift costs onto the patient. Right, you could make the patient pay for more of their costs to try to dissuade sort of what might be perceived as frivolous use of care due to the price being zero. The third option is you do neither you sort of don't take either tactic to rein in costs and you instead let this load into premiums because of costs of insurance go up that has to pass back to premiums either directly paid by your employer or you or by the taxpayer. Now one thing, you know, for instance, Josh finds that this is much more prominent Medicaid, you might expect that because you can't charge premiums and you don't really want to have cost during for lower income Americans. And so instead you end up with a lot of things like prior authorization and sort of denial of the Josh finds. But our paper we let we actually focus on low income Medicare beneficiaries and because they're low income. It's really hard to think about charging them premiums or or inducing cost sharing because we give them subsidies because you don't think they can afford these things. We specifically look at part D, which is drug insurance. Very nice nice for an economist setting where people are randomly assigned to different plans and we can say what happens if you face a prior authorization restriction on a specific drug. Well, two things. So one is you're about 25% less likely to use those drugs. So these prioritization restrictions really really do bite. The second is about half of those people that 25% about half of them end up on a substitute drug and about half of them end up on no drug whatsoever. No drug whatsoever. Or at least no drug in the sort of relevant class as the same relevant class as the drug being restricted. Overall, when it happens that the prior authorization restrictions in part D in the period we study, which is 07 to 2015, reduced costs by about $100 per person per year. Now, in contrast, something you might be really worried about, say, organizations like the AMA are very worried about are the bureaucratic costs imposed on doctors, right? This is the exact sort of thing that Josh is thinking about in his paper. So one thing we do is we try to quantify those savings, the sort of what I call the payer savings, which are the savings jointly for the sort of insure, the joint insuring entity, which includes the sort of insurers who, the private insurers as well as the Medicare program. So that's about $100 per year. We then estimate what are the bureaucratic costs for doctors serving those patients. And we estimate those in about $10 per person per year. So even though $10 per person per year is not trivial, the sort of spending being moved by these policies is really large, even relative to those bureaucratic costs. And so what we conclude is that many people have thought about the idea that say, we can save a lot of money in health insurance by getting rid of all this bureaucracy. Our point is some of this bureaucracy has a real cost saving purpose, especially in the absence of using other tools, especially in settings where we don't want to shift costs otherwise onto low income folks. All right. And finally, Maggie, she, over to you, and you looked at programs to combat waste in this federal program, Medicare, specifically what monitoring for waste in Medicare does to save government dollars and prevent unnecessary care. So tell us what you found in your research and how these monitoring programs work and how effective they are. Yeah, definitely. So my work, I think, compliments what Josh and Zarek have been looking at in that I use a natural experiment to look at something similar to denials, but you can think of denials just very large denials in the sense that I'm looking at the monitoring and the recouping of spending for big ticket items. So specifically, this is for entire hospital stays. And so this was a program that Medicare implemented because they were worried about waste on these particular big ticket items, $7,000, $8,000 at a time for unnecessary hospital stays. And so we do, I do a few things in the paper. So I quantify what are the savings from it, both directly from the money that's recouped, but also the indirect effects through changes in provider behavior. And I'm able to connect kind of all this discussion about sort of the paperwork burden, the back and forth, with some of these broader trends that have been happening in the healthcare industry, notably the take up of health IT, the role of the administrator. Because what I find is that given that this was a really big shock for hospitals in terms of their bottom line. So if they didn't react and change what they were doing in terms of how are they were thinking about which patients to admit or not, they were going to be losing tens of millions of dollars in the line. This was a particularly nice context to look at sort of zooming out beyond just the costs of back and forth, then negotiating with the insurer. Our provider is responding by incurring costs like investments in IT, changes in kind of hospital level procedures, and how are they going to treat patients. And so what I find is that it seems like this IT angle is the reason for why I find that most of the savings from this monitoring, about 90% of it, is actually through the indirect effect, through changing hospital's admissions behavior. Basically, there's a certain type of software that you can use to really precisely be able to discern what types of hospital stays would be necessary or unnecessary, what is more less likely to be denied through a program like this. And hospitals didn't really have much of a reason to incur these costs prior to this program started because these were really expensive systems to implement. But what I find is that as soon as they start to lose tens of millions of dollars, because Medicare is paying attention to this, hospitals start to respond by taking up this health IT, and this fundamentally changes their admissions behavior going forward. And so we get these much longer lasting results that are coming from not providers responding just to the particular cases that they got dinged on for the denials, but really responding to the fact that it's fundamentally changed the incentives about how carefully they need to think about who should I give care to and who should I not give care to. Is it possible to say what kind of changes they made? Can you draw a picture for the listener before and after, particularly from both their standpoint and the hospital standpoint? What did that look like? Yeah, definitely. So the real source of Medicare is concerned with these unnecessary stays really was short hospital stays where there's a lot of ambiguity from the point of view of the hospital at the time that they're making the decision of do I admit or not. There's a lot of ambiguity is to really, you know, how sick is this patient? And so the canonical example is a patient who comes in complaining of severe chest pain where, you know, if you don't admit someone and they end up having had a heart attack, that could lead to them dying. But on the other hand, if you throw all your resources at them and you admit them and you give them a bed in the hospital, it does end up being the case in some of these cases. They're bad heartburns. Exactly. It's a heartburn or heart attack. And so when I say sort of they are changing their admissions practices, what I was finding was that prior to Medicare really scrutinizing these types of admissions, you know, hospital said as long as we have the bed open for better reverse, we're just going to admit this person and see what happens. And if it ends up they have heartburn, you know, we get to collect $7,000 from Medicare and no harm done. And they really didn't have an incentive to run additional tests to, you know, look at the patient's chart very carefully to try to understand, you know, was his heartburn or was it a heart attack? Once they got started to get scrutinized for this a lot more closely, this is when they started to implement software which would, you know, pull together the patient's chart, all their recent stays, recent documentation and help them make a much more sort of data-driven decision about, okay, is this a case in which this patient really does need this care or is this a case where we should hold out, we should just not admit this patient, but kind of keep them around. And if they go for that second option, what it means is that Medicare would have to pay about half as much compared to hospital state. All right. So the reason we wanted to bring all of this together is to talk about some of the trade offs involved in our healthcare system here in the United States. And all three of you have outlined some of that. So based on what we've heard here today, I'd like to hear you all talk about what to me seems to be basically processes and paperwork that seems to be the common thread here. You have billing issues, prior authorization issues, monitoring to combat waste inefficiency and IT issue for the patient. And as we've heard, even for the doctor, all of this tends to just mean constant frustration and confusion. What are some of the lessons from your research that show, well, yes, there's frustration, but also the outcomes have to factor in here, right? So anybody want to tackle that first? I think one thing that often gets ignored in some of the discussion is people often think about these things in isolation. So like I talked about earlier, you know, there's this dilemma, which is, you can do one of two things to cut costs, or you can do nothing and let sort of cost go up. And someone has to bear that. And so we're very frustrated by dealing with bureaucracy and I am too, like dealt with prior authorization myself. But the relevant sort of counterfactual, if we got rid of prior authorization is not everything else fixed. It's either insurging and starting much more aggressive and raising deductibles and shifting cost sharing onto the patient or their costs are going to go up and they're going to have to shift that into premiums. And so inevitably, I think there's this misconception that insurers are the ones who, you know, any money, deny any sort of claims denied are about the insurer getting some profits. And there is some extent to which that's true. But insurer profit margins are not massive. And so quite a lot of this is being passed through back into premiums. So it's not totally clear that in the absence of these horrible bureaucratic hurdles, it's not clear that the sort of next available option is something we prefer more. One question that comes naturally out of the comments that you just made, Zarek, is to what extent are these hurdles just hurdles for the sake of hurdles? And to what extent are they trying to be useful and say, okay, look, there is a generic or there is a cheaper alternative that you could try that really for maybe for 90% of patients would get the job done is pushing in the right direction. That would be a story that the prior authorizations in your context can really improve efficiency. to the extent that they're just hurdles, just paperwork that has thrown up just to see if a doctor will appeal their denial, just to see if they will call and wait unhold for an hour to get the preauthorization approved. That is potentially wasteful in that, this wasting, the doctor's resources it's creating, angst and a lot of time costs for the patient. Do we have a sense of which it is? Do you think that these preauthorizations and these denials are really pushing the system in an efficient direction in the sense that patients would be happy to pay the lower premiums in exchange for the more restrictive insurance coverage or is it just a hurdle that's making the insurance coverage pretty unattractive? I love that question Josh because I feel like as a patient that's exactly what I would think. They're just trying to squeeze me and see how much I'll do to squeeze back. Yeah, it's a good question. I mean I think you're right Josh right that fundamentally the way we set up for example in our paper is there's some drugs that are more efficient to restrict than others, right? You and you touched on something, right? What might be more willing to be more stringent on? Well stuff where we think there's some say cheaper alternative especially when that cheaper alternative is maybe reasonably good relative thing we're considering. We might want to not restrict things that are very common, right? So you definitely wouldn't want to put a restriction on aspirin because a lot of people get prescribed that it's pretty cheap and so you know the gains of say reducing wasteful use of aspirin are pretty small relative to the cost of making everyone jump through jump through hoops. You know there's and then there's the question of like well is the regime of restrictions imposed by insurers the right one or not? Since insurers are all doing different things it's probably not true that they're all doing this or most optimal thing. I think the other thing that sort of is implicit here Josh that you're saying is you know what if we imagine giving people a choice of like a menu of you can pay more to get out of these restrictions or you can pay less but face these restrictions and a lot of the settings like in Medicaid or prior authorization I think and denials are used the most. You know we don't give that choice because we want to give fairly generous subsidies and we don't want to expose people to sort of high-primins or high-cost sharing for reasons I think we've determined ahead of time. Could I go back to the example that Maggie raised a few minutes ago about the patient with chest pain? So Maggie your argument was that the patient with chest pain might be admitted and it might not be necessary might not be totally efficient if you studied their history in detail but your example was and I'll just run with your example there was an empty bed. No one's saying that they're going to admit the questionable patient ahead of the patient who is definitely having a severe episode, a severe heart attack or otherwise really needs a bed. But if you have a patient who's you're unsure about you'll admit them if they're space that that makes a lot of sense and admitting them if their space has a pretty low marginal cost. The bed is sitting there it's free in terms of the real resources that society is using either the bed is sitting there empty or it's getting used. So is it worth investing the billions and billions of dollars that the hospitals have invested as you say in these electronic records to optimize this just to save the admissions that no one's saying the admissions are totally wasteful you're saying in fact in your example they're kind of they're iffy they might be good they might be not so good we can target that a little more efficiently but it really is a lot of real resources billions of dollars of real resources that are being used to avoid what in your example was a minimal expense. That's a really great question Josh and I think in the in the picture that you paint there's sort of this additional opportunity cost which is not apparent neither to the patient who's looking at that empty bed saying I know you have an empty bed just sort of let me stay there and from the point of view the hospital if they don't have anyone who would have taken that bed and the the opportunity cost here is something that's a little bit more sort of invisible which is that the payment for the hospital state to use that bed it comes from somewhere right it comes from public coffers and that money could be spent on paying for this patient to occupy this hospital bed or it could be used for whatever else government funding can be used for and so I think there is the there is a kind of disconnect between what providers and what patients are seeing in front of them and especially when you're thinking about these public payers kind of the opportunity costs that policymakers are are thinking about and sort of relatedly back to sort of test this question about the trade-offs here I think that this chest pain example is is a good example of kind of another fundamental fundamental problem that I think is driving a lot of the frustration with health insurance denials in particular which is that there's a lot of uncertainty and nobody you know from the patient the provider from the including the insurer no one really has full information right so it's not necessarily the case that Medicare can point to you know with this particular case I know that if this patient had not been admitted they would have been fine and everyone's coming at it from a different perspective they might have you know additional information that is costly to to transmit so if you wanted to kind of make sure that everyone was on the same page you'd have to ask for more documentation and I think that's to me seems like an explanation for why people you know are particularly upset about monitoring and cost control in the setting of health care as opposed to maybe other cases where you know I don't think anybody would be super upset about you know additional monitoring for things like clear tax fraud where there's black and white rules of what is not what is okay and what is not okay there's just a lot of gray area and that's fundamentally tricky for I think everybody involved you know one thing I think Megan Joshua when a little to easy on some of the providers here right the other thing we worry about is not just gray area care we worry about care that providers know to some extent is not particularly valuable or may either either know or don't have the sort of incentive to invest and figure out when when these this care is or isn't valuable there's this anecdote that I got from another column of Sarah Miller about in the 90s that there was a study that showed the combining sort of high-dose chemotherapy with bone marrow transplant and could potentially improve survival for breast cancer patients but insurers were not willing to cover it because they felt the evidence wasn't strong enough and sort of similarly to how we feel about these denials and restrictions now there's a big outcry lawsuits against insurers I think people just don't think that insurers should be making that alternative question right I mean researchers should and doctors I think it makes sense now in the end it turned out that the follow-up studies couldn't replicate those initial results and in fact it turns out the original study was had that fabricated data oh dear and so you know there's this question about as patients we can't do a good job of figuring out whether our doctors are giving us good advice going back to you know when arrow talked about health care back in the 60s is the fundamental one of the fundamental sort of inefficiencies in health care market is we have to rely on these dot these expert doctors who both are telling us what's wrong with us and telling us what the solution is and by the way the ones performing the solution and so again I agree with you there's this there's the sentiment that like who are these insurers to determine you know what care is just fine what cares not just fight the question is you know in the absence of insurers or absence of some entity sort of who's the one who's monitoring whether our doctor is providing us with the best care you know well I feel like what Maggie was talking about with the the opacity of particularly billing this is something that you talk about in your research Zarek you make a case that if patients and other stakeholders in the health care system better understood what's behind the administrative costs that it could shed light on the relative merits of the system here in the US especially is compared to say a country with universal health care so I wanted to ask you what that potentially looks like you know our current understanding of administrative costs is that stupid explanation of benefits that we get from the insurance company that is in my experience one of the least helpful things I ever get in the mail what else could be done to educate patients consumers of the system that there maybe is some reasoning behind this that maybe they should know exactly what's going into that bill yeah I think there's two things one thing well I think a simple answer to question is there's a lot there really is a lot of opacity and then sure side here and there's really not enough reporting on things like how frequently are these prior authorizations applied how frequently are claims denied you know Josh's paper is great because he found an amazing data set which let him measure this sort of stuff directly and then you know there's great statistics in Josh's paper but there's just not enough required reporting for what exactly is going on so I think there's been this fervor to really regulate this stuff, but there's this sort of zero step of, to some extent we don't totally know what's even going on under the hood. And maybe if we found out we'd be even angrier, (laughing) but it was very possible. But there's a big fervor to do something about this problem, when actually we, a lot of our knowledge about this problem is from case studies and anecdotes and specific, very narrow contexts, and we just sort of lack a lot of general knowledge. Can I go back to a point that Maggie and Zarek were touching on just before that last question, 'cause I think it really hit the nail on the head in terms of who has the information and who is making the decisions. That's really the core of the issue. Is it the patients, is it the doctors, is it the insurers, and realistically in a lot of the cases in the US system is it the employers who are designing the policies that the insurers are implementing on their behalf. Right now the way the system works is, as Zarek was emphasizing, someone's got a control costs, and we leave that to the discretion of employers and insurers. And so yeah, it's natural that doctors and patients feel like their ability to make their own decisions is being restricted. But that's all downstream from the fact that we've decided to run so much of healthcare through this insurance machinery with all these rules that have to be followed in terms of what's covered and what's not. And those rules don't emphasize transparency to the patients, which is why you can read your 90 page insurance handbook and still have only the vaguest idea of what's covered. You could imagine a system in which people are buying more transparent insurance products or choosing not to, but this whole, this in transparency, I think is part of Y Costco up, right, it's the moral hazard versus insurance coverage pension. And then you do have this challenge that somebody has to make a decision. And of course you can't let patients and doctors do everything they want. They would say, well, insurance needs to cover my grocery bill. - It goes cover everything, yeah. - Should cover everything. And you know, sounds ridiculous. When I put it that way, but in fact, some insurance programs are covering grocery bills. So we have to decide the society. Should we run grocery purchases through health insurance? Is that actually going to improve efficiency? And we can ask that question about many other types of care. - Well, to close, I'd like to go around the virtual room here and ask each of you to address this question of insurance denials, the trade-offs you've all talked about. And I'd like to hear from you, if you're willing, first as a consumer, as a patient, what would you like to see happen to fix your own interactions with the healthcare system? And then as a scholar, what do you take away from your research that could help solve some of these issues that seem pretty intractable to the rest of us? Maggie, let's start with you. - Sure, yeah. Recently, right before I came to you Chicago, I was at a position where I was actually on the ACA market exchanges and asked to pick my own insurance plan. - From about 50 different options. - Yep, been there. - And what I learned from that, I think it really echoes a lot what Josh and Sarah have been underlining, which is the trade-offs are just not clear to patients. In terms of, I found it very difficult to even get a sense of, is there one table where I can compare various parameters of different types of plans? But inside, it was spread out across all these different pages and you could only compare two plans at a given time and be able to pick which provider in question. And I think, relatedly, especially with denials, there is just no transparency about denials. And so it's not clear that there's this sort of trade-off between, you know, you can have a plan with very low denials which you're gonna have to pay for it somewhere, either via cost sharing or premiums. And so as a consumer, I think, I was surprised and really frustrated as someone who I think I'm a pretty well-versed consumer of healthcare, I found it very difficult to navigate that choice. And then, sorry, what was your second question? Was it as a researcher? - As a researcher. What do you see from your research that might help solve some of these issues? - Yeah, I think just sort of a balanced, I don't know if it's reporting, but I think that there tends to be a lot of focus on, you know, just the cost. And what I found is in my research is there are a lot of benefits and, you know, there has been a lot of effort including from people in this room to quantify those benefits. And so I think sort of a more kind of balanced public understanding of, you know, listen, there are costs, they are valid, they are very large, but there are benefits as well. This is not sort of a system which is in place purely to waste your time and to your waste or provider's time. And so, yeah, I think if we can get that into the ether in some sense, I think that would help make this sort of more educated and more impactful kind of public conversation. - All right, Derek. - Yeah, so back in November, December, not that long ago, like many employers, you Chicago went through open enrollment for benefits, including health insurance. And, you know, a big part of what Josh said in a bit, what Maggie said is like, you know, could we imagine this idea where people can make a choice to trade off, say, you know, paying more premiums against sort of better, you know, less than I.L.s, better coverage. And you Chicago, we offered four plans. And two of them are sort of narrow HMOs, but two of them are plans where, with the same insurer, where you Chicago is ostensibly trying to give us a trade-off between paying higher premiums, you get a lower deductible versus taking lower premiums to get a higher deductible. And that sounds great. That sounds like, oh, I can choose whether I want better coverage or worse coverage. Now, I pick the high deductible plan, and my wife is not necessarily happy about that, 'cause she says, why are you picking the worst plan? (laughing) Well, it turns out that the premium for the low deductible plan is so high that there's almost, not exactly now, but there's almost no circumstance under which it would be financially beneficial to pick it, regardless of whether you're very healthy or very sick. And that's true, by the way, for about-- You have to be able to do that math to figure that out. Exactly. That's true for about, by the way, about two-thirds of large employers, according to a study by Justin Sidner, A.J. Policy. So that's something you would like to fix? I would like to fix that. Nonetheless, a bunch of our colleagues picked this plan. (laughing) And, you know, it would be nice for us to figure out a way to get people to, as a prerequisite first, the sort of choice that I think Josh suggests we should have, we need people to actually be able to make that choice in an informed way, which is not clear day, they are doing. How about as a scholar? What about, as a scholar, what in your research might help solve some of these issues? You know, we have some sense that, not for my own research, from others, that there are ways to sort of display these choices to make them easier for people. It's almost certainly true that the 90-page employee handbook is not the optimal way to confront people with making a complex, splenishing decision. - All right, and Josh, final word? - So I'll jump off of a point that both Maggie and Zerich made about transparency. I wholeheartedly agree with them. It's hard to make informed choices if you don't really know what choices you're making. But there's another important element that lots of research teaches us could be beneficial here, and which we currently have challenges with in the healthcare system, which is competition. It's one thing to say here is a choice between A and B, and let's say it's really transparent. If it's still only two choices or sometimes even fewer, that still doesn't give the consumer any opportunity to really express their preferences and get the kind of product that they need. And so this is relevant for physicians where entry barriers, thanks to the restrictions on medical school and residency, make it really hard to enter the profession. If a physician wants to set up a practice or an institution wants to set up a new clinic, there are numerous barriers that differ in different states and different settings to doing that. But I think we need to really relax entry barriers across these domains, both on providers. This gets to the point that Zerak was making, which earlier, which was absolutely right, that the providers and patients and sentives are not always perfectly aligned. But how are you going to resolve that without giving patients more opportunities to choose their provider? That seems like to me and according to various pieces of research, I think it seems like a good way to get providers to be more aligned with patients is through consumer demand. So I would advocate for transparency and reducing regulatory barriers to competition among hospitals, among insurers, among providers. And you would say that as a consumer or scholar, both? So that was my answer, I guess, as a consumer. On the scholar angle, I want to actually change tax slightly. As we're doing this recording right now, there's an event happening elsewhere at the University of Chicago celebrating the Chicago principles and the idea of free inquiry and diversity of opinions that is so important to the University of Chicago. So I just want to highlight this conversation as an example of that, that we've had a conversation among people who are interested in the same topic. We've got three people, the three of us, and others that we work with here at the University of Chicago taking different views, emphasizing different aspects of the problem. And I'm learning from them, and I hope they're also learning from me, and I hope the public is learning from all of us. But you don't get that in an ideologically homogeneous environment, or in a place where you are only allowed to express the most popular view. So I just want to highlight the value for this incredibly important public policy question of having this freedom to go where, take your scholarship wherever it goes and express whatever conclusions you come up with. And with the hope that perhaps policy makers might have the same discussion. That would be great. All right, very quick lightning round for all three of you. If you had to make a pie with the current contents of your kitchen, what would it be? Maggie. All right, so strangely, for the middle of January, there was a sale on blueberries this week at the grocery store. So we really loaded up on that. Now I kind of actually have an excess. So I would make a blueberry pie. Zerick, my wife is Ukrainian sweet, very frequently, and especially now have a large head of cabbage. So I think absent any sweet options, I think it'd have to make some sort of savory cabbage pie. Oh, I'm all about that. All right, Josh. We found the same sale on blueberries that Maggie did. So I think it would be blueberry pie for us. I'm not sure we have any flour, so it might be a blueberry cookie pie. All right, Maggie, Zerick, Josh, thank you so much. It's been just a terrific conversation. Appreciate your time. Thanks so much, Josh. Thank you. It's great talking to you, Josh. Thanks, Tess. The pie is a production of the Becker Free Min Institute for Economics and part of the University of Chicago podcast network. If you'd like to keep in touch with the latest economic research from the University of Chicago, you can visit bfi.ucicago.edu/subscribe. If you're enjoying the discussions we're having on this show, there is another University of Chicago podcast show you should check out. It's called the Chicago Booth Review Podcast. What's the best way to deliver negative feedback? How can you use AI to improve your business strategy? And why is achieving a soft landing so hard? The Chicago Booth Review Podcast addresses the big questions in business, policy, and markets with insights from the world's leading academic researchers. It's groundbreaking research in a clear and straightforward way. Find the Chicago Booth Review Podcast wherever you get your podcasts. Our theme music was composed by Story Mechanics, Production Assistance from the BFI Communications Team. I'm Tess Vigland, your host and executive producer. Thanks for listening, and we'll see you next time.