I analyzed hospital price lists so you didn't have to(dolthub.com)
dolthub.com
I analyzed hospital price lists so you didn't have to
https://www.dolthub.com/blog/2022-07-01-hospitals-compliance/
402 comments
While what you are saying is all true, in general terms, but the key story seems missing: The "top of the funnel" system is very much fighting to preserve itself.
- Insurance companies are in bed with hospitals to collaborate swindling money from the govt: read about kickbacks sent by the US Govt to hospitals as Disproportionate Share Hospital payments.
- Hospitals have a PR arm moving profits to defend their monopolies, including using SALT rules to create barriers to entry by geography.
- Hospitals also use govt rules against it. They were able to obtain an absolute advantage over all other players (ASCs, Independents) by getting the vaulted nonprofit status, which independents cannot get.
- Hospitals use their nonprofit status and barriers to entry to buy out competition: nimbler independent providers that are actually able to lower prices.
So, hospitals create their own rules, drive out competition, and create monopolies that leads them to hoard cash, which then they use to buy out competition and mire them in 1970s technology so we all pay more.
Then there's also PBMs, and Insurers. That's a story for another day, but plenty of blame to go around.
I post that hospital systems are so large, that at the bottom, Hanlon's razor may apply, but at the top, there's incentives one cannot ignore - and a lot of prejudice to keep the game as-is.
- Insurance companies are in bed with hospitals to collaborate swindling money from the govt: read about kickbacks sent by the US Govt to hospitals as Disproportionate Share Hospital payments.
- Hospitals have a PR arm moving profits to defend their monopolies, including using SALT rules to create barriers to entry by geography.
- Hospitals also use govt rules against it. They were able to obtain an absolute advantage over all other players (ASCs, Independents) by getting the vaulted nonprofit status, which independents cannot get.
- Hospitals use their nonprofit status and barriers to entry to buy out competition: nimbler independent providers that are actually able to lower prices.
So, hospitals create their own rules, drive out competition, and create monopolies that leads them to hoard cash, which then they use to buy out competition and mire them in 1970s technology so we all pay more.
Then there's also PBMs, and Insurers. That's a story for another day, but plenty of blame to go around.
I post that hospital systems are so large, that at the bottom, Hanlon's razor may apply, but at the top, there's incentives one cannot ignore - and a lot of prejudice to keep the game as-is.
All valid, but you forgot another big story, for another day: "medical billing". This, in my minimally-informed opinion, is the syndicate keeping the fence running. I've had dealings with 4 owners of separate small-to-moderately sized billers and their top-brass all owned > 1 multi-million dollar homes around the world. Also, their toy boxes contained millions in cars, boats & flying machines. It must be nice, but incompetence doesn't smell right.
Medical billing is by a product of government mandates on insurance to cover everything + medicare and medicaid.
Make those programs go away, and CPT codes would eventually die.
It is not going to go away so unfortunately we need to learn to live life with it, and instead make it irrelevant, or niche, just like a ferrari is niche.
The best way to cope is to have an alternative to CPT coding, which means, alternative to insurance-based healthcare, which means, medicine between patients and doctors.
The only way to do that is that insurance and CPTs get so expensive that an alternative system is demanded by the market.. and people opt in (and regs allow for it). In effect, ferraris vs corolla. Corollas don't care about CPTs, Medical Billing, Eligibility, Copays, Coinsurance, or Authorizations.
The only way we can get more honda's is by having more independent doctors and less hospitals.
Hospitals create monopolies, independent doctors break monopolies with competition.
Make those programs go away, and CPT codes would eventually die.
It is not going to go away so unfortunately we need to learn to live life with it, and instead make it irrelevant, or niche, just like a ferrari is niche.
The best way to cope is to have an alternative to CPT coding, which means, alternative to insurance-based healthcare, which means, medicine between patients and doctors.
The only way to do that is that insurance and CPTs get so expensive that an alternative system is demanded by the market.. and people opt in (and regs allow for it). In effect, ferraris vs corolla. Corollas don't care about CPTs, Medical Billing, Eligibility, Copays, Coinsurance, or Authorizations.
The only way we can get more honda's is by having more independent doctors and less hospitals.
Hospitals create monopolies, independent doctors break monopolies with competition.
Yes, I think that is correct - ending government intervention in health insurance would wither the medical billing industry. To be fair, the medical billing industry is not parasitic - it adds value by navigating health insurance billing, which is notoriously complex and time-consuming. But health insurance billing is only so prevalent because of massive government intervention. For example:
- The federal government is by far the largest health insurer - through Medicare and Medicaid it pays for 38% of healthcare in the US [1]. - The federal government directly subsidizes private health insurance through ACA [2]. - The federal tax exemption for employer-paid health insurance is by far the largest by dollars exempted [3].
All these government interventions increase reliance on health insurance, which increases the complexity of billing, which grows the medical billing industry.
[1] https://www.statista.com/statistics/237043/us-health-care-sp... [2] https://www.healthcare.gov/glossary/subsidized-coverage/ [3] https://www.npr.org/sections/health-shots/2012/12/04/1664342...
- The federal government is by far the largest health insurer - through Medicare and Medicaid it pays for 38% of healthcare in the US [1]. - The federal government directly subsidizes private health insurance through ACA [2]. - The federal tax exemption for employer-paid health insurance is by far the largest by dollars exempted [3].
All these government interventions increase reliance on health insurance, which increases the complexity of billing, which grows the medical billing industry.
[1] https://www.statista.com/statistics/237043/us-health-care-sp... [2] https://www.healthcare.gov/glossary/subsidized-coverage/ [3] https://www.npr.org/sections/health-shots/2012/12/04/1664342...
The best way to cope is to shift provider compensation from a fee-for-service model to a value-based care model. That reduces the need to code individual procedures using CPT for billing purposes. This industry shift is already underway, but moving slowly.
hard disagree.
value based care is another iteration of "pray for alternative" to non FFS model, aka the APM.
This is the road of the HMO, the RVU, the QCCS...and i could go on and on. Its the road that we have traveled on since the late 80s. Its the road of the wanderer in the desert.
It doesn't lead anywhere but more profits for the road-builders.
40 years of history with 0 decreases in healthcare costs is all the evidence you need to put this one to bed.
value based care is another iteration of "pray for alternative" to non FFS model, aka the APM.
This is the road of the HMO, the RVU, the QCCS...and i could go on and on. Its the road that we have traveled on since the late 80s. Its the road of the wanderer in the desert.
It doesn't lead anywhere but more profits for the road-builders.
40 years of history with 0 decreases in healthcare costs is all the evidence you need to put this one to bed.
> Hospitals create monopolies, independent doctors break monopolies with competition.
The question might be: can we create an Uber-like business that has gives doctors the tech infrastructure to consult with patients without it feeling like a mom and pop shop?
The question might be: can we create an Uber-like business that has gives doctors the tech infrastructure to consult with patients without it feeling like a mom and pop shop?
Investors are betting that its possible.
Not in the strict uber model. Mind you. Providers will need to keep more of a share for it to work.
Not in the strict uber model. Mind you. Providers will need to keep more of a share for it to work.
If your incompetence continually makes you money you aren't incompetent, you're malicious.
Courtesy of Louis Rossman, possibly stealing the quote, speaking about governments screwing up their fines and regulations.
Courtesy of Louis Rossman, possibly stealing the quote, speaking about governments screwing up their fines and regulations.
Don't forget the doctors who are part of that syndicate.
I'm a professional patient, 99.9% of the doctors I've took treatment from(not U.S.) for major ailments are businessmen masquerading as doctors and I'm not talking about some scrappy hospitals; These are world renowned hospital chains.
What happens when you optimize for profit, instead of medical science? Wrong diagnosis and prognosis; I'm a victim of one and it has ruined my life.
On the other hand, There are doctors who risk their lives every day to serve people in need e.g. Doctors without borders, Doctors who rushed to serve during pandemic(Many of them loosing their life to it) etc.
I'm a professional patient, 99.9% of the doctors I've took treatment from(not U.S.) for major ailments are businessmen masquerading as doctors and I'm not talking about some scrappy hospitals; These are world renowned hospital chains.
What happens when you optimize for profit, instead of medical science? Wrong diagnosis and prognosis; I'm a victim of one and it has ruined my life.
On the other hand, There are doctors who risk their lives every day to serve people in need e.g. Doctors without borders, Doctors who rushed to serve during pandemic(Many of them loosing their life to it) etc.
Is there any evidence that doctors in other countries have a lower rate of diagnostic errors?
I didn't include 'not U.S' for that but to not have comments suggesting I sue such doctors, hospitals etc.
They don't create their own rules. Most of the things in your list are failures of government.
Why are DSH payments bad?
Becuase they act as an incentive to raise prices with no incremental value in healthcare delivered.
DSH rules are gamed to extract more from the program
DSH rules are gamed to extract more from the program
Interesting, thank you. One remark:
> Modernization is hard, time consuming and very expensive. These regulations are a good driver for all that, but it takes time. Having been in some of these boardrooms there is not typically a cartel of evil executives figuring out how to screw patients. A lot of the time it is a group of relatively normal people trying to hold up a technological and business process house of cards with chewing gum, paper clips and hope.
It bears questioning how, in ”the richest country on Earth”, something as important as a hospital ends up held together with spit and twine.
Inside this richest country, the richest individuals and companies have been capturing ever-larger shares of GDP. Perhaps instead of growing private fortunes, this money could have gone towards modernising these regulated industries?
> Modernization is hard, time consuming and very expensive. These regulations are a good driver for all that, but it takes time. Having been in some of these boardrooms there is not typically a cartel of evil executives figuring out how to screw patients. A lot of the time it is a group of relatively normal people trying to hold up a technological and business process house of cards with chewing gum, paper clips and hope.
It bears questioning how, in ”the richest country on Earth”, something as important as a hospital ends up held together with spit and twine.
Inside this richest country, the richest individuals and companies have been capturing ever-larger shares of GDP. Perhaps instead of growing private fortunes, this money could have gone towards modernising these regulated industries?
> "the richest country on Earth"
This statistic is misleading. The US is only the richest country on Earth if you consider the mean wealth. By median wealth, the US is ranked 26th. The wealth gap is enormous, and if you're in the upper echelons of the pyramid your health outcomes are vastly better than the clownshoes shitshow that the rest of the country is subjected to.
This statistic is misleading. The US is only the richest country on Earth if you consider the mean wealth. By median wealth, the US is ranked 26th. The wealth gap is enormous, and if you're in the upper echelons of the pyramid your health outcomes are vastly better than the clownshoes shitshow that the rest of the country is subjected to.
The critique is perhaps not relevant here, since it suffices to say that the country's wealth can afford a health care system not held together by "spit and twine", irrespective of how that wealth is presently apportioned. The wealth gap is, as you say, enormous.
In fact, the wealth gap is but a reflection of the underlying cause of the problem: legislators corrupted to the interests of the donor class at severe cost to the actual constituents of those legislators.
In fact, the wealth gap is but a reflection of the underlying cause of the problem: legislators corrupted to the interests of the donor class at severe cost to the actual constituents of those legislators.
The system's complexity is a feature, not a bug. Regulatory capture is real. And much of the regulatory system in health care exists to limit competition. The AMA is a cartel of doctors that limits degrees even for qualified candidates. and the hospitals also operate as geographical cartels.
The problem is that it was built by the last 50+ years of technology and regulations. The system is a product of its upbringing. A company could starts out with noble goals of doing better and slowly year by year sink into this
morass and become just another “part of the problem” before it becomes obvious to everyone that it’s now just another entity making things worse.
These kinds of reforms would have had to begin decades ago to make much of a difference.
These kinds of reforms would have had to begin decades ago to make much of a difference.
> The problem is that it was built by the last 50+ years of technology and regulations.
So... perhaps if we'd had a better goal 50 years ago - single payer or universal medicare or whatever you want to call it - we'd have decades of technical debt that propped up a fairer system, instead of an unfairer one?
Perhaps we need to change our goals today so that 20-30 years from now things will be better then?
So... perhaps if we'd had a better goal 50 years ago - single payer or universal medicare or whatever you want to call it - we'd have decades of technical debt that propped up a fairer system, instead of an unfairer one?
Perhaps we need to change our goals today so that 20-30 years from now things will be better then?
I wonder if it is possible to design regulations with the intent that they may change and the data may require reformatting. At least a best standards practice of how these regulations should be written should be possible.
> “… noble goals of doing better…”
Compliance within regulation is a noble goal? I should think it’s ethical goal.
Compliance within regulation is a noble goal? I should think it’s ethical goal.
Richest Country - RiCo for shorter - is not a sentient being that sees and controls all...
What you refer to is actually a collection of hundreds of millions of individuals, with all sorts of interests, sentiments, ambitions, sometimes conflicting ones.
What you refer to is actually a collection of hundreds of millions of individuals, with all sorts of interests, sentiments, ambitions, sometimes conflicting ones.
>It bears questioning how, in ”the richest country on Earth”, something as important as a hospital ends up held together with spit and twine.
Voters are incredibly scared of change because it's so vital. The current situation isn't caused by a lack of resources but a lack of focused will
Voters are incredibly scared of change because it's so vital. The current situation isn't caused by a lack of resources but a lack of focused will
If the incentive is not more money in most cases then it won’t work.
And those who generously give may not oversee how money is spent and likely squandered to a certain degree.
Takes an incredibly self sacrificing individual to risk it all, which is what this requires.
And those who generously give may not oversee how money is spent and likely squandered to a certain degree.
Takes an incredibly self sacrificing individual to risk it all, which is what this requires.
> It bears questioning how, in ”the richest country on Earth”, something as important as a hospital ends up held together with spit and twine.
In less rich countries they use paper records, which are worse. Everything is held together with spit and twine.
In less rich countries they use paper records, which are worse. Everything is held together with spit and twine.
There's a lot of this concept, that if it doesn't work in the US, everybody else must have failed even worse. Well, not really, many times it's actually the other way around. I won't bother with other more obvious examples but in this context, even Pakistan has a digital health system in the meantime.
You could consider the fact that many countries have instant bank payments, ipV6 networks, better residential internet, have chip & pin and 10x less credit card fraud, have better justice system (lower recidivism, verdict is not determined by your wealth, etc), don't have the 'social security number is an identity', etc..
Of course many countries are worse, but surely you want to look at successes of others and replicate them.
Of course many countries are worse, but surely you want to look at successes of others and replicate them.
I honestly think it's because Americans are told from birth they live in "The greatest country in the world". In that context, it feels like trying to fix anything is not really a worthy pursuit, because it's already better than everywhere else anyway. So even if healthcare sucks, it's better than everywhere else. (Which everyone in a developed country knows first hand is simply not true)
I personally think it's a very dangerous thing to believe, because it means there's no driving force to improve, and it's a part of the reason the country has stagnated so badly.
I personally think it's a very dangerous thing to believe, because it means there's no driving force to improve, and it's a part of the reason the country has stagnated so badly.
My wife did part of her nursing program in St Kitts. They used paper records.
She also says that, of the half-dozen medical record systems she has used (here in the US), Epic is one of the better ones. (read: least bad)
I'm sure if you talked to medical professionals in Pakistan they would bemoan their medical record system too. It seems to be popular sport in the medical community.
She also says that, of the half-dozen medical record systems she has used (here in the US), Epic is one of the better ones. (read: least bad)
I'm sure if you talked to medical professionals in Pakistan they would bemoan their medical record system too. It seems to be popular sport in the medical community.
Nope, they just use a single national health insurer instead of many private ones. This changes the problem from many-to-many (as is in the US) to just many-to-one, which is immensely simpler.
Not necessarily true. At least all my medical records in all the facilities I visited in the last 5 years were digitized and I live in an eastern European, post-communist country.
The difficulty of fixing and improving these systems is frankly overrated. It has more to do with penny pinching and profiteering that they haven't modernized. I don't mean a rewrite in JavaScript either, I mean sensible engineering, which many people are ready to do but not paid to do, because it weakens the upwards money vacuum the finance cabal wants to maintain. Progress isn't profitable enough according to the Excel spreadsheet.
I was in the physical therapy space for over 15 years. The penny pinching that comes from healthcare giants towards their software vendors are dreadful. It prevents any serious software engineering from happening. One customer billed over a billion dollars in a year to Medicare through our software and paid us $1M that year. I'm still not certain that we didn't take a loss to take that client.
Passing around financial data on SFTP drops is something that irked me. Having the total not add up from the line items is also pretty ridiculous. The systems in place are all about edge cases that have formed over decades.
Software engineers are not invited to the discussions in a lot of these companies. The area is gate kept by healthcare people, which tend to be people who don't know how to do technical writing or planning.
Our company wasn't a huge one. But the huge ones looked to me as run by accountants. If you can't establish an income stream for them, they won't even talk to you.
Passing around financial data on SFTP drops is something that irked me. Having the total not add up from the line items is also pretty ridiculous. The systems in place are all about edge cases that have formed over decades.
Software engineers are not invited to the discussions in a lot of these companies. The area is gate kept by healthcare people, which tend to be people who don't know how to do technical writing or planning.
Our company wasn't a huge one. But the huge ones looked to me as run by accountants. If you can't establish an income stream for them, they won't even talk to you.
> Passing around financial data on SFTP drops is something that irked me.
I see this a moderate amount in fintech, or perhaps at least older fintech?
Had a colleague tell me about a new financial info provider he was supposed to connect with for data. "Oh this one will be easy" he was told. "They use oauth". OK... well... you oauth in, then you hit an endpoint that triggers a data build which then puts your data file in to an FTP account of your configuration. But you can't even configure it via hitting the endpoint behind the oauth. You have to log in to a web app to configure the FTP account for your account.
You hit the API endpoint and get 'OK'. But... that's it. You might get a file in your FTP account 5 minutes later. Or an hour later. It's just whenever it gets processed on their end. And... if it doesn't show up - you have no indication whether something broke, or perhaps the data service "just doesn't have any data for you today - you can't expect data every single day".
It's insanely crazy how across-the-board poor so many of these mid-level data vendors are. Colleague is currently supporting 8 different integration ingests like this - some deliver FTP daily, some you have to pull down, etc.
One delivers data which is only ever a delta. You have to continually request previous daily info from them to get to the 'first record' for that account, which can sometimes go back years, but... you don't know that up front. So you have to loop and request "day before", pull down data, parse it, then check the day before, until you don't get anything for that customer, then presume the previous was "initial balance". But you also can't just do that once, because... there may not have been any data the day before because... holiday? system down? So in practice you need to go back 3-4 days at least to verify. Oh... and don't keep looping and requesting too fast... you'll exceed the low rate limit ("we don't want people abusing our API").
I can only barely imagine how systems evolve like this, because they don't really seem to serve anyone's interest fully.
I see this a moderate amount in fintech, or perhaps at least older fintech?
Had a colleague tell me about a new financial info provider he was supposed to connect with for data. "Oh this one will be easy" he was told. "They use oauth". OK... well... you oauth in, then you hit an endpoint that triggers a data build which then puts your data file in to an FTP account of your configuration. But you can't even configure it via hitting the endpoint behind the oauth. You have to log in to a web app to configure the FTP account for your account.
You hit the API endpoint and get 'OK'. But... that's it. You might get a file in your FTP account 5 minutes later. Or an hour later. It's just whenever it gets processed on their end. And... if it doesn't show up - you have no indication whether something broke, or perhaps the data service "just doesn't have any data for you today - you can't expect data every single day".
It's insanely crazy how across-the-board poor so many of these mid-level data vendors are. Colleague is currently supporting 8 different integration ingests like this - some deliver FTP daily, some you have to pull down, etc.
One delivers data which is only ever a delta. You have to continually request previous daily info from them to get to the 'first record' for that account, which can sometimes go back years, but... you don't know that up front. So you have to loop and request "day before", pull down data, parse it, then check the day before, until you don't get anything for that customer, then presume the previous was "initial balance". But you also can't just do that once, because... there may not have been any data the day before because... holiday? system down? So in practice you need to go back 3-4 days at least to verify. Oh... and don't keep looping and requesting too fast... you'll exceed the low rate limit ("we don't want people abusing our API").
I can only barely imagine how systems evolve like this, because they don't really seem to serve anyone's interest fully.
No, I also see this in InsurTech. These companies are so deathly afraid of data breaches and system compromises that anything remotely modern frightens them...sadly.
And btw, that description given by your colleague brought cringy mental flashbacks on meetings I've recently attended.
And btw, that description given by your colleague brought cringy mental flashbacks on meetings I've recently attended.
I had a client medical clinic that had to use encrypted files on FTP. their old version of SunOS they ran on did not support SFTP or ssh. This was in 2017.
I also worked with a state medicaid office. They refused to use DNS, they decided it was insecure. Which was lots of fun any time we changed datacenters (3 times over my 7 years there). They would also go down, and nothing would happen until around 9:30-10am the following work day when they would finally come around and fix it.
I also worked with a state medicaid office. They refused to use DNS, they decided it was insecure. Which was lots of fun any time we changed datacenters (3 times over my 7 years there). They would also go down, and nothing would happen until around 9:30-10am the following work day when they would finally come around and fix it.
The irony of attributing the free market healthcare disaster we have here to regulation. Things are plenty regulated in Australia and other socialized countries and they have none of the crazy billing / coverage issues we have. It's frankly, bullshit.
A common thing many tend to misunderstand, is that there's a difference between a free market, and a competitive market.
The most competitive/efficient markets generally need the optimal amount of regulation to keep/get them that way. Those regulations would ensure that these conditions continue to be met in order for it to be a competitive market: https://en.wikipedia.org/wiki/Perfect_competition#Idealizing...
Free markets that are completely unregulated will tend to veer towards collusion and monopolies, in which case they're no longer competitive and the customers suffer. Free markets that are overly regulated will also suffer, but more-so due to things like the regulatory burden/barriers for new entrants.
What we have in the US healthcare system is a demented hybrid where some parts are free market but under-regulated, while other parts are free market but over-regulated. It's the worst of free market and state-run combined.
The most competitive/efficient markets generally need the optimal amount of regulation to keep/get them that way. Those regulations would ensure that these conditions continue to be met in order for it to be a competitive market: https://en.wikipedia.org/wiki/Perfect_competition#Idealizing...
Free markets that are completely unregulated will tend to veer towards collusion and monopolies, in which case they're no longer competitive and the customers suffer. Free markets that are overly regulated will also suffer, but more-so due to things like the regulatory burden/barriers for new entrants.
What we have in the US healthcare system is a demented hybrid where some parts are free market but under-regulated, while other parts are free market but over-regulated. It's the worst of free market and state-run combined.
It's not the same regulation.
Yeah. A lot of flamewars have happened: "regulation bad!" vs "no, regulation good!".
But in reality, good regulation is good, and bad regulation is bad.
It sounds silly written out because it's a tautology, but if more people internalized it we could have much more productive conversations. Instead of going back and forth on whether regulation is good or bad, we should try to figure out which regulations are good and which are bad, and then try to get rid of the bad ones and pass more of the good ones.
But in reality, good regulation is good, and bad regulation is bad.
It sounds silly written out because it's a tautology, but if more people internalized it we could have much more productive conversations. Instead of going back and forth on whether regulation is good or bad, we should try to figure out which regulations are good and which are bad, and then try to get rid of the bad ones and pass more of the good ones.
I’d argue that the underlying system that makes the regulation in US is broken. So you aren’t going to end up with many good regulations without changing the system. Which looks nigh impossible until some black swan event.
>But in reality, good regulation is good, and bad regulation is bad.
No one brick in the road to hell is bad. But you can definitely pave a road to hell with the accumulation of "positive" changes. People tend to define positive over too short a timeline or too narrowly.
No one brick in the road to hell is bad. But you can definitely pave a road to hell with the accumulation of "positive" changes. People tend to define positive over too short a timeline or too narrowly.
No one square meter of nature is bad. But you can definitely doom people to horribly die because there is a natural swamp between them and the hospital. People tend to define 'natural' too narrowly, forgetting that 'things that are natural' includes cocaine, tapeworms, rape, birth defects, the Plague and cancer
Are you implying that individual regulations all have some inherent goodness on their own?
They're just rules we make for ourselves. There's nothing special about them. Opinions like that are why we can't fix messes like this.
They're just rules we make for ourselves. There's nothing special about them. Opinions like that are why we can't fix messes like this.
It sounds silly because it is silly. Interested parties prioritize various policies with varying degrees of priority.
Effective regulation is somewhat of an organisational skill.
Perhaps its just low pay attracting low talent
Perhaps its just low pay attracting low talent
No. It's the high profit attracting high incentive to capture the regulation.
The goal of the regulation is to increase prices (profit) while preventing other parties from competing on prices
The goal of the regulation is to increase prices (profit) while preventing other parties from competing on prices
I am always amazed by these "no-regulation" arguers - how are you doing to resolve disputes?
Suppose I want to sell my product, and find a company willing to buy, a middle manager signs the contract. When the company recieved my product, it refuses to pay, says this person was not authorised to sign the contract on behalf of the company.
Must the company prove the purchase was unauthorised, or must I prove the employee was authorised? Suppose employee was unauthorised, is it my or the company's problem if this guy 'took initiative', who eats the loss?
What if they already used my product and only realised after the bill came due? What if the deal was overpriced like 10x from market average? What if the guy's title says 'Head of procurement' but the company swears their bylaws don't allow him to authorise purchases?
Suppose I want to sell my product, and find a company willing to buy, a middle manager signs the contract. When the company recieved my product, it refuses to pay, says this person was not authorised to sign the contract on behalf of the company.
Must the company prove the purchase was unauthorised, or must I prove the employee was authorised? Suppose employee was unauthorised, is it my or the company's problem if this guy 'took initiative', who eats the loss?
What if they already used my product and only realised after the bill came due? What if the deal was overpriced like 10x from market average? What if the guy's title says 'Head of procurement' but the company swears their bylaws don't allow him to authorise purchases?
They weren't talking about the concept of regulation. Just the reality of the US's ones.
And I think you're talking about contract law, not regulations.
And I think you're talking about contract law, not regulations.
There can be bad actors in free markets or socialist institutions. The issue isn't the system itself, but instead the people overseeing it.
It seems more regulated healthcare systems are also significantly less capable of developing innovative treatments (although this could be a misunderstanding of mine)
I think it is a misunderstanding. The two places in the world where everyone agrees it is easiest to get medtech devices developed are Australia and Mexico.
(Source: was doing medtech development for a while in the early 2010s).
(Source: was doing medtech development for a while in the early 2010s).
You are wrong on this point. Some years ago, I’ve undergo some pretty innovative surgery procedure (I was one of the first hundreds people in the entire world).
I don’t know how it works in the US but at least in France, most hospitals are part of universities so they are also doing a lot of research.
I don’t know how it works in the US but at least in France, most hospitals are part of universities so they are also doing a lot of research.
> Progress isn't profitable enough according to the Excel spreadsheet.
It's precisely the opposite. Its a racket but its not for profit. If you made a health care service that didn't have any of this cruft and just provided great care, it would not be used, because it would not be compliant with insurance, and employees would not get the tax benefit of using it.
If it were for profit, it would work better.
It's precisely the opposite. Its a racket but its not for profit. If you made a health care service that didn't have any of this cruft and just provided great care, it would not be used, because it would not be compliant with insurance, and employees would not get the tax benefit of using it.
If it were for profit, it would work better.
Yes, the fact that literally all health care goes through insurance is a big part of the problem. As my dad says, if you had to get all car maintenance done through your car insurance, changing your oil would cost $5,000.
This has been well understood in policy circles. The problem is that the employer insurance payment is tax deductible. This subsidy, along with scale, locks people into employer-based care through insurance. The Obama administration attempted to reform this by reducing the deduction on "Cadillac" health care plans but even that modest reform has since been scraped. (Insurance companies framed it as a "tax increase" when really it was closing a loophole.)
https://www.cigna.com/employers-brokers/insights/informed-on...
https://www.cigna.com/employers-brokers/insights/informed-on...
It is not like that at all in countries like Germany and France, where really literally all health care (for a lot of people) is covered (mostly) by general medical insurance. The pricing explosion is exclusively an US problem.
(Germany has private insurance and France as well in parallel, but the main system is "sozialised")
(Germany has private insurance and France as well in parallel, but the main system is "sozialised")
I wish more Americans knew this.
The healthcare systems in Canada, the UK, France, Germany and Switzerland are all distinctive (they’re main commonality I suppose is that they somehow deliver quality healthcare at a fraction of the US cost.). But to hear Americans say we should “do it the way it’s done in Europe” is to understand that the person likely don’t know how the healthcare systems operate in different countries.
The other frustration in talking about this is the tendency to “It’s just” the problems. If this were a simple problem with an obvious solution it likely would have been solved. We are where we are because of a century of organic, and often idiosyncratic, growth. Well intentioned policies of decades ago have come back to bite us with unintended consequences as likely are our best ideas today.
I don’t say we should throw up our hands and give up, but when anyone says there is an easy solution - we just need the political will to let them do what they want - I do see snake oil.
The healthcare systems in Canada, the UK, France, Germany and Switzerland are all distinctive (they’re main commonality I suppose is that they somehow deliver quality healthcare at a fraction of the US cost.). But to hear Americans say we should “do it the way it’s done in Europe” is to understand that the person likely don’t know how the healthcare systems operate in different countries.
The other frustration in talking about this is the tendency to “It’s just” the problems. If this were a simple problem with an obvious solution it likely would have been solved. We are where we are because of a century of organic, and often idiosyncratic, growth. Well intentioned policies of decades ago have come back to bite us with unintended consequences as likely are our best ideas today.
I don’t say we should throw up our hands and give up, but when anyone says there is an easy solution - we just need the political will to let them do what they want - I do see snake oil.
All you need for progress is a sensible regulatory environment.
"Some of you may not be in compliance. We start you off at a fine of $1. For every month this continues, the fine doubles."
All you need for a sensible regulatory environment is a complete overhaul of how your society works, starting with a campaign finance & congressional staffing system that isn't built on implicit corruption.
"Some of you may not be in compliance. We start you off at a fine of $1. For every month this continues, the fine doubles."
All you need for a sensible regulatory environment is a complete overhaul of how your society works, starting with a campaign finance & congressional staffing system that isn't built on implicit corruption.
All you need for those things is a complete overhaul of capitalism itself.
Exactly. IT, software, systems, etc… are viewed as a cost center. Hospitals aren’t in the business of selling software. How do you increase profits (or get yourself promoted, a bigger bonus)? One way is contain or reduce cost centers. The incentives are stacked against overhauling antiquated systems and modernizing, at least until the issue is forced by major business disruptions or regulations.
Right, and the fact that they are in this mess of tech debt in the first place is because they've cut corners and pinched pennies over many many decades. We shouldn't just nod our heads and be all like, "ah yeah, that's annoying, no way it could be helped". I'm so tired of companies continuing to be short-sighted about technical debt. Clearly it's been that way for more than 50 years, and we continue to validate this sort of behavior with understanding and extending deadlines.
Fine these people out of existence and let someone competent (if such a person exists) pick up the pieces and start anew.
Fine these people out of existence and let someone competent (if such a person exists) pick up the pieces and start anew.
> The difficulty of fixing and improving these systems is frankly overrated. It has more to do with penny pinching and profiteering that they haven't modernized.
Eh, I'd rather listen to duffpkg, with his extensive, real world experience in health tech, than a random comment.
FWIW, a former coworker of mine spent a few years at a health technology company (also worked with MUMPS), and legal compliance was the number one hurdle to modernizing. It was expensive, and created a huge drag.
Eh, I'd rather listen to duffpkg, with his extensive, real world experience in health tech, than a random comment.
FWIW, a former coworker of mine spent a few years at a health technology company (also worked with MUMPS), and legal compliance was the number one hurdle to modernizing. It was expensive, and created a huge drag.
I wasn't exactly disagreeing with duffpkg in my little rant there; just reframing the "difficult and expensive" as an unwillingness by various actors to spend the appropriate engineering cost on competently built systems.
On other hand looking at experiences here the projects to change these systems seem not to go well... So there is also not promise that things will get better...
Interesting to read mention of MUMPS
I'd never heard of it -- until I was at an afterparty at last year's AWS ReInvent and started talking to an older couple near us over some drinks.
The guy was well to do and had been in technology a long time. We had a great discussion where he told me about things like MUMPS and other tech I'd never heard of.
When they left, his wife gave me his name. Looked him up, it turns out he was C-Suite at a company nearly everyone has heard of (but is not known for being a tech company).
Makes me wonder how many billions of dollars are being pumped into tech I wouldn't recognize the name of.
I'd never heard of it -- until I was at an afterparty at last year's AWS ReInvent and started talking to an older couple near us over some drinks.
The guy was well to do and had been in technology a long time. We had a great discussion where he told me about things like MUMPS and other tech I'd never heard of.
When they left, his wife gave me his name. Looked him up, it turns out he was C-Suite at a company nearly everyone has heard of (but is not known for being a tech company).
Makes me wonder how many billions of dollars are being pumped into tech I wouldn't recognize the name of.
I heard of Mumps for the first time from tdwtf. https://thedailywtf.com/articles/a_case_of_the_mumps
What the...?
Back when I was leaving school and looking for a job, I came across Epic and MUMPS.
From what I read, MUMPS is actually very performant. Although other companies use it, Epic is the giant. Epic was considered a decent company to work at - good reviews, good work/life balance. The downside is mastering technologies that no one else would value. Or so everyone thought. The reality was that if you become well versed in MUMPS and the Epic stack, a lot of hospitals would pay good amounts of money to you - a lot more than what Epic paid.[1] The only catch was that Epic had a 1 year non-compete clause.
At the time I considered them, they were starting to develop stuff with Visual C++ and .NET, so there was a chance you'd learn more transferable skills.
Fun story: The first time I encountered them at a career fair, I knew nothing about them. I was a grad student. At the booth, they asked me my SAT and GRE scores and were crazy impressed, and immediately booked me for their "entrance exam". At the time (perhaps even now), all candidates had to do a written exam - they'd arrange for the university to conduct it. The exam was mostly assessing logical skills, etc. No advanced material.
I didn't know anything about Epic at the time, and was extremely turned off by anyone being so easily impressed by things like SAT scores. I didn't bother to go through with it. I was studying an advanced degree, and wanted to work for a place that was not so superficial.
Fast forward a semester later when I really needed a job. I researched Epic and it actually didn't feel so bad. I felt I would easily ace their logic exam. So I applied to them. This time, though, they made me do an online behavioral screen first. The type where they ask questions like "Are you more of a X or Y?" where you feel you're neither X nor Y. Apparently I flunked that test and they didn't invite me to take the logic test. Bummer.
[1] Not FAANG level money, but still a lot more than industry average, and a relatively cushy job with you being treated as "the expert".
From what I read, MUMPS is actually very performant. Although other companies use it, Epic is the giant. Epic was considered a decent company to work at - good reviews, good work/life balance. The downside is mastering technologies that no one else would value. Or so everyone thought. The reality was that if you become well versed in MUMPS and the Epic stack, a lot of hospitals would pay good amounts of money to you - a lot more than what Epic paid.[1] The only catch was that Epic had a 1 year non-compete clause.
At the time I considered them, they were starting to develop stuff with Visual C++ and .NET, so there was a chance you'd learn more transferable skills.
Fun story: The first time I encountered them at a career fair, I knew nothing about them. I was a grad student. At the booth, they asked me my SAT and GRE scores and were crazy impressed, and immediately booked me for their "entrance exam". At the time (perhaps even now), all candidates had to do a written exam - they'd arrange for the university to conduct it. The exam was mostly assessing logical skills, etc. No advanced material.
I didn't know anything about Epic at the time, and was extremely turned off by anyone being so easily impressed by things like SAT scores. I didn't bother to go through with it. I was studying an advanced degree, and wanted to work for a place that was not so superficial.
Fast forward a semester later when I really needed a job. I researched Epic and it actually didn't feel so bad. I felt I would easily ace their logic exam. So I applied to them. This time, though, they made me do an online behavioral screen first. The type where they ask questions like "Are you more of a X or Y?" where you feel you're neither X nor Y. Apparently I flunked that test and they didn't invite me to take the logic test. Bummer.
[1] Not FAANG level money, but still a lot more than industry average, and a relatively cushy job with you being treated as "the expert".
> Epic was considered a decent company to work at
heard this is no longer the case with the pandemic. Apparently the CEO had some questionable perspectives on COVID for someone who managed health tech. None of my friends who had jobs there made it through covid without quitting or watching their team quit.
Anecdotally, their recruiting is a mess and the IQ test type interviewing is very common for them instead of FAANG style interviews. I reached out to them at a career fair and they laughed at me and told me I was unqualified because by resume said "medical engineering with a focus on software" and said they only wanted software engineering. That day I re-wrote my resume to say "CS with a focus on medical tech" (I was formally un-declared as a student at the time) and the same person who threw out my resume offered to interview me - I declined.
* I also would later graduate with a degree in computers not medicine, in large part due to that interaction, despite forming a very negative perception of that recruiters behavior.
heard this is no longer the case with the pandemic. Apparently the CEO had some questionable perspectives on COVID for someone who managed health tech. None of my friends who had jobs there made it through covid without quitting or watching their team quit.
Anecdotally, their recruiting is a mess and the IQ test type interviewing is very common for them instead of FAANG style interviews. I reached out to them at a career fair and they laughed at me and told me I was unqualified because by resume said "medical engineering with a focus on software" and said they only wanted software engineering. That day I re-wrote my resume to say "CS with a focus on medical tech" (I was formally un-declared as a student at the time) and the same person who threw out my resume offered to interview me - I declined.
* I also would later graduate with a degree in computers not medicine, in large part due to that interaction, despite forming a very negative perception of that recruiters behavior.
What do you find to be a mess about weird IQ tests compared to FAANG interviews?
From my brief time working there, it seems their recruitment pipeline is wonky for the devs while the support staff are open to applicants of any and all backgrounds (provided they can pass the IQ tests)
From my brief time working there, it seems their recruitment pipeline is wonky for the devs while the support staff are open to applicants of any and all backgrounds (provided they can pass the IQ tests)
As a side note, Hanlon’s Razor is applied so liberally and in ways to shut down criticisms of what very well could be a number of root causes, some of which could include malice and greed.
At the end of the day, Hanlon’s Razor is just something some dude came up with to explain what is the most likely but not even necessarily correct assessment of a given situation. It is often unjustifiably treated as some immutable law when it is really just a flourish of rhetoric.
At the end of the day, Hanlon’s Razor is just something some dude came up with to explain what is the most likely but not even necessarily correct assessment of a given situation. It is often unjustifiably treated as some immutable law when it is really just a flourish of rhetoric.
You've touched on regulation being one source of this problem. But do you think prices will become more normal if regulations disappeared? What do you think is different between the US health care regulatory structure, vs. those in other countries? Can we have the same desired effect with regulations that are easier for hospitals to follow (so as not to be dependent on Epic)?
It's really convenient to cherry pick parts of "healthcare" or the "healthcare system". The thing is, it's 20-25% of our entire economy, so it's really hard to make meaningful comparisons to other countries and their distinct economic systems, in my opinion. To compare you end up having to get into labor, education, taxation, political systems, etc. The most obvious thing is that the USA is a federation of states and with regard to healthcare the federal government has relatively little direct power (but a lot of money). I think the transparency regulations are an excellent small step, I think that there is a little bit of disconnect in regards to timeframe. It will take several more years to see how that plays out.
Regulation is one piece but ultimately dysfunction stems from huge differences between what different constituents want from a healthcare system and what they want it to be (and not be). People hold extremely different views about it. Depending on your circle and where you live you may not realize just how far apart your thinking is from people in other circles and places. Creating palatable compromises between those groups has proved almost impossible and so a lot of what we have in lieu of a compromise occurs by default and accident.
Regulation is one piece but ultimately dysfunction stems from huge differences between what different constituents want from a healthcare system and what they want it to be (and not be). People hold extremely different views about it. Depending on your circle and where you live you may not realize just how far apart your thinking is from people in other circles and places. Creating palatable compromises between those groups has proved almost impossible and so a lot of what we have in lieu of a compromise occurs by default and accident.
> Everyone is deathly afraid of making too many changes too fast because when those systems break the money stops flowing and a health system will literally go insolvent.
Isn't this the desired outcome, that such organizations go broke? And let their assets, employees and customers go to some other organization that isn't saddled with technical debt?
Isn't this the desired outcome, that such organizations go broke? And let their assets, employees and customers go to some other organization that isn't saddled with technical debt?
The code looks like this:
``` I X?1.N1"H" S X=X3600,%H=$H,@("X=$P(%H,"","",2)"_Y_X),%=$S(X<0:- 1,1:0)+(X\86400),X=X#86400,%H=$P(%H,",")+%_","_X G RT D DMW G 1^%DT:'% S @("%H=$H"_Y_%),%H=%H_","_$P($H,",",2) RT D TT S %=$P(%H,",",2) D S S %=X_% I %DT'["S" S %=+$E(%,1,12) Q:'$D(%(0)) S Y=% G E^%DT PF S %H=$H D YMD S %(9)=X,X=%DT["F"2-1 I @("%I(1)*100+%I(2)"_$E("> <",X+2)_"$E(%(9),4,7)") S %I(3)=%I(3)+X ```
I mean, I can see why reimplementing could be scary even with org churn.
``` I X?1.N1"H" S X=X3600,%H=$H,@("X=$P(%H,"","",2)"_Y_X),%=$S(X<0:- 1,1:0)+(X\86400),X=X#86400,%H=$P(%H,",")+%_","_X G RT D DMW G 1^%DT:'% S @("%H=$H"_Y_%),%H=%H_","_$P($H,",",2) RT D TT S %=$P(%H,",",2) D S S %=X_% I %DT'["S" S %=+$E(%,1,12) Q:'$D(%(0)) S Y=% G E^%DT PF S %H=$H D YMD S %(9)=X,X=%DT["F"2-1 I @("%I(1)*100+%I(2)"_$E("> <",X+2)_"$E(%(9),4,7)") S %I(3)=%I(3)+X ```
I mean, I can see why reimplementing could be scary even with org churn.
That is from VA Fileman, right? I did a "lite" replatforming a few years ago.
https://www.hardhats.org/fileman/pm/index.htm
https://www.hardhats.org/fileman/pm/index.htm
Binary looks like this 010100101001010 or something, surely the task of writing a mumps parser is long done?
What language is it?
From the context I'm guessing MUMPS, and it kinda seems to resemble it, if it had more line breaks: https://github.com/programarivm/mumps-examples/blob/f160bfb6...
"There are some bad actors, absolutely true. However 'Hanlons Razor' -- never attribute to malice that which is adequately explained by stupidity -- definitely applies."
In healthcare especially incompetence opens the door for bad actors to exploit weaknesses in the system which amount to huge amounts of money being wasted. Medical fraud, for example, is one of the most sophisticated organized criminal activities in the United States. Mafias setup hijack doctors offices and pharmacies (or setup fake ones) and they know exactly how long it will take until they get caught. In the meantime they can extract tens of millions of dollars from insurance companies in fake claims.
And the fraud pales in comparison to the blatant waste. Doctors office's who order unnecessary CT scans when they or their affiliates happen to own a CT scanner. Pharmaceutical companies who market brand name pills that are no more effective than generics. Insulin manufacturers who manage to charge $1,000 a month for a product that's over a hundred years old.
In the case of pharma specifically, there are a lot of pricing inefficiencies that are deliberately not corrected due to political corruption so that they can be exploited.
In healthcare especially incompetence opens the door for bad actors to exploit weaknesses in the system which amount to huge amounts of money being wasted. Medical fraud, for example, is one of the most sophisticated organized criminal activities in the United States. Mafias setup hijack doctors offices and pharmacies (or setup fake ones) and they know exactly how long it will take until they get caught. In the meantime they can extract tens of millions of dollars from insurance companies in fake claims.
And the fraud pales in comparison to the blatant waste. Doctors office's who order unnecessary CT scans when they or their affiliates happen to own a CT scanner. Pharmaceutical companies who market brand name pills that are no more effective than generics. Insulin manufacturers who manage to charge $1,000 a month for a product that's over a hundred years old.
In the case of pharma specifically, there are a lot of pricing inefficiencies that are deliberately not corrected due to political corruption so that they can be exploited.
$1000/month insulin is not 100 years old. Your comment is like complaining that because penicillin was isolated in 1928, nobody should have a patent on any antibiotic.
Humalog insulin was patented in the 90s, and IIRC, is what Walmart sells for $25/vial. Novo Nordisk (among others) continually improves the product. Those improved products are where you see the $1k/month prices.
Humalog insulin was patented in the 90s, and IIRC, is what Walmart sells for $25/vial. Novo Nordisk (among others) continually improves the product. Those improved products are where you see the $1k/month prices.
From the Mayo Clinic:
The 3 main reasons cited by pharmaceutical companies for the high cost of new prescription drugs do not apply to insulin. First, the “high cost of development” is not relevant for a drug that is more than 100 years old; even the latest and most commonly used analog insulin products are all over 20 years old.8 Second, the pricing is not the product of a free market economy. Free market forces are clearly not operational; there is limited competition on price, the person who needs the product is not in a position to negotiate the price, and there is no relationship of price increases over time compared with overall market inflation. The price of insulin has risen inexplicably over the past 20 years at a rate far higher than the rate of inflation.9 One vial of Humalog (insulin lispro), which used to cost $21 in 1999, costs $332 in 2019, reflecting a price increase of more than 1000%.10, 11, 12 In contrast, insulin prices in other developed countries, including neighboring Canada, have stayed the same. Insulin pricing in the United States is the consequence of the exact opposite of a free market: extended monopoly on a lifesaving product in which prices can be increased at will, taking advantage of regulatory and legal restrictions on market entry and importation. Third, the arguments that high costs are needed for continued innovation and that attempts to lower or regulate the prices will hamper innovation are not a valid excuse.13 There is limited innovation when it comes to insulin; the more pressing need is affordability.
https://www.mayoclinicproceedings.org/article/S0025-6196(19)...
The 3 main reasons cited by pharmaceutical companies for the high cost of new prescription drugs do not apply to insulin. First, the “high cost of development” is not relevant for a drug that is more than 100 years old; even the latest and most commonly used analog insulin products are all over 20 years old.8 Second, the pricing is not the product of a free market economy. Free market forces are clearly not operational; there is limited competition on price, the person who needs the product is not in a position to negotiate the price, and there is no relationship of price increases over time compared with overall market inflation. The price of insulin has risen inexplicably over the past 20 years at a rate far higher than the rate of inflation.9 One vial of Humalog (insulin lispro), which used to cost $21 in 1999, costs $332 in 2019, reflecting a price increase of more than 1000%.10, 11, 12 In contrast, insulin prices in other developed countries, including neighboring Canada, have stayed the same. Insulin pricing in the United States is the consequence of the exact opposite of a free market: extended monopoly on a lifesaving product in which prices can be increased at will, taking advantage of regulatory and legal restrictions on market entry and importation. Third, the arguments that high costs are needed for continued innovation and that attempts to lower or regulate the prices will hamper innovation are not a valid excuse.13 There is limited innovation when it comes to insulin; the more pressing need is affordability.
https://www.mayoclinicproceedings.org/article/S0025-6196(19)...
You’re right about the comparison between airlines and systems like SABRE and healthcare.
You are mischaracterizing MUMPS which is now called M and has been updated many, many times since its invention and has a robust standard library of functions from M vendors.
You are mischaracterizing MUMPS which is now called M and has been updated many, many times since its invention and has a robust standard library of functions from M vendors.
If ever there was a need for an antitrust litigation and investigation such as United States vs. Microsoft (see below), then "Epic Systems" (see below) would seem like a corporation that needs to be investigated, penalized and broken into tiny pieces to prevent its predatory practises.
https://en.wikipedia.org/wiki/United_States_v._Microsoft_Cor.... https://en.wikipedia.org/wiki/Epic_Systems
https://en.wikipedia.org/wiki/United_States_v._Microsoft_Cor.... https://en.wikipedia.org/wiki/Epic_Systems
What kind of pieces should it be broken into?
Hanlon’s Razor is the most stupid meme I have seen. It doesn’t matter that X did not implement a way to cancel their subscription easily because they were “incompetent.” The key point to ask is, if the incentives were reversed, would X suddenly become much more competent? If yes, they are very much a malicious agent and must be dealt with accordingly.
For those unaware of the travesty that is MUMPS please consult the following article.
https://thedailywtf.com/articles/A_Case_of_the_MUMPS
https://thedailywtf.com/articles/A_Case_of_the_MUMPS
Would rewriting healthcare systems in enterprise Java or modern JS or Clojure actually improve them any compared to MUMPS? From my brief experience, the #1 MUMPS problem is that the syntax makes Perl and regex look legible. The two points that I miss in modern languages are:
1. There is absolutely nothing special you need to do when handling values out of the database compared to in-memory values 2. The nested data structure—it's like a nested Python dict, except each level can contain a value and children.
1. There is absolutely nothing special you need to do when handling values out of the database compared to in-memory values 2. The nested data structure—it's like a nested Python dict, except each level can contain a value and children.
I remember getting educated about MUMPS when we were researching about health informatics and interoperability in my PhD programme. My superviser said it was the earliest record system and also most reliable one. I was then opened to a rabbit hole of sophisticated electronic standards for health information exchange and standardisation for multi-domain medical knowledge/terminologies in hospitals. To this date I think it's still pretty much the same status quo if someone is to do research in this area and go for an introduction.
I work in the payments and billing area for my company. So, this idea of medical billing being so out of date is interesting.
Can you share your insight as to why it is not something that smaller companies or starts up have tried to fix? You can also email me (email is my HN username at Gmail dot com). I'm interested in learning more about this on a technical/"behind the scenes" level.
Can you share your insight as to why it is not something that smaller companies or starts up have tried to fix? You can also email me (email is my HN username at Gmail dot com). I'm interested in learning more about this on a technical/"behind the scenes" level.
When modernizing processes becomes too hard, it is almost always a sign for the processes being way too complex and needing a complete overhaul.
US healthcare billing certainly could benefit from a massive simplification, and the reason of the success of neobanks/fintech is the same: they always started from green fields and didn't have to fight internal politics battles to change a data entry mask.
US healthcare billing certainly could benefit from a massive simplification, and the reason of the success of neobanks/fintech is the same: they always started from green fields and didn't have to fight internal politics battles to change a data entry mask.
In other words, it is a matter of priorities. If the fines were significant, the initiatives would be prioritized. It is that simple.
I don't think vendor lock-in is a sufficient explanation here, respectfully.
I feel this is why efforts like FHIR are very important, though certainly scratching the surface.
I feel this is why efforts like FHIR are very important, though certainly scratching the surface.
As someone who works for an HIE and in the interoperability space, I feel like we have been talking about FHIR for the last decade. Hopefully it hits critical mass soon but I doubt it.
Have you ever heard about OpenEHR? https://www.openehr.org/
FWIW, pretty sure duffpkg was involved in the creation of OpenEHR, and therefore probably has heard of it.
but doesn't it solve problems he wrote about (Epic and vendor locking of data?)
Conceptually, yes, it solves a small corner of them.
I'm going to ballpark migrating from Epic to OpenEHR without losing data would probably cost you something around $500/patient. So consider a medium-sized hospital that has 250k patient records. $12.5m project. That takes 2 years. (I'm considering all the places that Epic has custom integrations with other systems, with your insurer, etc, in that $500/patient, which is probably low, but gotta start somewhere). Add in the cost of re-training staff to use the new EMR, finding out after implementation the 'shadow IT' systems like someone exporting data to an excel spreadsheet and then doing a huge workflow on that that no one outside the department really knows about but is absolutely vital to the pharmacy's ability to operate...
OpenEHR can help address some things for one part of the system. But that is like saying fixing OpenSSL bugs will make all the internet secure.
I'm going to ballpark migrating from Epic to OpenEHR without losing data would probably cost you something around $500/patient. So consider a medium-sized hospital that has 250k patient records. $12.5m project. That takes 2 years. (I'm considering all the places that Epic has custom integrations with other systems, with your insurer, etc, in that $500/patient, which is probably low, but gotta start somewhere). Add in the cost of re-training staff to use the new EMR, finding out after implementation the 'shadow IT' systems like someone exporting data to an excel spreadsheet and then doing a huge workflow on that that no one outside the department really knows about but is absolutely vital to the pharmacy's ability to operate...
OpenEHR can help address some things for one part of the system. But that is like saying fixing OpenSSL bugs will make all the internet secure.
So just post the amounts actually billed/collected instead of a "price."
When High Deductible Insurance was introduced the supposed concept was to "give employees a stake in their costs, and therefore lower them for both employer and employee."
However, even today doing so is very challenging, and before laws like this it was essentially impossible. There's no way to shop around American healthcare, with the system itself working against you at every turn (e.g. doctors prescribing named brand, and you not be allowed to switch back to generic without another $100+ appointment).
You can try calling and getting quotes, but they'll just waste a bunch of time and then give you a RANGE with no assurances. Even getting the quote requires your doctor to write up the entire work-order, which itself can get pushback, and or cost money.
Then you have random things like for-profit life flights, which are automatic bankruptcy machines. Imagine one minute driving down the road, then suddenly waking up in a hospital, and then getting billed $80K for just the trip to get there let alone your hospital treatment or recovery. And insurance doesn't cover it.
Aside but all ambulances around me are "out of network" and don't work with insurance at all. So I guess I should shop around by moving cities..?
However, even today doing so is very challenging, and before laws like this it was essentially impossible. There's no way to shop around American healthcare, with the system itself working against you at every turn (e.g. doctors prescribing named brand, and you not be allowed to switch back to generic without another $100+ appointment).
You can try calling and getting quotes, but they'll just waste a bunch of time and then give you a RANGE with no assurances. Even getting the quote requires your doctor to write up the entire work-order, which itself can get pushback, and or cost money.
Then you have random things like for-profit life flights, which are automatic bankruptcy machines. Imagine one minute driving down the road, then suddenly waking up in a hospital, and then getting billed $80K for just the trip to get there let alone your hospital treatment or recovery. And insurance doesn't cover it.
Aside but all ambulances around me are "out of network" and don't work with insurance at all. So I guess I should shop around by moving cities..?
I broke my foot recently. Calling around and asking for quotes ranged from a straight up "I don't know" to "Here is the cash price. We won't know your HDHP insurance price until after we bill them, which could be good for you or could be bad. It will probably be bad, because there are more middlemen."
I tried paying the cash price. They inadvertently billed my insurance anyway. Turns out, I actually saved like 33% using the insurance price ($180 vs $120 for an xray + analysis).
They said the only way to get a copy of the x-ray was to pay $5 for a CD. None of the computers I still use have a CD reader.
The whole system is such a clusterfuck. I understand the aversion to giving a governmental bureaucracy more control (esp over something as important as healthcare); however, it's hard to imagine a worse way to pay for care than what we have now.
I tried paying the cash price. They inadvertently billed my insurance anyway. Turns out, I actually saved like 33% using the insurance price ($180 vs $120 for an xray + analysis).
They said the only way to get a copy of the x-ray was to pay $5 for a CD. None of the computers I still use have a CD reader.
The whole system is such a clusterfuck. I understand the aversion to giving a governmental bureaucracy more control (esp over something as important as healthcare); however, it's hard to imagine a worse way to pay for care than what we have now.
I just got billed $5000 for a routine echocardiogram at Stanford, and in the process of fighting it. My insurance is supposed to cover preventative care 100% (not even a copay). They billed $18000 total (yes, for a 1-hour ultrasound) and insurance is leaving me to pay $5000.
This is about the 6th time this has happened. It's always 15+ e-mails back and forth, then threatening lawyers, then they back off.
I'm wondering if it would be faster if I just take it directly to a small claims court. I am insured and it is preventative care, so I believe I'm entitled to pay nothing. Advice welcome.
This is about the 6th time this has happened. It's always 15+ e-mails back and forth, then threatening lawyers, then they back off.
I'm wondering if it would be faster if I just take it directly to a small claims court. I am insured and it is preventative care, so I believe I'm entitled to pay nothing. Advice welcome.
My son had strep throat. Stanford billed us just shy of $50K, but not before sending us a letter letting us know they had stopped accepting our insurance (BCBS) a few weeks prior. Obviously, more done than just a throat swab for the 50K, but whole thing was insane.
I really want to expose Stanford's ridiculous billing and shame them to no end, but I don't have enough Twitter followers.
I know healthcare billing in the US is f-ed up but Stanford is particularly bad.
I know healthcare billing in the US is f-ed up but Stanford is particularly bad.
Not really that bad. San Francisco used to have crazy bills. Trauma response fees go up to 50k even if nothing is wrong.
I can get the price of my fast food burger to the penny - but good luck getting a quote on something that will cost 50,000.
I did medical billing for a bit and in my space 70% of the issue was stupid politics
I can get the price of my fast food burger to the penny - but good luck getting a quote on something that will cost 50,000.
I did medical billing for a bit and in my space 70% of the issue was stupid politics
San Francisco as in UCSF?
I'm due for an ICD battery replacement later this year or early next year and trying to figure out where to get it done.
I'm due for an ICD battery replacement later this year or early next year and trying to figure out where to get it done.
Not sure you need to expose them - everyone is pretty much aware it’s a shitshow. Not only in billing but quality of care and treatment of staff also
Agree. After seeing the trauma some of my friends went through, I do my bit to recommend against going to Stanford. The standard of care is poor, and the cost is exhorbitant.
That is nuts. Was he admitted to the hospital or something?
Yeah, they kept him for a night. Kid complained about sore throat so my wife took him to doctor (regular pediatrician was busy, so another doctor). Kid kinda mentioned a stiff neck, and doctor told my wife to get him to the ER immediately, b/c meningitis. Wife took him to Stanford ER, they were all omg we’re kinda sure it’s meningitis, but we need to do a spinal tap first. While prepping for that they put him on an IV and after ~20min he perked up a bit. A nurse noticed that and said it wasn’t normal if really meningitis, and put spinal tap on hold. Then doctor said there was a chance of an abscess in his throat/neck and wanted to rule it out; ordered a CT scan. Once that returned negative, they were like, oh yeah, it’s just strep… but, let’s prescribe an uncommon liquid antibiotic that tastes like trash reheated. Kid refused to swallow it, despite efforts of 3 nurses trying to waterboard him with the liquid. So the only way to deliver the antibiotic as prescribed was intravenously. Learned several lessons about advocating during that ER trip.
I had the same experience with a endoscopy/colonoscopy at Palo Alto Medical Foundation / Sutter Health.
We should crowdsource a guide to navigating healthcare in Northern California, it’s utterly fucked up.
Even getting a primary care physician is impossible, nobody is taking patients and the websites of any place (sutter, ucsf etc) don’t reflect any accurate info about who could actually become a primary care provider for you.
The best healthcare situation I experienced was via Cedar Sinai while we lived in Los Angeles.
We should crowdsource a guide to navigating healthcare in Northern California, it’s utterly fucked up.
Even getting a primary care physician is impossible, nobody is taking patients and the websites of any place (sutter, ucsf etc) don’t reflect any accurate info about who could actually become a primary care provider for you.
The best healthcare situation I experienced was via Cedar Sinai while we lived in Los Angeles.
Medical billing is the worst.
I got a physical in Oct 2020, but the coronavirus spiked and it took me until April 2021 to go in and do the labs. One Medical screwed up the billing, coding them as diagnostic instead of preventative (or however that works).
I got nasty letters from both LabCorp and One threatening to send me to collections and ding my credit and all that. I'd text One and they'd be like "oh, just ignore those. We'll fix it." Months go by. "Just ignore them. We'll get to it."
It's such a massive what the fuck.
I got a physical in Oct 2020, but the coronavirus spiked and it took me until April 2021 to go in and do the labs. One Medical screwed up the billing, coding them as diagnostic instead of preventative (or however that works).
I got nasty letters from both LabCorp and One threatening to send me to collections and ding my credit and all that. I'd text One and they'd be like "oh, just ignore those. We'll fix it." Months go by. "Just ignore them. We'll get to it."
It's such a massive what the fuck.
I'm from Germany and just recently got a preventative coloscopie.
I'm not 50 years old yet, so I had to pay for it myself. A magical experience, since it's the first time I ever saw a medical bill in my life.
It was two pages long. Everything from taking blood to the medication and doctor was listed there, but the price at the end was only 200€. I thought it was a joke and expected a lot more.
I'm not 50 years old yet, so I had to pay for it myself. A magical experience, since it's the first time I ever saw a medical bill in my life.
It was two pages long. Everything from taking blood to the medication and doctor was listed there, but the price at the end was only 200€. I thought it was a joke and expected a lot more.
Imagine the fact it would be cheaper to take a plane trip to Germany, also account for lost hourly work cost that takes out of your work schedule, and still be cheaper than doing it locally.
> I am insured and it is preventative care
How or why do you think an echo is preventative care? While insurance plans are free to define any additional menu of services as preventative - an echo is not included in the minimum set required by the federal government - which are procedures based off of US preventative services task force guidelines - there are no published guidelines that include an echo.
I wish you luck on your billing problem but I think you’re going to hit a wall on your own definition of “preventative”.
https://www.healthcare.gov/preventive-care-adults/
How or why do you think an echo is preventative care? While insurance plans are free to define any additional menu of services as preventative - an echo is not included in the minimum set required by the federal government - which are procedures based off of US preventative services task force guidelines - there are no published guidelines that include an echo.
I wish you luck on your billing problem but I think you’re going to hit a wall on your own definition of “preventative”.
https://www.healthcare.gov/preventive-care-adults/
It's fully preventative in my case. I have heart issues (I'm a cardiac arrest survivor) and an echo is recommended every 2 years to spot any possible future issues early.
As to the original question, unfortunately I don't know where you got the idea that all possible preventative healthcare interventions are covered under the "free" rule - ie no out of pocket - but in the US that just isn't a thing - the free coverage applies to the list I posted prior (ie ACA Preventive Care) - its a bunch of consensus primary and secondary preventative primarily screenings and medications that are thought to have the greatest impact on public health.
> It's fully preventative in my case.
Fully preventative is not a term of art either for delivery or billing - but there is a difference in categorization between screening tests given to the entire population (ie colon, mammo) and screening given to those with personal risk factors or family history (LD chest CT, echo for congenital HD), and then further on surveillance for personal history of a pre-disposing condition (ie surveillance echo for prior potential fatal arrhythmia).
This is where it starts to get complicated - but the need for an echo every 2 years is not normal. I can't really divine your specific history from the information given - and it isn't necessary - but a history of cardiac arrest alone is not an indication for serial echocardiography. There are numerous specific circumstances where it is recommended, and then there are the cases where it is not consensus recommended but there is controversy. I assume because your insurance company is willing to touch it at all it falls in the former - but we are way off the ranch here in terms of the scope of routine preventative care/health maintenance.
As to whether it should be this way, probably not. If a surveillance echo is clearly indicated to prevent costly sequelae (unfortunately answering this question isn't nearly cut and dry as most think), then it makes sense that an insurance or public health agency would want to do this. Curious if you know if your indication for serial echocardiography falls under the European guidelines? Maybe move there /s. Is Stanford your only reasonable place to obtain an echo?
> It's fully preventative in my case.
Fully preventative is not a term of art either for delivery or billing - but there is a difference in categorization between screening tests given to the entire population (ie colon, mammo) and screening given to those with personal risk factors or family history (LD chest CT, echo for congenital HD), and then further on surveillance for personal history of a pre-disposing condition (ie surveillance echo for prior potential fatal arrhythmia).
This is where it starts to get complicated - but the need for an echo every 2 years is not normal. I can't really divine your specific history from the information given - and it isn't necessary - but a history of cardiac arrest alone is not an indication for serial echocardiography. There are numerous specific circumstances where it is recommended, and then there are the cases where it is not consensus recommended but there is controversy. I assume because your insurance company is willing to touch it at all it falls in the former - but we are way off the ranch here in terms of the scope of routine preventative care/health maintenance.
As to whether it should be this way, probably not. If a surveillance echo is clearly indicated to prevent costly sequelae (unfortunately answering this question isn't nearly cut and dry as most think), then it makes sense that an insurance or public health agency would want to do this. Curious if you know if your indication for serial echocardiography falls under the European guidelines? Maybe move there /s. Is Stanford your only reasonable place to obtain an echo?
Lol you mad bro? He just wants an echo to make sure his heart is beating normally
There are two categories of healthcare right? Palliative and preventative. Which one would an echo be in this case? If he had violent symptoms it would clearly be palliative, but in this case it can only be preventative
> There are two categories of healthcare right? Palliative and preventative.
The simple answer to this is that “preventative” in the case of billed medical services has a specific and clearly defined meaning - it does not even mean all services that ever would be considered preventative. This definition will be found in your insurance paperwork and corresponds at least to the site I posted - so a further philosophical discussion is irrelevant.
To your actual question - No, the echo is usually pallative. However, right off the bat I'll say this is an overly reductionist and not terribly useful schema for classifying the delivery of medical care. While it might be good as a way for the general public to think about prevention, it’s way too oversimplistic to be useful beyond that.
An aside, palliative has a specific and different meaning within medicine: roughly, treating symptoms without a goal of cure. Reducing a broken arm or removing an inflamed appendix is not palliative care in that sense.
But even if we widen the scope of palliative to be treatment an echo would be neither. An echo is diagnostic - it doesn’t prevent nor treat heart failure or disease. Often when an echo is ordered it leads to some form of treatment for some found disease, in which case if we’re going to stick to the simple classification would be “palliative” - we’re using it to guide treatment, we can’t prevent something that we already see.
> If he had violent symptoms it would clearly be palliative
It's just not that simple. Echos are sometimes used to further evaluate or manage asymptomatic disease, for instance A-fib or a concerning murmur. We're using the echo to rule out suspected coexisting conditions, that's not prevention, and it's not treatment either at that point. Also, echos usually have some symptomatic indication - and they don't have to be violent, whatever that means.
> it can only be preventative
Can you actually think of a disease that an echo would be used to prevent?
But again, in practice we don’t think of delivery of medical care in such grossly general terms - it’s doesn’t simplify in a useful way.
The simple answer to this is that “preventative” in the case of billed medical services has a specific and clearly defined meaning - it does not even mean all services that ever would be considered preventative. This definition will be found in your insurance paperwork and corresponds at least to the site I posted - so a further philosophical discussion is irrelevant.
To your actual question - No, the echo is usually pallative. However, right off the bat I'll say this is an overly reductionist and not terribly useful schema for classifying the delivery of medical care. While it might be good as a way for the general public to think about prevention, it’s way too oversimplistic to be useful beyond that.
An aside, palliative has a specific and different meaning within medicine: roughly, treating symptoms without a goal of cure. Reducing a broken arm or removing an inflamed appendix is not palliative care in that sense.
But even if we widen the scope of palliative to be treatment an echo would be neither. An echo is diagnostic - it doesn’t prevent nor treat heart failure or disease. Often when an echo is ordered it leads to some form of treatment for some found disease, in which case if we’re going to stick to the simple classification would be “palliative” - we’re using it to guide treatment, we can’t prevent something that we already see.
> If he had violent symptoms it would clearly be palliative
It's just not that simple. Echos are sometimes used to further evaluate or manage asymptomatic disease, for instance A-fib or a concerning murmur. We're using the echo to rule out suspected coexisting conditions, that's not prevention, and it's not treatment either at that point. Also, echos usually have some symptomatic indication - and they don't have to be violent, whatever that means.
> it can only be preventative
Can you actually think of a disease that an echo would be used to prevent?
But again, in practice we don’t think of delivery of medical care in such grossly general terms - it’s doesn’t simplify in a useful way.
> Can you actually think of a disease that an echo would be used to prevent?
Yes, checking the extent of mitral valve prolapse (which I have, doesn't warrant valve surgery yet but it's expected I may need valve repair in 10-30 years if it gets worse), ejection fraction, early detection of dilated cardiomyopathy (which I'm known to be genetically predisposed to), etc.
Yes, checking the extent of mitral valve prolapse (which I have, doesn't warrant valve surgery yet but it's expected I may need valve repair in 10-30 years if it gets worse), ejection fraction, early detection of dilated cardiomyopathy (which I'm known to be genetically predisposed to), etc.
Checking the extent of MVP is not really preventing or treating MVP, is it? The echo isn't preventing the mitral valve prolapse, it is also not an intervention - it is a diagnostic tool to guide further intervention. Yes, this could be considered a type of tertiary prevention - but hopefully it should also be clear how this is more usefully classified as diagnostic. Pretty much all medical care is to some extent preventive, even reducing the broken arm - so it becomes a meaningless word if it is loosely defined as any intervention that can potentially prevent sequelae. That means it’s ultimately going to be defined with some restrictive set of criteria. Is the US ACA definition very restrictive, yes, but that’s how it is.
Ejection fraction is not a disease, but let's call it heart failure. An echo evaluating for heart failure is a good example where we can use it as a diagnostic tool to prevent further progression - but again through other interventions - and if we're evaluating for abnormal ejection fraction we haven't prevented it.
Another example might be evaluating for a shunt to prevent stroke. However we don't routinely screen everyone for this.
Echo for inherited cardiomyopathies is a good example of primary or secondary prevention.
There are definitions within medicine that matter for defining appropriate use criteria, but all this preventive vs palliative is arguing loose semantics - the people you’re up against have already put in place the policy to avoid most of that.
Ejection fraction is not a disease, but let's call it heart failure. An echo evaluating for heart failure is a good example where we can use it as a diagnostic tool to prevent further progression - but again through other interventions - and if we're evaluating for abnormal ejection fraction we haven't prevented it.
Another example might be evaluating for a shunt to prevent stroke. However we don't routinely screen everyone for this.
Echo for inherited cardiomyopathies is a good example of primary or secondary prevention.
There are definitions within medicine that matter for defining appropriate use criteria, but all this preventive vs palliative is arguing loose semantics - the people you’re up against have already put in place the policy to avoid most of that.
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Hospital IT systems are incredibly locked down, especially from a network perspective. And DICOM images (the format things like x-rays are stored in) are very large, and not readable by most image readers. I honestly don't know if there are even free DICOM readers out there, but there probably are.
CD is honestly the easiest way for them to send the images to you, because you can give them to any doctor and they can load them within minutes. For the hospital to send them directly to another hospital would literally take weeks (at a minimum) of back and forth between two overworked and incompetent IT teams.
CD is honestly the easiest way for them to send the images to you, because you can give them to any doctor and they can load them within minutes. For the hospital to send them directly to another hospital would literally take weeks (at a minimum) of back and forth between two overworked and incompetent IT teams.
There are multiple free DICOM readers, but each imaging device manufacturer has its own interpretation of what a "DICOM" file is, so there are a lot of quirks.
I've worked with DICOM files from at least 10 different sources. I was able to eventually parse/view all of them. I seem to remember trying almost as many open source libraries in the process, however. That's one of the many problems in healthcare - even the standards have competing standards.
All standards have competing standards unless actual interop happens.
> For the hospital to send them directly to another hospital would literally take weeks (at a minimum) of back and forth between two overworked and incompetent IT teams.
Last time I had imaging done, my doctor gave me a list of nearby imaging services, and the one I selected was able to electronically send files back to my doctor.
Heck I've witnessed my old dentist send x-rays over to my new dentist, it took like 5 minutes. Then again it seems like dentists are better at technology all around.
Last time I had imaging done, my doctor gave me a list of nearby imaging services, and the one I selected was able to electronically send files back to my doctor.
Heck I've witnessed my old dentist send x-rays over to my new dentist, it took like 5 minutes. Then again it seems like dentists are better at technology all around.
I can't speak at all to dental stuff as I've never worked with it. But to your first point, that's sort of expected - they're on a list already, the access has already been configured. They've already gone through all the nonsense.
The point is to send it to any arbitrary doctor they've never spoken to before, which requires offline media.
The point is to send it to any arbitrary doctor they've never spoken to before, which requires offline media.
> I honestly don't know if there are even free DICOM readers out there, but there probably are.
If you've ever gotten a cd with your medical imaging on it, it will come with the software required to read it.
If you've ever gotten a cd with your medical imaging on it, it will come with the software required to read it.
Yes, and that software requires some esoteric proprietary OS that I've banned from all of my memory. :D
The weird thing is that there are signs all over the clinic about how they now have Athena Health for telemedicine.
Cool dudes. Have you considered letting me download the x-rays I just paid for from that portal?
Cool dudes. Have you considered letting me download the x-rays I just paid for from that portal?
I'm not sure if "proper" DICOM files are different (DRM?) but during my undergrad I had a medical imaging class working with anonymized DICOM files and we used Pydicom (With Jupyter Notebook) to display the images and annotations: https://pydicom.github.io/pydicom/stable/index.html
There’s (luckily) no such thing as DRM in DICOM, but there is a billion ways to interpret the standard. Pydicom does work for the more common things but there’s some rare types of DICOM it unfortunately can’t handle.
I've worked in a medical image processing field and there's a few out there, Orthanc is the most featureful one I know of.
> "Here is the cash price. We won't know your HDHP insurance price until after we bill them, which could be good for you or could be bad."
This is the reason that non-emergency healthcare is so expensive - the purchaser does not know the price of something at the point of purchase.
This results in the price being significantly higher than what the market can bear.
When consumers are informed and can force suppliers to compete with each other, prices go down to exactly what the market can bear.
Emergency healthcare is a different beast, but will probably also decrease if non-emergency healthcare prices was left up to the market to set.
This is the reason that non-emergency healthcare is so expensive - the purchaser does not know the price of something at the point of purchase.
This results in the price being significantly higher than what the market can bear.
When consumers are informed and can force suppliers to compete with each other, prices go down to exactly what the market can bear.
Emergency healthcare is a different beast, but will probably also decrease if non-emergency healthcare prices was left up to the market to set.
> the purchaser does not know the price of something at the point of purchase.
This is only solvable for the cases where what needs to be done is completely known and certain in advance. Which for very complex human biological systems would not be the majority of cases, unless providers decide to only deal with health issues that fit that criteria and send everybody else to someone else.
I think the problem of not being able to accurately predict the required care is an intrinsic part of health care. Some of it actually is taken care of in some way, for example, if you go to ER they will only fix any immediate urgent issues and then send you home. Or, they send you home after n days in the hospital no matter what (example links: https://www.ombudsman.org.uk/sites/default/files/page/A%20re... or https://pubmed.ncbi.nlm.nih.gov/12568426/).
> When consumers are informed and can force suppliers to compete with each other,
Uhm... how do you imagine this would happen? Genetical engineering so all humans become standardized clones with identical completely predictable issues? I think you severely underestimate the inherent unpredictability. Simple stuff like teeth cleaning can be a price known in advance, or coming in only to renew a prescription for a known health problem, but many, most?, of the "real" issues are not.
OR, what would happen if you enforce this is that the MDs would be forced to press the cases into the pattern. They may think they should order an additional test or imaging procedure after actually looking at the patient, but since it's not in the pre-approved plan it would not get paid, so they don't, only things that were known before any doctor looked at the person get treated and only using the predicted methods.
This is only solvable for the cases where what needs to be done is completely known and certain in advance. Which for very complex human biological systems would not be the majority of cases, unless providers decide to only deal with health issues that fit that criteria and send everybody else to someone else.
I think the problem of not being able to accurately predict the required care is an intrinsic part of health care. Some of it actually is taken care of in some way, for example, if you go to ER they will only fix any immediate urgent issues and then send you home. Or, they send you home after n days in the hospital no matter what (example links: https://www.ombudsman.org.uk/sites/default/files/page/A%20re... or https://pubmed.ncbi.nlm.nih.gov/12568426/).
> When consumers are informed and can force suppliers to compete with each other,
Uhm... how do you imagine this would happen? Genetical engineering so all humans become standardized clones with identical completely predictable issues? I think you severely underestimate the inherent unpredictability. Simple stuff like teeth cleaning can be a price known in advance, or coming in only to renew a prescription for a known health problem, but many, most?, of the "real" issues are not.
OR, what would happen if you enforce this is that the MDs would be forced to press the cases into the pattern. They may think they should order an additional test or imaging procedure after actually looking at the patient, but since it's not in the pre-approved plan it would not get paid, so they don't, only things that were known before any doctor looked at the person get treated and only using the predicted methods.
When you take your car in for repair, you also can’t know for sure what the cost will be, because cars are complex systems and every car is unique in its own way. But if the garage overcharges you then you will figure this out and you will not go there again.
In the US healthcare system because of the lack of price transparency it seems to be impossible to know which hospital or doctor overcharges, and so a free market cannot arise. It is not even possible for a competitor to advertise better prices, because there is no practical way to check that their prices are indeed better.
In the US healthcare system because of the lack of price transparency it seems to be impossible to know which hospital or doctor overcharges, and so a free market cannot arise. It is not even possible for a competitor to advertise better prices, because there is no practical way to check that their prices are indeed better.
I'm not sure cars as an example work for health care. Each model has orders of magnitude less complexity, it's not living tissue, and variability within a model is very small. And it's all logically engineered instead of the mess that is biological systems (I have a small bit of background in life sciences - only studies, not work). But that's only an aside that I don't want to concentrate on.
> a free market cannot arise
A free market is not the best model I think, because even if you had perfect price transparency, people don't have nearly enough knowledge to evaluate the suggestions of doctors. Sure, they will select one the like more, but base don superficial information, not based on actual medical knowledge. For some truly "free market" you really want easily comparable and quite equal things to shop for. Medicine is too individual. Yes I know the desired model is you go in with your list of symptoms, get a few tests based on it, then an algorithm, right now in an MDs head, selects the appropriate treatment - time for the next patient in the overcrowded waiting area. It seems to me, and I had personal experiences with this model's limitations too, that there is a lot of dissatisfaction with this model not least with burned out medical professionals. But it sure is something the business-minds like, you can optimize processes and manage the heck out of such a system beautifully.
I - German (but I lived in the US for a decade and also had a bit of regular contact with various health providers, such as Stanford hospital or a Berkeley orthodontist for minor - and predictable, as you say - stuff like straightening teeth and hypo-sensitization) - am certainly not against a free-market component. I grew up in the GDR and we had a small bit of it even there! As a child my parents and grand parents actually did shop around for some specialists for some very reasonable amount of money, for my eyes for example (it worked out great, I stopped needing glasses as a late teenager, I ran around with one side of the glasses covered for a few years very early in childhood, for example, to strengthen one eye).
I think a little bit of that helps to reward those who care a bit more about their health and go about looking for solutions to problems more diligently and intelligently than others who just go with the flow. But I think this works best in small doses, not with the entire system set up this way.
> a free market cannot arise
A free market is not the best model I think, because even if you had perfect price transparency, people don't have nearly enough knowledge to evaluate the suggestions of doctors. Sure, they will select one the like more, but base don superficial information, not based on actual medical knowledge. For some truly "free market" you really want easily comparable and quite equal things to shop for. Medicine is too individual. Yes I know the desired model is you go in with your list of symptoms, get a few tests based on it, then an algorithm, right now in an MDs head, selects the appropriate treatment - time for the next patient in the overcrowded waiting area. It seems to me, and I had personal experiences with this model's limitations too, that there is a lot of dissatisfaction with this model not least with burned out medical professionals. But it sure is something the business-minds like, you can optimize processes and manage the heck out of such a system beautifully.
I - German (but I lived in the US for a decade and also had a bit of regular contact with various health providers, such as Stanford hospital or a Berkeley orthodontist for minor - and predictable, as you say - stuff like straightening teeth and hypo-sensitization) - am certainly not against a free-market component. I grew up in the GDR and we had a small bit of it even there! As a child my parents and grand parents actually did shop around for some specialists for some very reasonable amount of money, for my eyes for example (it worked out great, I stopped needing glasses as a late teenager, I ran around with one side of the glasses covered for a few years very early in childhood, for example, to strengthen one eye).
I think a little bit of that helps to reward those who care a bit more about their health and go about looking for solutions to problems more diligently and intelligently than others who just go with the flow. But I think this works best in small doses, not with the entire system set up this way.
> I think a little bit of that helps to reward those who care a bit more about their health and go about looking for solutions to problems more diligently and intelligently than others who just go with the flow
But caring about pricing is entirely different than caring about the right solutions
But caring about pricing is entirely different than caring about the right solutions
The majority of healthcare is for routine and known in advance procedures, not for emergency or exploratory procedures.
Sure, the GP might want to order tests, but the cost of the test will be known in advance, the cost of the consultation was already known by the patient.
The patient can tdecide which radiologist they want, using price as a criteria if they want to.
The existing method is basically "you can only know what the cost is after you owe it to us", which is, frankly, insane. It allows the sellers to set a price that the ma let cannot bear, which results in secondary markets that provide insurance and skim even more off the top.
Sure, the GP might want to order tests, but the cost of the test will be known in advance, the cost of the consultation was already known by the patient.
The patient can tdecide which radiologist they want, using price as a criteria if they want to.
The existing method is basically "you can only know what the cost is after you owe it to us", which is, frankly, insane. It allows the sellers to set a price that the ma let cannot bear, which results in secondary markets that provide insurance and skim even more off the top.
> The majority of healthcare is for routine and known in advance procedures
Yes what kind of procedure is needed often is known in advance. The details often only emerge after it's been started though. Just because it's routine does not at all mean it's all predictably-in-advance the same throughout, except for really basic stuff, which in turn is unlikely to be the big cost driver.
Yes what kind of procedure is needed often is known in advance. The details often only emerge after it's been started though. Just because it's routine does not at all mean it's all predictably-in-advance the same throughout, except for really basic stuff, which in turn is unlikely to be the big cost driver.
> Yes what kind of procedure is needed often is known in advance. The details often only emerge after it's been started though. Just because it's routine does not at all mean it's all predictably-in-advance the same throughout, except for really basic stuff, which in turn is unlikely to be the big cost driver.
I dunno that I'd call a broken leg "really basic stuff".
This is what I responded to and what I quoted in my original post:
> "Here is the cash price. We won't know your HDHP insurance price until after we bill them, which could be good for you or could be bad."
So, yeah, the supplier currently knows in advance what it costs to fix a broken leg. There is no reason for the price of more mundane medical care to be opaque at all.
I dunno that I'd call a broken leg "really basic stuff".
This is what I responded to and what I quoted in my original post:
> "Here is the cash price. We won't know your HDHP insurance price until after we bill them, which could be good for you or could be bad."
So, yeah, the supplier currently knows in advance what it costs to fix a broken leg. There is no reason for the price of more mundane medical care to be opaque at all.
Broke my finger and did the whole CD thing to. I accidentally laughed on the phone when they told me what I had to do. Felt a little bad. I had to drive to the urgent care to get the CD and then drive it to the orthopedic specialist days before the appointment. As I was driving I just thought to myself, here is everything that's wrong with the medical industry, synthesized in a 700Mb metallic disk I'm holding in my hand.
People don't want universal healthcare because then all the poors increase waiting times. But then they complain when healthcare is expensive?
>So I guess I should shop around by moving cities
No, the solution to most social ills in America is to simply not be poor. If you are poor, stop it. Then you don't have to worry about any of this. Consider abortion, a procedure now outlawed in many US states. If you're not poor, you can just pay to travel to another state or country, have the procedure, do some sight-seeing, and come home. The law has no de facto effect on you. Same with every aspect of healthcare. So, just don't be poor and you'll be fine. (Even better if you are connected to the wealthy and powerful in your city & state. It is very nice indeed to be a VIP in an American hospital, court, or anywhere else.)
No, the solution to most social ills in America is to simply not be poor. If you are poor, stop it. Then you don't have to worry about any of this. Consider abortion, a procedure now outlawed in many US states. If you're not poor, you can just pay to travel to another state or country, have the procedure, do some sight-seeing, and come home. The law has no de facto effect on you. Same with every aspect of healthcare. So, just don't be poor and you'll be fine. (Even better if you are connected to the wealthy and powerful in your city & state. It is very nice indeed to be a VIP in an American hospital, court, or anywhere else.)
> the solution to most social ills in America is to simply not be poor
American healthcare works well if you have money and better than anywhere else in the world if you have money and a chronic condition. If you get in an accident, however, particularly while away from your posh neighbourhood, you’re getting the same overworked, hyper-indebted surgeon as the homeless man. (If you’re a billionaire or head of state, that’s different, but that’s different everywhere.)
American healthcare works well if you have money and better than anywhere else in the world if you have money and a chronic condition. If you get in an accident, however, particularly while away from your posh neighbourhood, you’re getting the same overworked, hyper-indebted surgeon as the homeless man. (If you’re a billionaire or head of state, that’s different, but that’s different everywhere.)
> better than anywhere else
Spoken like a salesman!
It's mostly false. Last time I did a deep dive on this, the US had a genuine but small edge in treatment for diabetes and breast cancer, but that was it -- and the edge was nowhere near proportional to price.
Spoken like a salesman!
It's mostly false. Last time I did a deep dive on this, the US had a genuine but small edge in treatment for diabetes and breast cancer, but that was it -- and the edge was nowhere near proportional to price.
That's something I've always been very curious about as someone who doesn't live in the US and was very unimpressed by the healthcare there when he lived there and had to deal with issues with my Asthma.
What documentation/studies did you find in your deep dive?
What documentation/studies did you find in your deep dive?
> US had a genuine but small edge in treatment for diabetes and breast cancer
You’re looking at gross statistics. On average, American healthcare is average. If you zoom into the top 10%, it outperforms other countries’ top 10% (in general; of course there are exceptions). This goes from virtually instant imaging with concierge medicine to the Cleveland Clinic’s global medical evacuation jets and helicopters.
You’re looking at gross statistics. On average, American healthcare is average. If you zoom into the top 10%, it outperforms other countries’ top 10% (in general; of course there are exceptions). This goes from virtually instant imaging with concierge medicine to the Cleveland Clinic’s global medical evacuation jets and helicopters.
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Not just if you have money. If you have a lot of money. The majority of the country is one major accident away from being completely wiped out. It's the number one cause of bankruptcy.
I had an emergency this year within a very tiny insurance gap between employers and now all of my savings and retirement are gone.
I'm really not sure who it works out better for versus universal healthcare, but I can't imagine it's a whole lot.
I had an emergency this year within a very tiny insurance gap between employers and now all of my savings and retirement are gone.
I'm really not sure who it works out better for versus universal healthcare, but I can't imagine it's a whole lot.
You weren’t able to use COBRA? Or was the coverage just very poor even with it?
My probably naive understanding was that COBRA can be activated retroactively if you get in an accident during the coverage gap.
My probably naive understanding was that COBRA can be activated retroactively if you get in an accident during the coverage gap.
Yeah, I tried all of that. I'll spare you the details, but things just lined up in a way that made me ineligible for COBRA, but the insurance that I had at my previous employer was absolute trash and they wouldn't have covered a single thing anyway. It was the only option given aside from Kaiser (my Kaiser saga is an even longer story), and even before this emergency it covered almost nothing.
My prescriptions seemed kind of high so I checked with GoodRx and they were cheaper! Cheaper without insurance than with, like how does that even make sense?
Right now I'm trying to negotiate on my last and only unpaid bill, the hospital won't negotiate with 1st parties so I've been trying to go through a newer company called Goodbill or something. I can't vouch for them yet as it's still in process, but just trying to get this all out of the way so I can just move on. Honestly, this whole thing has been so terrible that I'm just like, nope you're not even going in the worry pile. I'll go through the motions, pay it as best I can, and move on. I'll save the worry for the next totally normal work meeting coming up :)
I'm just very fortunate that I don't have a family to support or a mortgage to pay, even though I've been very close to breaking my lease and moving in with my parents until I can get back on my feet. I mean, I make good money too, I never thought I'd be in this situation.
I will absolutely go through the insurance options with a fine toothed comb when I interview again. Mama mía, aye yay yay
My prescriptions seemed kind of high so I checked with GoodRx and they were cheaper! Cheaper without insurance than with, like how does that even make sense?
Right now I'm trying to negotiate on my last and only unpaid bill, the hospital won't negotiate with 1st parties so I've been trying to go through a newer company called Goodbill or something. I can't vouch for them yet as it's still in process, but just trying to get this all out of the way so I can just move on. Honestly, this whole thing has been so terrible that I'm just like, nope you're not even going in the worry pile. I'll go through the motions, pay it as best I can, and move on. I'll save the worry for the next totally normal work meeting coming up :)
I'm just very fortunate that I don't have a family to support or a mortgage to pay, even though I've been very close to breaking my lease and moving in with my parents until I can get back on my feet. I mean, I make good money too, I never thought I'd be in this situation.
I will absolutely go through the insurance options with a fine toothed comb when I interview again. Mama mía, aye yay yay
> hospital won't negotiate with 1st parties
Talk to an FCRA lawyer. There are certain notices that if you send them and they are ignored can let you remove the lines from your credit report should they mark them as defaulted on. They will likely also help if the hospital chooses to sue.
Talk to an FCRA lawyer. There are certain notices that if you send them and they are ignored can let you remove the lines from your credit report should they mark them as defaulted on. They will likely also help if the hospital chooses to sue.
I very much appreciate the tip, I'll check that out. Thank you! It's amazing how much time and work I've put into this and more info just keeps coming up. Crazy thing for people to navigate.
I don't know about poster, but offering COBRA isn't required for companies below a certain size. (I had to unexpectedly obtain private insurance to cover a gap in the pre-Obamacare era because the co I worked for only had a few employees.) It is a qualifying event for using the exchanges, but no idea about that being retroactive.
That shit is so expensive. I think I paid nearly $800 a month for a good short term policy during my gap.
Fun Fact: COBRA coverage doesn’t exist when your startup shuts down and you’re laid off.
This did not stop my insurance company from cashing my premium payments for over three months, even though they silently canceled my policy (no email, mail, or phone call). I only learned I had no coverage when I actually tried to have a dental appointment. Refunds of these premium payments took another another 3 months to be returned!
This did not stop my insurance company from cashing my premium payments for over three months, even though they silently canceled my policy (no email, mail, or phone call). I only learned I had no coverage when I actually tried to have a dental appointment. Refunds of these premium payments took another another 3 months to be returned!
COBRA is fuxking expensive. I have no desire to pay for it again on a low salary.
Sigh. This isn't your fault. But COBRA is retroactive. EG. You have 60 days to find new insurance with a new employer. So you don't have to ever pay for COBRA. IF / when something happens - you pay all the missed bills and you are covered. That is the entire point of COBRA. People paying for COBRA are using it wrong or can't find employment in 60 days.
> So you don't have to ever pay for COBRA.
Not technically true when I used it last. I did have to pay for it.
"Employers may require individuals to pay for COBRA continuation coverage. Premiums cannot exceed the full cost of coverage, plus a 2 percent administration charge." But yes, the American Rescue Plan act allocated funds to make COBRA free. I wouldn't doubt that I was using cobra wrong at the time either prior to the passage of the act. Small pdf warning: https://www.google.com/url?sa=t&source=web&rct=j&url=https:/...
Not technically true when I used it last. I did have to pay for it.
"Employers may require individuals to pay for COBRA continuation coverage. Premiums cannot exceed the full cost of coverage, plus a 2 percent administration charge." But yes, the American Rescue Plan act allocated funds to make COBRA free. I wouldn't doubt that I was using cobra wrong at the time either prior to the passage of the act. Small pdf warning: https://www.google.com/url?sa=t&source=web&rct=j&url=https:/...
Was retroactively electing cobra not an option for some reason?
Longer story, but the timing of the emergency and recovery period fell within an ineligibility window for COBRA. My previous insurance company wouldn't have covered it anyway. It was the worst Blue Shield plan that I didn't even know could be legal. Also, I got the first few bills, was like okay, I'll just pay these off and move on and not even bother. These were the only bills I could find in their patient portal at the time. Then I got hit with the massive ones that made my head spin. By that time I had started at my new employer, my new insurance hadn't kicked in and I was outside of the COBRA window, not that it would have covered it anyway.
From now on I'm making sure I have good insurance, which requires a crazy amount of due diligence, but not something I'll take for granted anymore. It's one of reasons I'm currently trying to move to another country. Quality of healthcare is important, but how much does it matter if you're in massive debt, lost nearly everything, and don't have a retirement anymore?
From now on I'm making sure I have good insurance, which requires a crazy amount of due diligence, but not something I'll take for granted anymore. It's one of reasons I'm currently trying to move to another country. Quality of healthcare is important, but how much does it matter if you're in massive debt, lost nearly everything, and don't have a retirement anymore?
What ineligibility window are you talking about?
You have 60 days to file (in writing by mail, in my case) once you leave your previous job, I didn't have enough time between jobs to really need it, emergency happens + a few weeks of recovery time where I'm incapable of basically doing anything, I get a few bills, I pay them, start working at my new job, get more and much larger bills, now I'm ineligible for Cobra. Not that it would have mattered with that insurer anyway in my case.
> better than anywhere else in the world if you have money and a chronic condition.
Which isn’t saying much. Even for wealthy people in the US, chronic conditions get you labeled anywhere from annoying to chronic drug seeker to mentally ill. Many doctors simply don’t believe that conditions that thousands to millions of people have are real, and no amount of money will change their minds. You do however get targeted for all kinds of scams!
Which isn’t saying much. Even for wealthy people in the US, chronic conditions get you labeled anywhere from annoying to chronic drug seeker to mentally ill. Many doctors simply don’t believe that conditions that thousands to millions of people have are real, and no amount of money will change their minds. You do however get targeted for all kinds of scams!
also: when wealthy you become a customer instead of a patient.
So they will do all kinds of useless tests and treatments because that is what they earn money on.
You will never really know if this treatment is good for you or good for the hospital.
So they will do all kinds of useless tests and treatments because that is what they earn money on.
You will never really know if this treatment is good for you or good for the hospital.
This might be true initially. But such people have networks who know people, pull strings, and move them pretty quickly to "the best" hospital in the area. You know, the Mayo Clinics, the Johns Hopkins, the Cedar Sinais of the world. It makes the hospitals happy, too because they run fundraisers and happy rich patients tend to give a lot, for just this reason.
> American healthcare works well if you have money and better than anywhere else in the world if you have money and a chronic condition.
Citation needed.
Citation needed.
Disagree. A friend who had dual citizenship moved from Canada to the US because Medicaid covered her kids rare disease drug but Canada didn’t.
Medicaid is actually very good coverage.
Medicaid is actually very good coverage.
With rare diseases this is always the case. Here in NW Europe we have the same issue with some one in a million diseases. The main issue is the insane prices charged by the companies to recouperate in a few years time to appease shareholders instead of several decades, which results in the cold truth it is not worth the effort looking at the grand scheme of things.
That’s the thing. The US system is expensive not only due to inefficiency but also due to a willingness to pay for things other countries don’t.
If you happen to have a kid with a rare disease, that matters.
If you happen to have a kid with a rare disease, that matters.
> Medicaid is actually very good coverage.
As the saying goes, "it's the best insurance money can't buy".
As the saying goes, "it's the best insurance money can't buy".
Bullshit.
> No, the solution to most social ills in America is to simply not be poor. If you are poor, stop it.
Those people deserve it. I mean, some people chose to be born to wealthy parents; if you were too lazy to do that why should I have to reward your laziness by paying to look after you? Really, some people can be so selfish!
> It is very nice indeed to be a VIP in an American hospital
My gf had a life threatening illness and went to Stanford hospital. They gave her the special blanket just for Stanford Faculty so she'd get the VIP treatment. Which in practice meant nothing. Thankfully she survived; now I wonder if I should be glad or not that VIPs get the same shitty health care there as everybody else.
Those people deserve it. I mean, some people chose to be born to wealthy parents; if you were too lazy to do that why should I have to reward your laziness by paying to look after you? Really, some people can be so selfish!
> It is very nice indeed to be a VIP in an American hospital
My gf had a life threatening illness and went to Stanford hospital. They gave her the special blanket just for Stanford Faculty so she'd get the VIP treatment. Which in practice meant nothing. Thankfully she survived; now I wonder if I should be glad or not that VIPs get the same shitty health care there as everybody else.
VIP treatment means a private room and doctors who personally really actually pay attention to your treatment because the administrator has reminded them to do that, or your friend from med school/business school has asked them to do that. It is not conferred by a blanket.
BTW there is a carrot and a stick going on. Yes, the hospital admin wants to make VIP patients happy for donations, but they also want to avoid making the patient unhappy because they have resources to sue, and win. All of this is highly motivational.
BTW there is a carrot and a stick going on. Yes, the hospital admin wants to make VIP patients happy for donations, but they also want to avoid making the patient unhappy because they have resources to sue, and win. All of this is highly motivational.
I don't really think the Mr/Mrs Moneybags "VIP patient" compares remotely to a board-certified member of La Cosa Nostra Medical Mafia with an iphone full of colleagues and professional acquaintances with a friend-of-an-attending across all specialties
When you are a doctor, you're part of the club. Skipping the line and getting a consult in 30 seconds? Well, that is 15 seconds too long. Got a laceration on your child, and want a 3 layer closure by the head of Plastics? No issue there. Want to convene a board on your rare medical issue? Well, there is a doctors only Facebook group for that, with about 500 docs ready to chime in on their breaks.
It goes way behind this too. Indepth knowledge and advice about who the actual locally best doctors and surgeons are, across specialties (not the popularity contest or bought magazine ones either). Early tracks on new promising studies. Handouts of non-scrip medical supplies like event swag. Pharma-reps wanting to market their novel products and spread the info on them. The amount of free stuff is off the charts.
I've seen exponentially more over the top professional courtesy "Good Old Docs" club from my Dr. wife and the associated professional network, than I have in any other profession by far.
When you are a doctor, you're part of the club. Skipping the line and getting a consult in 30 seconds? Well, that is 15 seconds too long. Got a laceration on your child, and want a 3 layer closure by the head of Plastics? No issue there. Want to convene a board on your rare medical issue? Well, there is a doctors only Facebook group for that, with about 500 docs ready to chime in on their breaks.
It goes way behind this too. Indepth knowledge and advice about who the actual locally best doctors and surgeons are, across specialties (not the popularity contest or bought magazine ones either). Early tracks on new promising studies. Handouts of non-scrip medical supplies like event swag. Pharma-reps wanting to market their novel products and spread the info on them. The amount of free stuff is off the charts.
I've seen exponentially more over the top professional courtesy "Good Old Docs" club from my Dr. wife and the associated professional network, than I have in any other profession by far.
I think the abortion case is more problematic than this. The laws raise a high barrier to entry, not just financial, but logistical and social. You can leave to get an abortion if you have the money, but there will be a fine on you, and you have to make travel arrangements for a very uncomfortable medical procedure. Poor people still have other, riskier options available.
"No, the solution to most social ills in America is to simply not be poor. If you are poor, stop "
In healthcare not being poor is sufficient. You actually have to be quite well off in order to not worry about cost.
In healthcare not being poor is sufficient. You actually have to be quite well off in order to not worry about cost.
Yes! My salary is twice the local average and still worry a medical event could wipeout my life savings.
There are annual out of pocket maximums. Mine is something like $7000 last I checked. Its a lot of money, but not an amount that would bankrupt most people.
Talk to somebody who has a chronic illness or multi year cancer. There are plenty ways to charge people way more than their out of pocket maximums. People also get worn down by constant mistakes and weird bureaucratic hurdles by hospitals and insurance.
I always wonder about those. Are they real? Or will insurance companies find exclusions or ways to mark things as out of network and the maximums don't apply?
Right, my insurance company tries to weasel out of paying for things all the time. I have zero confidence in the maximums.
Me. too.
cancer treatment costs can make anyone poor. just sayin'
That's why AFLAC offers cancer insurance.
https://www.aflac.com/individuals/products/cancer-insurance....
https://www.aflac.com/individuals/products/cancer-insurance....
Probably you still be broke
> The out-of-pocket expenses displayed are estimated at 40% of the total medical cost, assuming that average major medical plans cover approximately 60% of the expense. Your major medical coverage may be more or less, and if an individual or family incurs expenses for non-covered benefits, these out-of-pocket expenses may increase potential unexpected costs. You will also need to pay for any limits or exclusions on your benefits which may include the number of refills for certain drugs, visits to certain specialists, or days covered for certain benefits.
> The out-of-pocket expenses displayed are estimated at 40% of the total medical cost, assuming that average major medical plans cover approximately 60% of the expense. Your major medical coverage may be more or less, and if an individual or family incurs expenses for non-covered benefits, these out-of-pocket expenses may increase potential unexpected costs. You will also need to pay for any limits or exclusions on your benefits which may include the number of refills for certain drugs, visits to certain specialists, or days covered for certain benefits.
How do I figure out if I need something like this and how well my current insurance covers me?
I'm trying to find a case study but nothing turns up. A story - someone got a major injury, cancer, or other life-threatening hard/impossible-to-cure condition, and how exactly the events had unfolded financially. I.e. how many tens of millions the treatments were worth, how much insurance had covered, and how much was still left to pay and why. So maybe I could see what my insurance covers and see if I need another insurance to fill some obvious gaps.
All that my naive search attempts produce are mentions about people without coverage or with insufficient cheap coverage, which is a problem but a different one from what I'm trying to research. Oh, yes, and lots of mentions of out-of-network ambulance drives' crazy costs - I get this one.
I'm trying to find a case study but nothing turns up. A story - someone got a major injury, cancer, or other life-threatening hard/impossible-to-cure condition, and how exactly the events had unfolded financially. I.e. how many tens of millions the treatments were worth, how much insurance had covered, and how much was still left to pay and why. So maybe I could see what my insurance covers and see if I need another insurance to fill some obvious gaps.
All that my naive search attempts produce are mentions about people without coverage or with insufficient cheap coverage, which is a problem but a different one from what I'm trying to research. Oh, yes, and lots of mentions of out-of-network ambulance drives' crazy costs - I get this one.
Do they offer poverty insurance?
Having two different forms of medical insurance can be worse than one. I’ve not had such an experience, but I’ve heard horror stories of the two providers pointing fingers at each other and refusing to pay.
My spouse is on a very expensive treatment. For the first 5 years or so, the insurance company would call us every six months to ask if we had other insurance because they do not like paying for it. I think they’ve finally stopped asking. Next, they started harassing our doctors telling them to switch her Rx over to their (fucked up) internal pharmacy. Luckily the doctor knew they couldn’t be forced to do it and called us about it. We had to call the insurance company and tell them we aren’t changing pharmacies and to stop calling us or our doctors about it. They continued to call for a few months but have apparently relented.
The other solution is simply not to be sick. If you're sick, stop it. Welcome to America.
Or don't be racist and rebuild the social safety net
Americans desocialized because of equal rights.
Americans desocialized because of equal rights.
What does racism has to do with broken medical health care system in the US?
Privatization since the 60s is a reaction to equal rights and "welfare queens"
> the solution to most social ills in America is to simply not be poor
No, the solution is to be either poor or well off. The lower middle class are the people that have the most to worry about in the US healthcare system.
No, the solution is to be either poor or well off. The lower middle class are the people that have the most to worry about in the US healthcare system.
The primary cause today of doctors prescribing name brand medications without the ability for substitution of generics is a form of institutional stupidity. EMR prescribing systems are driven by a common "formulary" that has an entry for each drug and defaults. Often the people that define formularies are a weird mix of technological people that don't know anything about the drugs/medicine and medicine people that don't know anything about the technology. The checkbox for the formulary entry that defaults to "allow substititions" is not properly set or is defaulted to disallow them.
Also this reminds me of one of the more evil things I have ever seen in healthcare. Practice Fusion gave doctors a "free EMR" because it was being paid by opiate pharmecuitcal companies to create an electronic EMR workflow that intentionally increased unecessary opiate prescribing. Absolute evil in my opinion.
https://www.justice.gov/usao-vt/pr/electronic-health-records...
Also this reminds me of one of the more evil things I have ever seen in healthcare. Practice Fusion gave doctors a "free EMR" because it was being paid by opiate pharmecuitcal companies to create an electronic EMR workflow that intentionally increased unecessary opiate prescribing. Absolute evil in my opinion.
https://www.justice.gov/usao-vt/pr/electronic-health-records...
> institutional stupidity
If you are a hospital, and you are shopping for an EMR to maximize revenue, is that a feature or is it a bug?
Evil, yes, stupid, no.
If you are a hospital, and you are shopping for an EMR to maximize revenue, is that a feature or is it a bug?
Evil, yes, stupid, no.
I've worked with many, many hospital IT departments as a consultant, contractor, and vendor.
It's absolutely stupidity.
It's absolutely stupidity.
Do you understand that you’re claiming that if the money flow was reversed, the IT departments wouldn’t fix this issue in, say, three years?
Because I have seen many people, and they do the tasks asked of them. They are “stupid” on tasks not prioritized, but their employers are perfectly happy with that.
Because I have seen many people, and they do the tasks asked of them. They are “stupid” on tasks not prioritized, but their employers are perfectly happy with that.
From a doctor compaining about the difficulties faced by generic alternatives to EpiPens:
If you know anything at all about doctors, you know that they have way too much institutional inertia to change from writing one word on a prescription pad to writing a totally different word on a prescription pad, especially if the second word is almost twice as long, and especially especially if it’s just to do something silly like save a patient money. I have an attending who, whenever we are dealing with anything other than a life-or-death matter, just dismisses it with “Nobody ever died from X”, and I can totally hear him saying “Nobody ever died from paying extra for an adrenaline injector”. So Adrenaclick continues to languish in obscurity.
https://slatestarcodex.com/2016/08/29/reverse-voxsplaining-d...
If you know anything at all about doctors, you know that they have way too much institutional inertia to change from writing one word on a prescription pad to writing a totally different word on a prescription pad, especially if the second word is almost twice as long, and especially especially if it’s just to do something silly like save a patient money. I have an attending who, whenever we are dealing with anything other than a life-or-death matter, just dismisses it with “Nobody ever died from X”, and I can totally hear him saying “Nobody ever died from paying extra for an adrenaline injector”. So Adrenaclick continues to languish in obscurity.
https://slatestarcodex.com/2016/08/29/reverse-voxsplaining-d...
I thought that most of the time pharmacists were empowered to substitute generics where comparable/available?
I generally have a pretty high opinion of physicians, but they are incredibly overworked, and typically just lazy enough for this quote to be more true than we probably think it should, especially with e.g. 20 years of history writing a specific word for a specific diagnosis.
I generally have a pretty high opinion of physicians, but they are incredibly overworked, and typically just lazy enough for this quote to be more true than we probably think it should, especially with e.g. 20 years of history writing a specific word for a specific diagnosis.
In this particular case EpiPens are protected from substitutions: https://abcnews.go.com/Health/epipen-users-options-generic-a...
> doctors prescribing named brand, and you not be allowed to switch back to generic without another $100+ appointment
I'm not sure this is that common, unless you have an adversarial relationship with your doctor. It's actually the opposite: in most states the Dr. must write DAW-dispense as written or 'name brand only' to get the expensive brand. Otherwise, the pharmacist can and will substitute a generic if available.
I've always found docs to be very willing to work with you on budget issues. If there's a similar med that is available in generic where their original recommendation isn't, they're happy to switch.
I'm not sure this is that common, unless you have an adversarial relationship with your doctor. It's actually the opposite: in most states the Dr. must write DAW-dispense as written or 'name brand only' to get the expensive brand. Otherwise, the pharmacist can and will substitute a generic if available.
I've always found docs to be very willing to work with you on budget issues. If there's a similar med that is available in generic where their original recommendation isn't, they're happy to switch.
Fun fact, your pharmacist is allowed to change your prescription in some states! Try asking them if there are cheaper generics.
In France, the pharmacist is legally obliged to offer the cheaper generic. If the doctor wants the primary brand specifically, he has to write "non-substitutable" on the prescription and a shorthand mention of the reason.
Good to know, thanks!
BTW, Hopefully the last word is just a typo.
BTW, Hopefully the last word is just a typo.
In most states they don’t have to ask. A generic is equivalent substitute for the brand name.
I feel like if your response when I ask you the price is, "I don't know", then my response is, "well then I don't know if I can/will pay that". A friend of mine with limited means says his medical plan is just to go the ER and give them a fake name - he came up with it after suffering a head injury (pool cue to the head) and being unable to remember the details of his treatment. I don't think it's a good system, but it seems to be the one we've got.
For reference, the legal grounding of this is EMTALA: https://en.m.wikipedia.org/wiki/Emergency_Medical_Treatment_...
Which basically summarizes as "EDs that accept payments from Medicaid are required to at minimum stabilize all patients, regardless of their ability to pay or several named statuses."
Which basically summarizes as "EDs that accept payments from Medicaid are required to at minimum stabilize all patients, regardless of their ability to pay or several named statuses."
> give employees a stake in their costs, and therefore lower them for both employer and employee
The idea wasn't to get people to shop around, at least in my opinion, but rather to not use healthcare altogether unless absolutely necessary, because they feel the cost of the services more when they pay for the directly.
The idea wasn't to get people to shop around, at least in my opinion, but rather to not use healthcare altogether unless absolutely necessary, because they feel the cost of the services more when they pay for the directly.
> Aside but all ambulances around me are "out of network" and don't work with insurance at all. So I guess I should shop around by moving cities..?
That’s rather disturbing, and from a purely pragmatic point of view, you might consider raising a fuss with your employer…
That’s rather disturbing, and from a purely pragmatic point of view, you might consider raising a fuss with your employer…
I believe some states regulate that better than others. At the least, some prevent 'surprise bills' where the provider selected is out of network while the referer is in network. That's just not fair when you're unconscious or suffering.
It's complete nonsense even when you're conscious and fine!
CMS took administrative action this year to try to improve those situations:
https://www.cms.gov/nosurprises/consumers/new-protections-fo...
https://www.cms.gov/nosurprises/consumers/new-protections-fo...
Me and my colleagues (actuaries by training) ran some very interesting what-if scenarios based on our companies insurance packages, and every single scenario indicated that going with the highest deductible (or HSA) was more cost effective for the employee...the employer (with the insurance companies) had stacked the deductibles and cost structure to shift the risk from the company to the employee.
And the medical providers (not the insurance company) will always have discounts on their procedures...just have to ask for them. Makes one wonder how steep the mark-ups are.
And the medical providers (not the insurance company) will always have discounts on their procedures...just have to ask for them. Makes one wonder how steep the mark-ups are.
> When High Deductible Insurance was introduced the supposed concept was to "give employees a stake in their costs, and therefore lower them for both employer and employee."
Funny, I always thought it was just squeezing every last penny out of customers without letting them feel like they didn’t have health insurance for big ones
Funny, I always thought it was just squeezing every last penny out of customers without letting them feel like they didn’t have health insurance for big ones
HDP is definitely in the right path, but you need to get rid of many layers of bureacracy and paperwork. Need an absolute de-reg.
It's not going to happen, so the most likely scenario is innovation will be coming from fringe services.
It's not going to happen, so the most likely scenario is innovation will be coming from fringe services.
I belive that ACA plans must cover out of network emergency services.
Interesting to read that only 33%-50% of hospitals comply with the law and post their prices. If there's one thing this country needs to do it's demand transparency everywhere.
Especially our government. Spending. Salaries. It all needs to be public.
Especially our government. Spending. Salaries. It all needs to be public.
> Especially our government. Spending. Salaries. It all needs to be public.
A lot of it is. In California for example you can go look up any public employee's compensation at https://transparentcalifornia.com/
A lot of it is. In California for example you can go look up any public employee's compensation at https://transparentcalifornia.com/
WTF about, not just the compensation, but the fact that some of these show a salary of $200k with $2.X million in benefits. Like, what?
https://transparentcalifornia.com/salaries/2021/gateway-comm...
https://transparentcalifornia.com/salaries/2021/gateway-comm...
Almost certainly the value of pensions. There are teachers on that list making $65k with "benefits" of 1mm, which is probably the NPV of ~20 years of pension income.
Doesn't seem to add up though, if you keyword search for "teacher" [0], the results are dominated by GCC with consistently elevated benefits. Once you get out of GCC dominated results, the numbers start looking a lot less surprising - until another GCC entry shows up.
[0] https://transparentcalifornia.com/salaries/search/?q=teacher
[0] https://transparentcalifornia.com/salaries/search/?q=teacher
My completely uneducated guess is that GCC reports the entire value of the DB pension as "income" for that year, whereas all other institutions correctly report just the increase in value.
Plausible, maybe the Superintendent/CEO would be willing to comment if contacted:
> Please feel free to contact me at [email protected], or (916) 286-5129.
From https://www.gcccharters.org/welcome/
> Please feel free to contact me at [email protected], or (916) 286-5129.
From https://www.gcccharters.org/welcome/
Yeah but it would only show that year’s gain in pension value.
Transparent California is also incorrect in a lot of cases. I worked in CA as a seasonal worker and they reported what I would have earned if I worked full time for a year. In reality I only worked at that rate for 3 months making a quarter of what was reported. So I am not sure how much I trust it anymore.
The top salaries in that database match the people's names in this article: https://www.eastcountymagazine.org/east-county-superintenden...
Not seeing any of the Gateway Community Charter leaderboard on that list.
That's lifetime comp.
What's up with those million dollar benefits ? What could they possibly be spending those on ?
Defined benefit pensions and retiree healthcare.
Politicians get to calculate the present value however they want today (which always means understating the real cost), and letting the future deal with the problem and playing catch-up to the real costs.
No one cared about this enough so government employee unions and politicians back then got away with underpaying employees in cash (hence reputation of government pay being low), but then give cops and some others 3% final average pay pay pensions including overtime or just averaging the final 3 or 5 years of pay. I have even seen pension plans just use the final year of pay.
The pensions start at 20 years of service, so you can have people earning a couple hundred thousand in their final years in mid 40s or 50s, and then get an annuity worth $200k * 20 years * .03 per year = $120k per year, and then on top of that some even negotiated cost of living adjustments (currently wrecking Illinois’ taxpayers).
Go ask an insurance agent for a quote for an annuity of $120k starting at age 50 until you die and see what they quote you.
They will probably laugh you out of the room.
Add government doctors, lawyers, university management, etc and the costs explode.
Politicians get to calculate the present value however they want today (which always means understating the real cost), and letting the future deal with the problem and playing catch-up to the real costs.
No one cared about this enough so government employee unions and politicians back then got away with underpaying employees in cash (hence reputation of government pay being low), but then give cops and some others 3% final average pay pay pensions including overtime or just averaging the final 3 or 5 years of pay. I have even seen pension plans just use the final year of pay.
The pensions start at 20 years of service, so you can have people earning a couple hundred thousand in their final years in mid 40s or 50s, and then get an annuity worth $200k * 20 years * .03 per year = $120k per year, and then on top of that some even negotiated cost of living adjustments (currently wrecking Illinois’ taxpayers).
Go ask an insurance agent for a quote for an annuity of $120k starting at age 50 until you die and see what they quote you.
They will probably laugh you out of the room.
Add government doctors, lawyers, university management, etc and the costs explode.
This is why looking at government spending over time is an incomplete picture. If a huge chunk goes to retirees and wasn’t 40 years ago, there’s simply less leftover for everything else.
Tax revenue might be higher than ever but net available for programs is down. Thus, the feeling by many that government must be wasting money.
Tax revenue might be higher than ever but net available for programs is down. Thus, the feeling by many that government must be wasting money.
> If a huge chunk goes to retirees and wasn’t 40 years ago, there’s simply less leftover for everything else.
If you are talking about state governments in the US, that's approximately true.
If you are talking about the federal government, it's not, because the idea of a fixed purse is simply false. Spending and revenue are separate policy decisions that don't constraint each other.
If you are talking about state governments in the US, that's approximately true.
If you are talking about the federal government, it's not, because the idea of a fixed purse is simply false. Spending and revenue are separate policy decisions that don't constraint each other.
I do not understand why you are downvoted. It is obviously true the federal government can simply issue new money to pay its debts.
It's true, but you get inflation or exchange rate devaluations as a side effect.
> Especially our government. Spending. Salaries. It all needs to be public.
This is especially useful for valuable gov't employees that want to negotiate a higher salary :) Totally fine by me, but just be aware you may not realize the second order effects. The primary people that care may actually just be the employees for pay fairness
This is especially useful for valuable gov't employees that want to negotiate a higher salary :) Totally fine by me, but just be aware you may not realize the second order effects. The primary people that care may actually just be the employees for pay fairness
The US government is the last entity that should be playing games with salary negotiations. The G payment schedules are well established and can be updated. If they need to figure out other ways of providing a salary, they can update the existing schedules or make a new set that is also publicly available. If I’m paying taxes to provide a salary for a federal employee, I want that to be recorded, publicly accessible, and for there to be a controller somewhere accountable for how they money is allocated.
Not the US govt. think more state and local. US govt salaries are pretty transparent.
https://www.fedsdatacenter.com/federal-pay-rates/
A fairly searchable database of individual salaries
A fairly searchable database of individual salaries
What is the penalty for non compliance?
CMS just fined some hospital $900k. So it's not nothing.
Reading this thread and watching the US news in general, transparency is pretty far down the list of things the US needs.
This study uses polars [0][1] -- a new Data Science library written in Rust (core) with bindings to Python and Javascript. Perfect replacement for pandas. Polars' claims to fame are speed (faster than pretty much anything out there [2][3]), low memory pressure (very visible when comparing to pandas) and consistent API across Rust, Python, JS.
[0] https://www.pola.rs/
[1] https://github.com/pola-rs/polars
[2] https://h2oai.github.io/db-benchmark/
[3] https://www.pola.rs/benchmarks.html
[0] https://www.pola.rs/
[1] https://github.com/pola-rs/polars
[2] https://h2oai.github.io/db-benchmark/
[3] https://www.pola.rs/benchmarks.html
Thanks! I had not heard of it before. As a Python pandas user I have to say this look really promising. The speed claims are obviously great but what really stood out to me is the syntax. Reminds of the the dplyr syntax which I enjoyed a lot when I was still using R.
>Require a standard format. Pick JSON or CSV in some standard encoding. We don't need hospitals publishing XML files and Excel spreadsheets.
Definitely CSV. Always CSV. It's easy to produce, easy to parse, and kind of human readable. And easy to do some basic analysis with tools that everyone has access to - Excel, Google Sheets etc.
Definitely CSV. Always CSV. It's easy to produce, easy to parse, and kind of human readable. And easy to do some basic analysis with tools that everyone has access to - Excel, Google Sheets etc.
You cannot require CSV as a standard format because CSV itself has no standard. There are multiple variants of CSV and there's no way for a CSV file to declare which variant it's using in a standard way, which means you have to manually check that every single file parsed correctly, because if you accidentally parse a CSV file as the wrong variant there is no way for the parser to know and it will just silently corrupt your data.
Sometimes CSV files themselves are ambiguous because they don't use any quoting so you end up with some lines that have more columns than others, and require manual repair line-by-line by a human.
Don't use CSV, it's a dreadful format.
Sometimes CSV files themselves are ambiguous because they don't use any quoting so you end up with some lines that have more columns than others, and require manual repair line-by-line by a human.
Don't use CSV, it's a dreadful format.
> Sometimes CSV files themselves are ambiguous because they don't use any quoting so you end up with some lines that have more columns than others, and require manual repair line-by-line by a human.
It's wild that we haven't just started using unicode and line/group separator characters for tabular data instead of csv/tsv. Whoever decided to use a common semantic character as syntax is an evil, devious bastard.
That said, there is one thing I like about CSV and similar formats: they are inherently tabular. You don't have to worry about someone adding sub-objects to your JSON (or replacing a primitive field with an object/array). Extra columns are brainless to add or process, but converting sub-data to a line is not.
It's wild that we haven't just started using unicode and line/group separator characters for tabular data instead of csv/tsv. Whoever decided to use a common semantic character as syntax is an evil, devious bastard.
That said, there is one thing I like about CSV and similar formats: they are inherently tabular. You don't have to worry about someone adding sub-objects to your JSON (or replacing a primitive field with an object/array). Extra columns are brainless to add or process, but converting sub-data to a line is not.
In 2007 (15 years ago) Veneto and Lombardia italian regions elder health care ptivate facilities had to provide monthly data with a specific, mandatory excel template provided by regional health authorities. The company I worked for was in charge to collect data and create those files.
It was not a perfect format, it was closed source format (still .xls) but everyone knew it was that format.
Standards matter.
I didn't like CSV because too much actual data has commas in it, so commas aren't a good delimiter.
From the perspective of reading/writing CSVs programmatically, I actually prefer that it's a common character. You'll discover very quickly whether the parser handles escapes correctly. With a more exotic delimiter it might be a long time to discover the problem, and by then it will be harder to fix.
From the perspective of writing CSVs by hand in a text editor, commas suck.
From the perspective of writing CSVs by hand in a text editor, commas suck.
Tabs are a better delimiter than commas. Using the ASCII control characters meant for record and field delimiters are even better: https://en.wikipedia.org/wiki/C0_and_C1_control_codes
Quoting every column is a safe way to handle this, at the cost of slightly larger files. You can then escape a quote with another quote.
That is just one simple problem. People say CSV is hard because it is hard: https://www.delimited.dev/csv-file-quirks/
> CMS's price transparency law, which requires all hospitals to post their prices online in a single, machine-readable file
Whoever got this legislation through deserves a pat on the back.
Whoever got this legislation through deserves a pat on the back.
It was part of the ACA, but hospitals tied it up in court for a long time.
Thanks, Obama!
Many hospitals and providers are ignoring it, perfectly willing to eat the fine, if it ever comes.
I wonder if one could automate finding the hospitals that don’t do this and filing a complaint that leads to a fine
like patent trolls for a cause
like patent trolls for a cause
The competitors that do publish the data have a reasonable interest in that, so I would expect this to happen.
The fact that we're talking about "competitors" in the context of hospitals whose job is to save lives is incredibly broken as a non-american.
If there was a bounty I would do it
> Whoever got this legislation through deserves a pat on the back.
That would be Trump.
That would be Trump.
Trump's administration offices finalized the rules on how it would work, but the law was part of the Affordable Care Act, so it would be the Democratic congress and presidency of the Obama era.
Per https://www.sihd.org/affordable-care-act-price-list-2718-e and others
One wonders what took so long, of course.
Per https://www.sihd.org/affordable-care-act-price-list-2718-e and others
One wonders what took so long, of course.
> One wonders what took so long, of course.
No One doesn't.
One need only appreciate the incestuous network of corruption that controls how long these cans get kicked down the road to fathom what took so long. Unfortunately for the medical industry someone that wasn't beholden to them got into office briefly and made it happen.
No One doesn't.
One need only appreciate the incestuous network of corruption that controls how long these cans get kicked down the road to fathom what took so long. Unfortunately for the medical industry someone that wasn't beholden to them got into office briefly and made it happen.
Not exactly: In 2019: "Specifically, we updated our guidelines to require hospitals to make available a list of their current standard charges via the internet in a machine-readable format and to update this information at least annually, or more often as appropriate." [1]
Which is part of this executive order that Trump signed: "Within 60 days of the date of this order, the Secretary of Health and Human Services shall propose a regulation, consistent with applicable law, to require hospitals to publicly post standard charge information, including charges and information based on negotiated rates and for common or shoppable items and services, in an easy-to-understand, consumer-friendly, and machine-readable format using consensus-based data standards that will meaningfully inform patients' decision making and allow patients to compare prices across hospitals." [2]
> One wonders what took so long, of course.
What took so long is that you misunderstand how these rules work, Obama didn't actually do it, Trump did.
1: https://www.federalregister.gov/documents/2019/11/27/2019-24...
2: https://www.federalregister.gov/documents/2019/06/27/2019-13...
Which is part of this executive order that Trump signed: "Within 60 days of the date of this order, the Secretary of Health and Human Services shall propose a regulation, consistent with applicable law, to require hospitals to publicly post standard charge information, including charges and information based on negotiated rates and for common or shoppable items and services, in an easy-to-understand, consumer-friendly, and machine-readable format using consensus-based data standards that will meaningfully inform patients' decision making and allow patients to compare prices across hospitals." [2]
> One wonders what took so long, of course.
What took so long is that you misunderstand how these rules work, Obama didn't actually do it, Trump did.
1: https://www.federalregister.gov/documents/2019/11/27/2019-24...
2: https://www.federalregister.gov/documents/2019/06/27/2019-13...
> (e) STANDARD HOSPITAL CHARGES.—Each hospital operating within the United States shall for each year establish (and update) and make public (in accordance with guidelines developed by the Secretary) a list of the hospital’s standard charges for items and services provided by the hospital, including for diagnosis-related groups established under section 1886(d)(4) of the Social Security Act.
Signed 2010, PATIENT PROTECTION AND AFFORDABLE CARE ACT. Sure sounds like Obama did it and not Trump.
http://housedocs.house.gov/energycommerce/ppacacon.pdf
Signed 2010, PATIENT PROTECTION AND AFFORDABLE CARE ACT. Sure sounds like Obama did it and not Trump.
http://housedocs.house.gov/energycommerce/ppacacon.pdf
Obama might have tried to do it, but there's more to lawmaking than just writing it - there's also implementing it, which Obama most certainly did not do. And as a member of the Executive Branch, that's kind of his job....
Or are you implying everyone just ignored it for 12 years?
Also, Trump's order is significantly larger than what's in the ACA, and Trump actually implemented his order.
You can give Obama credit for trying, but Trump gets credit for actually doing it, and for doing it much better than Obama.
Or are you implying everyone just ignored it for 12 years?
Also, Trump's order is significantly larger than what's in the ACA, and Trump actually implemented his order.
You can give Obama credit for trying, but Trump gets credit for actually doing it, and for doing it much better than Obama.
It was Trump through a regulatory change by HHS.
https://www.forbes.com/sites/joshuacohen/2020/11/06/on-healt...
https://www.forbes.com/sites/joshuacohen/2020/11/06/on-healt...
I'm as surprised as anyone to see this #1 on HN. Glad y'all like it. AMA.
Feedback, criticism, comments, directions to go, whatever.
Feedback, criticism, comments, directions to go, whatever.
> You have to hope your hospital uses CPT codes and not, say, DRG coding, or something else entirely, otherwise you'll need to look up those codes too.
This is a bit of a misunderstanding. CPT codes are part of professional services billing, while DRGs are exclusively for inpatient acute care billing. If you are admitted to a hospital, you’ll probably have to deal with both.
This is a bit of a misunderstanding. CPT codes are part of professional services billing, while DRGs are exclusively for inpatient acute care billing. If you are admitted to a hospital, you’ll probably have to deal with both.
That's a great piece of information that I'd have never known about without an insider telling me. So thanks!
re the CPT codes--
27486 and 27487 are for total knee revisions, not for a first-time replacement. 27486 is used if you only revise 1 component (ie the femoral side or the tibial side). 27487 is billed when both components are revised.
Thank you! I appreciate the correction, and this exactly shows how challenging it is for the average consumer to actually use these chargemasters in the first place to do their own research.
Might be a dumb question, but if I joint hospitals and prices, and filter to the couple nearby hospitals that I care about, and I get 0 rows, that means they're violating the transparency law, correct?
It's not quite that simple. Remember that this database was built collaboratively, and it's possible that our bounty hunters just didn't get to that hospital. We have fairly good coverage, but it's impossible to say if 1) they didn't find the chargemaster, but it exists or 2) they didn't look for it.
We'll probably run another price bounty in the future to capture the rest of the chargemasters.
We'll probably run another price bounty in the future to capture the rest of the chargemasters.
I wanted to see how different the price for the knee replacement would be at different hospitals.
Good point. With the data as sparse and dirty as it is, it's hard to get a reliable analysis for specific procedures. Or at least one I consider publishable. That, plus, I don't have a good understanding of how medical billing works on the inside.
Some of that will hopefully change in the coming months as new data comes in (will write more about that in another blog.)
If you want to look at how prices for different procedures can vary between hospitals, you can get a rough idea from a previous blog post I wrote:
https://www.dolthub.com/blog/2022-05-06-the-most-expensive-h...
Some of that will hopefully change in the coming months as new data comes in (will write more about that in another blog.)
If you want to look at how prices for different procedures can vary between hospitals, you can get a rough idea from a previous blog post I wrote:
https://www.dolthub.com/blog/2022-05-06-the-most-expensive-h...
You can simply ask the hospital to give you good faith estimates:
https://www.cms.gov/nosurprises/consumers/understanding-cost...
https://www.cms.gov/nosurprises/consumers/understanding-cost...
> 1)The hospitals that comply often publish the least information they can get away with
2)The CMS law appears to be written by non-technical people and leaves room for hospitals to do (1)
I know the people who wrote this law. #2 is actually a false assumption. The law was written like that to incur the least resistance as a first step toward change.
I know the people who wrote this law. #2 is actually a false assumption. The law was written like that to incur the least resistance as a first step toward change.
I believe that this price transparency will have a pretty radical impact.
I used to negotiate with hospitals on reimbursement and if I were still doing the job, the first thing is do is pull up this data and say “This other plan of similar size is paying $X. I’m willing to pay the same.”
Sure it will take time to shake out. Hospitals will reject super low prices (that they were possibly losing money) for all payers. In exchange insurers will likely reduce the ultra high payments where they were paying a 500% mark up.
It will likely take a few years for it to shake out, but assuming the transparency remains I could see this actually driving prices closer to cost. Sure, big payers will drive it lower and small payers will pay more, but we could start to see a much smaller range.
Fingers crossed.
I used to negotiate with hospitals on reimbursement and if I were still doing the job, the first thing is do is pull up this data and say “This other plan of similar size is paying $X. I’m willing to pay the same.”
Sure it will take time to shake out. Hospitals will reject super low prices (that they were possibly losing money) for all payers. In exchange insurers will likely reduce the ultra high payments where they were paying a 500% mark up.
It will likely take a few years for it to shake out, but assuming the transparency remains I could see this actually driving prices closer to cost. Sure, big payers will drive it lower and small payers will pay more, but we could start to see a much smaller range.
Fingers crossed.
What's cost though? You've seen inflation when the supply chain is constrained. This is the case with medicine so the cost is possibly infinity here.
Only way to get hospitals to abide is to complain. It’s quite sad as a person who wants to get care about an issue in their health and needing to bounce between the insurance quote and the hospital costing quote.
You shouldn’t have to do napkin math to know how much it’s going to cost you in worst or best cases for simple visits, procedures, or devices/drugs.
This is a positive change as you can now ask directly and hold parties responsible for a transparent price. No more ranges or “estimates”. It’s been slow rolling, but I did have success when complaining recently to my local hospital. I just hope that the fees for ignoring this start to become hefty enough to change the healthcare industry’s behavior.
You shouldn’t have to do napkin math to know how much it’s going to cost you in worst or best cases for simple visits, procedures, or devices/drugs.
This is a positive change as you can now ask directly and hold parties responsible for a transparent price. No more ranges or “estimates”. It’s been slow rolling, but I did have success when complaining recently to my local hospital. I just hope that the fees for ignoring this start to become hefty enough to change the healthcare industry’s behavior.
Why can’t insurance companies post the actual price they are paying and being charged by the hospital with proper billing taxonomies. They seem like they probably have these things well ironed out since they actually deal with various hospitals whereas hospitals only deal with themselves.
The health insurance companies are now required to publish this and in fact the rule went into effect July 1 2022.
Look up price transparency by CMS (the data will be published in this format: https://github.com/CMSgov/price-transparency-guide)
Note: the data being published by payors in machine readable format (MRF) is MASSIVE - terrabytes of data. Example: https://transparency-in-coverage.uhc.com/
Look up price transparency by CMS (the data will be published in this format: https://github.com/CMSgov/price-transparency-guide)
Note: the data being published by payors in machine readable format (MRF) is MASSIVE - terrabytes of data. Example: https://transparency-in-coverage.uhc.com/
There is no actual price. Its rent extraction. They can change how much they charge you for 18 months.
I’m guessing you’re serious. Can you link me to more info on this specific thought?
Insurance companies have always given out prices. I have been able to type in CPT codes online and my insurance tells me the price on a map of all the providers in network in my area.
Before that, you could call and give them the code and they would tell you the price.
The problem is the doctor will not give you a code, and sometimes that makes sense since they do not know what they will be seeing or doing, so they cannot know the code in advance.
But I have also had doctors not give me codes for completely preventative services, which makes no sense.
Before that, you could call and give them the code and they would tell you the price.
The problem is the doctor will not give you a code, and sometimes that makes sense since they do not know what they will be seeing or doing, so they cannot know the code in advance.
But I have also had doctors not give me codes for completely preventative services, which makes no sense.
Because they don't know it yet. They audit and review each claim a an office sends, which starts a negotiation process to see if each claimed item by the physician was warranted and done properly. All that information is codified then into a level of visit, which changes the amount it will be payed out.
It is grotesquely complex, but the core issue here is that patients want to consume their healthcare through insurance, because it is tax advantaged. Thus it is impossible to make a cash business that would cut through all this bullshit for the majority of healthcare.
It is grotesquely complex, but the core issue here is that patients want to consume their healthcare through insurance, because it is tax advantaged. Thus it is impossible to make a cash business that would cut through all this bullshit for the majority of healthcare.
Congress has been considering transparent, prior authorization legislation in the realm of CMS. I don't know much about it, but they did publish an RFI recently[0]. I hear it has bipartisan support (that's obviously hearsay, but a lot of this recent healthcare legislation that has been passed has not been divided along party lines, AFAICT)
[0] https://www.federalregister.gov/documents/2022/01/24/2022-01...
[0] https://www.federalregister.gov/documents/2022/01/24/2022-01...
A few routine billing concepts that skews line item amounts in raw claim dumps or price lists derived from claim dumps:
- CPT modifiers (The service or procedure has both professional and technical components OR More than one provider performed the service or procedure. More than one location was involved OR A service or procedure was increased or reduced in comparison to what the code typically requires etc.,)
- Bundling (1 line item as opposed to 2 or 3 when the second and third procedures are an outcome of the first. eg: bone-xray + procedure(s) to fix the broken bone detected through the x-ray)
- Rendering provider vs. Billing provider (Rendering provider is the physician or provider that provided the service and billing provider could be the hospital/clinic/lab/ambulatory/billing company etc.,)
But here's the kicker. Medicare is the largest payer in the US and it already has a Fee-for-service pricing schedule. You can be sure that it covers all states, locality-wise price adjustments, hospital density factors in the price schedule and every possible procedure billing scenario. So, one just needs to compare (within a ZIP code or County or other geographic area) the hospitals prices against this to find anomalous pricing issues.
- CPT modifiers (The service or procedure has both professional and technical components OR More than one provider performed the service or procedure. More than one location was involved OR A service or procedure was increased or reduced in comparison to what the code typically requires etc.,)
- Bundling (1 line item as opposed to 2 or 3 when the second and third procedures are an outcome of the first. eg: bone-xray + procedure(s) to fix the broken bone detected through the x-ray)
- Rendering provider vs. Billing provider (Rendering provider is the physician or provider that provided the service and billing provider could be the hospital/clinic/lab/ambulatory/billing company etc.,)
But here's the kicker. Medicare is the largest payer in the US and it already has a Fee-for-service pricing schedule. You can be sure that it covers all states, locality-wise price adjustments, hospital density factors in the price schedule and every possible procedure billing scenario. So, one just needs to compare (within a ZIP code or County or other geographic area) the hospitals prices against this to find anomalous pricing issues.
A chain of clinics recently opened in our area that post all of their prices online.
We almost exclusively go there now for everything. Even if they are occasionally more expensive (briefly, until the normal UC would send their surprise bills), it's just so much easier to pay up front.
Thankfully we have an HSA and it's our money.
We almost exclusively go there now for everything. Even if they are occasionally more expensive (briefly, until the normal UC would send their surprise bills), it's just so much easier to pay up front.
Thankfully we have an HSA and it's our money.
If you can afford to pay for it with post tax non HSA money, then investing the HSA funds in a Fidelity HSA and letting them grow is the ideal maneuver.
Pdf your healthcare expense receipts and reimburse yourself from the HSA 50 years in the future completely tax free.
Pdf your healthcare expense receipts and reimburse yourself from the HSA 50 years in the future completely tax free.
HSA for those who are “international”: https://en.m.wikipedia.org/wiki/Health_savings_account
That's insane! Goes to show again that the solution in the US is "be rich" and then you'll be given additional benefits.
They're usually offered as an option for work-sponsored plans. You can get a low deductible plan that your work pays $1k a month for, or you can get a high deductible plan for $500 a month and the company gives you the other $500 into your HSA tax-free (oversimplified, of course).
They actually make a ton of financial sense, but too many in the US would rather overpay for insurance rather than have to shop around.
They actually make a ton of financial sense, but too many in the US would rather overpay for insurance rather than have to shop around.
Anyone can buy HSA eligible high deductible health plans on healthcare.gov too.
The fundamental problem is that we have chosen to use a free market mechanism for a condition that is not voluntarily acquired. No one chooses to get sick. Why then should we provide choice for its solution?
Can you imagine the same solution for our police? Military? Emergency services?
Can you imagine the same solution for our police? Military? Emergency services?
Despite all the problems with the law and with compliance, I'm optimistic about this. I think various orgs are going to ravenously pick apart this data, normalize it, make it easy to use for regular people, etc. Gaps are gaps, but messy formats and inconsistent codes and such are the smallest of speedbumps, in my mind.
Journalists, nonprofits, and startups are going to extract every bit of juicy truth there is to find in this stuff. They're going to get to the bottom of every cryptic string by hand if they have to, because there's so much value in this for nearly our entire society. And hopefully, the fines will mean the true gaps get smaller and smaller.
Journalists, nonprofits, and startups are going to extract every bit of juicy truth there is to find in this stuff. They're going to get to the bottom of every cryptic string by hand if they have to, because there's so much value in this for nearly our entire society. And hopefully, the fines will mean the true gaps get smaller and smaller.
I'm not optimistic. The data that has been out there for years has not yielded end-user usable information. There is too much missing context and billing trickery that it's not possible to tell how much something costs unless you're a
medical coder.
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Frankly, this exercise motivates me toward universal care more than ever.
I do not mean to devalue the work. It's great honestly! Thank you.
That said, this is a major league mess most of the world would look at and wonder whether we are crazy or high.
I do not mean to devalue the work. It's great honestly! Thank you.
That said, this is a major league mess most of the world would look at and wonder whether we are crazy or high.
Yes, as someone outside the US, the fact that this is a thing is just... weird. When I go to the hospital I'm already worrying about health, I'm thankful I don't have to worry about money too.
It can be rough. Cost me a home once!
Right now, it appears the US will have to learn this all the hard way. The financials are super attractive for people at the business level, and can be compelling for care providers, who may have expensive school to pay down.
For most everyone else, including many employers, it is increasingly painful.
The nature of the issue also makes change hard. Many people do not want to disturb what is working for them however painful. Can't blame them.
Right now, it appears the US will have to learn this all the hard way. The financials are super attractive for people at the business level, and can be compelling for care providers, who may have expensive school to pay down.
For most everyone else, including many employers, it is increasingly painful.
The nature of the issue also makes change hard. Many people do not want to disturb what is working for them however painful. Can't blame them.
If the law were serious about medical price transparency, it would just state that no medical bills are valid or enforceable in any court unless the exact price is clearly disclosed to the customer and agreed upon up front. Without relying on any government enforcement, we'd see an end to surprise billing overnight.
Business practices would have to change. In cases where the all the steps and treatments aren't knowable up front, providers would have to pick a price and stick to it - like any business or service provider they'd make money on some and lose money on others. Instead of issuing separate random bills from various providers, hospitals would have to pay their subcontractors out of their fixed prices, like a normal business. There may be exceptions for emergency care but those would be the rare exception, not the rule.
Business practices would have to change. In cases where the all the steps and treatments aren't knowable up front, providers would have to pick a price and stick to it - like any business or service provider they'd make money on some and lose money on others. Instead of issuing separate random bills from various providers, hospitals would have to pay their subcontractors out of their fixed prices, like a normal business. There may be exceptions for emergency care but those would be the rare exception, not the rule.
Does anyone know if the 2019 law opens hospitals to civil action or whether individuals can be awarded some portion of the fines for reporting as in whistleblower cases? If so, that could be a decent alignment of incentives to get the hospitals to comply.
American hospital price lists.
If you want this to improve: get rid of privatized health care. There are plenty of countries that set the example on how you could deal with this in a far more humane and fair way.
If you want this to improve: get rid of privatized health care. There are plenty of countries that set the example on how you could deal with this in a far more humane and fair way.
From an accounting and compliance perspective, not complying might make sense depending on the cost of upgrading systems. Hospitals and healthcare networks are going to upgrade their systems piecemeal and hodgepodge as their funding allows and pay the fines in the meantime. It'll be a good time to work in healthcare IT consulting. I'd imagine revenue will increase as EMR and so on require updates due to changes in regulation, assuming that we continue this trend.
What a strange concept, "hospital price".
Why? What do you think pays for the "hospital cost"?
(That's not to say there aren't MANY opportunities to reduce the price and cost, starting with complying with the law to post prices, which many hospitals don't adhere to because the current administration isn't enforcing the EO)
(That's not to say there aren't MANY opportunities to reduce the price and cost, starting with complying with the law to post prices, which many hospitals don't adhere to because the current administration isn't enforcing the EO)
Pretty sure he's just writing commentary on the US not having a single payer healthcare system
I posed my question to warrant a discussion from either the commentary or faithful statement regardless of their intent.
Mainly to understand the expectations, values, and reasoning.
Mainly to understand the expectations, values, and reasoning.
I don't think the concept is lost on any half intelligent adult that running a hospital has expenses and has to be paid by someone. The commentary is accurate that's is messed up to have a "price", like something is being sold. Having hospitals run off funding by taxpayers isn't a price any more than the military buying an F35 having a per-American price (and no one thinks of it that way)
> The commentary is accurate that's is messed up to have a "price", like something is being sold.
Services are being sold, whether it's private or government ran.
> Having hospitals run off funding by taxpayers isn't a price any more than the military buying an F35 having a per-American price (and no one thinks of it that way)
It is a price, so is the F35, and yes more people should think that way. Whether it's being paid for via taxes collected or paid directly is irrelevant.
The problem is not the method of collection of payment (taxes or direct) but the corruption of administrators.
Services are being sold, whether it's private or government ran.
> Having hospitals run off funding by taxpayers isn't a price any more than the military buying an F35 having a per-American price (and no one thinks of it that way)
It is a price, so is the F35, and yes more people should think that way. Whether it's being paid for via taxes collected or paid directly is irrelevant.
The problem is not the method of collection of payment (taxes or direct) but the corruption of administrators.
Spoken like an American. In other countries where healthcare is not paid for by the government, the prices are readily available.
Here are some examples:
https://www.ktph.com.sg/patients/hospital-charges
https://www.sgh.com.sg/patient-care/visiting-specialist/char...
Here are some examples:
https://www.ktph.com.sg/patients/hospital-charges
https://www.sgh.com.sg/patient-care/visiting-specialist/char...
I was going to say. Singapore has universal healthcare and they want all patients to have “skin in the game”.
So even if you’re destitute you need to pay something within your means, even if it’s $5 for a hospital stay.
So even if you’re destitute you need to pay something within your means, even if it’s $5 for a hospital stay.
There’s always a price, you just may not pay directly.
Toothless law. What article writer should do is just shame the hospitals who don't comply. Tweet at them and make it known.
What's more toothless than tweeting? Words don't hurt the pocketbooks all that much, especially of hospital groups.
A NYT article about the hospital I'm not even certain does very much.
A NYT article about the hospital I'm not even certain does very much.
It really is a toothless law, the hospital probably makes more surplus profit from price discrimination in a single week than their entire fine for the year. The damages should be increased 100x.
In my fantasy world there's a full-on constitutional amendment demanding that any monetary fine must meet or esceed the profits gained by breaking the law.
I've long advocated for a few variations of this:
1. fines must conform to a percentage of the targets earning wealth (e.g. someone who makes 30K a year gets fined $3000, someone who makes 300K gets a 30K fine etc)
2. flat out just as you said, fine must EXCEED by a multiple, the amount they gained (however, determining the gain is in many situations, requiring a lot of forensic accounting to sort out).
...now I'm amused by which Ayn Rand sycophant is downvoting me because I propose proportionality so the efficacy of punishment affects evenly across the board. Y'all are the Scientology of pop-econ.
I would advocate a more direct form of damages: a hospital that does not comply may not charge more than the minimum over all hospitals in a 500 mile radius for any procedure. A hospital that does charge more and is caught must refund double the difference. Furthermore, no contractual provision may penalize patients for attempting to seek that double refund, and a class action lawsuit to recover the difference that actually goes to trial recovers triple instead.
Hospitals will comply immediately :)
Hospitals will comply immediately :)
How about if you can’t post the prices, you simply aren’t allowed to bill for any services?
This is the one that's simple to enforce. No price, no bill.
Y'all are leaving out the no service part that would come with that.
Wut? The service has already been rendered at that point. Without an upfront price, no contract has been formed, so there's no basis for the hospital to bill an unjustifiable amount. At best they could request reimbursement for cost incurred. eg $0.01 for an aspirin and not $60.
At which point? The hospital would stop providing services shortly after it was informed that it would not be able to bill for them.
Also, I'm pretty sure you can write a contract that doesn't have an upfront price.
Also, I'm pretty sure you can write a contract that doesn't have an upfront price.
Informed by who? Hospital performs services, sends out a "bill" 30 days later, patient responds "due to the lack of published pricing as per federal reguation, no contract was formed and thus this bill is invalid". Are you saying the hospital would then react by stopping providing care to all patients from then on? Why wouldn't they react by you know, complying with the law to stay in business?
A contract has to have defined consideration, otherwise it is not a contract. Time and materials (hourly rate + cost/plus) is another standard form of financial consideration, but "we'll charge you whatever we feel like at some later time" is not.
A contract has to have defined consideration, otherwise it is not a contract. Time and materials (hourly rate + cost/plus) is another standard form of financial consideration, but "we'll charge you whatever we feel like at some later time" is not.
No service = no bonus for whatever exec decided not to publish the list.
In general, I’d love to see the same consumer protection required from auto shops applied to a hospital. An auto shop must give an estimate in advance.
In general, I’d love to see the same consumer protection required from auto shops applied to a hospital. An auto shop must give an estimate in advance.
The only reason these laws have any teeth is medicare/medicaid reimbursements.
If you make working with the govt on reimbursements too painful, many hospitals in well-off insured areas (good payer mix which is like gold to medicine) will just stop treating medicare/medicaid.
If you make working with the govt on reimbursements too painful, many hospitals in well-off insured areas (good payer mix which is like gold to medicine) will just stop treating medicare/medicaid.
Not only that, but it costs money for the hospital to make the chargemaster available, deal with people asking about it, etc. If the fine is really just $900K, if I was a hospital CFO I'd pay that every year without a second thought, or even work up a service charge to add to all hospital billing a la the "Federal Access Charge" AT&T puts on phone bills so I can get people to blame the government for $15 Motrin tablets in the hospital.
An interesting game. The govt could then raise the fine, but would they risk bankrupting the hospitals by pushing too far?
It costs money for the hospital to do payroll for the CEO too but that never gets dropped somehow!
I did it for the UK. It didn’t take long :-)
Having recently moved to Germany from Seattle ... it really is nice to not have to worry about this stuff. This is especially true since I have leukemia and take medicine daily. At some point I'll have a big frustration with the German healthcare system I'm sure, but it hasn't happened yet.
Where to start...
1. Somehow in the mid-2010s congress decided that anyway that walks onto private property, demands care from a private organization, will receive it, even if they declare they will not pay a dime to the staff working.
2. Congress could have totally create/build a system of hospitals that provides "one time care" for those people, but doesn't.
3. Instead they pass the buck and say "figure it out" to the private industry.
4. Hospitals are squeaking by largely flopping duties on nurses, making their jobs far less enjoyable (wrangling entitled individuals instead of healing people and providing care), and charing double-triple to responsible individuals who will pay for themselves.
5. E.R.s are now becoming "primary care" for large majority of the US population, as they show up, then disappear knowing they won't be stuck with a bill.
6. Members of Congress literally don't give a crap about "common folk" and go on golfing and enjoying their free healthcare for life. Meanwhile commonfolk and the poorest of the poor don't get the same deal. One set of rules for peasants, one set of rules for the 1%.
1. Somehow in the mid-2010s congress decided that anyway that walks onto private property, demands care from a private organization, will receive it, even if they declare they will not pay a dime to the staff working.
2. Congress could have totally create/build a system of hospitals that provides "one time care" for those people, but doesn't.
3. Instead they pass the buck and say "figure it out" to the private industry.
4. Hospitals are squeaking by largely flopping duties on nurses, making their jobs far less enjoyable (wrangling entitled individuals instead of healing people and providing care), and charing double-triple to responsible individuals who will pay for themselves.
5. E.R.s are now becoming "primary care" for large majority of the US population, as they show up, then disappear knowing they won't be stuck with a bill.
6. Members of Congress literally don't give a crap about "common folk" and go on golfing and enjoying their free healthcare for life. Meanwhile commonfolk and the poorest of the poor don't get the same deal. One set of rules for peasants, one set of rules for the 1%.
> Somehow in the mid-2010s congress decided that anyway that walks onto private property, demands care from a private organization, will receive it, even if they declare they will not pay a dime to the staff working.
False. I mean, not only is this an exceptionally emotionally loaded description of EMTALA, it was adopted in 1986 which is not, even approximately, the mid-2010s.
> Congress could have totally create/build a system of hospitals that provides "one time care" for those people, but doesn't.
Yet another set of independent physical infrastructure would be even less efficient. The multitude of separate payment and delivery systems is a major source of the US inefficiency
> Instead they pass the buck and say "figure it out" to the private industry.
No, instead they find hospitals that have a large share of uncovered patients through the Medicaid's Disproportionate Share Hospitals payments program.
> E.R.s are now becoming "primary care" for large majority of the US population
Some support for this “majority” claim would be welcome.
> Members of Congress literally don't give a crap about "common folk" and go on golfing and enjoying their free healthcare for life.
Under the ACA, members and staff of Congress don't have special government healthcare plans, they have access to plans they are required to have coverage through plans available to others created under the ACA including exchange plans.
False. I mean, not only is this an exceptionally emotionally loaded description of EMTALA, it was adopted in 1986 which is not, even approximately, the mid-2010s.
> Congress could have totally create/build a system of hospitals that provides "one time care" for those people, but doesn't.
Yet another set of independent physical infrastructure would be even less efficient. The multitude of separate payment and delivery systems is a major source of the US inefficiency
> Instead they pass the buck and say "figure it out" to the private industry.
No, instead they find hospitals that have a large share of uncovered patients through the Medicaid's Disproportionate Share Hospitals payments program.
> E.R.s are now becoming "primary care" for large majority of the US population
Some support for this “majority” claim would be welcome.
> Members of Congress literally don't give a crap about "common folk" and go on golfing and enjoying their free healthcare for life.
Under the ACA, members and staff of Congress don't have special government healthcare plans, they have access to plans they are required to have coverage through plans available to others created under the ACA including exchange plans.
> Yet another set of independent physical infrastructure would be even less efficient.
I think this misses just how basic much of the care performed in an ER (which is oriented towards critical care for major problems) is. Duplicate infrastructure is OK when the use-cases are totally different. We need better urgent care clinics.
I think this misses just how basic much of the care performed in an ER (which is oriented towards critical care for major problems) is. Duplicate infrastructure is OK when the use-cases are totally different. We need better urgent care clinics.
Urgent care should be a billing code at the ER. Pretty much the second they triage you out of immediate care, the separate facility and separate providers are increasing costs.
Medical providers suffer under central planning and believe that moving low risk, high value care out of hospitals will make things cheaper. The thing that will make things cheaper is to figure out ways to directly make them cheaper.
Medical providers suffer under central planning and believe that moving low risk, high value care out of hospitals will make things cheaper. The thing that will make things cheaper is to figure out ways to directly make them cheaper.
EMTALA dates to the Reagan era¹ and applies to hospitals that have contractual agreements with the Federal government (ones that accept Medicare).
What else in your analysis is terribly wrong?
1. https://en.wikipedia.org/wiki/Emergency_Medical_Treatment_an...
What else in your analysis is terribly wrong?
1. https://en.wikipedia.org/wiki/Emergency_Medical_Treatment_an...
I wonder how member of Congress justify that they need a special health care that is different from the public.
It seems to make sense and align incentives to have members use the same public systems (eg transport, education, health, housing) as everyone else, otherwise they will never understand how their policies affect real people.
It seems to make sense and align incentives to have members use the same public systems (eg transport, education, health, housing) as everyone else, otherwise they will never understand how their policies affect real people.
> I wonder how member of Congress justify that they need a special health care that is different from the public.
There don't. Them not doing so is part of the ACA. Grandparent was just lying.
There don't. Them not doing so is part of the ACA. Grandparent was just lying.
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Correct me if i'm wrong, but aren't some hospital bills/prices considered to be negotiable estimates? If so, wouldn't that skew the data?
And yes, prices should be set in stone and be easily accessible, unless it's something that is hard to evaluate due to one reason or another.
And yes, prices should be set in stone and be easily accessible, unless it's something that is hard to evaluate due to one reason or another.
Starting Jan 1, 2022, a healthcare provider has to provide an estimate and you are only liable for that estimate plus $400 in case of overage.
https://www.cms.gov/nosurprises/consumers/understanding-cost...
https://www.cms.gov/nosurprises/consumers/understanding-cost...
Thanks for clarifying!
Here's a solution: Let doctors be doctors and not glorified algorithmic-assembly-line workers. Incentivize transparency through something better than Yelp reviews. Incentivize diagnostic outpatient facilities, make them more accessible and discoverable. Especially through telemedicine if possible, but make sure they can be seen in person by someone competent if needed.
I'm sure I'll get downvoted here for this part, but government shouldn't be micromanaging care standards, even through a proxy like medicaid and medicare claim criteria. Let the citizens regulate the system instead, and government's job should be to make it easier for them to do so.
Yes, transparency can come through price lists, but prices can never go down until quality goes up first. It's just like code quality: If it's bad, you'll have to spend more time dealing with technical debt than it would have been to invest in the quality up front. Bad medical care breeds more complicated patient situations, and the rate of seriously ill patients increases as a result. Supply cannot keep up with demand.
Analyzing price lists, shaming providers into lowering prices, etc., will not solve this, nor is that idea even novel. But it may be useful as a single part of a more comprehensive strategy to solve the root of the problem.
It's great for business, especially since Michael Moore's documentary made it politically incorrect to deny medical claims for terminally or seriously-ill patients. Still bad for life expectancy, but we'll probably need another "groundbreaking" documentary before the country really wakes up to the scheme.
And for Christ's sake, stop training doctors to ask "what are your symptoms" (when they are already reasonably aware of what the type of issue is), and use more yes/no questioning about specific symptoms. If doctors can't be trained fast enough to be able to do even that, I'd think about fixing that, too.
I'm sure I'll get downvoted here for this part, but government shouldn't be micromanaging care standards, even through a proxy like medicaid and medicare claim criteria. Let the citizens regulate the system instead, and government's job should be to make it easier for them to do so.
Yes, transparency can come through price lists, but prices can never go down until quality goes up first. It's just like code quality: If it's bad, you'll have to spend more time dealing with technical debt than it would have been to invest in the quality up front. Bad medical care breeds more complicated patient situations, and the rate of seriously ill patients increases as a result. Supply cannot keep up with demand.
Analyzing price lists, shaming providers into lowering prices, etc., will not solve this, nor is that idea even novel. But it may be useful as a single part of a more comprehensive strategy to solve the root of the problem.
It's great for business, especially since Michael Moore's documentary made it politically incorrect to deny medical claims for terminally or seriously-ill patients. Still bad for life expectancy, but we'll probably need another "groundbreaking" documentary before the country really wakes up to the scheme.
And for Christ's sake, stop training doctors to ask "what are your symptoms" (when they are already reasonably aware of what the type of issue is), and use more yes/no questioning about specific symptoms. If doctors can't be trained fast enough to be able to do even that, I'd think about fixing that, too.
> And for Christ's sake, stop training doctors to ask "what are your symptoms" (when they are already reasonably aware of what the type of issue is), and use more yes/no questioning about specific symptoms. If doctors can't be trained fast enough to be able to do even that, I'd think about fixing that, too.
I think you really don't understand enough about why these things get asked. Yes Gp work often seems like glorified flowcharts at first glance (especially if you only look at some of their study material), but once you dig into it (I helped my partner study for an exams and get to hear her stories every day), you realise the huge amount of background information that can flow into a diagnosis. Asking the patient about their symptoms is an important part of gathering the history and can not be done just with yes or no questions.
I think you really don't understand enough about why these things get asked. Yes Gp work often seems like glorified flowcharts at first glance (especially if you only look at some of their study material), but once you dig into it (I helped my partner study for an exams and get to hear her stories every day), you realise the huge amount of background information that can flow into a diagnosis. Asking the patient about their symptoms is an important part of gathering the history and can not be done just with yes or no questions.
> Asking the patient about their symptoms is an important part of gathering the history and can not be done just with yes or no questions.
I agree, but that wasn’t what I was arguing against. Absence of any yes/no question is what I was referring to.
And I’m not sure your argument is a good one. Things you do in the classroom or other training are intended to overprepare you, and are not supposed to mirror real life. While I did rebuild and scale (as a technical owner) an exam platform later used by millions, I am only mentioning that ironically. Appeals to authority tend to be pretentious, and serve to prop up an even more dangerous myth that professionals always know what they are talking about.
I agree, but that wasn’t what I was arguing against. Absence of any yes/no question is what I was referring to.
And I’m not sure your argument is a good one. Things you do in the classroom or other training are intended to overprepare you, and are not supposed to mirror real life. While I did rebuild and scale (as a technical owner) an exam platform later used by millions, I am only mentioning that ironically. Appeals to authority tend to be pretentious, and serve to prop up an even more dangerous myth that professionals always know what they are talking about.
And for the NHS at point of use (when you can get to the to of the queue): 0$ 0$ 0$ 0$ 0.....
Genuine wishes of good luck to those in dealing with that system and may you avoid it for as long in life as possible.
Genuine wishes of good luck to those in dealing with that system and may you avoid it for as long in life as possible.
Not only do we need public price lists, the middlemen need to be cut out — specifically, the doctors. You should be able to wander into a specialist's office and get an appointment without having to go through a GP first; you should be able to get most any test done in exactly the same way. Due to the insurance companies and the hospitals they work for, doctors aren't going to suggest anything other than the basic stuff you can find through Google about a low/high count in any test. Yes, GPs are useful and have a role — but as long as their hands are tied, they're glorified flowchart jockeys. Free the data, free the patients.
The reason insurers require a referral is to keep costs down. That even happens in places with universal healthcare.
It doesn’t make sense to pay for a dermatologist at $150 for a visit to look at a rash when a GP would do at $75.
It doesn’t make sense to pay for a dermatologist at $150 for a visit to look at a rash when a GP would do at $75.
You can do this with PPO insurance or paying cash.
No you can't. Some specialists are referral only. They do this to satisfy medical necessity requirements to make sure they get paid by insurance.
I have had PPO high deductible health insurance for 14 years, and I have been able to see whatever doctor I want whenever I want.
Obviously, I need to pay out of pocket until I meet the deductible, but it all counts toward the annual out of pocket max and I get the negotiated pricing between doctor and insurance company. After I meet the deductible, however, the insurance still pays for a consult for anyone I want to go see. Not necessarily for any procedure though, without justification. But that applies in any situation, PPO or not.
Obviously, I need to pay out of pocket until I meet the deductible, but it all counts toward the annual out of pocket max and I get the negotiated pricing between doctor and insurance company. After I meet the deductible, however, the insurance still pays for a consult for anyone I want to go see. Not necessarily for any procedure though, without justification. But that applies in any situation, PPO or not.
This healthcare thread is amazing, I want to meet you all.
I live in England so I don't have to either.
Nitpick, but, anyone else have issues reading the article? The grammar usage seems "off."
Content is excellent, but the writing feels off.
Content is excellent, but the writing feels off.
Love the post, however, your description of the problem leaves me wondering...did we work together?
I analyzed Italian hospital costs so you don't have to:
it's 0.
Your sarcastic comment was ironically invalidated by failing to copy the headline exactly. I assure you that the costs of Italian hospital are much, much greater than 0. Now, their prices on the other hand, that's another matter...
I love this comment
[deleted]
Great stuff thanks a lot
I hate Trump and am glad he was voted out, but you have to give him his dues.
This is 100% his doing, through executive action. The Dems could have done this but never did. It’s just another example of how neither side of the aisle is truly on your side.
This is 100% his doing, through executive action. The Dems could have done this but never did. It’s just another example of how neither side of the aisle is truly on your side.
All politicians are crooks. Left or right, doesn't matter. They are both accepting bribery under "lobbying".
This seems like a perilous line of thinking: If all politicians are crooks, then we should get rid of politicians. Without politicians, we either have anarchy or dictatorship. Politicians don't seem so bad at that point.
"All politicians are crooks" is often used as a way to discourage the public from participating in any sort of politics. Outside of this threads context – don't take it that seriously.
So when EFF goes and talks to their Senator to ask (“lobby”) for privacy laws you call that “bribery”?
The price transparency rule was actually an ACA provision. It just got tied up in legal limbo for a long period.
It was finalized during the Trump administration, but in no way should he get 100% of the credit.
It was finalized during the Trump administration, but in no way should he get 100% of the credit.
No that’s not what happened. Obama came up with a toothless proposal and once ACA was passed he didn’t push further because he didn’t want to piss of the AHA.
So it languished for 6 years with no movement. Trump came in a added it with an executive decision, and it was then that there were legal challenges that were denied. And that’s how we got here.
Like I said, Trump is the worst president of all time but give him his dues when he deserves them. This is one of them.
So it languished for 6 years with no movement. Trump came in a added it with an executive decision, and it was then that there were legal challenges that were denied. And that’s how we got here.
Like I said, Trump is the worst president of all time but give him his dues when he deserves them. This is one of them.
As I understand it from news articles a few months back, the Biden administration was letting the enforcement of Trump’s healthcare price transparency law really slip.
And it was severely under reported.
Recommend sending Biden a message (I guess via whitehouse.gov) that you’re tracking this issue.
And it was severely under reported.
Recommend sending Biden a message (I guess via whitehouse.gov) that you’re tracking this issue.
Was this not a Trump policy?
ramesh31(2)
It is very good there is are the transparency regulations. It is worth briefly explaining some of the reasons why many facitilities are having a hard time complying. There are some bad actors, absolutely true. However "Hanlons Razor" -- never attribute to malice that which is adequately explained by stupidity -- definitely applies.
Many health systems are a lot more like "medical malls" than they are single monolithic enterprises. Lots of health systems use really, really old technology and also a lot of it from a company called "Epic". Epic does what it wants, when it wants and there is basically nothing anyone can do about it. There is rarely one central consistent mechanism and source of truth for pricing data because it gets generated from a complex web of different entities, systems, and processes. Herding all those cats is why it can take a health system a long time to comply. And also why a fine of even a million dollars can be small potatos vs the cost of actually complying in a timely manner.
Just one facet, MUMPS is a widely used technology which you probably haven't heard of and which very few technologists understand. Lots of people are struggling to create new code to meet the new regulations using 1970s era technology including MUMPS.
Another, a lot of health systems have been around a really long time. The insurers they work with also, (since the 1960s at least). They have Electronic Data Interchange EDI relationships built on the standard called 837. Business logic that surrounds pricing and billing is often buried in 50 years of tech debt. Everyone is deathly afraid of making too many changes too fast because when those systems break the money stops flowing and a health system will literally go insolvent. People still have hard physical lines connected to Medicare mainframes.
This is a similar situation to other regulated industries like banking, airlines, etc. Modernization is hard, time consuming and very expensive. These regulations are a good driver for all that, but it takes time. Having been in some of these boardrooms there is not typically a cartel of evil executives figuring out how to screw patients. A lot of the time it is a group of relatively normal people trying to hold up a technological and business process house of cards with chewing gum, paper clips and hope.
Disclaimer: I have been involved with the development of some of the fee schedules and health systems mentioned/criticized.