$1,944 for a coronavirus test? Readers helped us spot an unusual trend(nytimes.com)
nytimes.com
$1,944 for a coronavirus test? Readers helped us spot an unusual trend
https://www.nytimes.com/2020/11/10/insider/readers-medical-bills-doctor.html
183 comments
I'm from Germany and here it's exactly the other way around.
Public health insurences (there are over 100, but they are all organized in an umbrella organization) give out licences to doctors to be allowed to practice on publicly insured patients. The doctors get some amount of money they can spent on patient-specific prescriptions, but in general the doctors only prescribe the active ingredient. When the patient goes to the pharmacy to get their prescription, the pharmacy looks up the insurence and hands the patient the medicine that the insurence dictates. A doctor can prescribe a specific medicine but has to pay for it themselves (mostly from the money the insurences previously provided, see above).
Insurences check about 10% of all hospital bills and just don't pay what they deem unnecessary. Hospitals are therefore careful not to do things the insurences didn't approve of. There is an open catalog of therapies that the public insurences will definitely pay and how much it may cost, so it's not a secret.
They will also push for modern treatments if they reduce recovery time and have less risks.
There is a lot more to the system but that's the gist.
Public health insurences (there are over 100, but they are all organized in an umbrella organization) give out licences to doctors to be allowed to practice on publicly insured patients. The doctors get some amount of money they can spent on patient-specific prescriptions, but in general the doctors only prescribe the active ingredient. When the patient goes to the pharmacy to get their prescription, the pharmacy looks up the insurence and hands the patient the medicine that the insurence dictates. A doctor can prescribe a specific medicine but has to pay for it themselves (mostly from the money the insurences previously provided, see above).
Insurences check about 10% of all hospital bills and just don't pay what they deem unnecessary. Hospitals are therefore careful not to do things the insurences didn't approve of. There is an open catalog of therapies that the public insurences will definitely pay and how much it may cost, so it's not a secret.
They will also push for modern treatments if they reduce recovery time and have less risks.
There is a lot more to the system but that's the gist.
I came here to extol the virtues of the German system. There's a lot more to it:
- It's priced according to income, not health condition
- You will never, ever be refused necessary healthcare, and you'll know it's covered before work begins
- You are not punished for using your insurance, and the premiums won't change
- There is no deductible, except a 5-10€/month co-pay for prescriptions
- Your employer/employment has no impact on your coverage, or the insurer you choose
This is for the public system. The private system is a bit more complicated, but generally, the same rules apply. The only difference is the pricing structure, and the possibility of having a deductible (usually ~1000€/year).
American expats tend to have trauma that affects their insurance choices. My job is to reassure them that our system is completely unlike the American system.
If you want a plain English overview of the system, you can have a look here: https://allaboutberlin.com/guides/german-health-insurance
- It's priced according to income, not health condition
- You will never, ever be refused necessary healthcare, and you'll know it's covered before work begins
- You are not punished for using your insurance, and the premiums won't change
- There is no deductible, except a 5-10€/month co-pay for prescriptions
- Your employer/employment has no impact on your coverage, or the insurer you choose
This is for the public system. The private system is a bit more complicated, but generally, the same rules apply. The only difference is the pricing structure, and the possibility of having a deductible (usually ~1000€/year).
American expats tend to have trauma that affects their insurance choices. My job is to reassure them that our system is completely unlike the American system.
If you want a plain English overview of the system, you can have a look here: https://allaboutberlin.com/guides/german-health-insurance
One important caveat to the German system is that if you make over a certain amount and are healthy, the private system will actually be cheaper since it's not tied to income.
The caveat of this caveat is that if you're employed and you choose to go private and you stay private for 5 years, you won't be able to switch back to public.
Exceptions being if you're under 55 and earn less than the limit amount (something like 65k EUR roughly) or if you earn under 450 euro per month (the so-called mini job).
If you're older than 55, you're f'ed, good luck with your private insurance in old age, 'case you're not allowed to go public. They've taken this measure because people were using private insurance for long stretches and then switched to public as they were reaching retirement, straining a system they haven't contributed to
Exceptions being if you're under 55 and earn less than the limit amount (something like 65k EUR roughly) or if you earn under 450 euro per month (the so-called mini job).
If you're older than 55, you're f'ed, good luck with your private insurance in old age, 'case you're not allowed to go public. They've taken this measure because people were using private insurance for long stretches and then switched to public as they were reaching retirement, straining a system they haven't contributed to
I'd say the average programmer makes $120k/yr USD after about 5 years in, which is roughly €100k EUR. What would a German citizen making 80k-100k EUR pay in healthcare monthly? I think my employer subsidizes about $200/mo into a medical program for just myself. Curious how it stacks up to Europe (which seems to do health care better than the US by leaps and bounds?)
The article linked in the comment chain you responded to gives numbers. For public insurance (which covers all essential care with no deductibles)
> The ninimum is 200€, [...] If you make more than 58050€ per year, you pay around 400€ per month. This is the maximum contribution (Höchstbeitrag). If your salary is higher than 58050€, you will not pay more.
For private insurance (possible if you earn above 64k or are a freelancer) its not linked to your income so rates vary.
> Private is cheap when you are young If you are young and healthy, you could pay as little as 175€ per month (350€ for freelancers) for private insurance. If you make a lot of money, this is much cheaper than public insurance.
But there are deductibles and fees can go up if you have frequent health issues. Freelancers cannot be covered by the public system so it only works when you're an employee, otherwise you're on private insurance.
> The ninimum is 200€, [...] If you make more than 58050€ per year, you pay around 400€ per month. This is the maximum contribution (Höchstbeitrag). If your salary is higher than 58050€, you will not pay more.
For private insurance (possible if you earn above 64k or are a freelancer) its not linked to your income so rates vary.
> Private is cheap when you are young If you are young and healthy, you could pay as little as 175€ per month (350€ for freelancers) for private insurance. If you make a lot of money, this is much cheaper than public insurance.
But there are deductibles and fees can go up if you have frequent health issues. Freelancers cannot be covered by the public system so it only works when you're an employee, otherwise you're on private insurance.
An employee would pay a little under 350 euros and their employer an equal share. It is calculated as 7.3% of your salary until your salary passes about 56k euros. Then it’s calculated as 7.3% of 56k regardless of much you earn. Not working spouses are automatically co-insured without any extra cost
It's not really 7.3%, since you need to account for the Zusatzbeitrag, and the Pflegeversicherung. In total, it's half of (14.6 + ~1.2 + 3.3)%, so around 9.5% assuming you don't hit the price limit.
The article linked above gives better, more recent figures on those limits.
Yes, the Pflegeversicherung is a separate thing, but it's charged by the health insurer, it's mandatory, and private insurers include it into the price. It's much simpler to bundle those things together.
The article linked above gives better, more recent figures on those limits.
Yes, the Pflegeversicherung is a separate thing, but it's charged by the health insurer, it's mandatory, and private insurers include it into the price. It's much simpler to bundle those things together.
I have no idea what those words mean, but long German words are cool.
Yes. Just to illustrate that, a high-earning self-employed developer would pay the maximum ~895€ amount, while they'd pay roughly half on the private system.
The point about no deductibles isn't entirely true: if you are publicly insured, you have to pay 10€ for every day you spend in the hospital. There is a hard cap at 280€ per year, after that the insurance pays the 10€ per day. Also you don't have to pay it if you are underage, are on state-aid, or for a few other, rare reasons.
I should correct that to "deductibles are a non-issue"
This is awesome. Can you think of any major downsides to an approach like the German system takes?
The private system is a bit of a problem. People with a high income (and the self-employed) end up switching to it save money, depriving the public system from their high contributions. It also means wealthy people get better access to healthcare, particularly mental health.
It also means that in a bid to save money, self-employed people pick an option that's cheaper now (private), but will cost them a lot more over time, with no option to switch back.
Normally, if you switch to private, you must stay on private. This prevents people from getting cheap private insurance when they're young, and cheap public insurance when they're old. In practice, you can just get a low income job for a year at age 50, and get forced back onto the cheaper public system. It's a solid financial decision.
It also means that in a bid to save money, self-employed people pick an option that's cheaper now (private), but will cost them a lot more over time, with no option to switch back.
Normally, if you switch to private, you must stay on private. This prevents people from getting cheap private insurance when they're young, and cheap public insurance when they're old. In practice, you can just get a low income job for a year at age 50, and get forced back onto the cheaper public system. It's a solid financial decision.
This is similar to the Situation with affordable care act in the US. I think max vs min age premiums are capped. Which means old people get a deal, and young people overpay. If people paid their true cost to the system, insurance would cost $50 if you are 20, and $2,000 if you are 70.
The same thing ultimately happens here where the young and healthy leave the public pool, leaving the older and sick. As rates go up, the cycle continues.
I don’t see how anything except a $0 for everyone really works. Otherwise you just have people gaming the system (like the 50 year old in your example working a year of low paying job to qualify)
The same thing ultimately happens here where the young and healthy leave the public pool, leaving the older and sick. As rates go up, the cycle continues.
I don’t see how anything except a $0 for everyone really works. Otherwise you just have people gaming the system (like the 50 year old in your example working a year of low paying job to qualify)
Ironically despite the lower cost, the German medical system also provides a wider range of services than are provided in the US.
For example my mother in law had an unusual cancer and after her treatments she had a rest spa paid for; once the treatments could no longer help she had in home care. In the US, good luck.
For example my mother in law had an unusual cancer and after her treatments she had a rest spa paid for; once the treatments could no longer help she had in home care. In the US, good luck.
Yes. The system is broken from the ground up. From doctors working with other doctors to make sure to limit new doctors coming into the workforce, to our multi-node insurance systems.
Anyone selling you an easy solution is lying. Anyone selling you a "reform" solution is also lying. We need a holistic approach to this that means the government needs to hire a bunch of experts that are given a lot of power to change the system to make it work.
Anyone selling you an easy solution is lying. Anyone selling you a "reform" solution is also lying. We need a holistic approach to this that means the government needs to hire a bunch of experts that are given a lot of power to change the system to make it work.
Everyone complains about the cost of healthcare and nobody asks why the AMA operates like a cartel. The number of doctors allowed to graduate hasn't changed in 40 years.
A lot of people talk about that, actually. I've heard it several times and it comes up in most of these discussions. However, doctor's pay is not enough on its own to explain even a small fraction of the cost problem. In reality it's an issue permeating every single component of the system, each one making a small contribution to the overall pile. I've heard of this situation being called "cost disease."
Perhaps in small, private forums, but in public physicians are a protected class. Not many op-eds criticizing the AMA vs the big, evil pharma companies. That said, it's not a panacea, but not great when a 15-min visit to get a $.10 pill costs $200.
Oh, of course, it just hadn't occurred to me to consider op-eds a meaningful participant or representative of the public discourse.
They set the Overton window of allowed policies.
A $.10 pill that the person has been taking for years and is maybe even safer than many things sitting on the shelves of the hardware or grocery store.
Not great, but also: people above this asked why the system doesn't get reformed, and the answer is that doctors are popular with the voting population, and tackling their salaries will only have a modest impact in reducing costs.
This is not to say that doctor's pay shouldn't be addressed, but the system doesn't get reformed because every discussion on fixing it gets derailed into a discussion of doctor's pay, which is literally the highest-effort lowest-payoff part of the problem. And the situation stays bad because of this dynamic.
This is not to say that doctor's pay shouldn't be addressed, but the system doesn't get reformed because every discussion on fixing it gets derailed into a discussion of doctor's pay, which is literally the highest-effort lowest-payoff part of the problem. And the situation stays bad because of this dynamic.
> doctor's pay is not enough on its own to explain even a small fraction of the cost problem
Not on it's own, but doctor shortage can still contribute to medical costs.
Do doctors make more mistakes due to high patient loads?
Are preventable items missed because doctors can't spend enough time with patients?
Would people be less likely to abuse the ER and/or wait to address conditions if they could get a primary care appointment more easily?
If doctors had a little more slack in their schedules, might they innovate in other ways?
If we had more doctors, would it be harder for mega-hospital chains to gobble up the supply of doctors in your area, leaving more independent practices to innovate in other ways?
Not on it's own, but doctor shortage can still contribute to medical costs.
Do doctors make more mistakes due to high patient loads?
Are preventable items missed because doctors can't spend enough time with patients?
Would people be less likely to abuse the ER and/or wait to address conditions if they could get a primary care appointment more easily?
If doctors had a little more slack in their schedules, might they innovate in other ways?
If we had more doctors, would it be harder for mega-hospital chains to gobble up the supply of doctors in your area, leaving more independent practices to innovate in other ways?
Also:
What if your pharmacist could do most of the practical things that matter to you about your medication, rather than requiring prescriber permission?
What if you could do X by going to a psychologist or optometrist, or some other profession that doesn't currently exist, instead of going to an MD or PA or LPN?
What if you could just buy certain things directly without a middleman?
US healthcare is over regulated in general (in many areas, even as it's arguably underregulated in others).
What if your pharmacist could do most of the practical things that matter to you about your medication, rather than requiring prescriber permission?
What if you could do X by going to a psychologist or optometrist, or some other profession that doesn't currently exist, instead of going to an MD or PA or LPN?
What if you could just buy certain things directly without a middleman?
US healthcare is over regulated in general (in many areas, even as it's arguably underregulated in others).
It's not doctor pay, it's economic repurcussions of monopolies. It's also not just limiting the numbers of physicians, it's locking out alternate providers of care and other models.
Right now US healthcare is very hierarchical, with physicians at the top, nurses close by. Other professions and services are subsidiary to them. You don't get to choose a provider based on skillset per se, you are forced to abide by this hierarchy.
That's the real economic cost, the restrictions in provider and service choice.
Right now US healthcare is very hierarchical, with physicians at the top, nurses close by. Other professions and services are subsidiary to them. You don't get to choose a provider based on skillset per se, you are forced to abide by this hierarchy.
That's the real economic cost, the restrictions in provider and service choice.
> The number of doctors allowed to graduate hasn't changed in 40 years.
In stark contrast, the number of hospital administrators, along with their salaries has ballooned over the same time period - even at non-profit systems.
In stark contrast, the number of hospital administrators, along with their salaries has ballooned over the same time period - even at non-profit systems.
Does anyone know of any general literature on this administratively top-heavy structure? It shows up in higher education as well, and I'm sure in other places too. I'm curious about patterns across domains and links to economic issues. Seems too coincidental that this type of structure is emerging in two of the most economically controversial areas of society.
How much of medical care is distributed through hospitals vs private practices?
Seems like a healthy person would go to hospital only for emergencies or major projects like birth. On the other hand, I know there are entire hospital systems in southern states that cater to elderly and are basically Medicare billing factories.
Seems like a healthy person would go to hospital only for emergencies or major projects like birth. On the other hand, I know there are entire hospital systems in southern states that cater to elderly and are basically Medicare billing factories.
what is this "allowed to graduate" business? What authority do they have to dictate such a thing and is it in writing anywhere what said quota is?
The number of residency spots is an artificial barrier to being able to properly practice medicine. That number is controlled by doctors.
Is this the organization where the barrier to entry is enforced?
https://en.wikipedia.org/wiki/National_Resident_Matching_Pro....
What does it look like precisely to the aspiring physicians who don't make the cut? Where exactly do they get communicated to that you didn't meet, get selected, etc for stage XYZ.
Which is why Nurse Practitioners are the best thing to happen for patients in decades. Better access to healthcare means better treatment.
It's a tough road for NPs in California at least https://www.usnews.com/news/health-news/articles/2019-07-03/...
> Everyone complains about the cost of healthcare and nobody asks why the AMA operates like a cartel.
That's not entirely a bad thing. It would be bad for Medicine to turn out like Law, with a huge glut of unemployable graduates after a long, expensive training program (IIRC, an intense 7 years post-college, minimum). There's a need to balance demand with the need for all (or nearly all) the graduates to be able to find a job.
Also, you're neglecting Osteopathic schools, which aren't controlled by the AMA but graduate students with the same practice rights.
> The number of doctors allowed to graduate hasn't changed in 40 years.
Do you have any data to back that claim up? The Association of American Medical Colleges says enrollment rates are increasing:
> In response to concerns that a projected doctor shortage could impact patient care, the AAMC in 2006 called on medical schools to increase first-year enrollment by 30%. That target was reached in 2018-19, when first-year matriculation reached 21,622 students. Osteopathic schools increased their enrollment by 164% during this same time period, with 8,124 first-year students enrolled. (https://www.aamc.org/news-insights/us-medical-school-enrollm...)
That's not entirely a bad thing. It would be bad for Medicine to turn out like Law, with a huge glut of unemployable graduates after a long, expensive training program (IIRC, an intense 7 years post-college, minimum). There's a need to balance demand with the need for all (or nearly all) the graduates to be able to find a job.
Also, you're neglecting Osteopathic schools, which aren't controlled by the AMA but graduate students with the same practice rights.
> The number of doctors allowed to graduate hasn't changed in 40 years.
Do you have any data to back that claim up? The Association of American Medical Colleges says enrollment rates are increasing:
> In response to concerns that a projected doctor shortage could impact patient care, the AAMC in 2006 called on medical schools to increase first-year enrollment by 30%. That target was reached in 2018-19, when first-year matriculation reached 21,622 students. Osteopathic schools increased their enrollment by 164% during this same time period, with 8,124 first-year students enrolled. (https://www.aamc.org/news-insights/us-medical-school-enrollm...)
Why do some professions get the benefit of cartel protection? Note that pharmacists don't have such restrictions and have similar training.
For the data, I had done a quick search and found this (which only goes to 2010):
https://www.researchgate.net/figure/Trends-in-the-Number-of-...
However, digging more, even the AAMC is saying you need residency slots:
https://www.medicaleconomics.com/view/enrollment-rates-rise-...
Increasing first-year enrollment is a good first step, but doesn't move the needle on the number of doctors who can actually practice because the number of residencies is still limited.
For the data, I had done a quick search and found this (which only goes to 2010):
https://www.researchgate.net/figure/Trends-in-the-Number-of-...
However, digging more, even the AAMC is saying you need residency slots:
https://www.medicaleconomics.com/view/enrollment-rates-rise-...
Increasing first-year enrollment is a good first step, but doesn't move the needle on the number of doctors who can actually practice because the number of residencies is still limited.
> However, digging more, even the AAMC is saying you need residency slots:
Which are determined by federal government Medicare funding, btw. From your link:
> Federally supported residency training slots have been capped by Congress for more than 20 years, limiting the spots for medical school graduates to undergo additional training in a residency program before they can practice medicine.
So maybe this is more of a "call your congressman" issue.
Which are determined by federal government Medicare funding, btw. From your link:
> Federally supported residency training slots have been capped by Congress for more than 20 years, limiting the spots for medical school graduates to undergo additional training in a residency program before they can practice medicine.
So maybe this is more of a "call your congressman" issue.
Your congressman probably listens to the AMA more so than you when it comes to medical matters, here is one example of what they have to say on the subject I could find with a quick search:
> In March 1997, months before the Balanced Budget Act was enacted, the AMA even suggested reducing the number of US residency positions by approximately 25% from 25,000 to fewer than 19,000. “The United States is on the verge of a serious oversupply of physicians,” said the AMA and other physicians’ groups in a joint statement. Since most states require at least some residency training for medical licensure, reducing the number of residency positions would curtail the supply of doctors in the US.
> Fast forward two decades, and what once seemed like a glut now looks like a shortage. The growth in the number of residency positions—and thus the number of doctors—slowed after the passage of the Balanced Budget Act. From 1997 to 2002, the number of residents in the US increased by just 0.1%. Although the number of positions has increased since then, each year thousands of residency applicants fail to secure a position. Factor in an aging population and a projected increase in demand for health care services, and the US is now forecasted to experience a shortage of 46,900 to 121,900 physicians by 2032. Absent a meaningful response from Congress, it will be doctors—particularly residents—and their patients who pay the price.
- https://qz.com/1676207/the-us-is-on-the-verge-of-a-devastati...
> In March 1997, months before the Balanced Budget Act was enacted, the AMA even suggested reducing the number of US residency positions by approximately 25% from 25,000 to fewer than 19,000. “The United States is on the verge of a serious oversupply of physicians,” said the AMA and other physicians’ groups in a joint statement. Since most states require at least some residency training for medical licensure, reducing the number of residency positions would curtail the supply of doctors in the US.
> Fast forward two decades, and what once seemed like a glut now looks like a shortage. The growth in the number of residency positions—and thus the number of doctors—slowed after the passage of the Balanced Budget Act. From 1997 to 2002, the number of residents in the US increased by just 0.1%. Although the number of positions has increased since then, each year thousands of residency applicants fail to secure a position. Factor in an aging population and a projected increase in demand for health care services, and the US is now forecasted to experience a shortage of 46,900 to 121,900 physicians by 2032. Absent a meaningful response from Congress, it will be doctors—particularly residents—and their patients who pay the price.
- https://qz.com/1676207/the-us-is-on-the-verge-of-a-devastati...
Honestly I don't understand why Congress needs to fund these slots as much as they do. Hospital residents do a big chunk of day-to-day work seeing and treating patients. They routinely work well over 80 hours per week based on the people I've talked to (despite this being illegal). And yet the government pays teaching hospitals $120k per year for each resident, while residents get something like $60k in salary from the hospital. It feels like a broken and exploitative system.
If I were king, I'd look into retraining biomedical grad students/postdocs to go into medicine. We've got a massive (taxpayer-funded!) glut of the latter and many of them have a relevant background and even skills.
Yet, only a few places currently try to convert PhDs to MDs; most places are overwhelmingly geared up for undergrads coming straight out of pre-med programs.
Yet, only a few places currently try to convert PhDs to MDs; most places are overwhelmingly geared up for undergrads coming straight out of pre-med programs.
The problem with this is that it's sensible.
Politics does not do sensible, it does what is expedient.
Consider the US preaching about democracy and consent of the governed and then funding radicals to do a coup and start a civil war to oust a democratic president they don't like in a sovereign state. Why?
Politics does not do sensible, it does what is expedient.
Consider the US preaching about democracy and consent of the governed and then funding radicals to do a coup and start a civil war to oust a democratic president they don't like in a sovereign state. Why?
Enrollment != graduation and licensure.
More people may be interested but nobody can practice until after residency, and you have a large pool of hopefuls basically in a lottery for residency slots.
You can get all the theory, but not be able to get the requisite practicum. Even if you do get a slot, you also get treated like a stevedore from what I have heard.
More people may be interested but nobody can practice until after residency, and you have a large pool of hopefuls basically in a lottery for residency slots.
You can get all the theory, but not be able to get the requisite practicum. Even if you do get a slot, you also get treated like a stevedore from what I have heard.
> Enrollment != graduation and licensure.
> More people may be interested but nobody can practice until after residency, and you have a large pool of hopefuls basically in a lottery for residency slots.
But my understanding is that residency capacity is matched to graduating class sizes, at least in the US. The selectivity is intentionally placed up front (at med school admission) so the path is clear to residency and licensure as long as the student doesn't totally fall apart (which the selectivity is supposed to guard against).
IIRC, it's foreign medical school graduates may have trouble getting a US residency.
> More people may be interested but nobody can practice until after residency, and you have a large pool of hopefuls basically in a lottery for residency slots.
But my understanding is that residency capacity is matched to graduating class sizes, at least in the US. The selectivity is intentionally placed up front (at med school admission) so the path is clear to residency and licensure as long as the student doesn't totally fall apart (which the selectivity is supposed to guard against).
IIRC, it's foreign medical school graduates may have trouble getting a US residency.
That is not my understanding at all, as that would imply we never have med school admissions without a residency slot, and I have seen many mentions over the years about how the great bottleneck is not med school admissions, but residency slots.
https://www.fiercehealthcare.com/practices/more-medical-stud...
https://health.wusf.usf.edu/npr-health/2019-07-03/american-m...
The above sources indicate residency matching is decoupled from graduation from Med school, and if I recall correctly, there is actually a legal cap on the number of residency slots.
https://www.aha.org/news/headline/2019-03-14-bill-add-15000-...
So everything I've seen suggests we actually have a dysfunctional system with no up front brakes. Our Medical education system maximizes fiscal extraction from hopefuls, but the residency slots don't scale elastically or in any way matched with demand. Quite literally, it seems to take an act of Congress to change the calculus of residency slots.
I could still be wrong, and welcome the removal of the veil of mistaken impressions, but that's the gist of my current understanding.
https://www.fiercehealthcare.com/practices/more-medical-stud...
https://health.wusf.usf.edu/npr-health/2019-07-03/american-m...
The above sources indicate residency matching is decoupled from graduation from Med school, and if I recall correctly, there is actually a legal cap on the number of residency slots.
https://www.aha.org/news/headline/2019-03-14-bill-add-15000-...
So everything I've seen suggests we actually have a dysfunctional system with no up front brakes. Our Medical education system maximizes fiscal extraction from hopefuls, but the residency slots don't scale elastically or in any way matched with demand. Quite literally, it seems to take an act of Congress to change the calculus of residency slots.
I could still be wrong, and welcome the removal of the veil of mistaken impressions, but that's the gist of my current understanding.
The US HC system basically runs as a "skim" operation. Since skim is fundamentally percentage based, the more money that flows through the system, the greater the absolute amount that is skimmed. Thus, no one has incentive, in the long run, to reduce costs. Short term, insurance companies might benefit from cutting costs, but they know that ultimately, when costs go up, they can justify proportional premium increases, which increase their skim in absolute value.
Not only that, no one has a financial incentive to improve outcomes. Surgeons are judged on outcomes, but no one judges them on whether they did the right surgery or just very skillfully gave everyone who came through the doors stents and spinal implants.
> "You're never as careful when spending other people's money."
That's a nice description of: https://en.wikipedia.org/wiki/Principal%E2%80%93agent_proble...
> This is highly unusual in most professions: Imagine if your roofer grabbed whatever shingles they liked best and billed you for it after they were up. Now imagine every roofer worked the same way.
I mean, this basically is my experience with contractors, auto mechanics and most other professions where there's a lot of information asymmetry between consumers and providers. In a capitalist exchange, buyer and seller are opponents and both will use the others' lack of knowledge to their advantage (or be outcompeted by others that do).
It's a fundamental dilemma of our world. The more expertise a task requires, the more important it is to hire someone to do it instead of doing it yourself. But the more necessary that person is, the less qualified you are to evaluate their performance.
That's a nice description of: https://en.wikipedia.org/wiki/Principal%E2%80%93agent_proble...
> This is highly unusual in most professions: Imagine if your roofer grabbed whatever shingles they liked best and billed you for it after they were up. Now imagine every roofer worked the same way.
I mean, this basically is my experience with contractors, auto mechanics and most other professions where there's a lot of information asymmetry between consumers and providers. In a capitalist exchange, buyer and seller are opponents and both will use the others' lack of knowledge to their advantage (or be outcompeted by others that do).
It's a fundamental dilemma of our world. The more expertise a task requires, the more important it is to hire someone to do it instead of doing it yourself. But the more necessary that person is, the less qualified you are to evaluate their performance.
>I mean, this basically is my experience with contractors, auto mechanics and most other professions where there's a lot of information asymmetry between consumers and providers.
The unique feature of the medical care system that's different from most other professions is that there's multi-way asymmetry.
An auto mechanic generally does have some rough idea of how much a given repair costs (inclusive of labor and materials) or at least can easily inform him/herself. It's a basic two-party information asymmetry where the professional making the decision has more information than most consumers.
In medicine, physicians often have no idea themselves what the total cost of treatment will be, and there are various structural and economic factors that discourage or make it very difficult for physicians to find this information. This is a very different type of information asymmetry, where both the providers and the consumers lack information.
The unique feature of the medical care system that's different from most other professions is that there's multi-way asymmetry.
An auto mechanic generally does have some rough idea of how much a given repair costs (inclusive of labor and materials) or at least can easily inform him/herself. It's a basic two-party information asymmetry where the professional making the decision has more information than most consumers.
In medicine, physicians often have no idea themselves what the total cost of treatment will be, and there are various structural and economic factors that discourage or make it very difficult for physicians to find this information. This is a very different type of information asymmetry, where both the providers and the consumers lack information.
> doctors don't actually put in any effort into prescribing generics or really learn how much anything costs
I'm hesitant to blame doctors, since I myself find it impossible to learn how much anything costs until after being billed for it. Is it any easier for the doctors?
(Note: clearly the doctor in this article is scamming his patients, but I'm talking about the situation in general)
I'm hesitant to blame doctors, since I myself find it impossible to learn how much anything costs until after being billed for it. Is it any easier for the doctors?
(Note: clearly the doctor in this article is scamming his patients, but I'm talking about the situation in general)
As much as Kaiser Permanente has been giving me awful, awful care, they tell you how much something will cost you before giving it to you, and you have to explicitly agree to pay that amount.
(In my case, I also pay before getting whatever it is, but it's possible to have the charge added to your bill instead.)
(In my case, I also pay before getting whatever it is, but it's possible to have the charge added to your bill instead.)
How do you do that? I tried to get Kaiser to tell me how much my wife's delivery would be and what they told us was much less than the actual bill, even though there weren't any complications
I have not made any effort to get them to do that. Most of my experience with them has been really routine stuff -- "visit copay", "get a blood sample taken", or the like -- but this also happened for a stomach biopsy involving cramming a huge device down my throat, and for which they wanted to have me sedated, which seems like a pretty close analogy to a childbirth with no complications. :/
I have never, ever had the experience of getting an answer to how much a health care procedure will cost, and believe me I've asked. Also never had Kaiser - mostly BCBS.
[deleted]
> because doctors don't actually put in any effort into prescribing generics or really learn how much anything costs.
Medicine is a pretty difficult art as is. I'm not entirely convinced that I want my MD to be price conscious over being outcome conscious. If it comes down to choosing one over the other, I'd rather my MD focus on their practice and not their billing.
Medicine is a pretty difficult art as is. I'm not entirely convinced that I want my MD to be price conscious over being outcome conscious. If it comes down to choosing one over the other, I'd rather my MD focus on their practice and not their billing.
I'd prefer not being destitute to many medical alternatives. Have you been homeless? It's actually really, really bad for your health.
I'd think being unhoused with a medical condition may be worse. Though in the suffer-olympics, no one wins.
Not sure if your comment is specific to the US, but my gf is a doctor working in public healthcare here. She has worked with private healthcare and doesn't enjoy it as she says half of the time is battling with insurance companies trying to get them to pay for the best drugs for the patient, while insurance companies always want to pay for the cheapest drug for the patients.
In a not life threatening situation, wouldn’t it make sense to try out the cheaper drug first? When you are paying the bills, that is what you do. Roof springs a leak? Try a $20 patch first. Don’t immediately spend $8,000 tearing off and installing a new roof. But when you are spending other people’s money, it’s real easy to try and skip steps.
If insurance didn’t push back, costs would be even more bonkers!!
If insurance didn’t push back, costs would be even more bonkers!!
She specialised in a long term degenerative illness, so giving an inferior drug may lead to a big loss of life quality down the road, an increase long term costs of treatment and care.
Why is there no incentive for the insurance company to be frugal? That's how it works elsewhere, and they have a lot of bargaining power.
Incentives are there, they are just not going in the right direction. First, the buyer does not care that much since it is all tax-deductible.
And there are other dynamics in play. Here is a nasty example:
Employers care that premiums only increase by X% per year. Fine. As such, insurance will try to protect its contract with employer by going to the hospital provider, and demanding a low premium increase.
Hospital says fine but "OK - but you agree to our increase of list price by 50%.... don't worry, we give you a discount on that amount. Insurance won't pay that increase"
Insurer says "Great! In fact, let's push it to 100%? OK?"
How did we come to this? Insurer and Hospital agreeing to increase price by 100% and discount that 100% back down?
Its because of the incentives.
Insurance will use this to go back to employer and say. "We got you that x% cap on increase in premiums. Employer, by the way, you still owe us money from the 100% discount we got you from the hospital bills " Employer says OK and pays a ~3% premium on the 100% 'discount' ("claims repricing" in industry parlance).
Meanwhile, Hospital goes back to the government. "We had losses from discounts given to govt patients totaling X in discounts". Now hospitals recoup some of that money. (in industry parlance Disproportionate Share Hospital (DSH))
Meanwhile, people with no insurance have to pay these inflated list prices...with no insurance discount whatsoever. HR staff gets promoted or leaves the job, because they did a great job securing that X% cap. The new person does not know what "claims repricing" is. It remains in the contract.
Premiums go higher next year.
And there are other dynamics in play. Here is a nasty example:
Employers care that premiums only increase by X% per year. Fine. As such, insurance will try to protect its contract with employer by going to the hospital provider, and demanding a low premium increase.
Hospital says fine but "OK - but you agree to our increase of list price by 50%.... don't worry, we give you a discount on that amount. Insurance won't pay that increase"
Insurer says "Great! In fact, let's push it to 100%? OK?"
How did we come to this? Insurer and Hospital agreeing to increase price by 100% and discount that 100% back down?
Its because of the incentives.
Insurance will use this to go back to employer and say. "We got you that x% cap on increase in premiums. Employer, by the way, you still owe us money from the 100% discount we got you from the hospital bills " Employer says OK and pays a ~3% premium on the 100% 'discount' ("claims repricing" in industry parlance).
Meanwhile, Hospital goes back to the government. "We had losses from discounts given to govt patients totaling X in discounts". Now hospitals recoup some of that money. (in industry parlance Disproportionate Share Hospital (DSH))
Meanwhile, people with no insurance have to pay these inflated list prices...with no insurance discount whatsoever. HR staff gets promoted or leaves the job, because they did a great job securing that X% cap. The new person does not know what "claims repricing" is. It remains in the contract.
Premiums go higher next year.
There is some incentive, but when you tell someone you can only make a profit of (for example) 10% of what you pay out; it warps their incentives.
They don't want to bankrupt themselves, but they can raise rates and keep more money when they pay more.
They don't want to bankrupt themselves, but they can raise rates and keep more money when they pay more.
This assumes they don't have any competition looking to take their market share (which reduces their intake).
It can be the case that the market isn't very competitive, but it isn't the case that the companies can just arbitrarily raise rates.
It can be the case that the market isn't very competitive, but it isn't the case that the companies can just arbitrarily raise rates.
Once a year the company can shop around, but you as an insured have no say. Your HR picks, and they may or may not be competent. They may optimize prices for family, or for single people, or any number of weird things.
Large insurers can stand up to smaller practices by threatening to exclude them out of network in favor of cheaper providers.
What seems to be happening lately is a consolidation wave on every level of medical business in order to counter-act that. Most of the smaller private practices in my area have been bought up by large healthcare organizations named after various medieval saints.
What seems to be happening lately is a consolidation wave on every level of medical business in order to counter-act that. Most of the smaller private practices in my area have been bought up by large healthcare organizations named after various medieval saints.
They don't actually have a lot of leverage. A hospital has a near monopoly on it's region/patients, but insurers have to compete with a dozen others to be accepted by the hospital. If the hospital wants to charge their patients, insurance just has a minimal amount of bitching they can do over prices.
HMOs often have a negative public image due to their restrictive appearance. HMOs have been the target of lawsuits claiming that the restrictions of the HMO prevented necessary care.
https://en.wikipedia.org/wiki/Health_maintenance_organizatio...
https://en.wikipedia.org/wiki/Health_maintenance_organizatio...
Short term, yes. But when costs go up, they know that they can then later use it justify a proportional increase in premiums.
> And as much as doctors and hospitals love to paint insurance as the bad guy, the only reason things like prior authorization is a pain in the ass is because doctors don't actually put in any effort into prescribing generics or really learn how much anything costs.
The only reason? Don’t put in any effort? How is this comment not flagged dead?
This is patently false and essentially slanderous. (I guess libelous since we’re on a written medium)
If you and the rest of the public had any idea how much your insurance company literally does not give a shit about you, when you are for example battling cancer, there would be pitchforks in the street.
The only reason? Don’t put in any effort? How is this comment not flagged dead?
This is patently false and essentially slanderous. (I guess libelous since we’re on a written medium)
If you and the rest of the public had any idea how much your insurance company literally does not give a shit about you, when you are for example battling cancer, there would be pitchforks in the street.
I have also worked in and around healthcare in various capacities (both tech and non-tech) and this is totally wrong. There are /many/ reasons the US healthcare system is broken, and I agree the issues are more systemic at this point, than any one bad actor, but if there /is/ a bad actor, it is definitely the health insurance companies.
There are a lot of good people in the health insurance industry that want to improve health outcomes and make a profit and are swimming upstream as well against those systemic forces (just maybe the market isn't the best way to distribute healthcare...) but as a whole it's not the health insurance companies reining in the costs of frivious doctors and hypochondriac patients, it's the incredible layer of bureaucracy and arbitrary decisions there that soak up a ton of monetary resources, constrain doctors into not even being able to do the preventative care work they want, and lead to all sorts of perverse incentives like showing up in ER 5x a year, instead of getting to show up at your GP and nutritionist every week, etc
There are a lot of good people in the health insurance industry that want to improve health outcomes and make a profit and are swimming upstream as well against those systemic forces (just maybe the market isn't the best way to distribute healthcare...) but as a whole it's not the health insurance companies reining in the costs of frivious doctors and hypochondriac patients, it's the incredible layer of bureaucracy and arbitrary decisions there that soak up a ton of monetary resources, constrain doctors into not even being able to do the preventative care work they want, and lead to all sorts of perverse incentives like showing up in ER 5x a year, instead of getting to show up at your GP and nutritionist every week, etc
> He said the use of the larger test was appropriate because it could catch a wider range of diseases, particularly for those who were symptomatic. [0]
Cant’t believe this isn’t an ethics violation, it is like going into the car dealership to change my oil and them charging me to take apart the engine because “It could catch a wider range of issues”.
I know what service I want and would consent to, this “Technically correct but costs 50x as much” is harmful.
[0] This is the doctor’s response when asked why he is testing for ~20 other respiratory diseases in the drive-through coronavirus line.
Cant’t believe this isn’t an ethics violation, it is like going into the car dealership to change my oil and them charging me to take apart the engine because “It could catch a wider range of issues”.
I know what service I want and would consent to, this “Technically correct but costs 50x as much” is harmful.
[0] This is the doctor’s response when asked why he is testing for ~20 other respiratory diseases in the drive-through coronavirus line.
This also betrays a lack of understanding of testing by the doctor.
If each test has a 1% chance of returning a false positive (and false positives are possible in most tests), there's a significant chance that one of the 20 will return a false positive, which will then prompt unnecessary treatments, further tests, etc.
The general medical guidance is to only test when there's a legitimate suspicion that a patient has the illness. In this case, these patients wouldn't have been tested for a wide range of respiratory issues anyway, and given the pandemic it's much more likely that they've got coronavirus, so they really shouldn't be tested for the other things, especially if asymptomatic.
If each test has a 1% chance of returning a false positive (and false positives are possible in most tests), there's a significant chance that one of the 20 will return a false positive, which will then prompt unnecessary treatments, further tests, etc.
The general medical guidance is to only test when there's a legitimate suspicion that a patient has the illness. In this case, these patients wouldn't have been tested for a wide range of respiratory issues anyway, and given the pandemic it's much more likely that they've got coronavirus, so they really shouldn't be tested for the other things, especially if asymptomatic.
[deleted]
Yeah that's straight up malpractice. If there's a 99% chance it's Covid and not something else, you do the Covid test first and if that comes back negative, then you test for the "something else" (if symptoms are severe enough).
It's even worse than that, he was testing asymptomatic patients with a full panel. That part takes it from probably unethical to full-blown fraud for me.
> But in interviews, asymptomatic patients said they had also received the more expensive test.
> But in interviews, asymptomatic patients said they had also received the more expensive test.
For asymptomatic patients, doing those tests could easily cause net harm from follow-up to false positives. So, even if the tests had been free, it's probably unethical.
This is why organizations like the United States Preventative Services Task Force exist. They review studies and recommend best practices for medical screening. They do recommend against asymptomatic screening for a lot of tests.
This is why organizations like the United States Preventative Services Task Force exist. They review studies and recommend best practices for medical screening. They do recommend against asymptomatic screening for a lot of tests.
>it is like going into the car dealership to change my oil and them charging me to take apart the engine because “It could catch a wider range of issues”.
This kind of stuff is pretty par for the course. They try and up-sell. If you agree then you're on the hook for the bill. That's just how the industry works. But businesses that make a habit of being sleazy don't survive long because the bill must be agreed upon beforehand and customer is free to go elsewhere with little friction and there isn't all sorts of gatekeeping and regulatory capture constraining supply.
This kind of stuff is pretty par for the course. They try and up-sell. If you agree then you're on the hook for the bill. That's just how the industry works. But businesses that make a habit of being sleazy don't survive long because the bill must be agreed upon beforehand and customer is free to go elsewhere with little friction and there isn't all sorts of gatekeeping and regulatory capture constraining supply.
There's a reason it's endemic and that's because people fall for it. Every few months there's an investigation by the government and some oil changer business gets fined for it. Dealers do it too but if your car is under warranty these days it tends to be less of an issue. Cars are more reliable now too. Out of warranty though, hold onto your hat!
Trustworthy mechanics are worth their weight in gold. Our local mechanic spent a lot of time diagnosing a problem and when he found out it was covered by the standard warranty (it was a part that has a longer than normal one, don't remember which exactly) sent us on our way to get it fixed by a dealership.
We brought them coffee and bagels the next day.
We brought them coffee and bagels the next day.
I mean, you should pay for the diagnostic time, which is usually $100 or so.
I've had multiple dealers discover a laundry list of problems on my/wifes "out of warranty" vehicles. Frequently for thousands of dollars. Then its pointed out its actually under a factory extended warantty (certified preowned from another dealer). And the resulting scrambles have been entertaining, as they do a ton of work replacing stuff on a vehicle no one in their right mind would have "fixed". Although at least a few times the repairs have been denied ("worn out" engine mounts).
> Cars are more reliable now too
This is hard to believe. If anything they are more disposable.
This is hard to believe. If anything they are more disposable.
People used to consider it a major milestone for their car to hit 100,000 miles. It wouldn't be particularly surprising if you needed your engine or transmission rebuilt before that point. American cars didn't even have 6-digit odometers for a long time. These days, your average inexpensive sedan will hit 100,000 miles with nothing but oil changes (every 10,000 miles instead of every 3,000 like it used to be), a couple sets of tires, and some new brake pads.
Of course, if it breaks, it's full of all these complex little systems that let modern cars run for hundreds of thousands of miles at 40mpg, and you'll need to pull in a professional, but they break a LOT less frequently.
Of course, if it breaks, it's full of all these complex little systems that let modern cars run for hundreds of thousands of miles at 40mpg, and you'll need to pull in a professional, but they break a LOT less frequently.
My experience is that the drivetrain is MUCH more reliable than it used to be, but the various electronic systems are subject to high failure rates - displays, buttons, computers, sensors, etc. Many of these failures don't impact your actual driving ability, but are just a nuisance, like if your AC button stops working or your cars information displays.
You must be a youngster. Cars are more reliable by several orders of magnitude compared to 50 years ago.
It wasn’t unusual to be stranded on the side of the road because your car stopped working. Maybe once per year? You rarely see that now.
And if your car hit 100k miles/160k km, that was pretty much it’s life span. Now hitting 300-400k km is not that unusual.
And good luck starting your car in the 80’s if it got cold out. Or too hot out. Fuel injection has made cars way more reliable.
It wasn’t unusual to be stranded on the side of the road because your car stopped working. Maybe once per year? You rarely see that now.
And if your car hit 100k miles/160k km, that was pretty much it’s life span. Now hitting 300-400k km is not that unusual.
And good luck starting your car in the 80’s if it got cold out. Or too hot out. Fuel injection has made cars way more reliable.
Average age has been ticking up for a while, at least in the US.
https://www.bts.gov/content/average-age-automobiles-and-truc...
I feel like the disposability angle comes from having relatively expensive parts/repair costs with low value older vehicles, which results in them being retired because of the economics of having someone else repair them.
https://www.bts.gov/content/average-age-automobiles-and-truc...
I feel like the disposability angle comes from having relatively expensive parts/repair costs with low value older vehicles, which results in them being retired because of the economics of having someone else repair them.
That and the ever present complaint that they can't take a hit like they used too.
Never mind that makes them way safer and saves tons of lives. Some people want to crash up derby their car every weekend.
Never mind that makes them way safer and saves tons of lives. Some people want to crash up derby their car every weekend.
It's also not even remotely true. Check out the IIHS crashing a 60s bel air into a modern malibu.
"They don't make them like they used to" has always been a nostalgic crock of shit, like the people who think the NES was the golden age of video games, despite the vast majority of the 700 or so releases being utter trash for $60 that sometimes didn't even work!
https://www.youtube.com/watch?v=C_r5UJrxcck
"They don't make them like they used to" has always been a nostalgic crock of shit, like the people who think the NES was the golden age of video games, despite the vast majority of the 700 or so releases being utter trash for $60 that sometimes didn't even work!
https://www.youtube.com/watch?v=C_r5UJrxcck
I think they're talking about damage from low speed hits. Older cars can take those without as much apparent damage because they have big heavy bumpers and aren't designed for occupant/pedestrian safety, but like you said they'll fold up like a tin can in higher speed crashes.
That's a promotional video for showcasing how far safety has come. It's about as grounded in reality as that Top Gear episode with the Hilux that the online fanboys all beat it to but people who actually work in industry roll their eyes at.
Nobody's ever done an 80s Town Car vs a 2010 Town Car at 30mph because a crash test where the result is "both drivers would have walked away" is boring and doesn't make for the kinds of DARE-esque media that the people who do crash testing have found it worthwhile to put out.
Nobody's ever done an 80s Town Car vs a 2010 Town Car at 30mph because a crash test where the result is "both drivers would have walked away" is boring and doesn't make for the kinds of DARE-esque media that the people who do crash testing have found it worthwhile to put out.
I can give you an anecdote. A modern car crashed on our nissan from 1990's a while ago and while absolutely nothing happened to ours the other car looked like a wreck. Maybe the behind of the car is made to be more durable than the front? I do not know.
The body may not have warped much, but that just means the force was transferred directly to the occupants with zero reduction from crumple zones. This is terrible for safety but good for the pocket book if you are lucky enough to escape unscathed.
With significant and well engineered crumple zones and fairly expensive components, modern cars are significantly easier to total.
With significant and well engineered crumple zones and fairly expensive components, modern cars are significantly easier to total.
Having a crumple zone turn to mush in a 10mph parking lot mishap does pretty much nothing to make your car more survivable in a crash that might hurt you.
There's no real reason slow speed crashes have to be as damaging as they are. It's just a result of what our tests our and natural optimization toward them. If the NHTSA reintroduced a "is the vehicle drive-able after a minor hit" type crash things would get a lot better very quickly.
There's no real reason slow speed crashes have to be as damaging as they are. It's just a result of what our tests our and natural optimization toward them. If the NHTSA reintroduced a "is the vehicle drive-able after a minor hit" type crash things would get a lot better very quickly.
I'd imagine that there are companies that buy these vehicles from salvage or auction and rehab them for sale in other countries.
Going back to when my parents were growing up, a car with 60,000 miles was near the end of its life. They checked the oil every time they got gas out of necessity.
Now almost nobody needs to check the oil that frequently (though it'd be good practice) and even lower end cars routinely last to 100,000 miles.
I'm driving a 2010 Honda Civic with 100k miles and fully expect to replace it with a newer vehicle out of concern for safety, desire for an electric vehicle, and wanting some better creature comforts. The thing will probably run to 250k miles, which would take me another 13 years to achieve.
Now almost nobody needs to check the oil that frequently (though it'd be good practice) and even lower end cars routinely last to 100,000 miles.
I'm driving a 2010 Honda Civic with 100k miles and fully expect to replace it with a newer vehicle out of concern for safety, desire for an electric vehicle, and wanting some better creature comforts. The thing will probably run to 250k miles, which would take me another 13 years to achieve.
Cars today may be harder/more expensive to fix, but they do seem to last a lot longer before they need it, and as pointed out down thread they tend to last a lot longer in the absolute sense.
As a kid, we had a van that made it to 150k miles and my parents friends were amazed it was still on the road. I've personally owned 4 or 5 vehicles older than that, all in better shape than that van at 150k.
As a kid, we had a van that made it to 150k miles and my parents friends were amazed it was still on the road. I've personally owned 4 or 5 vehicles older than that, all in better shape than that van at 150k.
What exactly do they get fined for? I recognize this sort of upselling is sleazy, but I'm curious about the wording of laws that make it a fineable offense.
It usually starts with an investigation by the attorney general who responds to customer complaints alleging fraud and deceit etc... Sometimes things are kicked off by a local news channel sting.
Yes, they do slimy stuff, but nothing like the parent was describing. I've never heard of a maintenance place taking apart your engine without asking you first.
That's exactly my point. Why aren't costs agreed upon first in healthcare? Sure the doctors, hospitals, insurance, etc will lose their ass on some jobs but it should more than balance out over time.
Oh sorry I misunderstood you, I thought you were referring to the car repair industry's upsells.
My own story is when I went to an ENT for something unrelated and he asked me if it was okay to pull out a hair he saw on my ear and I said yes, and then the bill had a $500 charge for it.
My own story is when I went to an ENT for something unrelated and he asked me if it was okay to pull out a hair he saw on my ear and I said yes, and then the bill had a $500 charge for it.
It is probably an ethics violation. I am sure he probably covered himself in the fine print but as you can see the customers are confused so that means they didn't expect the full respiratory panel testing. Insurance companies may have rules on it too so he could be in violation of contracts. I would expect negative flu test, negative covid test, then that justifies the remaining panel if symptoms worsen or what not.
This is though the same thing car dealers do. They always want to up sell services.
This is though the same thing car dealers do. They always want to up sell services.
Was this a modern machine-based test where testing for one disease is just as easy as testing for 20 at a time? There's been a lot of false information and insurance screwups in the news about such tests. A single lab test that the machine vendor charges $200 for, and thus costs the hospital probably $50 or less if they own the machine, gets coded by insurance as 20 separate tests.
We 100% should be using these kinds of tests way more often. If this was such a rapid multi-test, the villain here is the billing department and insurance.
We 100% should be using these kinds of tests way more often. If this was such a rapid multi-test, the villain here is the billing department and insurance.
Sure, on a forum like this you can talk like that. Go anywhere else and you'll be instantly shut down with "Oh, so you're supposed to know better than a guy who went to school for 15 years?!"
It's a beautiful rhetorical technique. Very effective.
It's a beautiful rhetorical technique. Very effective.
There was a similar story last September. Here's the lede:
> Physicians Premier ER charged Dr. Zachary Sussman's insurance $10,984 for his COVID-19 antibody test even though Sussman worked for the chain and knows the testing materials only cost about $8. Even more surprising: The insurer paid in full.
https://www.texastribune.org/2020/09/05/austin-texas-coronav...
> Physicians Premier ER charged Dr. Zachary Sussman's insurance $10,984 for his COVID-19 antibody test even though Sussman worked for the chain and knows the testing materials only cost about $8. Even more surprising: The insurer paid in full.
https://www.texastribune.org/2020/09/05/austin-texas-coronav...
I don't understand why insurance companies pay ridiculous bills like this but will fight tooth and nail to avoid paying for obviously necessary procedures.
In the US, insurance company profit margins are capped by law. The insurance companies have to spend at least a certain percentage of their premiums on claims. If they spend less than that, they have to partially refund premiums [0]. So insurance companies are unable to increase their profit percentage by law. The only way for them to increase their profits is if they keep the same percentage by increase the size of the pie. Higher across-the-board healthcare cost benefits insurance companies as much as healthcare providers—if the healthcare costs double, they get to keep 20% of 2X instead of 20% of X.
[0] https://www.nytimes.com/2020/08/05/health/covid-insurance-pr...
[0] https://www.nytimes.com/2020/08/05/health/covid-insurance-pr...
That is beyond fucked up.
It’s very easy for laws with good intentions to have unintended consequences.
Do you think we should add some laws or something to protect insurance companies' profits, which are suffering from this type of fraud?
Any laws introduced would only tangle the mess called Healthcare even further. Government doesn't know how to administer healthcare (at least in the US) so it defers it to the private sector. Putting caps in place was already done, the issue is pricing transparency is not a thing. The insurance company pill just pay it and amortize it on the claimants group (or however they account for losses).
I wish we could fix this broken system. The only way to fix it now is open-heart surgery while driving.
I wish we could fix this broken system. The only way to fix it now is open-heart surgery while driving.
If the issue is pricing transparency, and that it’s “not a thing”, we could maybe make laws requiring pricing transparency?
My memory of ACA may be hazy but I do remember talks of having that as part of the ACA law. Not sure if it made it in (probably not due to lobbyists).
I think if insurance carriers had the ability to verify the charges before paying we would see naturalized reform from sheer market power. No one will pay for a $5k thing if the site says it's $350.
I think if insurance carriers had the ability to verify the charges before paying we would see naturalized reform from sheer market power. No one will pay for a $5k thing if the site says it's $350.
It didn't make it into the ACA. Trump signed a pricing transparency law which is in effect now, but being fought in court.
Do you think this is affecting insurance companies' profits?
>Insurers that sell individual and small group health coverage must spend at least 80% of premiums on medical claims and quality improvements for members. No more than 20% of premium revenue can be spent on total administrative costs, including profits and salaries. For insurers that sell large group coverage, the minimum MLR threshold is 85%.
>Insurers that fail to meet these guidelines (ie, they spend more than the allowed percentage on administrative costs, for whatever reason) are required to send rebates to the individuals and employers groups who had coverage under those policies. From 2012 to 2019, under the MLR rule implementation, insurers rebated $5.3 billion to consumers.
https://www.verywellhealth.com/health-insurance-companies-un...
Insurance Companies probably see these extra costs as a good way to meet their spend targets.
I was not able to find any source but have heard that the government is giving healthcare providers monetary assistance for Covid-19.
Looking at those two factors and no-one has any reason to try and control cost.
>Insurers that sell individual and small group health coverage must spend at least 80% of premiums on medical claims and quality improvements for members. No more than 20% of premium revenue can be spent on total administrative costs, including profits and salaries. For insurers that sell large group coverage, the minimum MLR threshold is 85%.
>Insurers that fail to meet these guidelines (ie, they spend more than the allowed percentage on administrative costs, for whatever reason) are required to send rebates to the individuals and employers groups who had coverage under those policies. From 2012 to 2019, under the MLR rule implementation, insurers rebated $5.3 billion to consumers.
https://www.verywellhealth.com/health-insurance-companies-un...
Insurance Companies probably see these extra costs as a good way to meet their spend targets.
I was not able to find any source but have heard that the government is giving healthcare providers monetary assistance for Covid-19.
Looking at those two factors and no-one has any reason to try and control cost.
[deleted]
Fraud is already illegal, so we just need better enforcement mechanisms. For now, insurance companies are turning a blind eye, but once they are out of the spotlight, they would be less hesitant to resume denying claims involving fraud, and the user would be stuck with the bill.
[deleted]
Was this fraud?
This article is confusing. I was excited to see someone using research to bubble up a story. Then the writer puts a doctor on the hot seat with no conclusion in the article for him to refute. Is this a teaser for an article to come? I think a good article would tell us how the insurance providers felt about the charges. Do they disagree with the doctor's assesment? Does this represent fraud? Is he taking advantage of ill defined rules?
> Times Insider explains who we are and what we do, and delivers behind-the-scenes insights into how our journalism comes together.
The actual article is: https://www.nytimes.com/2020/11/10/upshot/covid-testing-doct...
The actual article is: https://www.nytimes.com/2020/11/10/upshot/covid-testing-doct...
Thank you! The link should be changed, this article actually makes sense.
I enabled JavaScript because I thought the rest of the article needed to load, but it just ends abruptly.
This is a special behind-the-scenes article describing how the journalist did her work. If you read the article with JS turned on, you would see a link to the original article this is the backstory for: https://www.nytimes.com/2020/11/10/upshot/covid-testing-doct...
Published back in November.
Published back in November.
this makes so much more sense now, thanks!
Just as a reference, in Estonia COVID antibody test costs 13.21€ for the state (14.40€ if you are private person) and PCR test costs 51.81€ for the state (58€ private). This includes PE, sampling and analysis. Most tests are paid for by the state. You may want to take privately funded one if you have no symptoms and want to travel; or are returning from affected area and want to shorten the 10 day isolation requirement to 6 with two sequential negative tests.
In Canada, it is free through public healthcare if it is for health concerns (e.g. if you are symptomatic). If you need it for non-health reasons, e.g. travel, it goes through a private company and the cost is 250 C$ (195 US$/165€) in Alberta.
In India, RT-PCR test costs Rs 500, about $7 at any private testing centers. And one can get the results in four hours. Also one can get Covid-negative report for travel purpose for $12 (a certificate in addition to the test). Even we quadruple this price in the developed world like US, it should be about $50; instead, 95% of Americans are fleeced to death.
Where I live in Austria they charge just 45€ for a PCR test and the antibody test is free.
Not sure about LFT, but in the UK private PCR tests (required for travelling, professional elite sport etc.) cost between £80-130.
[deleted]
Here in California tests are $150 if you want to pay yourself (say because you're curious, or require a negative test to travel), or paid 100% by insurance (so no out of pocket costs) if you have symptoms and are referred to a test by your doctor.
The issue at hand in the article is the amount being charged to insurance companies for the latter - due to lobbying and obscure regulations (which the article points out the Trump administration attempted to overcome), it is not uncommon for medical providers to charge insurance companies exorbitant amounts for services, and also charge them for unnecessary services.
The issue at hand in the article is the amount being charged to insurance companies for the latter - due to lobbying and obscure regulations (which the article points out the Trump administration attempted to overcome), it is not uncommon for medical providers to charge insurance companies exorbitant amounts for services, and also charge them for unnecessary services.
The tests are actually free in the USA. The contention here is about how much these testing sites are charging insurers.
I'm not sure why I'm being downvoted. In the United States Covid 19 testing is free with or without insurance. Nobody needs to pay anything for a covid 19 test in the USA, regardless of their residency or insurance status.
> The Families First Coronavirus Response Act ensures that COVID-19 testing is free to anyone in the U.S., including the uninsured.
https://www.hhs.gov/coronavirus/community-based-testing-site...
The issue here is these testing sites were performing more than a covid 19 test and then billing for those tests without a person's consent.
> Dr. Murphy wasn’t just billing for coronavirus tests, as his patients thought. He was billing for 20 other respiratory pathogens, too.
> The Families First Coronavirus Response Act ensures that COVID-19 testing is free to anyone in the U.S., including the uninsured.
https://www.hhs.gov/coronavirus/community-based-testing-site...
The issue here is these testing sites were performing more than a covid 19 test and then billing for those tests without a person's consent.
> Dr. Murphy wasn’t just billing for coronavirus tests, as his patients thought. He was billing for 20 other respiratory pathogens, too.
As somebody who pays taxes, pays insurance premiums, and owns dollars, I contend that unnecessary medical services are not free.
The full article (https://www.nytimes.com/2020/11/10/upshot/covid-testing-doct...) suggests that this doctor alone has run 60,000 covid tests. Billing $2k a pop. That's $120 million (ok, maybe revenue, but you don't need to skim much off $120 million to be very wealthy).
Complete madness.
Complete madness.
This is a story about a story. Readers sent her bills and she got a story about it.
https://www.nytimes.com/2020/11/10/upshot/covid-testing-doct... <—-This is the actual story she wrote.
https://www.nytimes.com/2020/11/10/upshot/covid-testing-doct... <—-This is the actual story she wrote.
Incredible, especially the part about testing asymptomatic patients with a full panel. That's...insane.
Thank you! I was very confused while reading this because the author never actually got to anything interesting. Just talks about their routine of sorting through other people's medical bills.
It would be really interesting to see a crowdsourced index of real cost and insurer-paid cost for procedures across the US. Maybe a service that pays patients some nominal sum to share the data, then aggregates it and presents it to patients, journalists, etc.
Here is another incentive:
When users share their bills and EOB, provide them with an automated analysis of their bills: what seems weird, which billed items were far above average prices, etc.
This information can be precious when negotiating with the doctor's office, when Yelp/google-maps reviews, or when contacting your politicians about the absurdity of health care costs.
When users share their bills and EOB, provide them with an automated analysis of their bills: what seems weird, which billed items were far above average prices, etc.
This information can be precious when negotiating with the doctor's office, when Yelp/google-maps reviews, or when contacting your politicians about the absurdity of health care costs.
This is an excellent idea. Also, sell aggregated data on cost of care in local areas to doctors and insurance companies, so they can make clear business decision on how to compete against the local market.
[deleted]
Though that creates an incentive for the company to not share its own data.
The author of this article, Sara Kliff basically did a smaller version of that for ER visits when she was a reporter at Vox. The reporting did end up affecting policy.
this is the real reason healthcare costs so much in the US. Clear anti-competitive and monopolistic practices by the hospital/health insurance complex. Obamacare did absolutely nothing about this one issue, other than essentially shifting the cost structures around. The billing is so ridiculous, it's comical. It literally makes no sense.. My son spent 10 days in the hospital a few months ago: total hospital bill 78K. I paid the max out-of-pocket for my Marketplace plan (about 6K). There is no way that the cost was actually 78K.. if it were, then there would be no hospitals, nor would there be any insurance companies. The economics wouldn't allow it. The only other explanation must be a concerted effort by these institutions to shield the actual costs so no one reviews all of the money changing hands behind the scenes. It also explains why these groups fought the Trump administration when it tried to mandate hospital pricing (I was no fan of Trump, but at least he, and the republicans tried). The market will never be able squeeze out these inefficiencies without government intervention.. there are too many moats already in place. It should be noted that specific hospitals/doctors will tell you how much something costs if you ask (and especially if you tell them that you have no health care). I spent a year without health care to discover this and it wasn't because I couldn't pay for it. It was just obvious to me that this was the most egregious example of state-sponsored fleecing of American citizens that I had ever seen.
This is how much the complete insurance covered hospitalisation & surgery costed for my late father (RF tumour ablation) including tests and medicines. Key thing here in India is that there is no objection in use of generics - in one case, I was looking for a medicine which would cost me around 10 USD for a blister pack, the chemist looked at me and gave a generic one which costed around 2 USD. Hospitals tend to consider tests done at outside labs which may be done at lower cost (case to case basis). Surgeries conducted/ consultations provided on daily basis per doctor vastly outnumber as compared to US. Price breakups are clearly provided (and can be compared easily) and you pay for exact tests or consumables as prescribed. From where I live currently, thanks to the government capping, COVID-19 test costs between 10 USD to 35 USD, you are free to pick where you want it to be conducted and get the same results.
edit : added more details
edit : added more details
Another related issue posted today:
https://www.kut.org/covid-19/2021-02-04/covid-19-testing-has...
If a solution to this can't be found then rich and poor alike will suffer. Widespread testing is how we got the virus situation in Australia under control. Especially if this situation follows through to the vaccine rollout. Here in Australia both tests are free and the vaccine will also be free
tldr: One doctor is defrauding thousands of people by charging $2000 for a test that costs him nothing, and presumably making millions doing so.
If people think it's just one doctor/one clinic profiting off from this pandemic, they'd be wrong.
I know a couple of people who worked at these COVID testing sites in NYC (area near Columbia University), Brooklyn and in New Jersey for $15/hour. If one wants to work there, s/he doesn't even need to have work permit (because these sites hire foreign medical graduates for cheap labor). One just need to be able to draw blood, if necessary and that's the main requirement to work there.
All of these clinics are owned by doctors. I'm 100% sure these clinic owners get reimbursed more than $15 per test from the US government. It is a financial windfall for those entrepreneurial doctors and clinic owners who are willing to ignore proper screening in hiring COVID testers at the sites.
I know a couple of people who worked at these COVID testing sites in NYC (area near Columbia University), Brooklyn and in New Jersey for $15/hour. If one wants to work there, s/he doesn't even need to have work permit (because these sites hire foreign medical graduates for cheap labor). One just need to be able to draw blood, if necessary and that's the main requirement to work there.
All of these clinics are owned by doctors. I'm 100% sure these clinic owners get reimbursed more than $15 per test from the US government. It is a financial windfall for those entrepreneurial doctors and clinic owners who are willing to ignore proper screening in hiring COVID testers at the sites.
It’s a blood draw, not brain surgery. It sounds like you have problems with a for-profit healthcare system run under capitalism, however.
Could well be. Many people are saddened by the whole idea of a for-profit healthcare system ... regardless of the politics ... and I'm among them. Health is a Human Right.
As for the predatory equity firms that control many of them, I'd be delighted to see them thrown out of the US ... after their owners serve serious jail-time.
Edit: While we're at it, how about 1 year of jail time for every US citizen who has died of opioids made by US pharmas. They can divide that time up however their employees decide is fair.
As for the predatory equity firms that control many of them, I'd be delighted to see them thrown out of the US ... after their owners serve serious jail-time.
Edit: While we're at it, how about 1 year of jail time for every US citizen who has died of opioids made by US pharmas. They can divide that time up however their employees decide is fair.
Not patients. Insurance.
> she was “shocked” to see a drive-through coronavirus testing site bill her insurance $1,944
> she was “shocked” to see a drive-through coronavirus testing site bill her insurance $1,944
Yes they bill the insurance $1,944. But the insurance isn't going to pay that. Most of the insurance companies have capped COVID testing at $100. That is what they will cover because that is what the CARE Act requires them to cover. So that person probably got a bill for $1,844 from their insurance because the insurance probably paid $100.
Insurance doesn't bill the patient.
I recently had COVID, so I have just gone through all of the stuff in this article.
You would be surprised how many "COVID Testing Sites" are scams. Pure scams.
Many of them are not even able to bill your insurance, probably because Insurance companies would refuse to pay the fees they are charging for. So you will be paying out of pocket for them.
I actually did shop this around, trying to find a legit one. Several of the ones I called charged $400 for a "screening visit" which is basically the person that comes to your car window and asks if you have any COVID symptoms. If you say "yes I have a cough" or you list any other symptom of COVID (which is almost anything) then they will determine that you should get a COVID test. This screening visit is laughable. Many of the people screening you aren't even licensed medical professionals in any way. Even more disgusting, half of them are volunteers. They think they are helping the community and have volunteered. They simply listen for a single symptom and when they hear it then they give you the test. This screening cost ranges from $200 - $600 in my area. But the average was $400. Then they administer the test which can be charged $99 - $299. Many of these "drive up testing sites" that you see advertised are legit scams. They want people to see the sign, pull up in their car, get the test without asking any questions, and they will get a surprise bill of $500 - $1000+ in a few months. The other charge that you often get is a test results charge. Some of these testing sites are charging you for the phone call they make to tell you the test results.
So be very wary if you are getting COVID tested. THere are a lot of places out there doing COVID testing that are PURE SCAMS!
Good news: there are some legit ones. But you need to really do your research ahead of time. I eventually went and got tested at a testing site that is operated by my state. They are authorized to bill the CARE Act which was the emergency bill that allows for free COVID testing and COVID care. They were also authroized to bill your insurance. They bill insurance a flat $99 fee. And if your insurance doesn't cover it then the CARE Act can cover the rest.
So please be careful out there. If you are getting COVID testing, make sure to do some research and go to a legit testing site. Call them and see if they can bill the CARE Act. Even if you have insurance, you want to go to these sites because they are the "official ones". If they are doing it legit enough that the CARE Act covers them, then the insurance companies will also cover tests from that same place. Make sure there are no additional costs for screening or delivering results. If they have any of those costs or are NOT covered by the CARE Act, then run. Those places are likely profiting off the pandemic and will surprise you with expensive bills that your insurance will refuse to cover.
You would be surprised how many "COVID Testing Sites" are scams. Pure scams.
Many of them are not even able to bill your insurance, probably because Insurance companies would refuse to pay the fees they are charging for. So you will be paying out of pocket for them.
I actually did shop this around, trying to find a legit one. Several of the ones I called charged $400 for a "screening visit" which is basically the person that comes to your car window and asks if you have any COVID symptoms. If you say "yes I have a cough" or you list any other symptom of COVID (which is almost anything) then they will determine that you should get a COVID test. This screening visit is laughable. Many of the people screening you aren't even licensed medical professionals in any way. Even more disgusting, half of them are volunteers. They think they are helping the community and have volunteered. They simply listen for a single symptom and when they hear it then they give you the test. This screening cost ranges from $200 - $600 in my area. But the average was $400. Then they administer the test which can be charged $99 - $299. Many of these "drive up testing sites" that you see advertised are legit scams. They want people to see the sign, pull up in their car, get the test without asking any questions, and they will get a surprise bill of $500 - $1000+ in a few months. The other charge that you often get is a test results charge. Some of these testing sites are charging you for the phone call they make to tell you the test results.
So be very wary if you are getting COVID tested. THere are a lot of places out there doing COVID testing that are PURE SCAMS!
Good news: there are some legit ones. But you need to really do your research ahead of time. I eventually went and got tested at a testing site that is operated by my state. They are authorized to bill the CARE Act which was the emergency bill that allows for free COVID testing and COVID care. They were also authroized to bill your insurance. They bill insurance a flat $99 fee. And if your insurance doesn't cover it then the CARE Act can cover the rest.
So please be careful out there. If you are getting COVID testing, make sure to do some research and go to a legit testing site. Call them and see if they can bill the CARE Act. Even if you have insurance, you want to go to these sites because they are the "official ones". If they are doing it legit enough that the CARE Act covers them, then the insurance companies will also cover tests from that same place. Make sure there are no additional costs for screening or delivering results. If they have any of those costs or are NOT covered by the CARE Act, then run. Those places are likely profiting off the pandemic and will surprise you with expensive bills that your insurance will refuse to cover.
for anyone wondering how US healthcare got to where it is today, this is a succinct historical summary in the form of a podcast, by a historian.
https://www.econtalk.org/christy-ford-chapin-on-the-evolutio...
https://www.econtalk.org/christy-ford-chapin-on-the-evolutio...
Ah, the American Health Care system. I think we are all starting to learn that indeed, capitalism is great, as long as agents have a choice. In healthcare there often isn't (drug or death is not really a choice, iPhone or Galaxy is). Not great to leave such a market free to optimize for profitability.
The healthcare system is not a free market.
1. It’s very hard to shop around to find better prices or better service.
2. People often make choices like “Do you want this expensive life saving procedure or not?”
3. The average person isn’t informed enough to understand what their medical treatment needs are. Patients ask doctors what their recommendation is. Doctors often have an incentive to sell the most healthcare they reasonably can.
4. My ability to pay for healthcare is directly tied to my employer. There simply are less jobs that provide good healthcare than people that would like them. My ability to change positions in society is limited by my desire to continue to have access to affordable healthcare. This is practically a freedom limiting mechanism.
5. I’m limited in my choice of which healthcare to purchase based on my Insurance policy. My choice in insurance policy is similar to a suburbanite’s choice in an ISP. I have very few choices.
1. It’s very hard to shop around to find better prices or better service.
2. People often make choices like “Do you want this expensive life saving procedure or not?”
3. The average person isn’t informed enough to understand what their medical treatment needs are. Patients ask doctors what their recommendation is. Doctors often have an incentive to sell the most healthcare they reasonably can.
4. My ability to pay for healthcare is directly tied to my employer. There simply are less jobs that provide good healthcare than people that would like them. My ability to change positions in society is limited by my desire to continue to have access to affordable healthcare. This is practically a freedom limiting mechanism.
5. I’m limited in my choice of which healthcare to purchase based on my Insurance policy. My choice in insurance policy is similar to a suburbanite’s choice in an ISP. I have very few choices.
If you don't mind me adding :)
6. Prices are often unknown at time of service.
No amount of research can make up for hospitals that haven't decided how much your surgery will cost until after the fact.
I recently paid a hospital invoice, and received a receipt covered in "PENDING FINAL BILL". I can't tell if the hospital will refund me some excess, or charge an extra $1000.
To extend the metaphor elsewhere in this thread, it's like going into a garage and being told that an oil change will cost between $40 and $400. It depends. We'll let you know.
6. Prices are often unknown at time of service.
No amount of research can make up for hospitals that haven't decided how much your surgery will cost until after the fact.
I recently paid a hospital invoice, and received a receipt covered in "PENDING FINAL BILL". I can't tell if the hospital will refund me some excess, or charge an extra $1000.
To extend the metaphor elsewhere in this thread, it's like going into a garage and being told that an oil change will cost between $40 and $400. It depends. We'll let you know.
Hospitals enjoy that luxury, of course:
https://www.healthcaredive.com/news/hospitals-pledge-to-figh...
However, it looks like that practice won't be allowed for much longer:
https://www.cnn.com/2021/01/04/politics/hospital-price-trans...
https://www.healthcaredive.com/news/hospitals-pledge-to-figh...
However, it looks like that practice won't be allowed for much longer:
https://www.cnn.com/2021/01/04/politics/hospital-price-trans...
The answers for Canada's public health care system differ slightly but aside from the potential monetary issues for people without adequate insurance in the US, the Canadian system depends on capacity if you aren't a) a critical care patient b) high profile i.e. athelete, politician etc
1. Almost impossible to shop around 2. Instead this is a Dr's or a public system policy choice. 3. Dr's incentive is to minimize costs 4. Your ability to aquire healthcare is based on limited availability and your condition. If you are critical you will get immediate care, if you need a MRI - perhaps 6 months, if you need a specialist i.e. liver doc, sleep study, orthopedic surgeon etc, 1+ year 5. You have very little choice. Finding a family doc is very constrained
OBVIOUSLY, this depends on the province as health care is a provincial domain.
1. Almost impossible to shop around 2. Instead this is a Dr's or a public system policy choice. 3. Dr's incentive is to minimize costs 4. Your ability to aquire healthcare is based on limited availability and your condition. If you are critical you will get immediate care, if you need a MRI - perhaps 6 months, if you need a specialist i.e. liver doc, sleep study, orthopedic surgeon etc, 1+ year 5. You have very little choice. Finding a family doc is very constrained
OBVIOUSLY, this depends on the province as health care is a provincial domain.
>The average person isn’t informed enough to understand what their medical treatment needs are.
The average person isn't informed about anything other than however they make money from 9-5
Consumer ignorance is not an excuse for a crappy market.
The average person isn't informed about anything other than however they make money from 9-5
Consumer ignorance is not an excuse for a crappy market.
It is the job of regulators to coerce the market, through regulation, into one that is less harmful to consumers.
It is unreasonable to expect every consumer to be an expert in every commerce transaction that takes place in their daily lives.
It is unreasonable to expect every consumer to be an expert in every commerce transaction that takes place in their daily lives.
The main purpose of capitalism is to shift blame onto the consumer. You didn't want your new lawn mower to maim you? You should have done your research, it's your fault.
Once captured, the regulators coerce the market, through mis-regulation, into one that more effectively captures consumer value for certain producers.
Is the price of specialization and sophistication the movement of decision power away from the source of decision quality information? I find it paradoxical to use regulation as a response to the fact that "it is unreasonable to expect every consumer to be an expert" in that it is likewise unreasonable to expect regulators to be expert in the context and values of each individual consumer.
Is the price of specialization and sophistication the movement of decision power away from the source of decision quality information? I find it paradoxical to use regulation as a response to the fact that "it is unreasonable to expect every consumer to be an expert" in that it is likewise unreasonable to expect regulators to be expert in the context and values of each individual consumer.
[deleted]
Consumer ignorance is not an excuse for a crappy market. Consumers should have access to advice from a third party.
When I want finical advice I hire an expert that gets paid the same no matter where I invest my money, because his incentive is to give me the best advice so I stick with him. If I get finical advice from someone that gets commission based on selling specific investments then the advice is more likely to be less than the best.
When I want finical advice I hire an expert that gets paid the same no matter where I invest my money, because his incentive is to give me the best advice so I stick with him. If I get finical advice from someone that gets commission based on selling specific investments then the advice is more likely to be less than the best.
> The healthcare system is not a free market.
You hit the nail on the head. Compared to buying a car, computer or apartment I'm not choosing to have a particular disease or accident. It just happens to us (yes, we can prevent some). Once you have a medical condition you are forced to "shop" for a solution in a "free market" so you can escape that situation. This is when people become vulnerable and the US healthcare model takes full advantage of their position.
You hit the nail on the head. Compared to buying a car, computer or apartment I'm not choosing to have a particular disease or accident. It just happens to us (yes, we can prevent some). Once you have a medical condition you are forced to "shop" for a solution in a "free market" so you can escape that situation. This is when people become vulnerable and the US healthcare model takes full advantage of their position.
Just to add another item to your list:
6. Pricing is almost impossible to know ahead of time, even if you ask.
Trust me, I have asked how much something will cost ahead of time and no one can tell you.
One time I had to go into a specialist for my leg. I had hurt my MCL, but the doctor wasn't sure if it was torn or pulled. So he sent me to a specialist to give advice on whether surgery was needed. Before I made the appointment I asked the receptionist how much it was going to cost for this appointment. She couldnt tell me. I asked her to figure it out and call me back. She never did. I called back before my appointment and talked to the clinic manager. She again refused to quote me a price.
In the end I went to the appointment. The doctor listened to me, then grabbed my leg and twisted it a few different directions and asked me to describe the pain as he did so. Then he told me it was a simple pull. I didn't need surgery. I just needed to rest. No prescriptions, no medications rendered, no operations performed, no diagnostic tests given. A simple 15 minute doctor visit.
3 months later I get the bill. It was $800. I had to pay it all out of pocket because this specialist was out of network. I had tried to get a price ahead of time and couldn't. The doctor didn't do anything for me except tell me to rest. The visit cost him 15 mins of his time. Nothing more. At this rate, he is billing $3,200 per hour. Possibly more because the 15 minute time estimate is me being generous. It was very possibly closer to 10 minute visit.
Another one that I won't go into detail with because it would take too long was for a pinched nerve in my back. I went to urgent care because the pain was so bad I couldn't stand. Again, a simple question+answer with the doctor revealed the pinched disc in my back. No xrays or diagnostic tests were given. She prescribed me a pain killer and a steroid to reduce inflamation which would allow the disc to naturally slip back into place. Because I was traveling and so was again out of network when this happened, I asked the receptionist as I was checking in how much a simple visit runs. She of course can't quote me anything. I pressed her and said, "what is the base price. I know it is more if they have to run tests and do things, but what is the cost of the visit". She refused to tell me. As I was now wheelchair bound because I couldn't stand, I had no choice but to gamble and get the help and learn the price 4 months later. The visit cost me $1,900. I had to pay 100% out of pocket. Despite having insurance that I already pay $500 a month for.
Furthermore I had $120 in out of pocket expenses on the medications.
Not only can you not figure out a price ahead of time, but it is equally crazy that I pay this much out of pocket when I have insurance that I pay $500 a month for ($6,000 per year). And no don't tell me to "get better insurance". That means finding a different employer and guess what... it's not like you can see what insurance the other employers have until after you start working there. There is no way to really shop insurance, you are stuck with what your employers offers, usually with 2-3 options from the plans they have selected.
6. Pricing is almost impossible to know ahead of time, even if you ask.
Trust me, I have asked how much something will cost ahead of time and no one can tell you.
One time I had to go into a specialist for my leg. I had hurt my MCL, but the doctor wasn't sure if it was torn or pulled. So he sent me to a specialist to give advice on whether surgery was needed. Before I made the appointment I asked the receptionist how much it was going to cost for this appointment. She couldnt tell me. I asked her to figure it out and call me back. She never did. I called back before my appointment and talked to the clinic manager. She again refused to quote me a price.
In the end I went to the appointment. The doctor listened to me, then grabbed my leg and twisted it a few different directions and asked me to describe the pain as he did so. Then he told me it was a simple pull. I didn't need surgery. I just needed to rest. No prescriptions, no medications rendered, no operations performed, no diagnostic tests given. A simple 15 minute doctor visit.
3 months later I get the bill. It was $800. I had to pay it all out of pocket because this specialist was out of network. I had tried to get a price ahead of time and couldn't. The doctor didn't do anything for me except tell me to rest. The visit cost him 15 mins of his time. Nothing more. At this rate, he is billing $3,200 per hour. Possibly more because the 15 minute time estimate is me being generous. It was very possibly closer to 10 minute visit.
Another one that I won't go into detail with because it would take too long was for a pinched nerve in my back. I went to urgent care because the pain was so bad I couldn't stand. Again, a simple question+answer with the doctor revealed the pinched disc in my back. No xrays or diagnostic tests were given. She prescribed me a pain killer and a steroid to reduce inflamation which would allow the disc to naturally slip back into place. Because I was traveling and so was again out of network when this happened, I asked the receptionist as I was checking in how much a simple visit runs. She of course can't quote me anything. I pressed her and said, "what is the base price. I know it is more if they have to run tests and do things, but what is the cost of the visit". She refused to tell me. As I was now wheelchair bound because I couldn't stand, I had no choice but to gamble and get the help and learn the price 4 months later. The visit cost me $1,900. I had to pay 100% out of pocket. Despite having insurance that I already pay $500 a month for.
Furthermore I had $120 in out of pocket expenses on the medications.
Not only can you not figure out a price ahead of time, but it is equally crazy that I pay this much out of pocket when I have insurance that I pay $500 a month for ($6,000 per year). And no don't tell me to "get better insurance". That means finding a different employer and guess what... it's not like you can see what insurance the other employers have until after you start working there. There is no way to really shop insurance, you are stuck with what your employers offers, usually with 2-3 options from the plans they have selected.
The healthcare market isn't free. Also, we should call it "lifecare" rather than "healthcare", because the market doesn't care if you're healthy or not, just alive and using medical services.
"If the image of medicine I have conveyed is one wherein medicine lurches along, riven by internal professional power struggles, impelled this way and that by arbitrary economic and sociopolitical forces, and sustained by bodies of myth and rhetoric that are elaborated in response to major threats to its survival, then that is the image supported by this study."
- Evelleen Richards, "Vitamin C and Cancer: Medicine or Politics?"
"If the image of medicine I have conveyed is one wherein medicine lurches along, riven by internal professional power struggles, impelled this way and that by arbitrary economic and sociopolitical forces, and sustained by bodies of myth and rhetoric that are elaborated in response to major threats to its survival, then that is the image supported by this study."
- Evelleen Richards, "Vitamin C and Cancer: Medicine or Politics?"
We've done a really good job of removing choice from the system at every available opportunity. Certificate of Need laws reducing the number of medical machines in localities. Insurance limiting provider choice. Totally opaque pricing for consumers. Restrictions on interstate licensing. There's a lot of mess that's entrenched.
From TFA:
> The patients who went to one of these drive-through testing sites had no chance of knowing what charges they would face beforehand.
This is just stupid. There are similar stories about the cost of going to the ER. If all health care providers were required to be transparent about pricing up front, then there might be some possibility for people to shop around.
> The patients who went to one of these drive-through testing sites had no chance of knowing what charges they would face beforehand.
This is just stupid. There are similar stories about the cost of going to the ER. If all health care providers were required to be transparent about pricing up front, then there might be some possibility for people to shop around.
The traditional view of libertarian capitalists where government, democratic or otherwise, has no moral validity when regulating or prohibiting various forms commerce, falls on its face when confronted with the real world. The free market works passingly well for basic items that people are free to chose whether to purchase or not. It fails spectacularly when one party is forced. In situations such as those presented in TFA the market fails spectacularly, and government can and should step in, and so long as backed by the democratic will, has the moral justification to do so.
It's not a free market. The US health system is highly regulated, and most importantly, there is a huge tax incentive for health care to be paid for not by individuals but by employers who buy full coverage.
This response is common, but flawed. At root it is a “no true Scotsman” fallacy. Behind that, it argues, or at least heavily implies, that the only “true” free market is one wholly unburdened by regulation. Such a thing does not exist outside of history books, and there are good, historical reasons as to why.
The fundamental premise, though — that the market is not ideal for healthcare —- remains. For shoes and smartphones, the market is fine. For MRIs and insulin, it is not.
The fundamental premise, though — that the market is not ideal for healthcare —- remains. For shoes and smartphones, the market is fine. For MRIs and insulin, it is not.
>It's not a free market.
If you hadn't opened with that I think we could have gotten another two or three people extending the chain of indirectly stating as much.
If you hadn't opened with that I think we could have gotten another two or three people extending the chain of indirectly stating as much.
I briefly worked in healthcare at a tech startup. The thing you quickly learn is that the market for healthcare is fundamentally broken. You could invent something that saves a patient $10,000 and they will never know. The hospital and doctors won't care about saving money. And the insurance company has no leverage to make them. And it will never make it onto the patient bill in a way that they understand.
And as much as doctors and hospitals love to paint insurance as the bad guy, the only reason things like prior authorization is a pain in the ass is because doctors don't actually put in any effort into prescribing generics or really learn how much anything costs. This is highly unusual in most professions: Imagine if your roofer grabbed whatever shingles they liked best and billed you for it after they were up. Now imagine every roofer worked the same way.