U.S. health care's widespread overbilling problem(axios.com)
axios.com
U.S. health care's widespread overbilling problem
https://www.axios.com/health-cares-widespread-overbilling-problem-2454995957.html
272 comments
The core difference between the American health insurance model and the Japanese model (which costs half as much and has better outcomes) is fixed pricing. In Japan, a government commission sets prices for every medical product and procedure, tuning the prices to insure profitability, while preventing profiteering.
In America, price negotiation is done between providers and insurance carriers. This has a few obvious effects. First, it gives us the in-network/out-of-network distinction. Second, it introduces complexity in the math sense to pricing - providers aren't charging one price, they're charging a wide array of prices, although those prices don't really vary much.
The network thing also has the effect of reducing consumer choice in providers. I can use whatever doctors/facilities my insurance has in-network, unless I'm willing to cough up the difference out of my own pocket.
Of course, fixed prices would be that wicked socialist government control we're told is ruining everything.
In America, price negotiation is done between providers and insurance carriers. This has a few obvious effects. First, it gives us the in-network/out-of-network distinction. Second, it introduces complexity in the math sense to pricing - providers aren't charging one price, they're charging a wide array of prices, although those prices don't really vary much.
The network thing also has the effect of reducing consumer choice in providers. I can use whatever doctors/facilities my insurance has in-network, unless I'm willing to cough up the difference out of my own pocket.
Of course, fixed prices would be that wicked socialist government control we're told is ruining everything.
Yeah, based on my experience living here I don't think this kind of price control is ever going to happen in the U.S.
In the majority of the 1st world where the goverment and general population accepted the fact that healthcare is a special case outside normal economic rules. That's why get things like single payer, price controls.
That's not the prevailing belief in the US. The majority of people in power (not sure about general population) believe that healcare is like any other business subject to the same rules. Single payer is government interference into the market; price controls are definitely out of the question. Price controls might even be unconditional (if challenged, depending on context).
Also, the various lobby groups representing doctors are very powerful much like unions used to be. However unlike labor unions these groups have broader cross party relationships. These groups tent to oppose any kind of limits on pay that could directly impact their constituents.
When you put that in perspective it's obvious to understand why we end up which such convoluted solutions as the ACHA in order to expand/guarantee medical coverage to people.
In the majority of the 1st world where the goverment and general population accepted the fact that healthcare is a special case outside normal economic rules. That's why get things like single payer, price controls.
That's not the prevailing belief in the US. The majority of people in power (not sure about general population) believe that healcare is like any other business subject to the same rules. Single payer is government interference into the market; price controls are definitely out of the question. Price controls might even be unconditional (if challenged, depending on context).
Also, the various lobby groups representing doctors are very powerful much like unions used to be. However unlike labor unions these groups have broader cross party relationships. These groups tent to oppose any kind of limits on pay that could directly impact their constituents.
When you put that in perspective it's obvious to understand why we end up which such convoluted solutions as the ACHA in order to expand/guarantee medical coverage to people.
You're not completely correct. Medicare has fixed prices that it will pay for visits, procedures etc. The prices depend on what region of the country you live in. Insurance companies then set their prices up or down from there. Independent physicians have little negotiating power and often get paid by private insurance companies less than the fixed government rate. Larger systems with more bargaining power can get significantly more.
But medicare's irrational price setting system is a big part of the problem.
It's the same thing, when it comes to the problem I'm pointing out, no matter how we describe it - medical providers charge different rates for the same products to different insurers, and insurers pay different rates for the same products to different providers. And the range of variation is not actually large, but we introduce tremendous complexity to the system in order to achieve it. It's not "competition" in the classical sense, and doesn't provide the benefits of competition to consumers, providers, or insurers.
I'm heading back from Japan today, and my family got a bunch of checkups and medical stuff done while we were here.
Even without insurance all our procedures cost total less than ~$100 apiece.
The most expensive thing I've ever had in japan was my full body workup last year for $500.
It included: stomach ultrasound, 5 blood tests, eye exam, MRI(brain) and barium scan. All without insurance.
By comparison, in the US I was charged $1200 to get my daughters arm cast changed (no xray, just a nurse changing the cast), and $800 for an ultrasound.
It is literally cheaper to fly to Japan and get treatment without insurance than to use my health insurance that I pay $1300/month for.
Also, as a bonus, because of the set prices of medical procedures in Japan, insurance is super cheap. For a family of 4 it was costing me around $500/month when I used to live here.
Even without insurance all our procedures cost total less than ~$100 apiece.
The most expensive thing I've ever had in japan was my full body workup last year for $500.
It included: stomach ultrasound, 5 blood tests, eye exam, MRI(brain) and barium scan. All without insurance.
By comparison, in the US I was charged $1200 to get my daughters arm cast changed (no xray, just a nurse changing the cast), and $800 for an ultrasound.
It is literally cheaper to fly to Japan and get treatment without insurance than to use my health insurance that I pay $1300/month for.
Also, as a bonus, because of the set prices of medical procedures in Japan, insurance is super cheap. For a family of 4 it was costing me around $500/month when I used to live here.
Yep - if you're sick and in the U.S., don't go to the hospital, go to the airport.
> I was charged $1200 to get my daughters arm cast changed (no xray, just a nurse changing the cast),
I hope the nurse got paid at least half of that.
I hope the nurse got paid at least half of that.
Did you need to speak Japanese to get this done?
I'm in the middle of nowhere, so in my case I would need a smattering. However, almost all doctors can read/write English, even if they can't speak it. I've had 80 year old doctors proudly write down the word rheumatism, where I can barely get by with spellcheck.
In bigger cities, you'll definitely be able to find doctors who can speak English easily.
In bigger cities, you'll definitely be able to find doctors who can speak English easily.
Google Translate is magical. I've used it to speak with vendors and negotiate prices in China. Not optimal, but amazing. Works on text too....
The United States will get single-payer before it gets government-set pricing for 15% of its economy. Both, by the way, are problematic solutions!
There are options for transparency that don't involve a government takeover of health care. But the brinksmanship in the politics of health care --- almost entirely the fault of the GOP --- is keeping us from exploring solutions.
There are options for transparency that don't involve a government takeover of health care. But the brinksmanship in the politics of health care --- almost entirely the fault of the GOP --- is keeping us from exploring solutions.
I've got news for you... you already have government price floors on all hospital procedures.
It's not a government takeover of health care - only of pricing. The Japanese model is largely private providers, and private, employer-provided insurance.
Standardized pricing gets rid of the problem of charging different customers (slightly) different pricing, and having massive negotiations on a per-carrier basis. This sort of thing isn't a matter of "competition drives down cost". It's just stupid and inefficient.
Standardized pricing gets rid of the problem of charging different customers (slightly) different pricing, and having massive negotiations on a per-carrier basis. This sort of thing isn't a matter of "competition drives down cost". It's just stupid and inefficient.
Don't Medicare and Medicaid pay fixed prices? And aren't they generally below cost for the provider? So they have to "make up the difference" by charging private insurers and cash payers more?
It's lower than what the provider charges other insurers, that doesn't mean it's below the provider's cost. It's also commonplace for providers to bill insurers one amount but the insurer only pays a lesser amount, it's a little game they play. Pricing of medical goods and services in the U.S. are very divorced from the actual costs of providing them.
Also, Medicare and Medicaid can't negotiate drug prices.
Also, Medicare and Medicaid can't negotiate drug prices.
I think so. My point is, government price ceilings on all health procedures are so noxious to half the polity that nobody will support it, and we'll get single payer by default.
They are generally less than what providers bill to others but Medicare doesn't pay below cost.
Medicaid varies because states have way more control and many states (especially Republican-leaning ones) have slashed their rates as part of a concerted effort to kill the program. Not that it matters - in Texas you generally can't qualify for Medicaid if you're childless or have a job. The income requirements are insanely low.
Medicaid varies because states have way more control and many states (especially Republican-leaning ones) have slashed their rates as part of a concerted effort to kill the program. Not that it matters - in Texas you generally can't qualify for Medicaid if you're childless or have a job. The income requirements are insanely low.
Sure, but that's why participation rate varies pretty wildly from one practice to the next on whether or not they accept Medicare or Medicaid.
If a doctor doesn't like the rates Medic[are|aid] are paying, they're free to not accept Medic[are|aid] patients.
If a doctor doesn't like the rates Medic[are|aid] are paying, they're free to not accept Medic[are|aid] patients.
Unless they are emergency room patients. :)
Having recently had the opportunity to compare Tokyo's rail system to DC's, I'd trust the Japanese government to set prices. But here in the US I suspect prices wouldn't be set to "ensure profitability while preventing profitability." Instead, they'd go back and forth between untenable extremes.
A few years ago my daughter needed a last-minute CT scan, the results of which would determine whether it was safe for my wife and I to go to a conference (long story). The hospital couldn't get authorization for the CT scan from Blue Cross, due to some glitch. "No problem", they said, "we'll just do the test tomorrow." Big problem for us, though; our flight out was the next day.
I ended up negotiating a price for the CT on the spot; none existed. They simply couldn't tell me how much the test cost. I had to extravagantly over pay in order to get the test done at all.
I ended up negotiating a price for the CT on the spot; none existed. They simply couldn't tell me how much the test cost. I had to extravagantly over pay in order to get the test done at all.
I had an equal and opposite experience getting an MRI. I also have a high deductible plan. When I was told I needed an MRI I went on my insurance provider's website to find MRI locations that are in network nearby. I called the first 5 on the list. I found that some place that was basically MRI-R-US was several hundred dollars cheaper than going to the local mega-hospital.
Pricing isn't transparent because people usually aren't paying with money they perceive as their own. What do you care if your insurance company pays $200 or $2000 for that MRI? Eventually that difference shows up in the form of higher premiums, but that's far too complicated for people to respond to intelligently.
Let's go one step further and imagine a world in which we completely replaced Medicare with a catastrophic coverage system. If you have a heart attack or something we'll take care of you, but for your day to day healthcare we'll just cut you a check for however much the government was previously paying. You can choose to use that money on anything you want whether it's healthcare related or not. You want to see price transparency and the power of competition to lower prices? Boom, done.
Pricing isn't transparent because people usually aren't paying with money they perceive as their own. What do you care if your insurance company pays $200 or $2000 for that MRI? Eventually that difference shows up in the form of higher premiums, but that's far too complicated for people to respond to intelligently.
Let's go one step further and imagine a world in which we completely replaced Medicare with a catastrophic coverage system. If you have a heart attack or something we'll take care of you, but for your day to day healthcare we'll just cut you a check for however much the government was previously paying. You can choose to use that money on anything you want whether it's healthcare related or not. You want to see price transparency and the power of competition to lower prices? Boom, done.
This will result in many people choosing to spend nothing on 'day to day' healthcare. Subsequently, this 'deferred maintenance' will result in increasing rates of catastrophic events, which will drive up costs for that part of the system.
Giving cash (or cash equivalents) to people is probably not a good solution.
Giving cash (or cash equivalents) to people is probably not a good solution.
Why do you care if someone chooses quality of life over longevity? Why do we get to make that decision for them?
It is difficult because each insurance provider will have a different contract with the hospital or care provider. My wife works at a hospital that just upgraded from an all Dos based system to a windows based system. Her job is resolving provider disputes where the provider billed a rate that was different then their contract. Old systems + lots of different rates = confusion!
It sounds like you're talking about something more complicated than a blood test, but in case you didn't know, most blood tests can be purchased online (and completed at a local branch of a national testing service e.g. Quest Diagnostics) with complete price transparency from a variety of competing providers.
I would love something like census data on how much a healthcare provider paid, on top of what a procedure or medicine costs. Not just how much they paid for you or your walking cane, but how much every provider pays for a syringe.
> I would love something like census data on how much a healthcare provider paid, on top of what a procedure or medicine costs.
$0. By definition.
But I think you may be confusing a health insurance provider (equivalently, a health care payer) with a health care provider.
$0. By definition.
But I think you may be confusing a health insurance provider (equivalently, a health care payer) with a health care provider.
Totally agree. If people in the US want to have markets for health care there should be price transparency. When I had a high deductible plan I always tried to compare prices but you almost never get a straight answer.
If the Republicans want to reform health care that's where they should be starting.
If the Republicans want to reform health care that's where they should be starting.
> If the Republicans want to reform health care that's where they should be starting.
They don't.
They don't.
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If people in the US want to have markets for health care
I think only certain 'legal persons' and their executive officers and major shareholders want that. Patients, not so much.
I think only certain 'legal persons' and their executive officers and major shareholders want that. Patients, not so much.
Health care is the only industry where you only find out how much something costs after you're already bought it.
Basic supply and demand theory depends on consumers having perfect information. A free market cannot work when a consumer has no information.
Basic supply and demand theory depends on consumers having perfect information. A free market cannot work when a consumer has no information.
A lot of trades give you estimates but you don't know the actual cost until the work is complete. Auto repair, construction, plumbing, electrical, etc. There are plenty of fixed costs that can be accounted for easily but there are a lot of unknowns that can't be seen ahead of time. That's why quotes and shopping around so prevalent because it allows for competition in price.
However in healthcare that's not an option, there is no competition. The cost of fixed cost procedures (e.g. lab work) are unknown. You can't shop around for surgeries or doctors. Everything is wrapping in mystery even after the fact, there is no final bill. Even if you pay everything you're asked to, you might still get a bill 2 years down the road for reasons no one can suitably explain.
However in healthcare that's not an option, there is no competition. The cost of fixed cost procedures (e.g. lab work) are unknown. You can't shop around for surgeries or doctors. Everything is wrapping in mystery even after the fact, there is no final bill. Even if you pay everything you're asked to, you might still get a bill 2 years down the road for reasons no one can suitably explain.
One difference with auto repair: I expect the garage to call me before they do any work that exceeds the estimate. And I may very well decide not to do it. They may tell me that I need a $1000 timing belt replacement when I ask for a $200 water pump replacement, and I may decide not to do it. I can even ask them to put everything back together and tow the car somewhere else for repairs. If they tell me I need a $3000 engine replacement, I may decide to just scrap the car.
The same is not true with healthcare - you may go in for a $20K stent, but have a serious complication that needs $200K open heart surgery -- you don't really have the option to say "put everything back together and I'll live with it".
The same is not true with healthcare - you may go in for a $20K stent, but have a serious complication that needs $200K open heart surgery -- you don't really have the option to say "put everything back together and I'll live with it".
One difference with auto repair: I expect the garage to call me before they do any work that exceeds the estimate.
It's not just an expectation, it's the law in many places. When I was a pro mechanic in Indiana, anything over original estimate + 10%, and authorization from the customer is required. Well, not required I guess, since if you show up and the bill is 20% over, you just pay the original estimate. (Yes, in the worst case you might have to sue to get your car back. Personally, I've never known that to have happened, because most shops aren't looking to rip you off.)
But, as you point out, me being in the middle of a top end job is a little different than a surgeon who's working on a running engine when it comes to needed extra work.
It's not just an expectation, it's the law in many places. When I was a pro mechanic in Indiana, anything over original estimate + 10%, and authorization from the customer is required. Well, not required I guess, since if you show up and the bill is 20% over, you just pay the original estimate. (Yes, in the worst case you might have to sue to get your car back. Personally, I've never known that to have happened, because most shops aren't looking to rip you off.)
But, as you point out, me being in the middle of a top end job is a little different than a surgeon who's working on a running engine when it comes to needed extra work.
I've often thought this could be solved by requiring a doctor to carry "estimate" insurance. The patient's bill would be the quoted price and the doctor's insurance would cover any complications leading to additional costs. This would have the additional benefit of increasing the costs of doctors with frequent complications. This would only work for immediate complications from surgery (i.e., less likely to be impacted by patient compliance).
It might also lead to doctors "missing" complications to avoid insurance premium increases.
Complications during surgery aren't necessarily caused by the surgeon or known ahead of time. The same is true of other things like home renovation where "we won't know until we open her up" is a common enough phrase.
Case in point, we want to remodel a bathroom that has a 7ft ceiling and my wife wants the ceiling raised to match all of the others. Why is it 7ft instead of 8ft? Can it be raised? Without significant cost? We won't know until we get in there.
Complications during surgery aren't necessarily caused by the surgeon or known ahead of time. The same is true of other things like home renovation where "we won't know until we open her up" is a common enough phrase.
Case in point, we want to remodel a bathroom that has a 7ft ceiling and my wife wants the ceiling raised to match all of the others. Why is it 7ft instead of 8ft? Can it be raised? Without significant cost? We won't know until we get in there.
> The cost of fixed cost procedures (e.g. lab work) are unknown.
I don't think that's the case. For example, if you get a lipid panel, it's going to be coded under a given CPT. The billing department should be able to obtain the cash and insurance price. The problem is that they're not forthcoming with it (at least in my experience even when I had the CPT).
I don't think that's the case. For example, if you get a lipid panel, it's going to be coded under a given CPT. The billing department should be able to obtain the cash and insurance price. The problem is that they're not forthcoming with it (at least in my experience even when I had the CPT).
An an anecdote: I've been on a high-deductible plan for nearly 13 years. I have been regularly met with shock and incredulity that I could possibly want to know the cost of a procedure. My wife and I have spent, collectively, hours on the telephone trying to get answers. It's particularly galling when we get "guilt trip" treatment for asking about costs for procedures for our young daughter. We have been met with both tacit and stated insinuations that we're placing a monetary value on her "health" by asking what procedures or drugs might cost.
I don't think price transparency will fix much, though. The average person I know has employer-provided insurance and doesn't think a bit about the costs of procedures. Price transparency combined with individuals having to pay for their healthcare expenses would help, but there's blame enough to go around for every player in the system, too.
I don't think price transparency will fix much, though. The average person I know has employer-provided insurance and doesn't think a bit about the costs of procedures. Price transparency combined with individuals having to pay for their healthcare expenses would help, but there's blame enough to go around for every player in the system, too.
For some of these you may have to resort to the "ludicrous claim" approach, because people will provide information to correct you when they would never provide it just because you asked - go look at old Usenet discussions if you don't believe me.
When they won't provide price information, act as if they've just told you that it's going to cost more than $100,000 and repeat that to them. If they then say "It's not going to cost that much!" "Oh, you mean you do have some information on how much it costs?" Then work them to more detail from there "Well, is it more than 50,000?"
You may also be running into a situation where the person thinks you want an exact price and doesn't have it, so be sure you tell them you're looking for a ballpark number - or if they've irritated you and you wish to unleash the snark, "Ma'am, I'm trying to find out whether I'm going to be feeding my family on rice and beans for a week, a month, a year, or until we lose the house and my child's getting meals at the women and children homeless shelter while I'm out on my own."
Edit: It doesn't quite have to be as ludicrous as I started - a simple "Oh man, I really can't afford $5,000 for that test right now." can also get the conversation started and information flowing.
When they won't provide price information, act as if they've just told you that it's going to cost more than $100,000 and repeat that to them. If they then say "It's not going to cost that much!" "Oh, you mean you do have some information on how much it costs?" Then work them to more detail from there "Well, is it more than 50,000?"
You may also be running into a situation where the person thinks you want an exact price and doesn't have it, so be sure you tell them you're looking for a ballpark number - or if they've irritated you and you wish to unleash the snark, "Ma'am, I'm trying to find out whether I'm going to be feeding my family on rice and beans for a week, a month, a year, or until we lose the house and my child's getting meals at the women and children homeless shelter while I'm out on my own."
Edit: It doesn't quite have to be as ludicrous as I started - a simple "Oh man, I really can't afford $5,000 for that test right now." can also get the conversation started and information flowing.
That's hilarious. They are making the health of your wife and daughter a profit center yet they act offended when you want to know the cost.
Black comedy, indeed.
I'm assuming you're ESL, ... in Polish you also call it literaly "black comedy". The proper term you're looking for is "dark comedy". In the US "black comedies" nowadays is a term referring to for/by African Americans; it's a whole sub genre.
Can't speak for American English but "black comedy" is standard in British English
https://en.wikipedia.org/wiki/Black_comedy
https://en.wikipedia.org/wiki/Black_comedy
https://en.wikipedia.org/wiki/Black_comedy_(disambiguation)
At best in the US is a ambitious term and accepted colloquial term refers to comedy by/for AA audiences. At least places I live in the US (MI, CA, NY).
Anyways English is a fun, dynamic, and at the same terrible language. But I'll take your word for British flavor of the English language.
At best in the US is a ambitious term and accepted colloquial term refers to comedy by/for AA audiences. At least places I live in the US (MI, CA, NY).
Anyways English is a fun, dynamic, and at the same terrible language. But I'll take your word for British flavor of the English language.
For this, shall we just stick to the English definition? They invented the language. African American Comedy sound more accurate for the other one.
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It would "help" in the sense that people would forgo care.
Sure you might shop around for a non-emergency specialist one-off procedure like an MRI, but the cost of MRIs is a drop in the bucket and wouldn't meaningfully impact overall healthcare costs if they were an order of magnitude more expensive. If you have "normal" insurance plan your insurance provider has presumably already shopped around and only providers willing to take the reduced rate are "in-network".
Don't get me wrong: you should be able to get a cost estimate up front and it is silly that it is so difficult.
Price transparency isn't the major problem in healthcare. The free market and profit are the major problems with healthcare. To set prices a free market requires price discrimination and the ability to price some people out of the market. That translates into debilitating illness (a deadweight loss to our economy overall) or death for serious medical issues. A free market in healthcare absolutely requires that some people be allowed to die of treatable diseases in order to maximize profit.
To put it another way: As a technical matter it is impossible to discover the maximally profitable price for a treatment without raising the price beyond at least some people's ability to pay.
Sure you might shop around for a non-emergency specialist one-off procedure like an MRI, but the cost of MRIs is a drop in the bucket and wouldn't meaningfully impact overall healthcare costs if they were an order of magnitude more expensive. If you have "normal" insurance plan your insurance provider has presumably already shopped around and only providers willing to take the reduced rate are "in-network".
Don't get me wrong: you should be able to get a cost estimate up front and it is silly that it is so difficult.
Price transparency isn't the major problem in healthcare. The free market and profit are the major problems with healthcare. To set prices a free market requires price discrimination and the ability to price some people out of the market. That translates into debilitating illness (a deadweight loss to our economy overall) or death for serious medical issues. A free market in healthcare absolutely requires that some people be allowed to die of treatable diseases in order to maximize profit.
To put it another way: As a technical matter it is impossible to discover the maximally profitable price for a treatment without raising the price beyond at least some people's ability to pay.
The average person I know has employer-provided insurance and doesn't think a bit about the costs of procedures.
While that has been true for decades, in my experience, those employer-provided plans are beginning to transfer some of the cost to the consumer through higher deductibles and copays.
My last few visits to the doctor tend to support this, as in both cases, the doctor offered cost-saving options and advice.
While that has been true for decades, in my experience, those employer-provided plans are beginning to transfer some of the cost to the consumer through higher deductibles and copays.
My last few visits to the doctor tend to support this, as in both cases, the doctor offered cost-saving options and advice.
Yep. And employer plans don't avoid the random bill in the mail from "lol you still have to pay the balance because we decided not to cover all of that even though you never had a chance to know the max downside".
And if you have major surgery even on a "platinum" level plan you are still on the hook for tens of thousands of dollars. Fuck the system, its calcified nonsense at every step.
The next stage is asking them what the number needed to treat is for the drugs: https://en.wikipedia.org/wiki/Number_needed_to_treat
> ... average number of patients who need to be treated to prevent one additional bad outcome ...
Here is an example for aspirin preventing a first heart attack or stroke (NNT is ~1,667): http://www.thennt.com/nnt/aspirin-to-prevent-a-first-heart-a...
> ... average number of patients who need to be treated to prevent one additional bad outcome ...
Here is an example for aspirin preventing a first heart attack or stroke (NNT is ~1,667): http://www.thennt.com/nnt/aspirin-to-prevent-a-first-heart-a...
My dental hygienist once told me to get 3 cleanings a year. I told her my insurance covered 2. She told me that it was like chemotherapy- you should do what's medically necessary whether or not your insurance covers it.
Incidentally, people undergoing cancer treatment tend to go into debt and file for bankruptcy at a significantly higher rate than the genpop
http://www.newsweek.com/many-cancer-patients-must-face-bankr...
If your dental office is recommending 3-4 cleanings a year and you have dental insurance that covers two, there is a good chance that they may cover more. My Delta Dental (a popular dental plan in the US) lets you add a free* rider via the website to cover four cleanings a year. It has a menu of medical reasons for the extra coverage from which you choose one.
I'm told diabetes and maternity are the most common reasons people access the additional cleanings.
* I realize this is priced into the default premiums.
I'm told diabetes and maternity are the most common reasons people access the additional cleanings.
* I realize this is priced into the default premiums.
That's probably good advice. The extra $80 for a cleaning is cheaper than many of the dental procedures that many folks will need.
I find it hard to believe that a two month difference between cleanings (4 months vs. 6 months) is going to prevent any more serious dental procedure.
I have GERD but before diagnosis the acid from coughing was terrible on my teeth.
My dentist with many years experience diagnosed it. I went to the doctor who confirmed it was GERD.
I lost my job but when I was working the insurance paid for two cleaning per year. I chose to keep the insurance but it's a lesser plan that only covers one cleaning every nine months.
Twice per year was good for me since I got lazy about three or four months after visiting the dentist. I needed the twice yearly pep talk.
And I should also say that 75% of people who are diagnosed with IPF a fatal lung disease have GERD. My father has IPF and GERD I have GERD but I hope I don't develop IPF. My grandfather died of emphysema at 52 I really hope there's no connection! So yeah a dentist could point you in a direction that may help you more than you realize.
My dentist with many years experience diagnosed it. I went to the doctor who confirmed it was GERD.
I lost my job but when I was working the insurance paid for two cleaning per year. I chose to keep the insurance but it's a lesser plan that only covers one cleaning every nine months.
Twice per year was good for me since I got lazy about three or four months after visiting the dentist. I needed the twice yearly pep talk.
And I should also say that 75% of people who are diagnosed with IPF a fatal lung disease have GERD. My father has IPF and GERD I have GERD but I hope I don't develop IPF. My grandfather died of emphysema at 52 I really hope there's no connection! So yeah a dentist could point you in a direction that may help you more than you realize.
It all depends on you. If you develop plaque more quickly, you want to go more to prevent gum disease. Gum disease never goes away and always requires more intervention and more $$$.
The recommendation that you go twice a year literally originates from a toothpaste ad in the 1950s. It was an arbritary number intended to encourage you to get preventative care, aided by their toothpaste. (In those days dentists were mostly tooth pullers)
The recommendation that you go twice a year literally originates from a toothpaste ad in the 1950s. It was an arbritary number intended to encourage you to get preventative care, aided by their toothpaste. (In those days dentists were mostly tooth pullers)
Or you could spend a fraction of that on decent floss, toothpaste, and a toothbrush. If you have decent home care, you really don't need to be getting cleanings three times a year.
That's part of the reason I ended up switching away from HD. It was a ton of work to get estimates, and there was such a delay if there were multiple invoices from different providers with my deductible that I ended up having to pay several thousand over my deductible and wait to be refunded after everything had processed through the system.
In the long term, it is better for your daughter if you don't bancrupt and manage the price down. Especially if she is sick.
The guilt tripping of father of sick cold is pretty disgusting tactic.
The guilt tripping of father of sick cold is pretty disgusting tactic.
Pricing does not solve the root problem which is everything trying to get someone else to pay.
I agree with you in that this is another problem but I think the two are highly related.
Consider:
1. If you don't have insurance, how do you know where to go?
2. If your insurance company wants to reward you for picking lower priced options, how do you comply?
3. If the government wants to lower systematic costs, how do they give you incentives?
Without basic pricing information, all the benefits of a free market are absent, and so are the benefits of any incentive system.
Consider:
1. If you don't have insurance, how do you know where to go?
2. If your insurance company wants to reward you for picking lower priced options, how do you comply?
3. If the government wants to lower systematic costs, how do they give you incentives?
Without basic pricing information, all the benefits of a free market are absent, and so are the benefits of any incentive system.
Related to 1 and 2, people on high deductible health plans are paying everything out of pocket until they hit their yearly cap (then insurance kicks in). It's not even whether you have insurance or the insurance company wanting to reward you, it's trying to save your own money like any other purchase.
High deductible health plans are becoming more and more common, from what I gather.
High deductible health plans are becoming more and more common, from what I gather.
Mine's $5500. The monthly premiums are ~$300. It's an obscenity for someone who's healthy, runs, bikes, or swims pretty much every day. But it gets worse.
Recently I went to a doctor for a minor problem, but did not get pre-authorization. I knew exactly what it was going to cost for the visit, and knew it would not be covered by insurance. What I did not know is, due to lack of pre-authorization, it also would not be counted against my deductible! Dicks.
I think major medical (true insurance for unpredictable things like congenital disease or accidents) should be something everyone gets, and it's paid for with taxes. Done. And then for poor lifestyle choices like smoking and having a crappy diet, you should either die (seriously) or you should pay the system out of your own pocket to take care of you (start a gofundme, see if anyone cares about your problems).
There is no possible way to fix healthcare in the U.S. with the multilayered middle man, for-profit approach we have, where everyone touches it wants their cut.
Recently I went to a doctor for a minor problem, but did not get pre-authorization. I knew exactly what it was going to cost for the visit, and knew it would not be covered by insurance. What I did not know is, due to lack of pre-authorization, it also would not be counted against my deductible! Dicks.
I think major medical (true insurance for unpredictable things like congenital disease or accidents) should be something everyone gets, and it's paid for with taxes. Done. And then for poor lifestyle choices like smoking and having a crappy diet, you should either die (seriously) or you should pay the system out of your own pocket to take care of you (start a gofundme, see if anyone cares about your problems).
There is no possible way to fix healthcare in the U.S. with the multilayered middle man, for-profit approach we have, where everyone touches it wants their cut.
You generally can't really directly associate specific cases of disease with specific lifestyle choices.
EX: Some non smokers get lung cancer, so a percentage of smokers would have gotten cancer either way.
EX: Some non smokers get lung cancer, so a percentage of smokers would have gotten cancer either way.
What about people who live in food deserts?
What about them? They'll live longer automatically, that's one incentive.
Every state should probably require every food related corporation to be a benefit corporation, with clear phrasing that an equal motive to profit for that business is incentivizing customers to eat healthy. If the incentive is just profit, you get crazy things like government subsidized sugar farmers and boner pill pharma.
Every state should probably require every food related corporation to be a benefit corporation, with clear phrasing that an equal motive to profit for that business is incentivizing customers to eat healthy. If the incentive is just profit, you get crazy things like government subsidized sugar farmers and boner pill pharma.
'High deductible' is so broad it's almost meaningless. At $1,300 single $2,600 family (2017) in the US many people hit every year making price shopping almost pointless.
https://en.wikipedia.org/wiki/High-deductible_health_plan now at the high end of that a $13,100 family plan does provide more incentive again unless there is something significant wrong when again the incentive to price shop suddenly goes away. Worse, medical spending tends to mostly be by a few very sick people vs. the healthy making high deducible plans have limited real impact.
https://en.wikipedia.org/wiki/High-deductible_health_plan now at the high end of that a $13,100 family plan does provide more incentive again unless there is something significant wrong when again the incentive to price shop suddenly goes away. Worse, medical spending tends to mostly be by a few very sick people vs. the healthy making high deducible plans have limited real impact.
Mine's $3000/6000, I've luckily been in good enough health to not hit it. It's been the right choice for me; the amount I've saved into my HSA vs employee contribution to our more expensive health insurance option will more than cover hitting the max for a year.
I was looking into sleep studies recently, a quick google suggests a cost range of $600 to $5000. I'd definitely shop that around, and if a place won't give me a price then I wouldn't consider doing it.
But like you said, I'm pretty small potatoes compared to sick people.
I was looking into sleep studies recently, a quick google suggests a cost range of $600 to $5000. I'd definitely shop that around, and if a place won't give me a price then I wouldn't consider doing it.
But like you said, I'm pretty small potatoes compared to sick people.
How much did it actually cost? Was the estimate correct?
You know, that is a great question.
I have (excellent) employer provided care and I knew my cost would be low. But I will post this when I find out.
I have (excellent) employer provided care and I knew my cost would be low. But I will post this when I find out.
Along with price transparency, everyone should leave a doctors office with a copy of their bill. Sure, it will probably also get sent to insurance, etc. But I have had doctors bills come to me 6 months after the fact, and it is extremely confusing to try to figure out what has been billed, what hasn't, etc.
I had a hospital decide to restart the entire billing process on me after it was all paid for. Only time I've ever been glad for the insurance company (car, not health). I dropped it in their lap, and 3 mo later got an "our mistake" from the hospital, didn't have to lift a finger to fight it.
One of the more surprising things for me, watching major medical events from a distance and relatively close-up in my family, has been that hospital billing departments are at least as inconsiderate, incompetent, out-to-get-you, and generally shitty as insurance companies. And considering how much trouble I've seen/had with insurance companies that's saying something.
The number of times I've seen a bill that made no sense and been told, "oh, yeah, you're not misreading it, it's a bill, but you can ignore it because [reasons]"... WTF are they doing? Seriously, no-one else gets away with being so entirely sloppy.
Then there's the wonderful "we sent you one bill for a trivial amount which you probably lost in the pile of 50 other damn bills from 20 different providers, many of which were bills but didn't actually need to be paid (see above), plus twice that many not-bills-but-still-kinda-look-like-them statements of benefits and whatnot, didn't send a followup or call you or anything, but now you're in collections for $90 or whatever and your credit's dinged, sucks to be you".
Then if there's a dispute with insurance the hospital/providers will harass you until it's over. And sometimes just try to bill you even though they know it's being disputed. I guess they think you're not already spending enough time on the phone fixing their screw-ups.
I'm not necessarily in favor of fully nationalized healthcare exactly (some form of universal health care, yes) but it'd almost be worth having the government directly take it all over just to drink up those sweet, sweet hospital billing/admin and insurance company CEO tears. I truly wish everyone involved all the worst.
The number of times I've seen a bill that made no sense and been told, "oh, yeah, you're not misreading it, it's a bill, but you can ignore it because [reasons]"... WTF are they doing? Seriously, no-one else gets away with being so entirely sloppy.
Then there's the wonderful "we sent you one bill for a trivial amount which you probably lost in the pile of 50 other damn bills from 20 different providers, many of which were bills but didn't actually need to be paid (see above), plus twice that many not-bills-but-still-kinda-look-like-them statements of benefits and whatnot, didn't send a followup or call you or anything, but now you're in collections for $90 or whatever and your credit's dinged, sucks to be you".
Then if there's a dispute with insurance the hospital/providers will harass you until it's over. And sometimes just try to bill you even though they know it's being disputed. I guess they think you're not already spending enough time on the phone fixing their screw-ups.
I'm not necessarily in favor of fully nationalized healthcare exactly (some form of universal health care, yes) but it'd almost be worth having the government directly take it all over just to drink up those sweet, sweet hospital billing/admin and insurance company CEO tears. I truly wish everyone involved all the worst.
I had a similar experience. My wife was hospitalized for several months when her liver failed and she got a transplant. I have no complaints about any of the care she received; everyone did their jobs very well except for the billing department. Overall the total cost was around $1.5 million, and my insurance company did a fantastic job weeding out all of the duplicate and invalid claims. Their numbers for amounts claimed, allowed, paid to the providers, owed by us (deductible, co-ins), paid to us to cover out-of-pocket expenses that exceeded our annual max, etc always added up. But when the hospital tried to bill us, the numbers didn't work. Their "itemized" bill included claims that were rejected, claims that were paid by insurance, was missing claims that went through the insurance, and had some things that didn't match up to insurance claims at all. Every month they'd resend the bill, and it'd have different items on it with a different total amount. We had money from the insurance company to use to pay for what we owed the hospital, but we refused to pay it until the hospital could produce a bill that matched what the insurance company said we owed. They never did. (I'm not sure what happened; my wife and I were separated before all of this, and the bills always went to her. I think they just stopped sending the bill.)
I've had this happen many times as well - a non-itemized invoice for services rendered six or more months ago. It's not my problem that they can't get their billing service sorted. When I worked in the oil industry, vendors were expected to bill promptly (within 30-60 days) or not get paid.
Amen. There was a great article about this in the The Atlantic a few years ago. https://www.theatlantic.com/magazine/archive/2009/09/how-ame...
Anecdote: my mother-in-law was a smoker, felt dizzy one day, went to the ER and died five days later from a brain tumor. Got the Statement of Benefits (or similar): the cost was $140k; Medicare paid $40k...
Anecdote: my mother-in-law was a smoker, felt dizzy one day, went to the ER and died five days later from a brain tumor. Got the Statement of Benefits (or similar): the cost was $140k; Medicare paid $40k...
This strikes me as absolutely absurd. Here, as an example, dentistry is highly regulated and prices are listed in a book. If you want procedure X done it will cost $Y no matter which dentist you visit. This means it's easier to budget for such things, you never have to price shop, and the insurance companies can also easily predict what the costs will be given statistical trends.
This idea of medical procedures having random prices is the sort of thing you have to deal with at veterinarians where a simple procedure can cost anywhere from $75 to $500 depending on the place you're going to.
This idea of medical procedures having random prices is the sort of thing you have to deal with at veterinarians where a simple procedure can cost anywhere from $75 to $500 depending on the place you're going to.
In the US dentists don't all charge the same thing in my experience although they're probably in the same general ballpark for a given procedure. A quick Google seems to confirm that. There is definitely more transparency in pricing because many/most people don't have insurance and insurance for semi-cosmetic procedures is somewhat limited. (And there are often treatment options that people will reasonably choose from based on price.)
Transparency would certainly help but it cant solve everything. But medical care isn't regular and predicable, so at best you can get better transparency about the routine costs.
My car was recently hit in the parking lot. The body shop said, here's the cost of the repair of the items we can see, but with the warning that it could go higher if we open things up, and find additional damage. Same with people.
The other thing is the you know with a car exactly what you will end up with in the end. And with simpler medical procedures that is true, but as they get more complex - the more you are navigating a mess of interlocking procedures, probabilities, and outcomes.
My car was recently hit in the parking lot. The body shop said, here's the cost of the repair of the items we can see, but with the warning that it could go higher if we open things up, and find additional damage. Same with people.
The other thing is the you know with a car exactly what you will end up with in the end. And with simpler medical procedures that is true, but as they get more complex - the more you are navigating a mess of interlocking procedures, probabilities, and outcomes.
Actually, one way to attack the problem is something Hacker News folk could help with:
Build "open source" coding, grouping and costing schemes and tools to maintain those schemes. It would look something like: 1) a software tool to maintain coding systems, grouping, and related costs (essentially a database front-end); 2) something like Wikipedia/GitHub that maintains version history and controls for coding, grouping and pricing schemes; 3) crowd-sourcing so healthcare professionals and organizations could help maintain the data; and 4) a non-profit, non-governmental organization (maybe something like the Mozilla or Apache foundations) that runs to help govern and provide structured releases of the open coding/grouping/costing data.
These are just my ideas, but having worked in this industry on the problem of health insurance/healthcare fraud and "healthcare cost" - there are a bunch of organizations making a small fortune controlling these schemes (ex. the AMA) - something ripe for disruption (I hate using this word, but it's the truth).
You need quality coding/grouping/costing schemes and systems for the industry to function, but it should be many, many times more open than it currently is.
Build "open source" coding, grouping and costing schemes and tools to maintain those schemes. It would look something like: 1) a software tool to maintain coding systems, grouping, and related costs (essentially a database front-end); 2) something like Wikipedia/GitHub that maintains version history and controls for coding, grouping and pricing schemes; 3) crowd-sourcing so healthcare professionals and organizations could help maintain the data; and 4) a non-profit, non-governmental organization (maybe something like the Mozilla or Apache foundations) that runs to help govern and provide structured releases of the open coding/grouping/costing data.
These are just my ideas, but having worked in this industry on the problem of health insurance/healthcare fraud and "healthcare cost" - there are a bunch of organizations making a small fortune controlling these schemes (ex. the AMA) - something ripe for disruption (I hate using this word, but it's the truth).
You need quality coding/grouping/costing schemes and systems for the industry to function, but it should be many, many times more open than it currently is.
Price transparency is not going to fix much, if anything. It may induce rage increased blood pressure on the front end (prior to receiving service), but ultimately health care is often a "must have."
Having a price list in hand doesn't suddenly make the price conscious consumer more of an expert regarding the necessity of various services estimated. Nor does it really encourage competition between competitors.
Having a price list in hand doesn't suddenly make the price conscious consumer more of an expert regarding the necessity of various services estimated. Nor does it really encourage competition between competitors.
You seem to be missing that people want to compare prices at various firms, as well as deciding whether to have a procedure.
No, I'm not missing that. It doesn't make as much of a difference as you'd think. There are plenty of companies and organizations in this space who offer "price transparency" services to varying degrees of accuracy.
There is significant difference in the price different places charge for services. It's not necessarily deciding whether or not to do the treatment, but can also encompass consumers being cognizant of cost and choosing providers who are cheaper.
Here is a planet money podcast which goes through some examples of significant expenses being saved.
http://www.npr.org/sections/money/2015/10/02/445371930/episo...
Here is a planet money podcast which goes through some examples of significant expenses being saved.
http://www.npr.org/sections/money/2015/10/02/445371930/episo...
Surprise! Pricing is "transparent", although massively complicated.
There are several systems, but let's take a look at Outpatient procedure pricing...
A good outpatient pricing guide is here: https://www.cms.gov/Outreach-and-Education/Medicare-Learning...
And coupled with the OPPS dataset here: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Paymen... as well as a couple others, along with a quick read of the federal register, you can kinda figure it out on your own (/s).
Every bill you get must also have the codes and modifiers on it by law. Its interesting to download the dataset and look them up.
--EDIT-- I incorrectly linked to the COBOL PC Pricer code above for OPPS! Here is the pricing data: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Paymen...
There are several systems, but let's take a look at Outpatient procedure pricing...
A good outpatient pricing guide is here: https://www.cms.gov/Outreach-and-Education/Medicare-Learning...
And coupled with the OPPS dataset here: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Paymen... as well as a couple others, along with a quick read of the federal register, you can kinda figure it out on your own (/s).
Every bill you get must also have the codes and modifiers on it by law. Its interesting to download the dataset and look them up.
--EDIT-- I incorrectly linked to the COBOL PC Pricer code above for OPPS! Here is the pricing data: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Paymen...
Pricing is not even nominally transparent. By law, you can get access to the chargemaster, which is the list price that nobody actually pays. If you try to get access to the negotiated price your insurance company will pay, you'll quickly discover that it's confidential up until the point where the provider actually issues a bill. Medicare pricing is a special case, but you can't get that price without being on Medicare. Also, many providers won't accept Medicare because reimbursement is meager and often unprofitable.
I wonder if there is a straightforward way to aggregate people's bills to estimate the cost of a procedure (eg appendectomy) at a given hospital. Eg pay people $1 to scan their bill. This would only work for common procedures I suppose.
HIPAA was passed largely to prevent this potential catastrophe for healthcare executives. b^)
De-identified data and data contributed by people (read, not Covered Entities) is not covered by HIPAA. Someone could build a database of procedure cost comprised of these data sets, but price transparency isn't so easy due to the nuances of the problem (See Castlight Health).
So build it in Europe?
That's a great idea because the codes are usually on the bill, too. The problem, of course, is keeping all of that volunteered data secure.
Replying to myself because I can no longer edit: California law requires public access to the chargemaster. This is not true in other states.
> Medicare pricing is a special case, but you can't get that price without being on Medicare.
As far as I recall, Medicare pricing is defined by law as a percentage of the lowest price the provider ever charges to anyone else. For the sake of this comment, call it 40%.
If Medicare pricing is public, you can look it up and try to negotiate for 250% or whatever of the Medicare price.
As far as I recall, Medicare pricing is defined by law as a percentage of the lowest price the provider ever charges to anyone else. For the sake of this comment, call it 40%.
If Medicare pricing is public, you can look it up and try to negotiate for 250% or whatever of the Medicare price.
If you're uninsured and unable to pay you may be able to get the Medicare rate as a "I will pay you this amount to settle this in full, and I will pay it today" because that rate is still higher than they'd get from selling it to collections.
If it's massively complicated and obscure, then it's not transparent. Transparent means the information is available up front or for the asking, not that it's possible to obtain it if you have expert knowledge.
What you're sharing is great information and a fine foundation for people to build on. But pateients shouldn't have to go off and do a pile of research, they should be able to get a straight answer from their health provider when they ask for one.
If you have a pet and have to visit the vet, you already know they prefer to get paid up front. They'll generally tell you there's a fixed fee for the consultation/ Then depending on what's wrong with your animal they offer a treatment estimate, which is prepared within minutes and about which the administrative staff are generally competent to answer questions (eg why there might be variations in price for some items like anaesthetic). Animal medicine is at once less complex than human medicine (narrower range of treatment options, fewer administrative/legal considerations) and more complex (considerable variation among species).
I've been to good vets and bad vets, but the administrative aspects of both regular and emergency care have been painless and yes, transparent. Until we get universal healthcare, veterinary service would be an excellent model to imitate.
What you're sharing is great information and a fine foundation for people to build on. But pateients shouldn't have to go off and do a pile of research, they should be able to get a straight answer from their health provider when they ask for one.
If you have a pet and have to visit the vet, you already know they prefer to get paid up front. They'll generally tell you there's a fixed fee for the consultation/ Then depending on what's wrong with your animal they offer a treatment estimate, which is prepared within minutes and about which the administrative staff are generally competent to answer questions (eg why there might be variations in price for some items like anaesthetic). Animal medicine is at once less complex than human medicine (narrower range of treatment options, fewer administrative/legal considerations) and more complex (considerable variation among species).
I've been to good vets and bad vets, but the administrative aspects of both regular and emergency care have been painless and yes, transparent. Until we get universal healthcare, veterinary service would be an excellent model to imitate.
Yes, hence the "transparent" in quotes and the overt sarcasm (apparently harder to detect than I intended). Of course patients shouldn't need to download a dataset and figure it out on their own! But please see my other response to see why it is tricky.
Regarding pets, they are not beholden to hospital/insurance provider duality, and it follows that since it is out of pocket, you would not be able to afford a $60k set of procedure if your dog had a broken leg...so the prices stay affordable.
Regarding pets, they are not beholden to hospital/insurance provider duality, and it follows that since it is out of pocket, you would not be able to afford a $60k set of procedure if your dog had a broken leg...so the prices stay affordable.
> "And these are your reasons, my Lord?"
> "Do you think I have others?" said Lord Vetinari. "My motives, as ever, are entirely transparent."
> Hughnon reflected that 'entirely transparent' meant either that you could see right through them or that you couldn't see them at all.
-- The Truth, by Terry Pratchett
> "Do you think I have others?" said Lord Vetinari. "My motives, as ever, are entirely transparent."
> Hughnon reflected that 'entirely transparent' meant either that you could see right through them or that you couldn't see them at all.
-- The Truth, by Terry Pratchett
This is why the Dutch system is interesting. They have a two-tier model of private and public coverage. For short-term, low-cost care, the private market operates (under regulation) and for long-term care they have a state supplied universal coverage system.
Tbh if I broke my own leg I think I'd rather have the vet do it. Every time I have had to bring a friend or family member to hospital I'm just appalled by it all.
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I suppose this would be helpful if they gave us the pricing before the decision of where (or, for many unfortunate people, if) to have the procedure or test done.
You seem to be talking about medicare and medicaid, and not about private hospital services. Is that correct?
You seem to be talking about medicare and medicaid, and not about private hospital services. Is that correct?
Yes, also sorry for the insensitive sarcasm in the previous post. It's a chicken and egg problem. In many cases you don't know if you need a test unless you've already had it. In the case of a procedure, there may be things that come up while it's happening that may complicate things. The irony is that OPPS/IPPS (inpatient) and APC (ambulatory) are meant to simplify things. Doctors and nurses usually do their best to know ahead of time, but medical procedures are complicated.
Fraud does happen most often against medicare/medicaid (as covered in this article with one trick known as "upcoding"), but I believe these codes are used with insurance providers as well. If a hospital or doctor is in your provider network (HMO/PPO) then there is a pre-agreed cost between the two set on these fees. Out of network occurs when there is no agreement, so there is no "trust" between the two and the insurance provider offsets the cost to you because they are legally able to do so.
In my opinion - overbilling is really caused not by pricing complexity, but by the control of the hospital and insurance provider duality. If there was no such thing as a network, and you were covered everywhere, then shenanigans with certain hospitals and providers would be more difficult.
Fraud does happen most often against medicare/medicaid (as covered in this article with one trick known as "upcoding"), but I believe these codes are used with insurance providers as well. If a hospital or doctor is in your provider network (HMO/PPO) then there is a pre-agreed cost between the two set on these fees. Out of network occurs when there is no agreement, so there is no "trust" between the two and the insurance provider offsets the cost to you because they are legally able to do so.
In my opinion - overbilling is really caused not by pricing complexity, but by the control of the hospital and insurance provider duality. If there was no such thing as a network, and you were covered everywhere, then shenanigans with certain hospitals and providers would be more difficult.
> In many cases you don't know if you need a test unless you've already had it. In the case of a procedure, there may be things that come up while it's happening that may complicate things.
If you're getting something like a chest x-ray (posterior and lateral views), or an abdominal ultrasound, or a lipid panel, you should be able to call around to various labs with the appropriate CPT code(s) and ask them what the price would be.
What's you're talking about would be something like if they order a test and based on the result of that test, they need to perform more tests to confirm or eliminate a possible diagnosis. But for each test, you should be able to get the price since each test has a couple of possible CPT codes that it would fall under for billing purposes.
If you're getting something like a chest x-ray (posterior and lateral views), or an abdominal ultrasound, or a lipid panel, you should be able to call around to various labs with the appropriate CPT code(s) and ask them what the price would be.
What's you're talking about would be something like if they order a test and based on the result of that test, they need to perform more tests to confirm or eliminate a possible diagnosis. But for each test, you should be able to get the price since each test has a couple of possible CPT codes that it would fall under for billing purposes.
at least in the US one has to remember that Medicaid pays less than Medicare for the same procedures with private insurance taking the price higher hits
"Let me add my big one: price transparency."
Lack of price transparency bothers me as well and I wish we had it.
However, I don't know if there will ever be enough pressure to manifest this. Price transparency really only matters to the person paying the bill. Our society is very rapidly evolving to consider any healthcare cost of any kind to be an insurmountable burden that no normal person could ever be expected to pay. I suspect that the incomprehensible, ridiculous healthcare schemes that we are living through currently are just death spasms on the way to fully socialized medicine.
I'm sure there are rare people here and there that care how much a mile of highway costs to pave or how much a mile of city sewer line costs to install ... I would expect the same number of people to care about the cost of a medical procedure when their own cost is $0.
Lack of price transparency bothers me as well and I wish we had it.
However, I don't know if there will ever be enough pressure to manifest this. Price transparency really only matters to the person paying the bill. Our society is very rapidly evolving to consider any healthcare cost of any kind to be an insurmountable burden that no normal person could ever be expected to pay. I suspect that the incomprehensible, ridiculous healthcare schemes that we are living through currently are just death spasms on the way to fully socialized medicine.
I'm sure there are rare people here and there that care how much a mile of highway costs to pave or how much a mile of city sewer line costs to install ... I would expect the same number of people to care about the cost of a medical procedure when their own cost is $0.
> I'm sure there are rare people here and there that care how much a mile of highway costs
No offense meant, but I find this attitude really odd. I'm not from US and only have an overall idea how things work there, but I wonder... Isn't that still your money, even if you pay $0 directly and the rest comes from the shared pool your insurance payments or taxes are also in?
I just tend to believe there ain't no such thing as a free lunch - someone has to pay for the medical services, highway pavement or sewer line installation. People can't be expected to work for free, right?
So I think anyone participating in a collective funding effort should have at least some rough ideas how the money they pay are used. If we don't care about how government or insurance company (or whatever entity we pay our share to) manages things - we would surely end up with insurmountable burdens called "things running out of control".
No offense meant, but I find this attitude really odd. I'm not from US and only have an overall idea how things work there, but I wonder... Isn't that still your money, even if you pay $0 directly and the rest comes from the shared pool your insurance payments or taxes are also in?
I just tend to believe there ain't no such thing as a free lunch - someone has to pay for the medical services, highway pavement or sewer line installation. People can't be expected to work for free, right?
So I think anyone participating in a collective funding effort should have at least some rough ideas how the money they pay are used. If we don't care about how government or insurance company (or whatever entity we pay our share to) manages things - we would surely end up with insurmountable burdens called "things running out of control".
> I find this attitude really odd. (snip) I just tend to believe there ain't no such thing as a free lunch - someone has to pay for the medical services, highway pavement or sewer line installation. People can't be expected to work for free, right?
I think the issue is that most of these services are so cheap that the cost isn't ever a major factor. "No one cares" is probably more accurately stated as "no one is forced to care, because the general public can have confidence it's handled mostly responsibly".
In Michigan, for example, to completely tear down and rebuild new a lane-mile of freeway that is rated to last 20 years, cost roughly $2 million dollars in 2016. So, a brand new stretch of freeway, 4 lanes wide and 100 miles long, would cost about $400 million dollars. (That distance covers, just as an example, an entire trip from Chicago to Milwaukee)
That cost sounds insane at face value, and gets everyone worked up about "costs". Until you math that out and realize it comes out to 33 cents per citizen per month. At which point, freeways seem like a crazy good bargain. Even if you go crazy and build 20 times more freeway than that, the total cost is still cheaper than a Netflix subscription.
They're not all that low of course, but this tends generally holds true of many social services or utilities (water, sewer, electrical, firefighters, schools, police, etc). High upfront cost, high "sticker shock" value, but as a common good everyone can benefit from it becomes a pretty reasonable cost per person. Far lower than it would ever cost to do so any other way.
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The only thing that doesn't seem to work that way in the US is healthcare. And I don't know why, but I suspect it's because it's so privatized and unregulated (so lots of profit and overhead) and also so intentionally hidden in terms of cost (so there's no way to look up costs, the way you can with any normal social service).
I think the issue is that most of these services are so cheap that the cost isn't ever a major factor. "No one cares" is probably more accurately stated as "no one is forced to care, because the general public can have confidence it's handled mostly responsibly".
In Michigan, for example, to completely tear down and rebuild new a lane-mile of freeway that is rated to last 20 years, cost roughly $2 million dollars in 2016. So, a brand new stretch of freeway, 4 lanes wide and 100 miles long, would cost about $400 million dollars. (That distance covers, just as an example, an entire trip from Chicago to Milwaukee)
That cost sounds insane at face value, and gets everyone worked up about "costs". Until you math that out and realize it comes out to 33 cents per citizen per month. At which point, freeways seem like a crazy good bargain. Even if you go crazy and build 20 times more freeway than that, the total cost is still cheaper than a Netflix subscription.
They're not all that low of course, but this tends generally holds true of many social services or utilities (water, sewer, electrical, firefighters, schools, police, etc). High upfront cost, high "sticker shock" value, but as a common good everyone can benefit from it becomes a pretty reasonable cost per person. Far lower than it would ever cost to do so any other way.
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The only thing that doesn't seem to work that way in the US is healthcare. And I don't know why, but I suspect it's because it's so privatized and unregulated (so lots of profit and overhead) and also so intentionally hidden in terms of cost (so there's no way to look up costs, the way you can with any normal social service).
"Isn't that still your money, even if you pay $0 directly and the rest comes from the shared pool your insurance payments or taxes are also in?"
Well, please do read the first sentence of my reply - I do care and I do wish that price transparency were extant.
Further, as a net tax payer, in California no less, I am quite interested in the actual costs of things like road paving and bridge building and subway tunneling.
But neither of those (net tax paying and interest in the pricing of social goods) are common traits.
Well, please do read the first sentence of my reply - I do care and I do wish that price transparency were extant.
Further, as a net tax payer, in California no less, I am quite interested in the actual costs of things like road paving and bridge building and subway tunneling.
But neither of those (net tax paying and interest in the pricing of social goods) are common traits.
Ouch. Sorry, seems that I misunderstood your post. My apologies.
> Our society is very rapidly evolving to consider any healthcare cost of any kind to be an insurmountable burden that no normal person could ever be expected to pay
On the other hand, if prices are not managed properly, premiums get higher and higher. So even if insurance pays, you should care that prices are reasonable.
On the other hand, if prices are not managed properly, premiums get higher and higher. So even if insurance pays, you should care that prices are reasonable.
Car insurance doesn't cover routine maintenance, for example. So the prices for things like oil changes are relatively reasonable. If we had to go through insurance for things like that, then I'm willing to bet that the price of the service would increase substantially and auto insurance premiums would go up quite a bit as well.
Thatv may be true but, for healthcare, there is an important difference in favor of you: a car is replaceable, a life isn't.
If you don't do routine maintenance, the engine breaks down and _you_ have to pay for it.
If you don't do routine checkups, you get sick and insurance has to pay---and also, if you die those sweet premiums stop coming to them. Insurance actually has a vested interest in paying for your checkups and screenings, just like in countries with socialized healthcare.
If you don't do routine maintenance, the engine breaks down and _you_ have to pay for it.
If you don't do routine checkups, you get sick and insurance has to pay---and also, if you die those sweet premiums stop coming to them. Insurance actually has a vested interest in paying for your checkups and screenings, just like in countries with socialized healthcare.
This is exactly what Castlight was originally trying to solve with their transparency tool:
https://en.wikipedia.org/wiki/Castlight_Health
Always thought their approach was quite clever and I think they did end up having some success though I'm not sure the overall impact has been as transformative as was originally hoped.
Always thought their approach was quite clever and I think they did end up having some success though I'm not sure the overall impact has been as transformative as was originally hoped.
Colorado has this cool law which, as far as I can gather, requires hospitals to report prices for various conditions.
It results in tools like this: https://cha.fhsclearquote.com/ You put in your zip code, how far you want to go, find the condition, and it gives you a list of hospitals, average charge, case volume, and 5th and 95th percentile costs.
I'd love a more nuanced analysis that looked at outcomes, too. Still. It's a great tool for planning purposes ("If I have an emergency, take me to . . . ")
It results in tools like this: https://cha.fhsclearquote.com/ You put in your zip code, how far you want to go, find the condition, and it gives you a list of hospitals, average charge, case volume, and 5th and 95th percentile costs.
I'd love a more nuanced analysis that looked at outcomes, too. Still. It's a great tool for planning purposes ("If I have an emergency, take me to . . . ")
Hey, that's wonderful. Price transparency is always touted as the panacea for the relentless runaway growth in healthcare costs in the States. Here's the natural experiment. Has this law managed to rein in healthcare costs?
You'd think it hasn't, and the missing focus on outcomes gives it away.
You'd think it hasn't, and the missing focus on outcomes gives it away.
I don't think most people know about it. It's helped rein in healthcare costs in this household at least, though? ;)
This has been a concern for me as well. I've had doctors order things and call them one thing in person that sounds like what my insurance covers, but then they're billed as something different and I get stuck with the bill, when I really wasn't willing to pay for what it was.
So now when I'm signing the papers accepting responsibility for the financial obligations if my insurance doesn't, I ask what it's going to cost if my insurance doesn't cover it. The nurses have no idea. It has to get "coded" before it's billed, and then after the bill is declined the coding people can tell me what I owe them. It's ridiculous.
So now when I'm signing the papers accepting responsibility for the financial obligations if my insurance doesn't, I ask what it's going to cost if my insurance doesn't cover it. The nurses have no idea. It has to get "coded" before it's billed, and then after the bill is declined the coding people can tell me what I owe them. It's ridiculous.
Price transparency is probably not feasible, most of the time. For the software developers, here's an analogy: asking your doctor how much it will cost to treat you is akin to a product manager asking you how long it will take to implement a feature. You might have a rough idea, but until you get into the requirements, do some design work, and dig into the details you can't even come up with a precise estimate. And you won't know the final time until you've actually completed the feature.
Doctors have a similar problem: too much uncertainty which can't be eliminated until the treatment is completed. They can't even tell you how much an office visit costs, because of the variability in how much time each patient needs, involvement of nurses and PAs, and any tests that must be performed.
Lab tests are a little better: they tend to take a predictable amount of time to perform, and the analysis is pretty standardized, but there's probably still some variability when the results are not routine. That explains the fairly narrow range you were eventually able to get.
I think we've got the wrong pricing model in mind for healthcare. Instead of itemizing every little action, test, and pill, we should be aggregating these costs. Pay medical professionals fixed salaries, fund institutions using budgets for fixed costs and consumables costs, and pay for it all via taxation as a common good, like public education, libraries, defense, etc.
Doctors have a similar problem: too much uncertainty which can't be eliminated until the treatment is completed. They can't even tell you how much an office visit costs, because of the variability in how much time each patient needs, involvement of nurses and PAs, and any tests that must be performed.
Lab tests are a little better: they tend to take a predictable amount of time to perform, and the analysis is pretty standardized, but there's probably still some variability when the results are not routine. That explains the fairly narrow range you were eventually able to get.
I think we've got the wrong pricing model in mind for healthcare. Instead of itemizing every little action, test, and pill, we should be aggregating these costs. Pay medical professionals fixed salaries, fund institutions using budgets for fixed costs and consumables costs, and pay for it all via taxation as a common good, like public education, libraries, defense, etc.
Well, in some sense that's true of most businesses, right? Some customer interactions take up more overhead and resources than others. The trick is to aggregate that uncertainty over your customer base and come up with a price that incorporates your expected average costs. There are a lot of businesses that do this successfully because they have to in order to participate in the market. The reason health care providers don't seems to me because that are isolated from competition by heavy regulation. (I'm not saying the regulation in the health care space is necessarily a bad thing on balance, but it means that change can only come through additional regulation rather than depending on hamstrung market forces.)
Hang on. The comment you're replying to is complaining that they can't get a price for a single test, a discrete unit of health care. That's not like not being able to get a price for a completed Rails app; it's like not being able to get a price for a Macbook. I think you've moved the goalposts a little.
I did say that lab tests have less variability, which means they should be easier to price. My guess is that the reason the OP had so much trouble getting a price is because the lab simply doesn't work that way. It doesn't have a consumer price list; instead they do the work first, then determine which insurer to send the claim to, and then sometime later get paid whatever the insurer has set the standard reimbursement to be.
What the OP found on the 10th attempt to get a price was somebody who was willing to look up claims for other people who had the same test, determine what the reimbursements were, and let him know the cross-insurer range of those amounts. Or maybe the range was over the claims sent to the insurance companies, rather than the amounts the insurers actually paid. If that's the case, then the range reflects actually differences in the test processing rather than differences in the insurers.
What the OP found on the 10th attempt to get a price was somebody who was willing to look up claims for other people who had the same test, determine what the reimbursements were, and let him know the cross-insurer range of those amounts. Or maybe the range was over the claims sent to the insurance companies, rather than the amounts the insurers actually paid. If that's the case, then the range reflects actually differences in the test processing rather than differences in the insurers.
I agree that the pricing model is wrong. Fee for service creates perverse incentives.
Having said that, though, unlike developing a new piece of software we have vast stores of data about procedures, complications, and outcomes from other patients who have already undergone the procedure. Surely there's a pricing model, if we are bound to fee for service, that could use this trove of existing data to provide more transparency.
I'd be happy with knowing pricing within half an order of magnitude.
Having said that, though, unlike developing a new piece of software we have vast stores of data about procedures, complications, and outcomes from other patients who have already undergone the procedure. Surely there's a pricing model, if we are bound to fee for service, that could use this trove of existing data to provide more transparency.
I'd be happy with knowing pricing within half an order of magnitude.
A lot of that trove of existing data is locked up behind privacy law barriers, and there's no incentive for doing the work to strip out the PII and make it available for aggregate analysis. And since we're talking about the costs for performing medical treatments, the details that would need to be stripped out could be significant.
For example, if Procedure A tends to be more costly when the patient also needs Procedure B, that's significant. But if the aggregate information includes the fact that the same patient needed both A and B, that might be usable to identify the patient, and so the relationship can't be shared in the data.
For example, if Procedure A tends to be more costly when the patient also needs Procedure B, that's significant. But if the aggregate information includes the fact that the same patient needed both A and B, that might be usable to identify the patient, and so the relationship can't be shared in the data.
The software development number is, arguably, almost completely unknowable. The healthcare pricing number is knowable (for some fuzzy value of knowable) if our society cared enough to do something about it. We don't, though.
> asking your doctor how much it will cost to treat you is akin to a product manager asking you how long it will take to implement a feature.
Not in all cases. If your doctor orders labs or procedures, then getting the price should be straightforward. The fact that it currently isn't is a problem.
Not in all cases. If your doctor orders labs or procedures, then getting the price should be straightforward. The fact that it currently isn't is a problem.
That sounds fine on paper but does tends to cause overuse of the resource. People don’t value what they get cheaply or free. I belive NHS from UK is facing a similar problem.
"overuse" is a tricky word to use here. Are we concerned about patients getting too much "good healthcare" without being adequately grateful for it? Should we give them "adequate healthcare" instead? Or maybe "barely adequate", so that they know what they're missing?
You're probably thinking more along the lines of unnecessary tests being performed, or prescribing drugs "just in case". I have a dermatologist near me who I like and who is widely known, but every time I see her if she prescribes one drug for me, she prescribes 1 or 2 others as well for the exact same thing.
I believe that this sort of waste comes partly from a financial incentive (line items on insurance claims, or justification for them, and in my dermatologist's case kickbacks from drug companies), and partly from as a defense against being accused of malpractice. It could also be simple laziness too: order a test and let the lab try to figure out a diagnosis.
Any major overhaul of the healthcare system along the lines I proposed would need to deal with these issues as well. The financial and malpractice incentives could probably be eliminated. Maybe laziness too, assuming doctors had to get annual reviews for salary adjustments, just like everyone else.
You're probably thinking more along the lines of unnecessary tests being performed, or prescribing drugs "just in case". I have a dermatologist near me who I like and who is widely known, but every time I see her if she prescribes one drug for me, she prescribes 1 or 2 others as well for the exact same thing.
I believe that this sort of waste comes partly from a financial incentive (line items on insurance claims, or justification for them, and in my dermatologist's case kickbacks from drug companies), and partly from as a defense against being accused of malpractice. It could also be simple laziness too: order a test and let the lab try to figure out a diagnosis.
Any major overhaul of the healthcare system along the lines I proposed would need to deal with these issues as well. The financial and malpractice incentives could probably be eliminated. Maybe laziness too, assuming doctors had to get annual reviews for salary adjustments, just like everyone else.
And yet, the idea that health care "consumers" would price-shop for the lowest-cost procedure is a dogmatic core of some American ideas about how to "fix" cost in health care.
It certainly wouldn't fix everything, but there are certain type situations it would help fix, yet the philosophy hasn't been tried (at least as long as employer-sponsored health cartels have been around). True price transparency requires that a given provider charge exactly the same amount, regardless of the customer - prohibit bespoke "negotiated" rates, hidden kickbacks, etc.
Just today I went to an major-hospital urgent care clinic that has an upfront $50 fee to "be seen". I normally avoid the system like the plague it is (hence not wanting to pay into its protection rackets), but my girlfriend had gone last week for the same week-long fever and had a good experience, so I figured I'd give it a shot.
The person working at the desk told me that there "could" be "extras" that would be beyond that fee. Okay, cool. The physician's assistant recommended a chest x-ray, added it was around $75, then confirmed it was $56, and I quickly agreed. My girlfriend was a bit miffed she had turned down the x-ray without knowing the actual price.
When it came time to settle up the bill, they had added on a $130 charge because the PA had added on some billable event for her seeing me, despite that this should have clearly been included in the "$50 to be seen".
This is textbook fraud, yet it is allowed to persist. I complained, and was met with the standard "it's nobody's fault" attitude, because these people are really just skinjobs on an opaque computer system. If I had been my normal self (currently dealing with some major life events), I would have only paid for the x-ray and told them to shove their unauthorized charge up their ass. Alas, they dropped the fraudulent charge to $80, but the bad taste remains.
If I had been told the higher charge up front, that would have been completely acceptable - and if I thought it too high I could have gone to a competitor, or simply not gone (never before in my adult life have I gone to the hospital for a fever).
And that doesn't even address the travesty of the only result coming out of this visit was receiving a prescription for the exact same antibiotic my girlfriend had received a week prior! It would have been much easier for her to buy two simultaneous doses from the pharmacy, but the cartel has that locked down as well.
Just today I went to an major-hospital urgent care clinic that has an upfront $50 fee to "be seen". I normally avoid the system like the plague it is (hence not wanting to pay into its protection rackets), but my girlfriend had gone last week for the same week-long fever and had a good experience, so I figured I'd give it a shot.
The person working at the desk told me that there "could" be "extras" that would be beyond that fee. Okay, cool. The physician's assistant recommended a chest x-ray, added it was around $75, then confirmed it was $56, and I quickly agreed. My girlfriend was a bit miffed she had turned down the x-ray without knowing the actual price.
When it came time to settle up the bill, they had added on a $130 charge because the PA had added on some billable event for her seeing me, despite that this should have clearly been included in the "$50 to be seen".
This is textbook fraud, yet it is allowed to persist. I complained, and was met with the standard "it's nobody's fault" attitude, because these people are really just skinjobs on an opaque computer system. If I had been my normal self (currently dealing with some major life events), I would have only paid for the x-ray and told them to shove their unauthorized charge up their ass. Alas, they dropped the fraudulent charge to $80, but the bad taste remains.
If I had been told the higher charge up front, that would have been completely acceptable - and if I thought it too high I could have gone to a competitor, or simply not gone (never before in my adult life have I gone to the hospital for a fever).
And that doesn't even address the travesty of the only result coming out of this visit was receiving a prescription for the exact same antibiotic my girlfriend had received a week prior! It would have been much easier for her to buy two simultaneous doses from the pharmacy, but the cartel has that locked down as well.
I am always dismayed when I get back "it depends". depends on what? I want a pure cash price. however it has been this way for decades having listened to my grandfather back in the nineties trying to by his wife a wheelchair only to be told he could not buy one and no they would not give him a price. so he did what anyone of his generation did, goodwill, salvation army, and finally found one at a garage sale. he just didn't think it right someone had to pay for what he needed for his wife but damn if the system stymies people at every turn.
the new billing fun I have is required visits for prescription refills on some medicines and that to me is just overbilling in a different form. I didn't need to visit other than to get permission to refill; no it does not necessarily need to be a controlled substance
the new billing fun I have is required visits for prescription refills on some medicines and that to me is just overbilling in a different form. I didn't need to visit other than to get permission to refill; no it does not necessarily need to be a controlled substance
I would love to go to a doctor that had a price board hung in their waiting room so I'd know up front what the cost would be.
Well-baby checkup: $120
School sports physical: $150
Blood tests: $80
Minor broken bone: $400
Major broken bone: $1200"But we don't know [major vs minor] until we look at it!..."
So add what all car shops say:
Hourly rate: $100 / hour.
And begin with a 30 minute to 60 minute diagnostic estimate (providing findings at 30 minute increments).
So add what all car shops say:
Hourly rate: $100 / hour.
And begin with a 30 minute to 60 minute diagnostic estimate (providing findings at 30 minute increments).
But then they wouldn't be able to bill $1350 for a 15 minute visit.
I think that people always want to look for the worst in every situation. America's healthcare system may not be up to first world standards for treatment. And it bankrupts hundreds of thousands of people a year. But, it's the most profitable healthcare system in the world, and that's the metric that investors really care about.
I guess it won't hurt to offer my own anecdata point about idiot medical billing.
Stanford hospital billed us for an IVF procedure. However, we were in Paris at the time they claimed my wife was undergoing the procedure.
It took going down to the billing office with our ticket stubs and pitching a fit to get it zeroed out.
I agree there's lots of room for improvement in medical billing.
Stanford hospital billed us for an IVF procedure. However, we were in Paris at the time they claimed my wife was undergoing the procedure.
It took going down to the billing office with our ticket stubs and pitching a fit to get it zeroed out.
I agree there's lots of room for improvement in medical billing.
Because there's too much coverage, and effectively no choice (due to excessive standardization), the insurance companies are forced not to operate as insurance companies at all.
No choice, no competition, no money left when they're done with you.
No choice, no competition, no money left when they're done with you.
This is what happens when you make the health care system capitalist. Despite rumours to the contrary, capitalism doesn't reduce prices, that would make no sense for a company trying to make a profit.
French outpatient care runs in a capitalist manner. You pay full price at the office, and your insurance reimburses you at 80% of "reasonable and customary". You are free to choose any Doctor, and it is up to you to decide how much any conveniences or perceived quality is worth.
Can't say I am an expert on the French system, but a quick Google says that the insurance is pretty tightly regulated by government.
pancreas(2)
Healthcare will always be overpriced so long as we allow this guild system to limit the supply of doctors for its own member's profit. Everything else is window dressing.
If that's the case then how come in other countries with similar strong unions/guilds healthcare costs are so much lower? Nobody complains the BMA is increasing the price of healthcare in the UK.
> Everything else is window dressing
I think most reasonable people can figure out a) the difference between the US healthcare system and nearly all other countries, and b) what that difference might mean for costs. Here's a hint, it's not "the guild system limiting the supply of doctors".
> Everything else is window dressing
I think most reasonable people can figure out a) the difference between the US healthcare system and nearly all other countries, and b) what that difference might mean for costs. Here's a hint, it's not "the guild system limiting the supply of doctors".
Coming from a country where the number of MDs per capita is 100x that of the US, I am sorry to tell you that this would not have the impact you think it would have.
As of now, no first world country seems to have found a real solution to healthcare prices. My personal opinion is that doctor salaries have a minor impact on prices. Healthcare system structure and culture (as in how much do insurance companies control, and how readily you perform expensive tests) is much more important, I think.
According to the WHO the country with the most MD's per capita is Cuba with 7.5 per 1000, while the US has 2.5 per 1000. So at best you come from a country with 3x that of the US, not 100x.
Edit: http://gamapserver.who.int/gho/interactive_charts/health_wor...
Edit: http://gamapserver.who.int/gho/interactive_charts/health_wor...
Indeed, I was misinformed. The ratio is much lower than I thought. I think my point still holds, though.
You are asking me to believe that 2 in 10 people in your country are doctors? And accepting this, prices haven't come down?
I was told that the US had far less MDs than what is actually reported by the WHO. My bad for not checking my sources.
However, we apparently have 40 MDs per 10'000.
My main point was that doctors salaries have a minor impact on the cost of the whole system, and i think that still holds, though. If you calculate the ratio of the in-pocket sum that goes to the MD compared to the whole bill for a hospital stay, I do not think it is that high. So even if you are right about the guild problem, I don't think that makes it a solution. I admit I did not look at official numbers about that, though.
YES. Salaries are not that high, either, for people in medical academia and now in HMOs as well. One can justify paying a neurosurgeon 430 per year - after 8 years of post-graduate training, and if you count college and medschool, that is 16 years. During all that time a future neurosurgeon mostly acquired debt, while working 120 hours per week.
Guild systems do not inevitably resort to overbilling. They may resort to being overpriced but not to overbilling or lack of transparency in billing. I've not heard of doctor salaries being the reason for the U.S. spending far more per capita than other nations. It definitely contributes to this but my impression is that it is a very small part of this. Do you have evidence to the contrary?
Note that the same guild system is in force in just about every other country.
Note that the same guild system is in force in just about every other country.
This is basic supply/demand. We have an increase in demand with the supply of doctors apparently staying stagnant. I think that's the point of this particular thread – not necessarily the billing issue.
Yep. The AMA/AAMC is essentially screwing the rest of the US so that they can keep doctors' salaries artificially high. There are tons of medical school applicants who get rejected every year, and not because they can't become doctors, but because medical school sizes have remained constant while the country's population (and demand for healthcare) has increased drastically.
My wife recently completed her residency. She has $370,000 in student loans. In order to pay off the loans she needs a high salary. The high salary doesn't go away once the school loans are paid off. It'd make a whole lot more sense for the country to just pay for higher education upfront. We'd be fine with her making half her salary and have the loans forgiven. It'd be much cheaper for society to do this.
Indiana, and other states, have programs that will pay for your medical degree provided you go to an in-state institution and work with the under served. Now the definition of under served, just means people with not enough doctors per capita. In the case of Indiana, this includes large portions of the inner-circle of Indianapolis. So you could work with a 30-45 minute commute inside the circle (465) and go home to lovely Carmel Indiana. You'd have access to a diverse cultural center and no loans.
While it doesn't help your wife, this information can help readers that either want to go into medicine themselves, or have family members seeking such employment.
While it doesn't help your wife, this information can help readers that either want to go into medicine themselves, or have family members seeking such employment.
The problem is not medical school spots, it's residency spots. Having medical school graduates is useless if they can't get licensed or board certified.
How is that a problem? About 130 medical schools graduate on average 100 MDs every year, that is 13,000. Available residency spots are near 29,000. so, the rest of the spots are filled by FMGs, foreign medical graduates.
You think that doctors profit from the current system? How exactly?
Applications to med schools have been down for the last few years, and the trend is worrisome. Your doctor-bashing stance is common but uninformed.
Applications to med schools have been down for the last few years, and the trend is worrisome. Your doctor-bashing stance is common but uninformed.
To me hospitals are basically scam operations. My girlfriend has had several surgeries in the last two years. In addition to already outrageous standard prices ($40000 surgical center cost for a surgery where we spent in total five hours at the center) pretty much every bill had mistakes. Then after a few months a collection agency will try to collect for something that never got billed and never has happened. I can accept a mistake from time to time but this seems to be pervasive.
My son was born last year. We had two insurance companies and accidentally filed with the wrong one as primary.
I used my hsa to pay the balance of about $800
9 months later, instead of refilling with the correct insurance company, they sent us a $20k bill.
After we called them and said, hey you know you should probably refill with the right company, they did. The insurance company declined because they took to long to refile.
The hospital never bothered to follow up and explain the situation until we called the insurance company ourselves and had them restart the process.
In the meantime our secondary insurance approved the part of the bill that was for my son, rather than my wife. The hospital sent me a new bill for $200 for their deductible.
From here, there was an extended game of back and forth where they'd send me a bill and I'd call and ask if they figured out the rest of the insurance and what happened to the HSA check we sent them. This went on for 13 months.
My son is now walking and this week they finally sent us to collections.
I called and threatened to take them to court, and finally talked to a supervisor who admitted that they owed us $600.
But what about collections?
Sir, that was a different bill.
Why can't you take the money that you owe me and pay the bill that you just sent me to collections for?
Well you didn't ask us to do that. I'll go ahead and do that now.
I resisted throwing my phone through a wall just barely.
I used my hsa to pay the balance of about $800
9 months later, instead of refilling with the correct insurance company, they sent us a $20k bill.
After we called them and said, hey you know you should probably refill with the right company, they did. The insurance company declined because they took to long to refile.
The hospital never bothered to follow up and explain the situation until we called the insurance company ourselves and had them restart the process.
In the meantime our secondary insurance approved the part of the bill that was for my son, rather than my wife. The hospital sent me a new bill for $200 for their deductible.
From here, there was an extended game of back and forth where they'd send me a bill and I'd call and ask if they figured out the rest of the insurance and what happened to the HSA check we sent them. This went on for 13 months.
My son is now walking and this week they finally sent us to collections.
I called and threatened to take them to court, and finally talked to a supervisor who admitted that they owed us $600.
But what about collections?
Sir, that was a different bill.
Why can't you take the money that you owe me and pay the bill that you just sent me to collections for?
Well you didn't ask us to do that. I'll go ahead and do that now.
I resisted throwing my phone through a wall just barely.
This describes the whole craziness well. How is a regular person supposed to be able to figure all this stuff out?
To quote from my own comment when we discussed this six months ago (replying to https://news.ycombinator.com/item?id=13325022):
"[…] there's adverse selection. The hospitals that make errors in the client's favor or that don't make errors at all are more likely to go out of business than the ones that make errors in their own favor. So guess which ones are still around when you need a hospital. In other words, just because the errors are accidental, it doesn't mean they happen at random. (This argument applies to any shady business practice that "looks" like an accident, for example dark patterns on websites, or having great customer service for taking your money but terrible customer service for refunding it.)"
"[…] there's adverse selection. The hospitals that make errors in the client's favor or that don't make errors at all are more likely to go out of business than the ones that make errors in their own favor. So guess which ones are still around when you need a hospital. In other words, just because the errors are accidental, it doesn't mean they happen at random. (This argument applies to any shady business practice that "looks" like an accident, for example dark patterns on websites, or having great customer service for taking your money but terrible customer service for refunding it.)"
That's not a complete explanation, as it would likewise prove that every business errs as much as possible in their favor. It wouldn't explain what's different about hospitals and health insurance that makes them so brutal about it.
True. My assumption is that there's a complete lack of the usual consumer protections because (a) no ability to shop around and (b) no political will to fix it because most bills go to insurance companies who (i) are expert at questioning medical bills and (ii) have a negotiated relationship with providers so they don't pay sticker price anyway.
Right -- those factors would be more relevant, specific things to point to than "providers who err in their favor get more money than those who don't".
Agreed on the scam. The way to handle this is to not pay, and send a letter claiming that you don't owe it. If they send it to collections you can sue for collecting a debt not owed. If a collector contacts you about debts they know or should have known are disputed then you can also collect statutory damages from those people. If they report to credit rating agencies, and you dispute the facts with them and they take more than a month to resolve the issue you can also sue those agencies, and you have fresh grounds for suing the debt collector as well. You may be awarded treble damages!
This is an amusing pastime if you can afford temporary depressions in your credit score.
This is an amusing pastime if you can afford temporary depressions in your credit score.
Healthcare in the USA is not a scam, it's simply a for-profit business.
They have worked extremely hard to maximize those profits for decades.
They're actually good at it, and it were a startup extracting those profits they would be applauded for it.
They're actually good at it, and it were a startup extracting those profits they would be applauded for it.
I think most startups that repeatedly charge their customers for services not provided would be out of business quickly.
but you have to also take into account that a lot of people don't pay (charity care)
Fraud perpetrated against some Customers is not a remedy for non-payment by others.
Some non payment is also considered bad debt (they expect the patient to pay, the patient doesn't pay). With charity care, the bill is explicitly forgiven.
The hospital industry claims non payments total around 6% of hospital expenses.
http://www.modernhealthcare.com/article/20120106/BLOGS01/301...
I do wonder if they calculate that 6% on what they bill though, rather than on what things actually cost. The margin on an unpaid bill isn't really a cost.
The hospital industry claims non payments total around 6% of hospital expenses.
http://www.modernhealthcare.com/article/20120106/BLOGS01/301...
I do wonder if they calculate that 6% on what they bill though, rather than on what things actually cost. The margin on an unpaid bill isn't really a cost.
I remember reading that the 6% are from the billed prices, not the cost. The same when they claim to do things for poor people. They do a few procedures for free and claim the billed price so they can have nice PR for cheap.
Also for tax reasons, although different hospitals have different tax classifications.
No you don't.
This doesn't justify billing mistakes.
in reality that's covered by the price gouging and the hospital getting to write it off
It's also telling when the hospital gives you different bills depending on if you're insured or not. If you're insured they charge waaay more. They give you a more "realistic" bill if you are uninsured.
It's a ridiculous system.
It's a ridiculous system.
Another anecdote to this point: I had an experience in which a doctor accepted me as a patient (knowing what insurance I had and what reimbursement rates the insurer would pay), performed a procedure for me, then subsequently found out my insurance would not cover the procedure (because of a preexisting condition waiver I did not know was still in force).
The doctor then demanded full payment for his non-discounted rate-- 6x the insurance reimbursement rate.
To my mind, acceptance of the "deal" was done when the doctor took me on as a patient and agreed to perform the procedure. At that time the practice had full knowledge of what the reimbursement rate would be. I see the doctor's "windfall" of demanding the non-discounted rate as being fraudulent.
The doctor then demanded full payment for his non-discounted rate-- 6x the insurance reimbursement rate.
To my mind, acceptance of the "deal" was done when the doctor took me on as a patient and agreed to perform the procedure. At that time the practice had full knowledge of what the reimbursement rate would be. I see the doctor's "windfall" of demanding the non-discounted rate as being fraudulent.
What ended up happening in this case?
I met with the doctor face-to-face. He felt that he needed to stand-by his policy of demanding the non-discounted fee. He did not believe the rate for the service was set when he accepted my insurance (with a known reimbursement rate), but rather was based on his billing staff finding the highest amount to bill after the procedure was complete.
He made an argument (that I considered specious) about "fairness" to other patients and problems he'd had in the past with patients mistreating the office staff because of perceived "unfairness" in his offering discounts.
My attorney advised me that I'd likely spend more money fighting the doctor than just paying him. Because I care (probably more deeply than I should) about my credit rating I opted to pay the doctor and put the whole mess behind me. I also ditched my pre-ACA insurance that carried this never-expiring pre-existing condition waiver and moved to an ACA plan with no such waivers.
The surgery center that was involved in the ordeal was much more reasonable, BTW. They charged me the amount my insurance company would have reimbursed them. When I brought this up to the doctor (who is also a partner in the surgery center business) he simply stated that his office's policies differed from those of the surgery center, and that his policy was to receive his full fee.
He made an argument (that I considered specious) about "fairness" to other patients and problems he'd had in the past with patients mistreating the office staff because of perceived "unfairness" in his offering discounts.
My attorney advised me that I'd likely spend more money fighting the doctor than just paying him. Because I care (probably more deeply than I should) about my credit rating I opted to pay the doctor and put the whole mess behind me. I also ditched my pre-ACA insurance that carried this never-expiring pre-existing condition waiver and moved to an ACA plan with no such waivers.
The surgery center that was involved in the ordeal was much more reasonable, BTW. They charged me the amount my insurance company would have reimbursed them. When I brought this up to the doctor (who is also a partner in the surgery center business) he simply stated that his office's policies differed from those of the surgery center, and that his policy was to receive his full fee.
My experience is the opposite. The uninsured receive absurd bills because the hospital doesn't actually expect them to pay. The sell the debt to collections and get a big tax writeoff with little relation to reality.
This has been my experience as well. My understanding was that they technically bill the uninsured the same basic amount they bill the insurances, prior to them applying the "insurance discounts".
I've often thought this could be solved by legislation (something like the uninsured cannot pay more than the lowest insurance + copay amount), but lots of folks are against such price controls.
I've often thought this could be solved by legislation (something like the uninsured cannot pay more than the lowest insurance + copay amount), but lots of folks are against such price controls.
Wow, I hadn't even thought of that. The one anecdote I know of was the opposite, but I guess that's because it was clear that the uninsured patient could and would pay a reasonable bill... so presumably they can either get a small bill paid, or a huge bill sent to collections and write-off some tax... ugh, no wonder they need such huge finance departments...
You are probably right but this invites and rewards unethical behavior. If you pay the bill you are a sucker. You have to be a deadbeat.
It's back-handed socialized medicine. Hospitals cannot turn anyone away so the money has to come from somewhere and this is how they do it. Oddly enough this is what keeps the whole system from collapsing.
This "shadow" socialized system fills me with anger simply because we can't seem to deal with it in a mature and constructive way.
As long as Americans can't stomach the idea of turning away people who cannot pay for emergency care to die we have socialized medicine. I don't understand why we can't, as a society, have a "grown up" conversation about this fact.
As long as Americans can't stomach the idea of turning away people who cannot pay for emergency care to die we have socialized medicine. I don't understand why we can't, as a society, have a "grown up" conversation about this fact.
Why not just have proper socialized medicine, such as in Canada?
Instead of this perverse system of "shadow" socialized medicine, fraud, and over-billing, why not just make it come out of everyone's taxes? That way everyone pays a very modest amount in tax and no one has to be financially ruined by flukes of nature.
Also kills a huge amount of overhead in the billing departments, collection agencies, insurance companies, etc.
Instead of this perverse system of "shadow" socialized medicine, fraud, and over-billing, why not just make it come out of everyone's taxes? That way everyone pays a very modest amount in tax and no one has to be financially ruined by flukes of nature.
Also kills a huge amount of overhead in the billing departments, collection agencies, insurance companies, etc.
Because Americans are selfish.
Source: lived in US for 20 years.
Source: lived in US for 20 years.
I have lived in the US for 27+ years and I think Americans tend to be very generous, a lot of people donate their time and money to charities, churches, etc.
They just don't want to give their money to a bunch of bureaucrats, who spend it mostly on themselves, and seem to multiply like rabbits.
They just don't want to give their money to a bunch of bureaucrats, who spend it mostly on themselves, and seem to multiply like rabbits.
The funny thing is, the money is still going to a bunch of bureaucrats who multiply like rabbits -- it's just that they work for the insurance companies rather than the government. They're needed because of the ongoing arms race between providers and insurance companies, of which the overbilling described by this article is a major part.
In fact, a single payer system would sharply reduce the number of jobs for health care administrators -- to the point that I've seen a blog post somewhere pointing out that these people would need income support and retraining. The economies of several small cities depend heavily on these jobs.
In fact, a single payer system would sharply reduce the number of jobs for health care administrators -- to the point that I've seen a blog post somewhere pointing out that these people would need income support and retraining. The economies of several small cities depend heavily on these jobs.
So they pay for profit insurance companies owned by Wall Street investment firms. I don't understand why American's find that more palatable. The "government doesn't work" mentality is self-feeding. If you want government to work, you make it work. The alternative is just defeatist.
You won't find many conversatives in other countries who want to give up their socialized medical system.
You won't find many conversatives in other countries who want to give up their socialized medical system.
I've lived in the US for 40 years. I'd estimate that less than 5% of all the people I've ever known ever donate time. A substantially higher number donate money to the millionaire operators of charities and "ministries".
Americans aren't generous. Americans are preoccupied with moving money. The more it moves, the faster it accumulates to the top of the economic pyramid.
Americans aren't generous. Americans are preoccupied with moving money. The more it moves, the faster it accumulates to the top of the economic pyramid.
Do you have any evidence that socialized health care systems have more bureaucrats?
[NB I'm just out of a UK NHS hospital so therefore feeling very warm and fuzzy about our favourite chunk of socialism].
[NB I'm just out of a UK NHS hospital so therefore feeling very warm and fuzzy about our favourite chunk of socialism].
I think that basically, the "bureaucrats" of the government become the "employees" of the companies, and are somehow not counted as bureaucrats, even though they form a private, less efficient bureaucracy that has more trouble providing basic services for a decent price (like home nursing).
It will be nice to have socialized medicine, but please, not as in Canada. Their system is not good. I would prefer Medicare expansion to all, or a VA-like system while medicare and medicaids are phased out. This will happen eventually, but alas not soon.
I'm a Canadian, what's wrong with our system from your perspective?
(No system is perfect; there is always room for improvement and trade offs)
Just two weeks ago, my wife had an emergency appendectomy. She went to the free clinic first thing Sunday morning as she had terrible pains all night. They immediately referred to the local hospital. She had the ultrasound in the afternoon and Surgery at 3:00pm. She's been off work (more or less) for 2 week recovering. The only thing we paid for is parking.
This[1] redditor in the US has the same surgery and it cost $55,000 dollars, which insurance covered a lot of but still left him with an $11,000 bill. That's just one simple surgery and that's not a small amount of money.
[1] http://www.cbsnews.com/news/cost-of-an-appendectomy-reddit-u...
(No system is perfect; there is always room for improvement and trade offs)
Just two weeks ago, my wife had an emergency appendectomy. She went to the free clinic first thing Sunday morning as she had terrible pains all night. They immediately referred to the local hospital. She had the ultrasound in the afternoon and Surgery at 3:00pm. She's been off work (more or less) for 2 week recovering. The only thing we paid for is parking.
This[1] redditor in the US has the same surgery and it cost $55,000 dollars, which insurance covered a lot of but still left him with an $11,000 bill. That's just one simple surgery and that's not a small amount of money.
[1] http://www.cbsnews.com/news/cost-of-an-appendectomy-reddit-u...
>> I'm a Canadian, what's wrong with our system from your perspective?
longer wait times for non-emergency treatment and (most of the time) not being able to pay cash and get the procedure done without the wait. personally know ppl in Canada (Toronto, so not some little town in the boonies) who had to wait few months to get an MRI.
on the US side - takes 2 weeks or so to get the insurance company's approval (they do this dance with a mandatory x-ray and electromyogram appointment before approving) or $500 or so gets you in like tomorrow.
the kicker of course is they will charge the insurance company $3k.
that said - the current US system needs a major overhaul, no doubt. both Obamacare and the not-there-yet "Trumpcare" are lipstick on a pig solutions though.
longer wait times for non-emergency treatment and (most of the time) not being able to pay cash and get the procedure done without the wait. personally know ppl in Canada (Toronto, so not some little town in the boonies) who had to wait few months to get an MRI.
on the US side - takes 2 weeks or so to get the insurance company's approval (they do this dance with a mandatory x-ray and electromyogram appointment before approving) or $500 or so gets you in like tomorrow.
the kicker of course is they will charge the insurance company $3k.
that said - the current US system needs a major overhaul, no doubt. both Obamacare and the not-there-yet "Trumpcare" are lipstick on a pig solutions though.
Yeah, waiting a few months to get an MRI if your condition isn't serious isn't uncommon. Diagnostics like that tend to be the longest wait times -- actually getting surgery after a diagnosis is pretty quick.
On the other hand, my experience with the US is that the service is great. They'll even send you for unnecessary tests just because. And it's all pretty fast. But then you have so many people who get nothing at all. And then many of those who do get something are totally bankrupt.
There is no system that can give anyone health care and not have a triage system. So you might have to give up some comfort so your neighbors can live.
On the other hand, my experience with the US is that the service is great. They'll even send you for unnecessary tests just because. And it's all pretty fast. But then you have so many people who get nothing at all. And then many of those who do get something are totally bankrupt.
There is no system that can give anyone health care and not have a triage system. So you might have to give up some comfort so your neighbors can live.
sure, it's a balancing act.
another downside to mention - wait times in walk in clinics in Canada during the flu/cold season are pretty extreme - it's free so ppl just go if they suspect anything is wrong.
I remember reading in the news they were considering charging a nominal fee, like $5 to cut down on these types of visits. On the US side you'd pay around $50 for one of those visits (unless you go to your doc) - wait time is like 10 min.
I actually wouldn't mind something similar to a Canadian system - if they can manage that without tax increases :) - plus a private "network" someone who can afford paying for a private insurance (or using straight up cash) can use.
I remember reading in the news they were considering charging a nominal fee, like $5 to cut down on these types of visits. On the US side you'd pay around $50 for one of those visits (unless you go to your doc) - wait time is like 10 min.
I actually wouldn't mind something similar to a Canadian system - if they can manage that without tax increases :) - plus a private "network" someone who can afford paying for a private insurance (or using straight up cash) can use.
> wait times in walk in clinics in Canada during the flu/cold season are pretty extreme - it's free so ppl just go if they suspect anything is wrong.
Actually making an appointment with your family doctor is also free. You don't have to go to a walk in clinic.
Actually making an appointment with your family doctor is also free. You don't have to go to a walk in clinic.
Try getting a mammogram. The wait time always seems to be in the "months" range even though the demand can be perfectly forecast in advance.
>longer wait times for non-emergency treatment
I really want to see actual studies on this. We Americans LOVE to throw this in the face of the countries with single-payer, yet we conveniently gloss over the fact that many Americans PUT OFF health care procedures because they can't afford them. I've done it and I know many, many others that have as well. Oh, this is going to be 1500$ out of pocket and doesn't need to be done today? Great let's schedule it for 2 months out.
Additionally, Americans also have wait times for non-emergency procedures. Colon cancer runs heavily in my family and so all of the older members get regular colonoscopies. I have several anecdotes of family members having to wait 6 months before they can get it and get theirs done.
AMERICANS ARE NOT ANY BETTER WHEN IT COMES TO WAIT TIMES. However, the onus is typically not on the provider, it's on the patient. So we describe the situation differently even though it's the same outcome, the patient has to wait for treatment.
I really want to see actual studies on this. We Americans LOVE to throw this in the face of the countries with single-payer, yet we conveniently gloss over the fact that many Americans PUT OFF health care procedures because they can't afford them. I've done it and I know many, many others that have as well. Oh, this is going to be 1500$ out of pocket and doesn't need to be done today? Great let's schedule it for 2 months out.
Additionally, Americans also have wait times for non-emergency procedures. Colon cancer runs heavily in my family and so all of the older members get regular colonoscopies. I have several anecdotes of family members having to wait 6 months before they can get it and get theirs done.
AMERICANS ARE NOT ANY BETTER WHEN IT COMES TO WAIT TIMES. However, the onus is typically not on the provider, it's on the patient. So we describe the situation differently even though it's the same outcome, the patient has to wait for treatment.
On the other hand, if your condition is serious, it can be _very_ fast. My daughter had an MRI done about 2 hours after the doctor ordered it (this was after a concussion so we were worried about possible brain damage. Don't worry, she's fine, it was just a scare).
Not OP, but my biggest problem with your perspective is that it is almost pure single-payer, meaning that there's usually no choice in areas where government is involved, even if you're able and willing to pay for something better or faster.
In comparison, e.g. most European countries use a combined two-tier approach, where the role of the government is to ensure universal basic coverage and affordability of that coverage, but not to replace private insurance entirely.
In comparison, e.g. most European countries use a combined two-tier approach, where the role of the government is to ensure universal basic coverage and affordability of that coverage, but not to replace private insurance entirely.
Americans cannot stomach the idea of giving anyone anything for "free", without thinking about longer term benefits.
I don't think this is it at all. The argument is that there is no such thing as "free", there are only transfers of cost. Someone is paying.
Well, we usually refer to the UK NHS as "free" but we all know that it means "free at the point of delivery" we know it gets funded from our taxes and therefore all taxpayers pay.
As someone who just had a few days in an NHS hospital I'm pretty much delighted with the experience. When was money mentioned? Not once, not once.
As someone who just had a few days in an NHS hospital I'm pretty much delighted with the experience. When was money mentioned? Not once, not once.
>As long as Americans can't stomach the idea of turning away people who cannot pay for emergency care to die we have socialized medicine.
Seems a tad callous even by my standards as a staunch classical liberal; may be all other medical services but not emergency services.
Seems a tad callous even by my standards as a staunch classical liberal; may be all other medical services but not emergency services.
I'm not stating an opinion about this fact, I'm simply stating it. (Personally, I think Americans ought to have socialized medicine.)
The "conservatives" who bellyached that the ACA created "socialized medicine" willfully ignored (or were ignorant of) the fact that the mandate to treat emergency patients regardless of ability to pay "socialized" medicine when it was passed (by "conservative" stalwart Ronald Regan) in the EMTALA[1] in 1986.
[1] https://en.wikipedia.org/wiki/Emergency_Medical_Treatment_an...
The "conservatives" who bellyached that the ACA created "socialized medicine" willfully ignored (or were ignorant of) the fact that the mandate to treat emergency patients regardless of ability to pay "socialized" medicine when it was passed (by "conservative" stalwart Ronald Regan) in the EMTALA[1] in 1986.
[1] https://en.wikipedia.org/wiki/Emergency_Medical_Treatment_an...
Yet when you try and tell people that it was Ronald Reagan who effectively socialized medicine in the United States they get really angry.
For more information about the rough guidelines by which pricing works in the US (or doesn't work), check out the often referred to term "usual and customary" (UCR) charges. Read about it and then form your own opinion - I'd rather not bias too much by offering mine.
https://en.m.wikipedia.org/wiki/Usual,_customary_and_reasona...
https://en.m.wikipedia.org/wiki/Usual,_customary_and_reasona...
There was a reform, maybe sometime around 1985, that replaced "usual, customary and reasonable" with 'what should this procedure actually cost'. Your wikipedia links to this page:
Resource-based relative value scale - https://en.wikipedia.org/wiki/Resource-based_relative_value_...
It took the government 20 years to figure out that they couldn't give the medical system a blank check.
/methinks a helpful medical reform would be to get insurance-paid doctors on fixed salaries. Under the present status quo, some doctors bill insurance companies for as much as they can get away with.
Resource-based relative value scale - https://en.wikipedia.org/wiki/Resource-based_relative_value_...
It took the government 20 years to figure out that they couldn't give the medical system a blank check.
/methinks a helpful medical reform would be to get insurance-paid doctors on fixed salaries. Under the present status quo, some doctors bill insurance companies for as much as they can get away with.
Actually, I used to work in health insurance, so I have a bit more insight into this than most, although I've been out of it for a while (10 years or so).
If you look into how the RBRVS are calculated, there is effectively a privately run panel that determines input variables and factors that are used in the RBRVS calculations. At some point, someone has to determine the portion of the calculation that represents "physician value added". While it is true that RBRVS is an alternative system to pure UCR rates, I can assure you that UCR rates still play a major role in many health insurance lines of business and calculations.
By the way, RBRVS aren't the only system that organizations have tried to use to figure out how to bill/cost services - there are also DRG groups (diagnostic related groups), ASC groups (ambulatory surgical center) groups and others.
RBRVS were mainly made to try to control physician office costs in Medicare and are used by HMOs that offer Medicare plans. While other HMOs and private insurers use RBRVS, there are a lot of them that still use UCR (calculated internally) as well.
There was a huge problem around 2009/10 with a big company, Ingenix, that was offering a commercial UCR database which was probably of poor data quality - based on surveys of regional prices from doctor's offices. There were lawsuits, etc. over that and many insurers moved away from commercial sources of UCR and instead brought that in-house. Here's a link that talks a little bit about that: https://www.managedcaremag.com/archives/2009/5/ingenix-after...
Price transparency could help (if it could be achieved), but there are a lot of for-profit organizations who actively try to keep their strategies internal. Transparency might not be enough without pricing controls, but exercising control would be extremely difficult for legal/political/profit motive reasons as well. For that matter, coming up with singular pricing systems that govern controls at scale is incredibly difficult.
If you look into how the RBRVS are calculated, there is effectively a privately run panel that determines input variables and factors that are used in the RBRVS calculations. At some point, someone has to determine the portion of the calculation that represents "physician value added". While it is true that RBRVS is an alternative system to pure UCR rates, I can assure you that UCR rates still play a major role in many health insurance lines of business and calculations.
By the way, RBRVS aren't the only system that organizations have tried to use to figure out how to bill/cost services - there are also DRG groups (diagnostic related groups), ASC groups (ambulatory surgical center) groups and others.
RBRVS were mainly made to try to control physician office costs in Medicare and are used by HMOs that offer Medicare plans. While other HMOs and private insurers use RBRVS, there are a lot of them that still use UCR (calculated internally) as well.
There was a huge problem around 2009/10 with a big company, Ingenix, that was offering a commercial UCR database which was probably of poor data quality - based on surveys of regional prices from doctor's offices. There were lawsuits, etc. over that and many insurers moved away from commercial sources of UCR and instead brought that in-house. Here's a link that talks a little bit about that: https://www.managedcaremag.com/archives/2009/5/ingenix-after...
Price transparency could help (if it could be achieved), but there are a lot of for-profit organizations who actively try to keep their strategies internal. Transparency might not be enough without pricing controls, but exercising control would be extremely difficult for legal/political/profit motive reasons as well. For that matter, coming up with singular pricing systems that govern controls at scale is incredibly difficult.
Thanks for your insights. I have family in the medical field, so I've heard a lot of complaints about the system. It seems like most people don't appreciate how much "complication" in the medical industry derives from third-parties paying for almost everything.
I have a doctor who gives his patients a receipt that they can use to "try" to get reimbursed by insurance. He takes cash or check, has all the patients he wants, and zero employees.
I have a doctor who gives his patients a receipt that they can use to "try" to get reimbursed by insurance. He takes cash or check, has all the patients he wants, and zero employees.
I would like to ditch insurance and find a doctor who would allow me to pay a monthly subscription fee, much like a gym membership, for preventative care.
Isn't the primary purpose of insurance for exceptional and accidental situations? If that's true, then why am I using it for predictable monthly expenses?
Isn't the primary purpose of insurance for exceptional and accidental situations? If that's true, then why am I using it for predictable monthly expenses?
What you are looking for is called Direct Primary Care. It exists in nearly every major city in the US at this point, and is very affordable.
https://www.youtube.com/watch?v=bGZaRnC1wNg to hear one doctor talk about how this works out in practice.
Google Direct Primary Care + your city/state to see what's available. It's SERIOUSLY better than the mainstream option. I've been doing it for nearly a decade now, and would never go back. Combine it with a cost sharing plan (NOT insurance) such as https://www.libertyhealthshare.org/3-program-options to achieve superior care at lower cost.
https://www.youtube.com/watch?v=bGZaRnC1wNg to hear one doctor talk about how this works out in practice.
Google Direct Primary Care + your city/state to see what's available. It's SERIOUSLY better than the mainstream option. I've been doing it for nearly a decade now, and would never go back. Combine it with a cost sharing plan (NOT insurance) such as https://www.libertyhealthshare.org/3-program-options to achieve superior care at lower cost.
Wow that's great, thanks for the tip.
So what do you do when you get cancer and run up $1 million in bills? That's what insurance is for. Not sure if your monthly fee is going to work for you like that.
I think they meant they would still have insurance, just not for preventive care.
Preventative care means less risk of catastrophic care. Its cheaper for insurance to encourage you towards preventative care than pay for the catastrophic care.
This is available for rich folks. This is "boutique medicine". Possibly the way of the future - to coexist with social medicine, of course.
How rich do you have to be? Why is it not available for the rest of us?
It's not unavailable to the non-rich, just unaffordable.
Your information is outdated. It was unafforadable fifteen years ago . . . in the last five to ten, it has become very, very affordable and has exploded in popularity to the point that it's available all over the country. Here's one example: https://atlas.md/wichita/our-fees/
Children 0-19 years old, $10/month with at least one parent membership
Adults 20-44 years old, $50/month
Adults 45-64 years old, $75/month
Adults 65+ years old, $100/month
Employer groups with 5+ employees, $50/mo/adult
I don't have a dog in this fight — I was merely pointing out that no one is stopping non-rich people from buying anything. It's just that people with lots of money can afford more than people with less money, in medicine as in anything.
Just to be clear... the "grown up" conversation you wish Americans could stomach is the one that involves socializing medicine and not the one that involves letting random people die needlessly, right?
When a topic is divisive, please don't take discussion further into flamewar when commenting here.
We detached this subthread from https://news.ycombinator.com/item?id=14736827 and marked it off-topic.
We detached this subthread from https://news.ycombinator.com/item?id=14736827 and marked it off-topic.
I am an American.
When I'm particularly exasperated with the healthcare system (usually in the weeks/months following some kind of medical engagement) my answer would be "I don't give a damn which we choose. Let's just make a decision to either socialize medicine completely or let people die."
(My mood is unreasonably caustic after dealing with anything medical. The stress of dealing with healthcare billing, health insurance, and the patriarchal attitudes of medical practitioners raises my blood pressure and gives me near panic attacks.)
When I'm in a more calm and normal mental state my answer would lean toward socializing as much of the healthcare system as possible.
Literally nothing is a bigger fear-factor in my life than medical expenses. The fact that the entirety monetary value of my life's work could be destroyed in a moment by a medical issue freaks me out. The fact that I cannot, in any financially viable manner, insure against this kind of event amplifies that fear.
I feel comfortable in saying that, at least in an abstract way, I am less afraid of death than of leaving my family destitute as a result of unforeseen medical expense.
When I'm particularly exasperated with the healthcare system (usually in the weeks/months following some kind of medical engagement) my answer would be "I don't give a damn which we choose. Let's just make a decision to either socialize medicine completely or let people die."
(My mood is unreasonably caustic after dealing with anything medical. The stress of dealing with healthcare billing, health insurance, and the patriarchal attitudes of medical practitioners raises my blood pressure and gives me near panic attacks.)
When I'm in a more calm and normal mental state my answer would lean toward socializing as much of the healthcare system as possible.
Literally nothing is a bigger fear-factor in my life than medical expenses. The fact that the entirety monetary value of my life's work could be destroyed in a moment by a medical issue freaks me out. The fact that I cannot, in any financially viable manner, insure against this kind of event amplifies that fear.
I feel comfortable in saying that, at least in an abstract way, I am less afraid of death than of leaving my family destitute as a result of unforeseen medical expense.
I am so sorry you have to live with that shadow hanging over your head. :(
I know people must get sick of the "holier than thou" attitudes of the nations with universal health care, but it's stories like yours that make it all the more sad... living life only one medical emergency away from financial ruin and destitution...
It's truly a tragedy. It would already be awful enough that you'd be in ER facing a life-threatening situation, but add on looking forward to the bill... holy. fucking. shit.
I know people must get sick of the "holier than thou" attitudes of the nations with universal health care, but it's stories like yours that make it all the more sad... living life only one medical emergency away from financial ruin and destitution...
It's truly a tragedy. It would already be awful enough that you'd be in ER facing a life-threatening situation, but add on looking forward to the bill... holy. fucking. shit.
"fear-factor"
Worth noting that the book describing the principles of the UK NHS by its founder was called "In Place of Fear":
https://en.wikipedia.org/wiki/Aneurin_Bevan
Medical emergencies are stressful enough when there is no money involved - I have no idea how people cope when there is a stressful financial situation added on top as well.
Worth noting that the book describing the principles of the UK NHS by its founder was called "In Place of Fear":
https://en.wikipedia.org/wiki/Aneurin_Bevan
Medical emergencies are stressful enough when there is no money involved - I have no idea how people cope when there is a stressful financial situation added on top as well.
Thanks for that link. I'm looking forward to reading about Bevan and, in particular, finding this book.
"The United States remains one of the only advanced industrialized democracies in the world without universal coverage.
While this in and of itself is not a problem, the United States also spends more on health care as a percentage of GDP than any other advanced country in the world and has worse health outcomes – with lower life expectancy, higher infant mortality and higher obesity rates than comparable countries like Australia, Canada, the United Kingdom, Germany, France and Japan." - http://theconversation.com/three-reasons-the-us-doesnt-have-...
While this in and of itself is not a problem, the United States also spends more on health care as a percentage of GDP than any other advanced country in the world and has worse health outcomes – with lower life expectancy, higher infant mortality and higher obesity rates than comparable countries like Australia, Canada, the United Kingdom, Germany, France and Japan." - http://theconversation.com/three-reasons-the-us-doesnt-have-...
I think this is because we choose to live less healthy lifestyles rather than the quality of medical care.
Super size that...
Super size that...
Not just that, but remember not everybody can afford health care in US, so it's not unfathomable to think some of those bad statistics is due to people not being able to afford proper care, not just that they don't live a healthy life (which can certainly contribute to that).
I don't think the lifestyles are all that different between Canada and the US, and the healthcare expenditures in Canada are significantly lower.
I grant this is anecdotal, but you might want to learn about the Canadian system from the point of view of sick people in Canada. https://www.youtube.com/watch?v=q2jijuj1ysw
Thanks. I live in Canada and have first hand experience with the healthcare system.
At the risk of spiking my blood pressure I will write a few words on this topic. I will start by saying this:
The whole system is fucked.
I am referring to the system that facilitates American residents getting healthy and staying that way.
What is the basis of my claims? I admit that I am a healthy 33 year old white male and I probably have only seen that tip of the iceberg. I am also a father of 3. My oldest daughter was born with a chronic health problem, diagnosed at 19 weeks gestation.
Since her birth, a little over 7 years ago, we have received a bill from the hospital that provided her care at least once per week. This continues today, despite not having had any services provided in almost a year.
If I paid all of these bills, bankruptcy would be my only recourse. I try to communicate with my insurance provider (employer provided), to determine what's legitimate, and what should be covered. In the end, I'm mostly left to my own devices to pay for the services that I think I received. Every year we pay the deductible, and every year we get billed for significantly more.
As another example, not along ago, my third daughter was born. Due to the complications of my wife's first pregnancy we received care from two different OBGYN facilities, one local to us, and one at the delivering hospital.
Though the local facility was only responsible for less than 10 checkups, they claimed that we still owed our entire deductible to them, prior to delivery. We paid half.
A week prior (this much is hilarious in itself) to delivery by a doctor from the other facility, we received a bill for the full deductible amount, due to them also.
When the delivery actually happened, it took less than 2 hours, and we stayed one night. We also had 3 checkups at this other facility. Our bill of course is the same as everybody else's, regardless of whether they had a C-Section and stayed for 5 nights, or had 30 hours of labor. I could actually be OK with this (I'm onboard for socialized healthcare), if they could get the billing part right.
Again:
* I am constantly billed directly by healthcare providers over and above what my insurance policy says I should pay.
* I pay almost 25% of my yearly earnings in insurance premiums.
* I end up deciding what I will pay and what I will not pay. I admit that this is probably not the best situation for anyone.
The whole system is fucked.
The whole system is fucked.
I am referring to the system that facilitates American residents getting healthy and staying that way.
What is the basis of my claims? I admit that I am a healthy 33 year old white male and I probably have only seen that tip of the iceberg. I am also a father of 3. My oldest daughter was born with a chronic health problem, diagnosed at 19 weeks gestation.
Since her birth, a little over 7 years ago, we have received a bill from the hospital that provided her care at least once per week. This continues today, despite not having had any services provided in almost a year.
If I paid all of these bills, bankruptcy would be my only recourse. I try to communicate with my insurance provider (employer provided), to determine what's legitimate, and what should be covered. In the end, I'm mostly left to my own devices to pay for the services that I think I received. Every year we pay the deductible, and every year we get billed for significantly more.
As another example, not along ago, my third daughter was born. Due to the complications of my wife's first pregnancy we received care from two different OBGYN facilities, one local to us, and one at the delivering hospital.
Though the local facility was only responsible for less than 10 checkups, they claimed that we still owed our entire deductible to them, prior to delivery. We paid half.
A week prior (this much is hilarious in itself) to delivery by a doctor from the other facility, we received a bill for the full deductible amount, due to them also.
When the delivery actually happened, it took less than 2 hours, and we stayed one night. We also had 3 checkups at this other facility. Our bill of course is the same as everybody else's, regardless of whether they had a C-Section and stayed for 5 nights, or had 30 hours of labor. I could actually be OK with this (I'm onboard for socialized healthcare), if they could get the billing part right.
Again:
* I am constantly billed directly by healthcare providers over and above what my insurance policy says I should pay.
* I pay almost 25% of my yearly earnings in insurance premiums.
* I end up deciding what I will pay and what I will not pay. I admit that this is probably not the best situation for anyone.
The whole system is fucked.
I cannot imagine how America let this cancer of a health care system grow.
I live in Canada. For the next couple weeks, I'm unemployed. During this time, I'm planning to get some health checkups done, possibly get a referral to a sleep clinic, and maybe get my hearing checked. I don't have any fears or worries about this.
Friends always tell me I could be making so much more money in America... It's not worth the stress, the bullshit.
I live in Canada. For the next couple weeks, I'm unemployed. During this time, I'm planning to get some health checkups done, possibly get a referral to a sleep clinic, and maybe get my hearing checked. I don't have any fears or worries about this.
Friends always tell me I could be making so much more money in America... It's not worth the stress, the bullshit.
A family friend had twins. One born before midnight, the other after (different birth days). When they got their bill(s) from the hospital they noticed they were charging room fees for both infants starting the day of the first born. The second child wasn't even "alive" (born) for the first day they were trying to charge for! What's also absurd is that the first child wasn't in the receiving room until after midnight anyways (since all three, two infants, and mother were in a delivery room until the wee AM hours)!
Can confirm. Three births, hospital/insurance both effed up the billing on all three. If we hadn't been vigilant and wasted hours, and hours, and hours, on the phone and in one case gotten our state rep and the state insurance board involved we'd have been out several thousand dollars that we shouldn't have had to pay. I hate to think how much we didn't catch. Similar stories from others, plus tales from non-pregnancy major medical procedures that shake out similarly, though are even harder to sort out.
Everything that touches healthcare billing is scammy, incompetently managed, and often outright fraudulent. Good luck getting any compensation or justice other than what you were originally entitled to, though.
Everything that touches healthcare billing is scammy, incompetently managed, and often outright fraudulent. Good luck getting any compensation or justice other than what you were originally entitled to, though.
They don't even mention the harm caused by fraud that involves inventing conditions and treatments out of thin air. Those doctor's notes follow you around forever when you go to do things like purchase disability insurance or seek treatment.
Suddenly you are no longer a healthy individual you are an individual with a history of condition X and Y which you have never even heard of. And because a doctor wrote it down it's now a reality and the patient is a liar!
Suddenly you are no longer a healthy individual you are an individual with a history of condition X and Y which you have never even heard of. And because a doctor wrote it down it's now a reality and the patient is a liar!
There are so many variables that affect healthcare cost here in the US. Looking from outside, things are different than looking from inside. There is something really wrong with current US healthcare system, and it's really difficult to put a blame on one or two things.
Side note, I work IT in healthcare, so I sometimes view "interesting" things to say the least. A while back I stumbled upon a document that was accidentally shared. It showed accounts receivable in collections agencies for one hospital in our system. Between 2009 and 2012, there was $154m dollars in collection agencies from delinquent accounts. Remember, this is just one hospital that is actually in a more upscale location. We have some hospitals who are always in red due to their locations.
Then you deal with inflated prices for services and drugs. I really don't even know if they can ever fix this part.
Side note, I work IT in healthcare, so I sometimes view "interesting" things to say the least. A while back I stumbled upon a document that was accidentally shared. It showed accounts receivable in collections agencies for one hospital in our system. Between 2009 and 2012, there was $154m dollars in collection agencies from delinquent accounts. Remember, this is just one hospital that is actually in a more upscale location. We have some hospitals who are always in red due to their locations.
Then you deal with inflated prices for services and drugs. I really don't even know if they can ever fix this part.
I think this is a great argument for a single payer system. Let the government and hospitals duke it out. When it's the government's money that is being lost, the government might actually care and start negotiating with these providers. Even if it doesn't, at the very least, patients lives won't be ruined by bills for services that they had no control over or knew the cost of beforehand. Not only that, but the government can afford it. When they're losing trillions of dollars on the defense side, I'm certain they can pay for every medical procedure in the country and still have plenty left over. This whole idea that the government doesn't have money to pay for healthcare and other necessary social services is such fucking bullshit when they have the ability to lose trillions in defense and just shrug it off. That's not even mentioning the money that isn't lost on the defense side. Unfortunately, I don't think people have the capability to push their government to spend that money correctly. But that's a different problem altogether.
Since when has government cared about losing money?
That's my point. They don't care that much. And if they decide to care at some point, they have the resources to fight it out. Let these abstract entities (gov't, healthcare providers) fight it out on their own so that people don't have to die.
Single payer is overly restrictive (although it would still be a lot better than what we have now). A non-profit public option, with an explicit legislative grant to negotiate prices with its full strong-arming ability, would deal with this stuff just as well, while still enabling people to shop for insurance if and when they want to.
My friend's wife resigned from a nursing position over this issue. A superior asked her to falsify billing records to say they were providing a higher level of care than they actually were, and she refused.
Instead of resigning, wouldn't it have been better if she exposed the malpractice? Or would the consequences on her part damage her so much that their lives would be destroyed? Ethics would dictate she would fight otherwise.
Due to the corruption and other factors, she didn't wish to work for them any longer. I don't recall all the specifics, but I believe she did file a complaint with the state. Hopefully the company was investigated.
Another issue not mentioned, but associated with the same pool, is that hospitals get dramatically more money for the same procedure than a private practice doctor. Not even upcoding.
Fortunately, Medicare is looking at this problem now. http://www.compassphs.com/blog/health-navigation/medicare-to...
Fortunately, Medicare is looking at this problem now. http://www.compassphs.com/blog/health-navigation/medicare-to...
Generally it is really hard to negotiate fair pricing if one side knows the other side has tons of money. "Oh gee, government contract? That'll be $15,000 more for no good reason." Perhaps anonymizing all billing would help so that negotiations simply cannot know what the other side can afford.
Whereas it's really hard to negotiate pricing with people who are going to die or be physically impaired for the rest of their lives if they don't pay whatever you ask?
Let me add my big one: price transparency.
I had a simple test the other day. I could not get a price. I could not get a price with my insurance, or without it. I called at least 9 times. I got 5 call backs from people who asked me to schedule the procedure but no price.
On the 10th call, I finally got someone to tell me what the out-of-pocket price would be without insurance. She told me a range! It was $96-$115. This was close to the range that google says was about average for the procedure.
So this was not a case of over-charging, or unfair pricing. I really did not know if the test was $10,000 or $100 till this call.
If they just made the pricing transparent, I think a lot of the problems would evaporate.
(Although I think the profit centers would suddenly become the emergency medicine section of the hospital.)
I know this article focuses on fraud, but the non-fraud part of the healthcare is just as broken, and probably costs more.