
What I learned from reading a thousand emergency room bills - jedwhite
https://www.vox.com/health-care/2018/12/18/18134825/emergency-room-bills-health-care-costs-america
======
vec
Exhibit A for why "free market healthcare" is an oxymoron.

I have yet to hear a coherent explanation for how anyone can reasonably expect
for price discovery to even pretend to function in a market where the
consumers can't even guess the prices until after they've already purchased
and frequently couldn't reasonably be expected to refuse service even if they
did believe it was overpriced.

~~~
UnpossibleJim
Exactly. It's the same reason we don't have free market police and fire
services. You simply don't get to "shop around" for emergency services, which
includes privatized ambulance services (which are outrageously expensive, on
the order of $12,000 for the ride I took when I had to take one, and it was a
relatively benign one... thank god I had insurance). EMS is covered, but
that's the Fire Department. After that, it's all privatized. If it's cosmetic,
then I could see the argument. But when it comes to emergency services, and
for ambulances especially, the "free market" argument just doesn't hold water.

~~~
heavyset_go
The history of private firefighting is a particularly dirty one.

In the past, fire companies would show up and demand payment before putting
out fires. If a payment couldn't be made, the company might negotiate the
purchase of the burning property at a steep discount.

Later, insurance companies hired brigades to only put out fires on insured
properties. Fire companies might have fought or sabotaged one another in order
to win the right to put out a fire and get paid for it.

While it isn't perfect, and it's often underfunded, I definitely prefer the
system we have now.

~~~
ptaipale
Not everywhere, though. In Denmark, private operators have been handling
emergency services since 1926; currently one company (Falck) is handling 65
percent of municipal fire brigades and 85 percent of ambulance services. No
particular nastiness has been reported afaik.

~~~
Gibbon1
The US has lots services that are provided by regulated monopolies. My garbage
company, power company are all regulated monopolies. A key thing is you're
required to have garbage and power service but the rates are negotiated by a
public utilities commission or the city or county.

However Healthcare in the US isn't a regulated monopoly like that.

~~~
tokyodude
And there was an entire thread about how those regulated monopolies are not
working well. In particular PG&E in California.

I think it was this one

[https://news.ycombinator.com/item?id=18690916](https://news.ycombinator.com/item?id=18690916)

~~~
Gibbon1
My point was just we do have regulated monopolies in the US. But healthcare in
the US isn't a fully regulated monopoly.

I'll argue whatever PG&E problems are they don't rise at all to the level of
healthcare. And their problems are due to poor regulation and the US's current
terrible management culture.

------
y-c-o-m-b
I was a victim of the surprise out of network bill in the Portland, OR area. I
did all my research before hand: hospital in network, surgeon in network, etc.
but ONE person in that operating room was not in network and SURPRISE i'm out
thousands of dollars. The worst part about this is my state passed a bill to
stop this prior to my surgery, but the bill's effective date was roughly 3
months later. Talk about bad timing.

~~~
ddebernardy
I'm at a loss as to why the US is still dead set to have no meaningful health
coverage.

I got burned by this in California a decade ago. A dentist charged me $4,500
to fix a broken tooth (panic!) and fill in a cavity on a Sunday.

Had I known then what it might have cost I'd have simply flown back to Europe
in the next flight ($600-800 at the time) and get the same thing done for
under $100-200 with a full refund from my local social security.

Adding insult to injury I had a very expensive international health insurance
policy owing to my traveling around the world back then. And they didn't cover
dental with my plan. I knew they wouldn't. But it was still mind boggling to
me in that I never expected a casual procedure that would have cost me €150 at
most anywhere in Europe - most of which would have gotten refunded at that -
to cost me a whopping $4,500 in the US.

~~~
jessaustin
USA dentists don't work on Sunday. If you had waited until Monday you would
have had many more options. Besides what could she have possibly done to "fix
a broken tooth" in one day? Nobody was milling crowns in the office a decade
ago. If it was really just a filling, wow.

Do dentists in Europe work on Sunday? In my experience the grocery stores
aren't even open...

~~~
arethuza
I've had emergency dental treatment in an NHS hospital in the UK for an
extremely painful dental abscess - was treated first thing on a Sunday
morning.

~~~
chimeracoder
> I've had emergency dental treatment in an NHS hospital in the UK for an
> extremely painful dental abscess - was treated first thing on a Sunday
> morning.

Emergency dental care is provided in the US as well. Filling a cavity is not
considered an emergency.

~~~
jessaustin
Very few oral problems are emergent. GP's abscess would have been visible on
examination for months, and certainly was uncomfortable before it was
extremely painful. In many cases the first treatment is a course of
antibiotics, which any USA ER could administer perfectly well.

~~~
arethuza
"certainly was uncomfortable before it was extremely painful"

Actually it wasn't - went from nothing to blinding pain as if someone threw a
switch. I'd have 10-15 minutes of agony then it turned off for the same time
and it repeated at that frequency all of the Saturday until a GP came out on
the Saturday evening and gave me painkillers and told me to go to the
emergency dental clinic the next day.

It was right in the middle of my 3 years exams at University - which was a bit
of bad timing!

------
ams6110
I'm not an advocate of government paid health care, but hospitals and medical
providers should see that this train is coming and if they don't become more
transparent it's going to be forced upon them.

I don't have a problem with ER care being more expensive -- that isn't
necessarily unreasonable when you are getting care in an expensive facility
open 24x7, fitted out with equipment to handle any possible medical emergency,
and staffed with highly educated people who make a lot of money. But it is
unfair to have no idea what costs you are facing and whether any of those
costs are out of network on your insurance.

~~~
tivert
> But it is unfair to have no idea what costs you are facing and whether any
> of those costs are out of network on your insurance.

It's practically impossible to make an informed economic decision about truly
emergency medical care without heavy regulation. It's not uncommon to be
_literally unconscious_ while all the care decisions for you are being made by
others.

See this article for an example: some uninsured woman had a brain hemorrhage
and woke up with $357,000 in medical bills:

[https://www.nytimes.com/2017/03/29/magazine/those-
indecipher...](https://www.nytimes.com/2017/03/29/magazine/those-
indecipherable-medical-bills-theyre-one-reason-health-care-costs-so-much.html)

~~~
nightcracker
Considering she was unconscious she could not possibly have consented to those
transactions. What laws exist that allow these companies to unilaterally
create these transactions, and what limitations do they have?

~~~
stdplaceholder
They have literally no limitations. The reason that an advil at the hospital
costs $200 is because they were afraid if they made it cost $20000 people
would burn down the hospital.

~~~
dsfyu404ed
Considering how many people have had their lives ruined by absurd hospital
bills I'm honestly surprised nobody's shot one up yet.

~~~
jopsen
Really, the only surprise is that you didn't Google "hospital shooting", the
following hit from Google lists 15 hospital shootings in 2018 alone:

[https://www.campussafetymagazine.com/tag/hospital_shootings/](https://www.campussafetymagazine.com/tag/hospital_shootings/)

I guess you can go look for the motivation, most shootings probably isn't
financially motivated thought.

------
codemusings
Despite the fact that in my opinion this could be fixed by Universal
Healthcare I'm left wondering: how is it legal to be billed these insane
amounts of money without even getting a quote beforehand? Like just waiting in
the ER is worth more than buying a first class airplane ticket and getting
treated in another country.

~~~
serg_chernata
> without even getting a quote beforehand

Reminds me of this really good article. TLDR: Man tried to call a number of
hospitals to find out how much childbirth is going to cost him and received no
answers.

[https://www.vox.com/2016/5/5/11591592/birth-cost-hospital-
bi...](https://www.vox.com/2016/5/5/11591592/birth-cost-hospital-bills)

~~~
manfredo
Realistically, no hospital is going to give out a price. They don't know what
unexpected complication may arise that requires additional services.

~~~
SilasX
Realistically, no airline is going to give you a price for transit to a
destination. They don't know if there will be a terrorist attack or if the
baggage handlers on the other end will jack up their rates.

~~~
manfredo
A terrorist attack is an extremely low frequency event to the point is being
nearly non-existent. The same cannot be said of birth complications. Baggage
handler rates don't change on a dime. Labor rates do affect ticket prices, but
they're drastically more predictable.

~~~
SilasX
Yes, but the same logic applies: you either negotiate prices out with a
network in advance, or insure against the major complications. None of that is
different for a health care operation.

~~~
manfredo
No. The same logic does not apply, as the two situations are drastically
different. The regularity of airline costs is drastically greater than the
regularity of healthcare costs. Airlines can set ticket prices upfront because
they predict their expenses on a given flight with a reasonable degree of
accuracy. Hospitals, subject to extreme and frequent irregularities between
what patients may need, cannot. At least not with individual patients.
Insurance companies are very different types of customers as compared to
individuals. Because the negotiated price applies to a large group of people,
the question isn't "how much do we have to charge to break even on X
procedure?" The question becomes, "How much do I have to charge for X
procedure, *averaged over hundreds or thousands of patients?". Each patient is
effectively a slot machine for the hospital. Insurance companies negotiate on
behalf of a large number of patients so that the aggregate cost becomes
something that is predictable enough to negotiate.

------
edoo
Health care is the only industry where the felony laws regarding up front
pricing aren't enforced. It was allowed to become a twisted regulatory
nightmare where the laws were written by the industry itself utilizing
kneejerk methods to obtain profit at the cost of systemic corruption.

~~~
merpnderp
And yet it is by far the most regulated industry in the US. Almost as if the
more invasive the regulations the more invasive the corruption.

~~~
edoo
It takes a while to realize nearly every law is anti-competition
protectionism. I didn't realize it until I was working for a multinational
food company and the managers were bragging about how the company lobbied for
a safety bill that exactly regulated their own industry in a way that cost
their competitors billions in compliance fees. They were proud of it. I was
disgusted.

~~~
asdff
Disgusting, but know that there are good regulations—like environmental
protections—that are frequently combatted by industry groups and tend to get
weakened by the Republicans before they pass into law. Regulation can be
abused by industry and corrupt politicians for anticompetitive reasons, but
most of the time, it's to force companies from doing highly profitable things
that aren't good for people or the planet; its much cheaper to just dump all
your hazardous waste into the river, after all.

------
sparrish
"The prices are high — even for things you can buy in a drugstore"

Reminds me of the brief hospital visit I had in Paraguay where I needed to
have a friend or relative always with me because the hospital didn't stock
anything. If ibuprofen, bandages, syringes, antibiotics, etc were needed, the
hospital staff would tell me and I would have my friend or relative run across
the street to buy the necessary supplies from one of the pharmacies so the
doctor or nurse could treat me.

Cheap hospital bill, cheap pharmacy bill, pain in the butt for my friends and
relatives.

------
lolsal
I know $60 Ibuprofen can seem like a lot, but is anyone arguing that you're
literally paying for only the pill(s) with that $60? Aren't you paying for the
instant availability, the insurance that it's not expired (do they even
expire? I really don't know), and confidence that your healthcare provider has
signed off that XXX mg of Ibuprofen is a.) OK to have with your current
medications and conditions and b.) sufficient to do the job? Isn't some of
that cost the healthcare provider's expertise and service? Would it be better
if they prescribed morphine and charged you a magnitude more when ibuprofen
would have done the job?

I charge clients similarly. I overbid projects that I don't really want to do.
If you want me to setup Wordpress for you, I'll charge you out the nose.
Granted, you get to accept my fees before I ever send you a bill. It's not a
perfect analogy.

> This is all due to the key fee I’ve been investigating this year: the ER
> facility fee. This is the fee that ERs charge for walking in the door and
> seeking care, something akin to a cover charge at a bar.

This seems absolutely reasonable to me, I wish I could charge a 'fill my email
with RFPs' type fees. Walking into a waiting room, signing in and waiting is
not nothing. You and your symptoms get evaluated and triaged. That takes
expertise and know-how. The prices vary wildly because different hospitals
experience different levels of demand, I imagine.

~~~
dbt00
> I know $60 Ibuprofen can seem like a lot, but is anyone arguing that you're
> literally paying for only the pill(s) with that $60? Aren't you paying for
> the instant availability, the insurance that it's not expired (do they even
> expire? I really don't know), and confidence that your healthcare provider
> has signed off that XXX mg of Ibuprofen is a.) OK to have with your current
> medications and conditions and b.) sufficient to do the job? Isn't some of
> that cost the healthcare provider's expertise and service? Would it be
> better if they prescribed morphine and charged you a magnitude more when
> ibuprofen would have done the job?

It's hard to argue the 600x markup is there to cover overhead when they
literally have a facility charge there to cover overhead.

You also have separate line items for each of the things you mentioned --
doctors, nurses, staff, etc. You are paying for that expertise, often many
times over, in addition to a $60 pill that retails for $0.10 at the local
Walgreens (who also manages to make sure that it's not expired).

~~~
noelsusman
You also have to cover uncompensated care, which is a significant chunk of
change at any hospital in a major metro area. Besides, nobody actually pays
the charges. Insurance companies don't, CMS doesn't, and even the uninsured
can typically negotiate a bill down with a quick phone call. That's why the
charges are all made up bullshit. It doesn't matter so why bother?

Most hospitals in the US are non-profits. You can go look at their financial
statements yourself. They're not exactly raking in the dough. Running a
hospital is enormously expensive, and if somebody comes in needing $1 million
worth of care, then you're required by law to give it even if they can't pay.

That money has to come from somewhere. That's why Ibuprofen is $60.

~~~
JamesBarney
This just isn't true. The costs of the uninsured are not driving ibuprofen up
to $60.

The % of people who are uninsured has halved in the last decade, and this
hasn't changed a thing for insurance billing.

------
phyller
Great article. I think the narrative around health care is often around who
has access to good insurance and who doesn't, and as the cost has skyrocketed
we have doubled down on that debate. The real problem is that health care
providers won't or even _can 't_ tell you how much something costs. This has
set up this situation where, since money is not part of the decision making
process, they just keep raising costs. Imagine a grocery store where prices
are not labelled, and you get a complex bill a month afterwards. And every
grocery store does this. What are the chances prices for groceries are going
to be competitive? Zero.

If we can find a way to bring market forces to bear, it will pressure
healthcare organizations to reorganize themselves to provide services in a
more affordable way. And before anyone gets sanctimonious about putting money
over quality care, consider the actual harmful effects of these crazy bills on
people's lives. I used to do title work, and I became familiar with a pattern
of people quietly paying their mortgage on their house for a couple decades,
no liens, and then all of a sudden a lien from a hospital bill shows up. And
then everything starts to crumble, other liens accrue, and I'm doing the title
search for the foreclosure. A family just got moved from middle class to
living in poverty. Our healthcare system is becoming a vehicle to impoverish
people.

~~~
jwr
> If we can find a way to bring market forces to bear

I think the problem (also outlined in other comments) is that there are no
market forces in the US health services market. There is no pressure to
provide less expensive services, no pressure to reorganize, and no reason not
to do what is being done now: build a non-transparent system where people get
charged arbitrary amounts and prices are not known beforehand.

------
krupan
Let's be careful to not look at one type of health care, emergency care, and
generalize to all types of health care. Right now we all (Americans at least)
don't really have insurance. We are part of pre-paid health clubs and we try
to use the health club membership to pay for everything. For true time-
sensitive emergencies we should all have traditional insurance, and yes, the
services should probably be supplied, like fire fighting, by non-profit
organizations.

Health care that is not time critical should not work like the fire
department. In fact, emergency rooms, once they diagnose something as not
being an emergency should be able to say, "sorry, this isn't the right place
for this, go to a doctors office."

With non-emergency care we should all be able to get price quotes up front, we
should be completely aware of our choices and the be able to shop around. We
could maybe outsource that to health care clubs like Aetna and UHC if we
choose to (knowing that we are getting less choice and that we'll have to deal
with those bureaucracies as a trade-off), but there shouldn't be any tax
breaks or employee incentives for using those health clubs.

I recently had surgery to have my vision corrected with no "insurance" (or
health care club) involved and it was so nice. I shopped around, the doctors
all competed for my business and treated me like royalty, there was absolutely
no confusion over price, there were financing options available, the
technology was cutting edge (or I could have chosen to go less cutting edge
and paid less), it was incredibly refreshing. I'd _love_ if most of my health
care could be like that.

~~~
vec
This works reasonably well for things like vision care because they're
entirely opt-in. Patients who aren't satisfied with the prices they're being
quoted can realistically choose to keep wearing glasses instead.

No one in their right mind is going to decide that the going rate for
chemotherapy is a little steep right now so they're going to sit with the
cancer for a year or two and see if the prices come down.

~~~
krupan
So think of it in terms of food then. We don't have "food insurance," yet food
is a short-term need and it works pretty darn well as a free market.

~~~
vec
A) We do have socialized food insurance. That's literally what EBT is.

B) I'm not going to wake up in the morning to discover that my expected annual
food costs have suddenly increased by four or five orders of magnitude. There
is no budget-conscious version of a lot of non-emergency, but still
lifesaving, medical care.

~~~
krupan
A) we do not have universal single payer food. Some welfare for the poor yes.

B) that's because food is a free market

~~~
vec
A) Right. We have universal single payer food _insurance_ , also known as
taxpayer funded welfare for the poor. We're in essence covered by, and paying
premiums to, a mandatory State-run insurance policy such that if we ever can't
afford the minimum necessary food to survive the State will (at least in
theory) step in and buy it for us from the open market.

B) Let me rephrase. I'm not going to wake up one day to find that my required
daily calorie intake has increased by multiple orders of magnitude. There are
very few household budgets that could reasonably be expected to absorb such a
shock, no matter how efficiently the market for those calories functions.

~~~
krupan
A) and it works like insurance in that most of us don't ever need it, but it's
there just in case. Also, it does not regulate prices, providers, etc.

B) Again, yes, we need health insurance for rare surprises just like we get
fire insurance, auto collision insurance, etc. in case of those rare
occurrences. We do not need insurance for medical treatments that _everyone_
gets. We just need to plan ahead financially for those, just like we do for
food, clothing, housing, etc. Preparing ahead of time for known expenses is
not insurance. If everyone's house burned down a few times each year fire
insurance would not work, you would instead just factor that in to the cost of
living.

~~~
vec
As I understand it, we have a relatively small number of people with serious
or chronic illnesses whose normal, predictable healthcare expenses will
drastically and permanently outstrip their realistic ability to pay. The only
way they will ever be able to receive treatment is on someone else's dime, one
way or another. And because everyone involved knows they're going to cost more
to treat than they can pay then no sane insurer will willingly cover them if
they have a choice in the matter.

As far as I can tell the main difference between the socialized food insurance
we already have and the socialized medical insurance I'd like us to have is
that subsistence level food costs are uniformly low for everyone whereas
subsistence level medical costs vary wildly from person to person.

------
jvln
Last year my 1 year old baby had an accident in Germany. She fell off of a
bed. I took her to an ER and after the examination I paid approx. 100€ =
~100usd. I assume in USA I would have paid 10kUSD or more..

~~~
Johnny555
$10K? That's ridiculous, I really wouldn't expect any kind of trauma visit to
be that cheap, the ambulance ride alone could be over $2000 and the hospital
could charge a "trauma activation" fee of $5,000 - $15,000 which doesn't
include any treatment at all, that's just the price to have access to the ER
facilities.

------
lolsal
I wonder what healthcare bills would look like if they were itemized so that
things like Ibuprofen were literally billed at cost ($0.25 per?) and there
were line items for services/labor that captured the real cost of being a
medical professional:

\- Emergency room wait: $0.10 for lights

\- OTC eyedrops (4 drops): $0.20

\- Triage by on-duty nurse: $100 (@ $300/hr)

\- Consult by on-duty physician: $220 (@ $600/hr)

\- Late-night convenience fee: $100 (between 7pm and 7am)

etc. I made up all the numbers, I have no idea how healthcare professionals
calculate their hourly rate.

~~~
newyankee
Isn't there something like generally accepted accounting principles in
healthcare ? Genuine question if anyone knows the answer.

~~~
wyldfire
IIUC, much of healthcare billing in the US is governed by discrete codes for
services performed. I suspect this allows big customers like Federal Gov't &
insurers to audit bills easier. In order to either be more specific about the
bills or allow less wiggle room, they made these codes remarkably more
specific recently (ICD-10 [1]). IMO the descriptions of the items in these
codes are humorously specific. Imagine if your auto mechanic got $650/hr for
labor, I suppose you would get much more specific invoices for their work too.

[1]
[https://en.wikipedia.org/wiki/ICD-10](https://en.wikipedia.org/wiki/ICD-10)

~~~
newyankee
Interesting. Well the thing is if people really are motivated enough they will
always find a way to skirt certain types of regulations.

------
tschwimmer
I'm surprised to see lots of people in the comments talking about line items.
Line Items are irrelevant. They could include line items for oxygen and toilet
paper if they wanted to. The hospital charges whatever the market (and where
applicable, regulations) allow. The configuration of the line item is pretty
much a customer service problem: 'how do we show what we've done in a way that
will get the customer to pay it.'

~~~
Wowfunhappy
> The hospital charges whatever the market [...] will allow.

Except that in this case, the market is paying before being told the cost. So,
what is enforcing the upper limit on price in this type of bizarro market?

------
daniel_iversen
It makes me sad that there are places in the world where people have to pay to
go to an emergency doctor. I know it’s a political hot topic but all that
aside doesn’t most people deep down inside think that every fellow human
should have the right to free doctor?

~~~
rhexs
Okay, sure, I agree in general, but how far do we go with this?

Does every other human have the right to extraordinarily expensive, often
unproven cancer treatments only available at research institutions in the
United States? Are we willing to start making cost based decisions on who
should die (i.e. should we really be spending hundreds of thousands of dollars
keeping those above 90 alive for age related illnesses?)

Everyone will want everything free, but for this to work you have to make
uncomfortable decisions. If you put nothing into the system, how much should
you get out? Should others with more resources then be able to then buy
private insurance for access to better care even though that sounds "unfair"?

Everyone always glosses over these fun questions when they talk about
universal health-care systems.

~~~
jwr
Those are red herrings. Many (if not most) countries somehow figured it out
without having to deal with absolutes and black/white decisions. You can (and
should) draw a line somewhere, and this can be done reasonably.

As a European living in the US I find it mind-boggling that the richest
country in the world does not consider universal healthcare to be a
fundamental right of its citizens.

------
kawfey
I'm patiently waiting to have injuries and sudden symptoms until ER bills
become more reasonable and transparent. Until then, if something happens, I
guess I'll just die.

-youth of today

------
sly010
This is outrageous because the regulation wouldn't even have to be
complicated. In the EU there is a directive that you have the rights to know
the retail prices of things before you make a purchase and in some countries,
retailers have to honor the lowest posted price and we are talking about
baguettes!

I don't see why that same thing couldn't apply for healthcare. 1\. ERs should
publish prices in a public database. If a price is not published for an
item/procedure, the customer can pay the lowest price she/he can find for the
same procedure from an other provider. 2\. The same price must be charged from
everyone (regardless of insurance).

Even if only a small fraction of people shop around it might push down the
prices. Even if the above is too naive, I am sure someone smarter can come up
with a less naive version of it.

~~~
maxxxxx
"1\. ERs should publish prices in a public database. If a price is not
published for an item/procedure, the customer can pay the lowest price she/he
can find for the same procedure from an other provider. 2. The same price must
be charged from everyone (regardless of insurance)."

this would bring a lot of sanity into the system.

------
amriksohata
Brit here, thank God for the NHS

~~~
quickthrower2
+1. Moved from UK to Australia and it is very similar here too in that most
medical care is free.

One difference is that the ambulance service charges for residents, and
usually it is reasonable priced (but not cheap) but if it turns out you need a
helicopter the bill can be quite large! But insurance covers it. For most
professionals insurance is very cheap because of the tax saving you get.

~~~
newyankee
any idea how is it in NZ ?

~~~
james_s_tayler
It's fantastic here too. I had a scare recently and called the ambulance, was
at the hospital pretty quickly, got an x-ray, stayed overnight, turned out not
to be a serious thing but finally figured out what was causing it. No drama
and no crazy $100,000 bills. Just healthcare of an acceptable quality when you
need it.

There is just no way that any perceived marginal improvement in the quality of
care on an individual basis warrants an off chance of maybe being bankrupted.
I can't say I've ever found the quality of care of be poor or unacceptable.
It's always been available and served me well.

I kind of liken it to being forced to drive an $80,000 BMW as opposed to being
provided with a reasonable Toyota that does the job.

The economic experiment has been tried and the US is on the wrong side of it.

~~~
newyankee
Indeed. I am surprised though because the income taxes in NZ seem to be lower
than the quality of healthcare then. Wondering what the catch is.

~~~
veb
I've sadly been to hospital via ambulance quite a lot for seizure activity and
that kinda carrying on. The biggest bill was when I received my $54 bill for
the ambulance! Oh no. (St John is a volunteer ambulance service). So, I went
and paid it and _then_ paid them $80 for an annual househould membership -
meaning if anyone in my house ever needs an ambulance, it's free!

I'm aware however, with the rescue helicopters there can sometimes be
complications because at the end of the day, someone needs to pay - but as an
accident, everything's covered under ACC anyways. (and:
[http://www.police.govt.nz/faq/if-i-get-lost-and-need-
search-...](http://www.police.govt.nz/faq/if-i-get-lost-and-need-search-and-
rescue-will-i-have-to-pay))

~~~
newyankee
Wow, the more i read, the more difficult it is for me to believe. At this
point i feel that the US healthcare industry is the biggest rent extraction
industry in the world and they try to get away with it to the extent they can
with every stakeholder blaming someone else.

I have lived here for 9 years and although have paid my insurance diligently i
always get anxiety at going to the doctor's office.

~~~
james_s_tayler
It is.

------
kevin_b_er
> I started my project focused on one specific charge: the facility fee. I
> found this charge for walking through an emergency room’s doors could be as
> low as $533 or well over $3,000, depending on which hospital a patient
> visited and how severe her case was. I also learned that the price of this
> charge had skyrocketed in recent years, increasing much faster than other
> medical prices for no clear reason.

Is this why my local hospitals are advertising their ER wait times? The
arbitrary profit from arbitrary "in the door" fees?

------
andrewfong
I'm curious what percentage of costs were covered by insurance. I recently had
some genetic testing done and they were pretty open that they charge one lower
price if I paid out of pocket and another higher price if insurance covered
it. My hunch is that some of the price variation is just from providers
magically increasing prices to match whatever the insurer is willing to pay.

~~~
nonbel
Yes, it is called the "chargemaster":

[https://news.ycombinator.com/item?id=18722182](https://news.ycombinator.com/item?id=18722182)

------
diogenescynic
>3) You can be charged just for sitting in a waiting room

I once fainted during a comedy show because the comedian was talking about his
wife almost dying in surgery in graphic detail and I got nauseous and fainted.
I woke up outside the comedy club up against a wall with an ambulance there.
They basically took my blood pressure and gave me a bottle of water then asked
if I wanted to go to the hospital. I declined. I still received a $3000
emergency services bill later... Apparently they checked my ID/insurance when
I passed out and somehow I ended up with a bill even though I declined
service.

In contrast, I once hit my head on a train in France and had a huge gash that
needed stitches. I took a taxi to an ER, got seen within 20 minutes, left the
ER within 90 minutes, then had a $50 Euro bill.

The contrast between "socialized" healthcare in Europe vs privatized
healthcare in the US is shocking. We receive far, far, far worse quality and
fewer services despite paying a lot more. We're in the worst of all
situations.

------
jayess
I don't see the situation changing in the US anytime soon. In order for us to
have single-payer healthcare, doctors would need to accept drastic pay cuts,
pharma companies would get far less for drugs, and insurance companies would
go out of business. None of that will happen. Instead we'll have more and more
and more regulation until it just stops working.

------
dmh2000
I'm not saying the ER prices are reasonable, but an ER has to keep a lot of
expensive staff and equipment sitting around until they are needed. OK, some
ER's they are sitting around. But there is a price to have all that service
ready for an emergency.

As for high drug prices like the $60 ibuprofen, you are mainly paying for it
to be delivered to you by a nurse.

ER's have an average profitability of 7.8%. Higher than Walmart but lower than
Apple. So if they became non-profit in some way, they could cut that
percentage of costs. That's some, but still very expensive.

[https://www.beckershospitalreview.com/finance/7-things-to-
kn...](https://www.beckershospitalreview.com/finance/7-things-to-know-about-
emergency-department-profitability.html)

~~~
ncallaway
The thing is the "paying for it to be delivered by a nurse" is covered by
other things.

There will be a line-item for the ibuprofen itself, there will then
(generally) be a separate line item for staff time spent helping you, and
there will almost always be another line item for the facility fee.

The nurse's overhead is theoretically included in those latter two line items,
so shouldn't _also_ be charged in the ibuprofen line item.

Now, there are logistical concerns that will make the ibuprofen marginally
more expensive at an ER than at a clinic, but definitely not $60.

I accept the logic of high drug prices including staffing costs when those
staffings costs aren't included in other line items. In most hospital bills,
it seems, those staffing costs are already included.

------
AngeloAnolin
Reading this article and seeing all the startups sprouting in the field of
health care and medicine tells me that there's still a lot more areas to
innovate and disrupt in this industry.

One big issue though are that lobbyists who wanted to keep prices high - to
squeeze in as much profit as they can out of these. Drugs, Antibiotics,
Procedures, Medical Professionals. I know it would be far-fetched to
standardize and at least provide some level of transparency across all facets
of operation in this field, but that would be a good start.

Analyze the data, and find ways where things can be improved incrementally.

~~~
davidw
One way to disrupt the industry might be to have everyone be in one giant
insurance pool, perhaps paid for via taxes, and then give everyone access to
health care via some kind of non-profit entity.

Sounds crazy, right?

It worked well for my family and I during the many years I spent in Italy,
which has health care costs that are something like half of what they are in
the US in terms of GDP.

~~~
normal_man
Yup, it's worked nearly all over the modern world, for years and years. The
last thing I want in healthcare is more startup maniacs trying to "disrupt and
innovate" when there is a clearly viable alternative.

------
howard941
Florida typically comes dead-last consumer protection-wise except that it
requires ER physicians to be "in-network" when the hospital is also "in-
network".

------
jackkinsella
I often find in these discussions that Americans look with undue admiration
over to Europe and imagine that the same stuff doesn't happen here.

But it does.

I recently got my wisdom teeth pulled out in Germany, and without my asking,
the doctor sent me a pack of 12 Ibuprofen and billed me 24 euro, i.e. €2/pill.
I didn't want them because I had 500 of the same at home, which I bought for
25 euro — i.e. €0.05/pill. That's a markup of 40x.

------
cityzen
There is a documentary on HBO now called Bleed Out. If you want to know how
absolutely fucked the US medical system is, watch it. You will probably never
want you or anyone you love to ever step foot in a hospital again.

These insurance companies and hospital groups are pure evil. Absolutely
disgusted with what a backwards ass country America is.

------
OliverJones
This "ED is too expensive" situation has been going on for decades.

Is it possible the fairly new walk-in clinics could help?

Could there be a big red sign on the ED door saying, "Hey we are very
expensive and if your condition isn't serious you will wait a long time!
Consider using the walk-in clinic at 123 Main Street."

------
kwhitefoot
I stopped reading when I saw the minimum charge for walking through the door
was USD 500 and that a family was charged USD 18 k for a nap and some formula
milk; it was just too depressing.

No amount of analysis of the details is going to fix those things.

------
shdh
Profit not service. The system has zero incentive to reduce inefficiencies.
Its designed to increase overhead and deliver surprise bills.

The American system is largely a joke where doctors rather collect their co-
pays and write prescriptions.

------
keithnz
It would be interesting to compare prices with countries with free government
sponsored medical care. In NZ I know they work out the cost, and if you aren't
a resident/citizen you have to pay the bill.

~~~
newyankee
Is NZ healthcare decent? Asking because i am trying to decide between NZ and
Canada as my future destination for immigration after living in US for 10
years.

------
gammateam
Nice, now someone do this for legal fees

Even a dot-plot chart from different peoples experience with different
practices and needs would be a great improvement to the “it depends” of today

------
theandrewbailey
Duplicate of:
[https://news.ycombinator.com/item?id=18706522](https://news.ycombinator.com/item?id=18706522)

------
BenMorganIO
This title should be updated to state it is only in regards to the United
States and not relevant for Canadians, Australians, etc.

------
janesvilleseo
I wonder if price gouging laws can be applied in the case of healthcare,
especially in the case of emergency care.

------
nonbel
ctrl-F "chargemaster" gives no results.[1]

This article is BS. I didn't read it, it would be a waste of time.

[1]
[https://en.wikipedia.org/wiki/Chargemaster](https://en.wikipedia.org/wiki/Chargemaster)

------
hamilyon2
Meanwhile in Russia: free ER services, free nationwide health care and no-
franchise cheap voluntary insurance for everyone who doesn't want state
medicine. Cheap because you have to compete with rather-good and completely
free for everyone.

------
king_magic
American healthcare is basically massive legalized fraud.

------
HillaryBriss
the most amazing and unbelievable part of this story is "Congress wants to do
something about the issue"

------
tgsovlerkhgsel
Want to do something about it? Regulate it.

Like literally, have some government body write a table:

    
    
      1 pill of 400 mg paracetamol ............ $0.50
      1 pill of 800 mg paracetamol ............ $0.60
      prescribing medicine (once per day) ..... $4.32
      base fee for an ER visit .............. $200.00 
      5 minutes of work by an ER physician ... $27.43
    

etc. and impose that as the maximum price that can be charged.

It's not going to happen because "omg socialism", but this is literally how
other countries handle it. Possibly with a multiplier that the hospital/doctor
can apply within certain limits. If you really need to, maybe even allow
deviating from it as long as the patient is conscious, in a position to make
that choice (i.e. not emergency care), is explicitly informed that this is
above the "official" rate, is informed about the rate, and signs off on it
beforehand.

And I'd like to point out that this sort of regulation isn't unprecedented in
the US either. Taxi prices are regulated this way in many areas. Apparently,
transportation is more important and less suitable to be left to a free market
than healthcare...

~~~
thatswrong0
Shouldn't the max price of services (not things like RX of course) be
different depending on the cost of living in that area? You'd need different
prices in different areas otherwise the prices might be too expensive in some
areas and too cheap in others. If the prices set are too cheap, you might see
more people using the ER for non-emergency purposes, which would be bad for
the people that need to use the ER for actual emergencies.

~~~
AlexandrB
> If the prices set are too cheap, you might see more people using the ER for
> non-emergency purposes, which would be bad for the people that need to use
> the ER for actual emergencies.

The "long wait times" that Canadians sometimes complain about actually address
this problem within public healthcare. If you come into the ER for a non-
emergency, fine, but prepare to wait 4-6 hours. Every emergency case coming in
the door will get placement ahead of you.

Some provinces (e.g. Ontario) address this with phone triage hotlines that
help you make a decision about whether to go to the ER, a walk-in clinic, or
wait for a doctor's appointment.

------
dgzl
Sooo.... It's the hospital's fault healthcare is expensive! (Mostly joking)

------
Tepix
The idea suggests itself that the problems of the US healthcare system are
closely tied to unrestrained capitalism, includings its influence on/over US
politics.

------
dredmorbius
A question that frequently comes up in healthcare debates is "would you rather
be alive now or alive with the medical technology of 1970".

You'd be giving up genetic testing, numerous advances in wound care, a number
of advanced antibiotics, leaps in transplant technology, and a whole slew of
joint-replacement innovations. Plus cancer treatments, and of course, AIDS
therapies. Massive impacts, right?

And if today is better than 1970, 1970 was better than 1950, and 1950 better
than 1920, and....

Right?

Not so fast.

New York City have been tracking mortality rates since 1800, and there's a
chart I love to pass around in these discussions, with the charming cocktail-
party friendly title of "The Conquest of Pestilence in New York City ... as
shown by the death rate as recorded in the official records of the Department
of Health and Mental Hygiene".

The 20th century has seen a host of medical advances: antibiotics, vaccines,
transplants, tailored drugs, implants. High-cost, yes, but huge impacts.

No, not really.

[https://1.bp.blogspot.com/-uTWEATUzgxk/TXQoTibILtI/AAAAAAAAA...](https://1.bp.blogspot.com/-uTWEATUzgxk/TXQoTibILtI/AAAAAAAAAAM/eyirotYDmXo/s1600/2004_01_healthstat.jpg)

The turning point in the chart -- where the _increase_ in mortality as New
York as it grew from a town of 60,515 (1800) to a city of 813,669 (1860), _was
the formation of the Department of Public Health itself_ , in 1866. Peak
mortality hit 50/1,000 in the 1830s, 180s, and 1860s, with a sustained average
above 35/1,000, and marked volatility as the city was rocked by epidemics. By
the 1890s, it had fallen to 20, and 1920, about 12. The pre-WWII low was
actually in 1939-40, at just over 10, and mortality _rose_ through the early
1970s. There _has_ been a further decline, to about 7.5, since 1990.

Analysis elsewhere suggests that this is almost _wholly_ attributable to
increased longevity among minority populations -- nonwhites generally, black
women, and especially black men. My suspicion (though I've not researched in
depth) is that this is _largely_ attributable to _increased access to medical
care_ , either through improved socioeconomic status and access to the
commercial healthcare market, or through public health programmes. _There is
little if any evidence that the gains come from medical technology itself._

This is a topic that's been much studied. Robert J. Gordon's epic assessment
of US economic progress, _The Rise and Fall of American Growth_ (2016) looks
hard at medical advances, particularly since 1970, and finds them largely
absent. Victor Fuchs, healthcare economist (heavily cited by Gordon) has found
published similar results for the past few decades.

A personal anecdote is a close friend who'd died of an obscure cancer in the
early 1990s. The (brutal) treatments they'd undergone were essentially
unchanged since the early 1970s, or even 1960s, as I read the literature, _and
have changed little in the ensuing nearly three decades_. Given that one of
the questions and agonies we faced at the time was "what if some miracle cure
emerges, or we weren't doing enough", this failure-to-advance is in some ways
a bit of validation: we really try to do everything we could, and applied the
best available knowledge, and no, even now, the outcome is virtually
unchanged: four out of five patients with that diagnosis die within five
years, often less.

(Other friends _have_ survived their, mostly other, cancer diagnoses. And of
the cancer-friends we'd made, some are still alive, others have died, in cases
of complications from treatment, including blood- and tissue-donation related
infections such as hepatitis. Life is not fair.)

Real healthcare improvement, as with so many other quality-of-life
improvements, comes _not_ from heroic measures, _but by assuring adequate
access._ And the market is a terrible mechanism for assuring such adequacy.

------
fallingfrog
The reason we don’t have universal healthcare is mostly racism and male
supremacy. Racist white people dont want anyone with dark skin getting a “free
ride”. And, supporters of patriarchy don’t want their stay-at-home wives to be
able to get healthcare without going through them because it undermines the
husband’s power and control. They will use the language of “personal
responsibility” or “free markets” to describe it, but the same people who
don’t want universal healthcare also wave confederate flags and think that a
woman’s place is in the home.

~~~
fallingfrog
I was expecting to get downvoted for this, but it’s still true. In countries
where women can get free childcare and free healthcare, they have more
_power_. American men deeply fear this. In the end, like everything else, it’s
all about power- who has it, who doesn’t. Big healthcare also makes a killing
on the situation, but here in the states conservatives have always been
willing to make the devils bargain of allying themselves with the ruling class
in order to preserve white supremacy and male supremacy. It’s true no matter
how many downvotes I get.

