
Trump Signs Executive Order Compelling Disclosure of Prices in Health Care - harshreality
https://www.wsj.com/articles/trump-order-would-give-consumers-more-information-on-health-care-prices-11561384725?mod=rsswn
======
novalis78
For someone who worked on price transparency in 2013 - I was personally
affected with surprise billing - and spent long hours working on a price
discovery / transparency tool called pricepain.com, I completely welcome this
move. While it won’t solve all issues at once, shining some light into the
medical billing mess can only be a good thing, allow market forces to enter
the picture somewhat.

~~~
subhobroto
I really would love to hear your experience and some details about the work
you did on price transparency.

Can you share some?

I have been beaten by the surprise billing so many times that I now dedicate
some of my personal time to researching the root cause and taking action, one
of which is sharing my thoughts with other people in a vain hope that things
will get better and improve.

I wrote a response to this article here:
[https://news.ycombinator.com/item?id=20281150](https://news.ycombinator.com/item?id=20281150)

Would love any input!

~~~
novalis78
That sounds very familiar. At first I thought it was a mistake. The confusion
when you get several bills, one larger than the other. Then the shock, when
you get the final picture of what you owe. I went back and forth with the
hospital and finally got an itemized bill (I didn’t know such a thing existed
nor didn’t understand why all bills would be itemized.) A square gauze priced
at the cost of an iPad,... And then the upcoding racket. It all leaves you
confused. How is this possible? Why isn’t the media all over this or the state
attorney? And why in the world is the insurance company part of the game? Then
came the Time magazine front cover story (2013 I believe “Bills are killing
us”) about hospital charge masters (why was nobody going after this decades
ago?)... Finally I came across Dr. Keith Smith from the Oklahoma Surgery
center and finally the puzzle pieces fell into place. So one does what one has
to do: roll back the sleeves and get to work. Poured a couple of months into
pricepain.com after hours (a friend working at hospitals in Wisconsin helped
with some initial price finding), a NYT offspring that had gathered some
medical prices send a cease and desist when we copied their ‘transparent
prices for medical procedures in NY’ eye-roll. Eventually the government
released Medicaid prices - a first big breakthrough. I had discussions on HN
with Better Doctor who tried something similar - eventually they pivoted and
focused on other things. We pitched to YC and a medical VC fund. Latter said
in 2013 ‘there is at least 5 others that are working on this’ hahaha. Then
came Obamacare and the future of free market / direct healthcare with price
transparency became unclear - a super state nationalized Healthcare would have
buried prices in yearly increasing taxes. So eventually I had to move on but
always hoped that something like today’s news - more price transparency to
allow for competition and improvements of quality/service - would eventually
win out.

~~~
mirimir
> A square gauze priced at the cost of an iPad,...

Absurd list prices were used to screw Medicaid and Medicate. Because they
often paid at 85% of list price. When commercial payers had negotiated as much
as 90% _discounts_. But that doesn't work anymore, I think.

------
sailfast
> Industry groups are mobilizing to fight back, saying any requirement that
> hospitals and insurers disclose negotiated rates would go too far.

This kind of effort is what is required in order to allow for comparison
shopping to occur. Maybe this even enables consumers to shop better for their
insurance plans depending on their common needs. That would likely allow folks
with certain recurring conditions to shop for the best insurance plan for them
(thus also raising the risk level for that insurer and changing prices?) but
that's a bit more like how a market is supposed to work.

I can't speak specifically to whether the order just increases legal ambiguity
or whether it will be enforced, but I'm happy to see any initiative toward
price transparency in medicine that will allow the public to start making
better decisions.

> But the order doesn’t say if hospitals would have to disclose the average of
> all rates they get from insurers or the specific rate they get from an
> individual’s insurer. That detail matters: The average rates would have a
> milder effect on local markets as insurers and hospitals still wouldn’t get
> clarity on rivals’ specific secret rates.

PRECISELY. If everybody understands the negotiated rate, then any size
organization can argue for that rate. This would make it easier for smaller-
scale companies to get the same rates as larger plans and also reduce some of
the incentives for large insurer / care company mergers that seem to be really
rent-seeking given the industry comment on this order.

~~~
dv_dt
I wonder what happens when we create a market where prices are transparent,
without disclosure of performance or quality too.

~~~
justwalt
What do you mean? Aren’t we talking about the price of hospital visits, etc.,
meaning the performance/quality is expected to be good?

~~~
ip26
Medical care is not uniformly good. Your parent is alluding to a theoretical
race to the bottom on quality.

~~~
Fjolsvith
There is a standard of quality one can expect that is defined by malpractice
law.

------
ptmcc
If one argues in favor of "free market" solutions for healthcare, then one
MUST argue in favor of pricing transparency. A functioning free market
requires the open and honest sharing of price information for consumers to
make informed choices.

Now, whether or not health care should operate under free market principles is
a different discussion entirely. But the established powers seem to
consistently fall back on the free market argument, but continue to keep
pricing as opaque and complicated as possible.

~~~
dmix
The US has long ago abandoned free market healthcare. I don't know why people
keep calling it that.

It's some bastard child of socialized medicine where the poor and old are
covered mixed with gov mandated private insurance coming from a few very large
insurance companies capable of operating within the regulatory environment.

Which is basically one step removed from full blown single-payer public health
insurance (as we have here in Canada) and about a hundred steps removed from
"free market" health care.

I hope the US gov decides on single payer soon as I see no path towards going
back to an actual market. Which would be better than the current system which
features much of the worst of both worlds.

~~~
AzzieElbab
US health-care costs are out of this world. However, for the life of me I
cannot begin to comprehend why every Canadian keeps using our healthcare
system as example of success when incidents like these are becoming more and
more common

[https://www.cbc.ca/news/canada/newfoundland-
labrador/samanth...](https://www.cbc.ca/news/canada/newfoundland-
labrador/samanthan-rideout-amputee-broken-foot-1.5184582)

[https://www.cbc.ca/news/canada/nova-scotia/mother-iwk-
halifx...](https://www.cbc.ca/news/canada/nova-scotia/mother-iwk-halifx-
hospital-mental-health-refusing-to-leave-1.5181626)

and for a description of typical hospital visit
[https://www.cbc.ca/news/opinion/health-
care-1.5170948](https://www.cbc.ca/news/opinion/health-care-1.5170948)

note, CBC is basically a more liberal Canadian CNN

~~~
dmix
It’s always lesser of evils when you’re dealing with critical gov services.

If you can’t provide a better alternative then it’s still an improvement.

The much larger UK NHS system where even hospitals are publicly run would be
even harder to pull off in America. So single payer insurance is basically the
lowest hurdle. Plus the simpler the better.

At some point the right in the US has to concede on healthcare because it’s
already been gutted and killed by a thousand cuts. And I say that as a
libertarian leaning person. You can’t honestly believe they can solve this
problem by writing a thousand more small reform bills.

Plus if you give the mob public healthcare they will be much more tolerant of
pro-economy policies and take a strong argument away from the people who want
to gut even more industries so they function just as poorly as the pseudo
healthcare market in the name of “fairness” and “equity” (mediocrity for
all!). Lesser of evils.

------
flowerlad
I have good health insurance but recently my insurance declined payment for a
lab test on grounds it was experimental. Turns out the insurance company was
on solid grounds. At this point I was on the hook for the lab fees. But here’s
the interesting part: because the insurance declined payment, negotiated rates
no longer apply. This means the lab gets to charge me list price. The list
price is a random high price that has no relation whatsoever to reality. In my
case I was charged 3x the negotiated price! This executive order helps people
in my situation—you can argue that the list price is unreasonable and that the
negotiated price is all you should have to pay (even though you were not party
to the negotiation).

This executive order is also useful for uninsured patients because you now
have a basis for arguing for a lower bill. And the courts would be sympathetic
because everyone knows list prices are random numbers!

~~~
michaelmrose
You could have refused to pay and offered them the original price or
threatened to sue which you can do without benefit of a lawyer. The act of
litigating it would almost certainly be higher than any differential.

~~~
blackflame7000
That’s what I did after a surgical center told me that they spoke with my
insurance company and everything was fine only to later send me a bill for
$150,000 for a 1hr surgery to fix a broken hand. How are you supposed to deal
with in-network / out of network hospitals when you have a bone coming through
your hand? It eventually went away because balance billing was made illegal in
california.

------
drawkbox
This will help but until health insurance and healthcare is disconnected from
employer provided, and instead consumer focused, the pricing will continue to
be shrouded and fixed.

Healthcare and health insurance should almost be separate but should not be
tied to a workplace. Disconnecting health insurance from work benefits in
favor of payment will help the private market and public market pricing,
whichever or a combination of both that it eventually goes.

Healthcare that is consumer focused and disconnected from employer provided:

\- will have to be price transparent

\- will make starting a business easier

\- will make the US more business competitive as companies in other countries
don't have to provide it

\- will allow people to change jobs more easily

\- will make ageism less of an issue

\- will get companies out of your private health

\- will allow bigger grouping by insurance companies across the nation not at
the job level (right now small/medium/family/individual private insurance is
seen as more risky because private insurance groups by employer and smaller is
more risky)

Health insurance is personal and shouldn't be known by your employer, and re-
signing up every year and anytime you get a new job is tedious, it needs to be
like all other insurance (auto, home, life mostly) that it is a personal
consumer choice and private.

Unbinding and de-coupling healthcare from the job is pro-business and pro-
consumer health and will lead to true market price transparency.

~~~
IanDrake
Exactly, we really just need to change one tax policy to make this happen. It
doesn't get much easier than that.

------
sparrish
I'm loving this. I shop around for my healthcare needs and it's very difficult
to get a quote of any kind for any service. This will increase transparency
and competition and that will hopefully lower prices.

------
PeterisP
That's kind of cool, though the devil is in the details and I'm not sure about
the details for this case.

Essentially, free market relies on certain assumptions under which the
supply/demand 'invisible hand' works properly and the benefits of free market
are realized - the key economics 101 assumptions are (1) large amount of both
suppliers and buyers; (2) small barriers of entry and exit; and (3) full and
truthful information about market conditions. The further we get from these
assumptions, the less free (and usually worse for the people) the market
becomes, and often we need gov't intervention to ensure that these assumptions
stay true and the market behavior stays close to theoretical free market
instead of degenerating into an exploitative uncompetitive monopolistic market
with hidden information - as the USA medical market is doing, and seems to
need such intervention.

~~~
pitaj
The healthcare market isn't even close to free, it's the most tightly
regulated industry. Until that changes, nothing will get better.

~~~
Veelox
People I know who have worked in commercial aviation have claimed that it
takes more paperwork to put a bolt on a plane than into a human body. While
this may or may not be true, commercial aviation is a counter example of a
tightly regulated industry that very much a free market that challenges your
assumption that regulation alone are the reason for issues in healthcare.

~~~
CivBase
Commercial aviation may be a "free market", but it is full of its own
problems.

------
undersuit
I know larger cities are the norm but everyone else is acting like everyone
has a choice. My town has an urgent care center and a hospital that serves the
entire county. The next nearest hospital is two hours away. Even then we still
have people Life Flighted out to Spokane on a regular basis from both
hospitals.

All transparency will do is put a number in front of my single choice.

~~~
foota
I don't think this is true for non immediate care though. If you had something
that needed to be done in a number of weeks would you be willing to to to a
different hospital to save.. a couple hundred? A couple thousand?

~~~
amanaplanacanal
Exactly. For some things people fly to other countries because the price
difference is enough to pay for their mini-vacation.

------
erobbins
This is awesome. I'm sure he will be opposed by congress, as they get a ton of
money dumped in their pockets by pharma and insurance companies. Might be the
first time I'll be on his side lol.

~~~
humanrebar
To be fair, this sort of thing should be a law, not an executive order. Not
that Congress passes serious bills anymore.

------
rolltiide
Great use of an executive order, the executive branch is so big that having no
directives from the CEO is an odd way to run an organization that large

Overwhelming even

I dont think the constitution envisioned how big of an organization the
executive branch is, all with independent sweeping rule making autonomy. Only
industry enthusiasts know the specifics of one agency’s depth of rules.
Someone elected by the people for totally unrelated reasons has no way of
knowing everything these agencies are influencing

~~~
boapnuaput
The president is not a CEO; the executive branch is not a corporation. [0]
Moreover, the executive branch does not need to be "run" from the top;
instead, it operates in a distributed and semi-autonomous fashion. Think not
of the Cartesian brain, but the octopus.

The Constitution outlines specific responsibilities of the President in
Article Two. [1] Those responsibilities:

* Command the armed forces

* Have a Cabinet (have the heads of subbranches as direct reports)

* Conduct foreign diplomacy

* Give State-of-the-Union addresses

* Not be bad at carrying out the will of the law; "faithfully execute" whatever the law tells them to do

* Get impeached if Congress says so

There are some things that the President is enabled to do at a whim, but they
are not as broad as you'd think:

* Issue pardons

* Appoint judges, diplomats, etc. with Congress's approval

* Call special sessions of Congress

I agree that, in order to be aware of the full nature of the law, the
President needs to be surrounded with legal professionals who can advise them
on how to not violate the law. But, in Article Two, it's clearly spelled out
that the President should have a Cabinet _in order to_ delegate day-to-day
responsibilities further.

Finally, as a reminder, the President wasn't supposed to be chosen by the
people, but by the Electoral College. [2] The Presidency should not be a
popularity contest.

[0]
[https://en.wikipedia.org/wiki/Corporatism#Fascist_corporatis...](https://en.wikipedia.org/wiki/Corporatism#Fascist_corporatism)

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

[2]
[https://en.wikipedia.org/wiki/United_States_Electoral_Colleg...](https://en.wikipedia.org/wiki/United_States_Electoral_College)

~~~
nokcha
>The president is not a CEO

The president is, literally, the chief executive officer of the US government.
He holds an office under the United States, and that office is executive in
nature, and it is not subordinate to any other office.

~~~
boapnuaput
You obviously are not familiar with the USA's Constitution. Please re-read it.
In particular, Article Two, Section Four; "The President, Vice President and
all civil Officers of the United States, shall be removed from Office on
Impeachment for, and Conviction of, Treason, Bribery, or other high Crimes and
Misdemeanors." This means that the President may be removed from office in
certain circumstances.

In the time when the Constitution was framed, and in many times since, there
is the meme of "checks and balances". [0] The overall idea is that no one
branch of the Federal powers may be unilaterally or universally unabridged in
its ability to act; other branches have powers which may check, veto, review,
or otherwise neutralize certain actions.

So, why is the President sometimes called "chief"? Because, as Article Two
also states, they are the "Commander in Chief" of the armed forces. When it
comes to military decisions, yes, there is no office above the President's;
however, note that the President's military powers are neither unilateral nor
unlimited. Crucially, the President isn't able to declare war or allocate
funds for military use without Congress' approval.

Hope this was informative. The USA's Constitution is a fascinating document
worth reading, even for those not from the USA.

[0]
[https://en.wikipedia.org/wiki/Separation_of_powers#Checks_an...](https://en.wikipedia.org/wiki/Separation_of_powers#Checks_and_balances)

------
bcheung
Is the motivating idea behind this that patients can demand the same price
that insurance companies are getting and ultimately lessen the monopoly
insurance companies have? Maybe even just get much cheaper insurance for true
emergencies and pay out of pocket for everything else?

~~~
assblaster
If I can pay the negotiated rate, I'm leaving the health insurance marketplace
altogether and self-insuring.

Why pay $20k+ per year in premiums when I can just save and invest that and
pay low prices when needed?

~~~
ThrustVectoring
Because you cannot save enough cash to be able to afford every worthwhile
treatment through up-front payment. If you don't have $150k in cash and don't
have insurance, you can't get chemotherapy and die a preventable death. With
insurance, the worst case is paying your out of pocket maximum, _getting
treatment_ , and then declaring bankruptcy or otherwise fighting attempts to
balance bill you for hundreds of thousands of dollars.

~~~
assblaster
Your assumption of $150k for chemotherapy treatment is exaggerated, especially
in light of Trump's executive order to try to get price transparency at the
level of actual insurance reimbursement.

$25k/year over ten years is $250,000, and compounded at 6% is $319,000.

So yeah, I'd easily be able to self insure for anything.

------
nwah1
This is a really important goal, but whether simple mandates can solve it, I'm
not sure. The real problem is that consumers don't _care_ about the prices,
which is how all the various layers of providers and middlemen are able to
jack up all the prices without limit.

High deductibles are one way that consumers can be made to care, but obviously
that has its own problems. Single-payer would not fix the problem by itself,
either... although using monopsony power could certainly help, if executed
competently.

Merging a single-payer approach with a high deductible approach could work,
and the deductibles could actually be paid via a government-filled HSA account
that one could rollover into a retirement or college savings account, if
unspent.

~~~
yellow_postit
I’m not sure it’s a lack of “care” and more a lack of ability to take action.

If I have a broken arm I’m not going to price comparison shop amongst
hospitals.

Anecdote: I attempted to comparison shop for an mri to diagnosis a potential
rotator cuff injury. While I could get the actual scan fees I couldn’t get the
fully burdened cost and during the visit it’s entirely opaque what things will
be new line items on the bill.

~~~
count
And if you're taken in to the ER, you're possibly not even ABLE to consent to
charges. You're at the whim of the hospital staff! Did you know they charge
for 'chaplain time' for having a chaplain stop by and say hi (you don't get to
say yes or no, and this is obviously not medically necessary)?

~~~
Consultant32452
Emergency care accounts for about 2% of total healthcare expenses. The issue
you bring up about consent during an emergency is a real one, but it's not
where all the money is going.

[https://www.politifact.com/truth-o-
meter/statements/2013/oct...](https://www.politifact.com/truth-o-
meter/statements/2013/oct/28/nick-gillespie/does-emergency-care-account-
just-2-percent-all-hea/)

~~~
sbov
Note that your article cites at least 1 other study that says 5-6% or even as
high as 10%. It would be interesting to see a breakdown here - does this
include prescription medication? It seems like if you're talking about
provider regulation, you shouldn't include that.

Unfortunately the article doesn't make it easy to figure this out.

~~~
filoleg
Even assuming that the 10% number is the right one, it still seems good enough
in my book if, in the beginning, only 90% of the expenses get addressed
successfully.

------
guntars
> Industry groups are mobilizing to fight back, saying any requirement that
> hospitals and insurers disclose negotiated rates would go too far.

Can’t wait to hear their arguments how open pricing would only confuse
consumers and cause complete destruction of the US healthcare system.

~~~
observer12
I am more interested to see which side makes those statements.

------
beat
In the Japanese health care system, a government panel sets the prices for all
medical goods and services. Private providers and private insurers must then
manage their business to be profitable against known, fixed prices, and the
panel is responsible for setting prices that allow for profitability while
preventing gouging and rent-seeking.

They have private providers, employer-provided private insurance, and somehow
manage to come in at around half the cost of the US system, for universal
coverage and some of the best outcomes in the world.

If we used fixed prices, as Japan does, this sort of regulated transparency
would be unnecessary.

------
conanbatt
Very hesitant that this is the actual problem of healthcare. What you care
about is not how much the hospital bills, but how much is leftover after
insurance. And that is unknown to all parties.

~~~
pwinnski
There is no "the" problem of healthcare. There are many, many interlocking
issues that combine to drive up prices at every step of the way in every
corner of the industry.

This might help a little bit, but there is no silver bullet.

~~~
boapnuaput
In the USA, at least, there is a singular problem: In the early 70s, the HMO
Act and similar legislation was passed, bringing in the HMO-oriented system of
healthcare.

A silver bullet would consist of introducing a single-payer system and winding
down the HMOs.

~~~
conanbatt
HMO's are very successful in terms of providing cost/care solutions. The fact
that they are so unpopular reveals the american preference: they want to see
any doctor, at any time, with as much access as possible.

------
IanDrake
At best this is a bandaid and not a cure.

To treat the problem, you have to go straight to the root.

And that problem is: The cost of free is too damn high.

Most people in the US don't pay for their medical care or their medical
insurance. It's "free", at least in terms of money out of pocket.

We need to remove the corporate tax deduction for healthcare insurance from
the tax law. This in turn will solve most other problems as market forces are
brought back into the picture.

Once people start selecting and paying for their own policy, they will be more
price conscious on their claims, as most people already are on their auto
insurance.

Once people are more price conscious, medical facilities will begin to
complete again on price and insurance companies will focus on individual
plans.

It all has to start with the consumer though, and currently the consumer
doesn't care what the price is. They don't pay for the medical care and they
don't the insurance premiums.

------
lanrh1836
It’s crazy that a drug that prevents the spread of HIV (Truvada) is nearly
$2000/month. Even if you had insurance with a high deductible plan you’d
potentially need to pay $6-7k before having it covered.

The government should be giving this away for free.

~~~
SlowRobotAhead
>The government should be giving this away for free.

The government has no money. So you're saying the tax payers should be paying
$2000/mo/recipient.

In this scenario you've made nothing cheaper. You've only externalized the
costs on to us. You could argue this is for my/public good, but you didn't ask
me, you didn't get a representative vote from me. In your scenario you've just
decided how to spend my money. I hope you understand you've only just made the
problem worse because nothing has preventing it from being $4000/mo now that
they know the gov will buy an unlimited supply.

edit: To be clear since posts below don't seem to get it... You're missing a
step. You've done nothing to solve the $2000/mo problem, just shifted the
costs to everyone. This is the issue with healthcare, the off the cuff
solutions don't actually fix the root problems.

~~~
lanrh1836
Uh, no. Truvada is a generic drug in many countries around the world and cost
maybe $10/month not $2000/month. The US just allows Gilead to profit massively
from something that is generic and in the public health interest of all
Americans to be as cheap as possible. In fact, Gilead agreed to speed up the
expiration of their exclusivity so that it will become generic in 2020 due to
public outcry, but the fact that a life saving drug will still be $2000/month
for a year or more when it could be $10 tomorrow is terrible.

~~~
Veelox
> a life saving drug

I think you are technically correct that Truvada is a life saving drug but I
feel you are being dishonest. If you exclude occupations where you could be
exposed to HIV, most of the US users of Truvada could choose to change their
behaviors and reduce their chance of contracting HIV to <1%.

There is also the general trend that US companies pay large amounts of money
to develop drugs, charge US customers enough to cover R&D costs and then sell
the drugs at cost internationally. Does that suck for us? Yes, but it helps
the rest of the world significantly.

~~~
lanrh1836
Wow, this is a bad take. You could literally say that about any disease. Why
don’t all obese people just change their behavior and then we don’t need to
worry about cheap insulin anymore! Why don’t men stop having sex with each
other and then they won’t be at risk for HIV?

~~~
Veelox
>Why don’t all obese people just change their behavior and then we don’t need
to worry about cheap insulin anymore!

For type 2 diabetics, behavior changes should be a part of the treatment plan.
That said, if you currently have diabetics and you don't get insulin you will
die thus it does qualify as life saving medicine.

>Why don’t men stop having sex with each other and then they won’t be at risk
for HIV?

While it is not pleasant, people are not going to die just because they have
to stay abstinent. You don't even have to be abstinent, you can find a group
of 10 or even 50 guys, make sure everyone is HIV negative and then you can do
what ever you want, as often as you want, with no need for drugs.

Calling it a "life saving drug" is correct in many cases (NGO worker in parts
of Africa) using the term "life saving drug" to advocate for people to be able
to cheaply have unprotected sex with strangers is dishonest rhetoric.

~~~
djakjxnanjak
If those filthy citizens would just wash their hands, we wouldn’t need to
waste money developing flu treatment either. You’re a genius! We can save so
much money.

And we can stop working on making cars safer - all we have to do is tell
everyone to follow the rules of the road and almost all collisions will be
prevented!

~~~
Veelox
While you are taking the idea to the extreme to make a point, I agree with the
underlying argument that we should work to modify behavior to improve
outcomes.

A lot of money has been spent reducing tobacco use which has paid for itself
in better health outcomes.

~~~
djakjxnanjak
When there are multiple cost-effective public health measures that can achieve
the same end, we should pursue all of them.

In the case of Truvada, we already did the hard part (inventing it). Now it’s
just a chemical that can be infinitely duplicated a low cost. It would be a
huge wasted opportunity, a moral crime really, not to give it away for free to
everyone that can benefit from it.

And the same is true for the flu vaccine, the birth control pill, the seat
belt, etc. These are miraculous technological advances. If you support the use
of these advances, but not Truvada, I would take a hard look at what factors
might be playing into that.

------
metalliqaz
The entire exercise is pointless because the health care market isn't actually
a free and open market. There's lots of regulation on health services
(obviously, as there should be, because safety is important), but more
importantly, when a person is sick or injured, they usually are not able to
comparison shop. Emergencies make it impossible, but even a relatively common
illness makes comparison shopping unrealistic. What we have is not a market
and efforts to help comparison shopping really do almost nothing to fix
things.

Has anyone else had a doctor or nurse filed the wrong paperwork for a blood
test, and then you get stuck footing the bill for an obscenely expensive test
you didn't need or want? It's happened to me several times. And you have to
pay whatever price the test facility sets, period.

The system is broken and until the insurance industry's grip is broken, we are
not going to get relief.

~~~
pdpi
> but more importantly, when a person is sick or injured, they usually are not
> able to comparison shop

You don't need to comparison shop reactively. You can look up some prices
preemptively, and choose a preferred hospital that you know to go to when you
need it. Obviously not ideal, but it does allow for _something_.

~~~
nostrademons
Also, just having the _ability_ to comparison shop tends to hold down prices,
because firms know that you _could_ go elsewhere if they're gouging you and
that information tends to escape. It's like how when the wage-fixing cartel
among Silicon Valley employers was discovered, everybody at Google got an
immediate ~50% pay bump. You didn't need to actively interview at Facebook,
because they knew you _could_ and would rather that you not get that idea in
your head.

~~~
jerf
Heck, even post facto, if you're in an emergency and you end up stuck at a
hospital that charges $50K for a procedure, and then while recovering you find
a nearby hospital that does it for $10K, you're not necessarily without
options. It's not hard to go to the provider who actually gave you service and
say "You know, they charge 20% what you do... what's the odds I can cause
$40K's worth of stink in the local news if you don't cut my price down now?"

(You may want to consult with a lawyer friend a bit before making quite such a
naked statement; that may constitute blackmail in your jurisdiction. But there
will still be "ways" of phrasing things in your jurisdiction. Talking to a
lawyer may not be all bad anyhow, whatever it is you have to say will sound
more credible with some lawyer's letterhead on top. Hospitals hear a lot of
amateur lawyers expound their novel legal theories every day.)

I'm not going to deny the relationship in that situation is still lopsided in
the direction of the first hospital, but the situation is not necessarily 100%
in their favor.

------
WomanCanCode
The government (federal/state) and our legislators (senate and house of
representative) don't always work for us or in our favor. Our political system
is not strong enough to overcome the strong lobby/interest of few. We can
however design our economy around solving these problems. Make it profitable
to solve health-care problems. We would willingly pay a 'prime' membership if
such an organization/corporation exist. And if we have more subscribers, then
we will have more payer into the system.

------
m0zg
Requiring explicit written consent to receive each service (after mandatory
price disclosure) would also be welcome. I broke my ankle a few years ago, and
half the bills sent to me I didn't recognize what they were for. In one
particularly egregious example, some doctor literally spent less than 30
seconds near my ER bed, did not even look at the injury or the charts, and
billed my insurance $700. And I've never seen him after that, received no
prescriptions, no recommendations, and no treatment of any kind.

~~~
hn23
Well this Dr. probably had to pay for his student loan:P The price tag comes
from somewhere...

~~~
m0zg
Dude was in his late 40s from the looks of it. Definitely too old for a
student loan to be an issue. Probably just got used to charging people
arbitrary amounts without their consent.

------
dclowd9901
There's an unsettling aspect to this story that is being glossed right over:
This is, what should have been, a simple bit of congressional legislation that
could/should have been drafted in the House or Senate and sent to the
president for signing. Yet it had to be drafted as an executive order. Why is
the legislative branch so willing to give up the power of the pen to the
president? What the hell is going on? This feels like a huge breakdown in the
responsibilities of the federal government.

~~~
SlowRobotAhead
Excuse me for being a little cynical... But I find the timing a little
convenient that only after 2016 are people concerned about Executive Orders
and presidential overreach.

I'm sure this comment will be followed up with someone saying "nah I've been
concerned" and that may be true, but let's look at the common mode here.

It's like the people arguing for bigger government are many of the same people
arguing against government when it's someone they don't like in power and
can't see past their own noses on this.

~~~
dclowd9901
Oh good, a whataboutism. Not enough of those, lately.

I'm not everyone, and it is something that's of deep concern to me, as it
should be to you. So feel free to shelve your cynicism and join me in asking
our representatives to do better.

~~~
SlowRobotAhead
A whataboutism would be if the topics weren't directly related. How is this
that?

Let me help you out. A "whataboutism" would be if I made a post saying "Well,
Trump did this one good thing, but Obama passed Credit Card Reforms!" See how
those are non-sequitur?

------
rolltiide
Good first step

------
ilaksh
My sister suddenly needed a few surgeries and seems to now owe an effectively
infinite amount of money.

I work for a startup without funding. Health care costs was one of the reasons
I decided to move to Mexico. Some of the medicine is still kind of expensive
to me, but for those ones it's still literally 10X less than across the
border.

------
elamje
To say the healthcare system in the US is broken is an understatement, but
this is a step in the right direction. Especially, if we cannot get a single
payer system passed through Congress in the near term. Who knows, if the
policy is actually done right, it might lower costs.

------
oarabbus_
I don't understand how anyone (of course, besides Big Healthcare/Big
Insurance, who is scalping the common man and lining their pockets with cash
with these practices) could not see this as a good thing

------
m0zg
Mark my words: later this year Trump will allow re-importation of drugs, and
Big Pharma won't be able to charge 5-10x for the same thing in the US. The
only reason why previous administrations haven't done this is good old
fashioned corruption.

------
pkaye
I think there needs to be the concept of $5 generics. Have the common stuff
readily available to anyone in any part of the US for $5 or less per month.
And if the private industry in any one region doesn't meet this challenge, the
government should offer it.

Lets put it this way. Being in kidney failure/dialysis. I take around 12
medications a day and I think only 1 is non-generic. I think lots of health
needs could be met by affordable access to the basic stuff.

------
epr
Do healthcare providers think that consumers would make decisions differently
if presented with pricing up front?

If so, how does their omission not fit the legal definition of fraud?

------
refurb
I'm kind of shocked that no healthcare providers have offered price guarantees
as a selling point - I know I'd be incentivized by them.

My guess as to why is that hospitals are just as confused about how insurance
pays for things as the general public is. They could never accurately estimate
what a patient would pay out of pocket.

~~~
viraptor
> I'm kind of shocked that no healthcare providers have offered price
> guarantees as a selling point

It would make sense if there was enough competition pressure. Lack of price
guarantees pretty much proves lack of real competition / price finding.

~~~
refurb
Agreed.

I always look to things like Lasik surgery or plastic surgery where there is a
ton of competition and real price transparency. Sure, those are elective
surgeries, but so are most medical procedures people get done. We might not be
able to solve it for every medical procedure, but it seems like there is a lot
of low hanging fruit.

Hell, in Canada, there are private MRI facilities for people who don't want to
wait for the public system. Here is one in Vancouver and _look,_ all the
prices are listed.[1] Why the hell can't we have that here?

Speaking of which, I had an MRI done that a bay area hospital charged $18K
for. Insurance discounted it down to $8K, but apparently I could get done in
Canada for $1400 out the door.

[1][https://www.canmagnetic.com/contact-
us/](https://www.canmagnetic.com/contact-us/)

------
thorwasdfasdf
Ideally, we need to move to a system that prevents individuals from being
liable for predatory pricing. There should be a law that prevents medical
providers from charging their victims directly. They should be forced to only
deal with the insurance companies and make it illegal to hold victims
accountable.

------
RocketSyntax
Thank god. I had to go to urgent care once and it cost me $700 for a 5min
throat swab.

------
systematical
Making a "free" market operate like one? What a novel idea!

------
mgoetzke
So now they can see each others prices and collude in the open and ensure no
one strays or undercuts on certain deals ?

------
HillaryBriss
_It calls for the Department of Health and Human Services to issue a rule
within two months that could require hospitals to publicize information on
their negotiated rates with insurers for common procedures._

and

 _Lawsuits could be likely, meaning any action could be delayed until after
the presidential election._

a great idea, but it sounds like the EO may not actually change anything for a
long, long time, if ever.

------
legitster
Pricing transparency was already included in the ACA. What happened to that?
Why did it fail?

~~~
pwinnski
It was somewhat limited. The ACA required hospitals to provide their charge-
masters for their services online in “machine readable” format. These charge-
master prices have limited relation to the prices faced by insurance companies
or people seeking medical care.

[https://pbghpa.org/blog/aca-price-transparency-results-in-
st...](https://pbghpa.org/blog/aca-price-transparency-results-in-sticker-
shock-epidemic/)

------
Someone1234
I support this.

That being said, does Trump have that power? Executive Orders are very
powerful because the executive branch is huge. But this is an EO compelling
private companies to do a certain thing. That seems beyond the reach of EOs.

I'd be happily wrong here, as I said I do strongly support this. Can anyone
explain why I am wrong?

~~~
mi100hael
It's almost guaranteed to get challenged in court, at which point the
judiciary will determine whether it is congruent with existing legislation.

Worst-case it's not, and congress will probably take up a similar initiative
so as not to appear ineffective.

~~~
amanaplanacanal
> congress will probably take up a similar initiative so as not to appear
> ineffective.

It would be nice if it worked that way, actually.

------
inflatableDodo
If this ever translates into reality then it is great, and I _really_ dislike
Trump both politically, and as a person. Willing to give credit where it is
due, even though I strongly suspect that it is a political stunt that will get
lost in committee. Would be delighted to be proved wrong however.

------
RickJWagner
Seems like it can only help consumers.

Kudos to Trump on this one.

------
DataDrivenMD
Not too long ago I led a team that built data products using a massive dataset
comprised of more than 6B medical claims. This included Medicare, Medicaid,
and private insurance. Two thoughts:

1) Trump is either bluffing or he doesn't have anyone around him that actually
knows how medical billing works. If he were serious, the executive order would
mandate that HHS publish the information based on the data that's already
included in _every_ claim (i.e. invoice) submitted to CMS for payment.

From a policy standpoint there are already rules in the federal register that
allow HHS to publicly disclose cost information at the hospital-level. I'm no
lawyer but it seems to me that a well-crafted executive order could stand up
in court. Even if it were struck down, putting forth such an executive order
would be a shrewd political move because it would cast its opponents in a bad
light. These would presumably be insurance companies, the medical billing
industry, and for-profit healthcare providers.

From a technical standpoint: there are already data pipelines in place for
this sort of thing. The CMS Open Data initiative already reports hospital-
level aggregates. It's not that hard to comment out a few 'GROUP BY'
statements in order to get a POC up and running quickly.

2) Even if the current executive order comes to pass, people will continue to
receive surprise bills and experience sticker shock. That's because the total
(billed) cost is a function of:

\- professional services (procedures rendered by doctors/therapists, etc)

\- facility fees (hospital bed, in-house labs, etc)

For any given hospital stay or office visit the quantity and types of items in
each category can (and does) vary. The current executive order mostly
addresses the latter.

Furthermore, two patients seeing the exact same doctor for the exact same
thing but using different insurance companies will get vastly different bills.
That's because different insurance companies require healthcare providers to
bundle/group (and sometimes break out/itemize) services in their own way.

Because out-of-pocket costs are, in turn, a % of the total negotiated rate
patients necessarily end up with the short stick in terms of cost
transparency.

Given the current medical billing system, there's simply no way for patients
to know exactly what they're going to pay ahead of time because the charges
won't be finalized until the insurance company decides what they will/won't
cover.

No executive order will change that. Transparency will require Congress to
muster up the will to write laws that put the patient first, not last.

------
marcrosoft
This is a huge win for competition in health care.

------
subhobroto
Price transparency in healthcare sounds great after the first few seconds of
thought about the matter, ever - after all with price matching TVs and Google
Home at BestBuy, Amazon and the like work so well!

It's not just fancy electronics - it works for healthcary stuff too:

Look at how cheap plastic surgery is! Free market at its best!

However, past the above sarcasm and after a few more minutes of deep
reflection, it starts to unravel that price transparency just does not work if
there is no free market.

And guess what: healthcare in the U.S. is no free market:
[https://www.quora.com/Is-free-market-healthcare-actually-
pos...](https://www.quora.com/Is-free-market-healthcare-actually-
possible/answer/Subhobroto-Sinha-1)

Yes, price transparency works well in a free market

No, healthcare is no free market. Definitely not the U.S. market.

Healthcare in the U.S. is a pseudo socialized care where private healthcare
dollars subsidize social care programs.

Employees on employer sponsored health plans, which are only federally
regulated and rarely have the additional protections that the states they
reside in afford them are nickle, dimed and squeezed for the very last dollar
that can be extracted from them.

Employees are beholden to the employer choosing good plans for them, keeping
those good plans around at affordable prices and continuing to be in business
and able to employ these employees. TOO MANY ifs and buts if you ask me but I
digress.

As long as we have something like the EMTALA or similar where services have to
be rendered regardless of ability to pay, the deficit in payment recieved will
have to be covered somehow!

Here are two scenarios with Price transparency:

Base Scenario:

\-------------

Provider: I charge $100 cash to see a patient

Insurance company (InCo) 1: We will pay you $170 if you agree to work with us.
You cannot tell our insured that you will accept $100 cash or we will
blacklist you.

Provider: ok

Insurance company (InCo) 2: We will pay you $120 if you agree to work with us.
You cannot tell our insured that you will accept $100 cash or we will
blacklist you. Provider: ok

Medicare: We will pay you $70 if you agree to work with us. Patient 1 (w/
InCo1): Doctor, I want to see you. How much do you charge

Provider: I cannot tell you. Depends. Speak with my biller

Patient 1 calls biller and they estimate $180

Patient 2 (w/ InCo2) has the same conversation and gets a $150 estimate

Patient 1 and 2 are friends and they compare notes.

Patient 1 complains to InCo1 that he paid too much money for the same visit
that costs his friend, Patient 2, much less. Plus there's this website that
shows the Provider accepts on the average, less than $120!

InCo 1 calls Provider: Hey! We heard you charged less for someone else! Trump
has this website that says you accept on the average, less than $120! You
better charge us less too or we will not renew our contract!

Medicare patient: Doctor, I would like to see you Cash patient: Doctor, I
would like to see you

Scenario 1: \----------

Provider: InCo1, Fair enough. I guess I will absorb the cost of your
paperwork, cumbersome claims process, 90+ days of payment delays and reduce my
reimbursement amounts because I don't have student loans, rent, staff bills to
pay. Medicare patient, I will see you even if I lose money because I'm in this
business because I love it. Cash patient, I will honor my $100 rate but I will
appreciate if you could tip me $20 because I just lost a few hundred

InCo1: No, you have to accept $100 now because you're a push over

InCo2: Yeah, what they said. It's not fair you charge us more! Cash patient:
Do you want this money or not?

Scenario 2: \----------

Provider: InCo1, InCo2, not interested. There are few of me compared to the
number of insureds you have and I will not absorb the cost of your paperwork,
cumbersome claims process, 90+ days of payment delays. Infact, to renew our
contract, my reimbursement amount is now $300 because dealing with you is too
much of a hassle. Medicare patient, I will not see you because I am losing
money on you. Go see someone else in a better position than I. Cash patient, I
will honor my $100 rate because I don't have to deal with all the nonsense but
only if you keep your mouth absolutely shut. If this $100 ever makes it to a
Yelp review, our relationship is over. I almost considered charging you $200
instead because you don't have an insurance company bargaining for you but I
have a weak spot for the unrepresented. President Trump, I charge everyone
$300!

InCo1: Yeah, he charges $300. That's literally what it says in our paperwork.
Here, see it!

InCo2: Yeah, he charges $300. That's literally what it says in our paperwork.
Here, see it!

Cash patient: I have no clue what Provider charges. I am on a payment plan and
paid $150 or $100. Maybe. I don't know, please keep me out of this I just want
to get better OK?

Medicare patient: I have some cash but not enough to pay per visit. Maybe I
should also go into business with InCo1 or InCo2 as supplements

Which is more likely you think?

As long as we have something like the EMTLA or similar where services have to
be rendered regardless of ability to pay, the solution to sane pricing is to
have King Kong fight with Godzilla and keep each other in check.

We just have to ensure we can control both King Kong fight and Godzilla - and
so far - they both have been very selfish and barely controllable.

We must begin with killing employer sponsored health plans and put individual
citizens in direct control of their care instead of whatever the distracted HR
team puts together or the even more distracted brokerage company that the
distracted HR team contracted after googling for "employee health benefits
examples"

Individual citizens are not even in the game. They have no bargaining power.

Time to change that. Let them regain control of which network they want to
work with regardless of where they happen to work or not even work at all.

The employer might be looking for the cheapest network but the employee might
be looking for a network with good coverage or covers certain doctors of their
choosing etc

Why complicate matters? Keep things simple.

Politics, employment and healthcare do not mix.

Healthcare is too important.

Keep them separate. Break the ties.

------
Waterluvian
The idea of requiring list prices of drugs to be displayed in commercials
seems like it might be _very_ effective.

Imagine if you were able to do some quick mental math on your couch:

"Okay so ask my doctor about Poopathome for my rectal bashfulness... Well
let's see first. It says $890/month average dose. My insurance covers 80% so
that would cost me something like $180 a month. Yeah sorry Pfizer you'll have
to do better."

~~~
cr1895
>The idea of requiring list prices of drugs to be displayed in commercials

It's bizarre that prescription medication is advertised like that in the first
place.

~~~
arcticbull
Exactly. In Canada you an only advertise either that a drug to treat a certain
condition exists, or that a drug with a certain name exists, but not both in
the same ad. Why advertise drugs to customers, they're not medical
professionals - that's why we have GPs.

~~~
cVwEq
_Why advertise drugs to customers, they 're not medical professionals - that's
why we have GPs._

Frankly (and maybe it's different in Canada), but I feel like people will have
better health outcomes if they are aware of the options and consult, work
with, and even challenge if need be, their GP.

GPs (or Primary Care Physicians, PCPs in the U.S.) share some goals with their
patients, but many goals are not shared:

* Spending less money / good drug success / less side effects vs. using only tests/drugs they GP is comfortable with * Avoiding lawsuits vs. candid discussion * Taking time to research medical hypotheses vs. needing to get to the next patient

Come to think of it, if one is willing to invest the time, have an inquisitive
mind, and demand a partnership relationship with most service providers,
perhaps that person will generally have better outcomes in many areas (home
repairs, dental, car service, etc.).

~~~
arcticbull
The only thing drug companies are incentivized to do is make money and you’re
giving them a side channel to an uninformed audience, then they go and whack
the trained professionals over the head with this data and risk they don’t
understand because TV told them.

------
sonnyblarney
Even though this is one step in the direction of 'free markets' ... they need
to go further.

With healthcare, we fall into an entirely different domain of economics,
especially because the leverage of those who have 'life saving' services over
those who don't is basically existential.

A better solution would be: 'one price for everyone'.

The entire gambit of 'negotiated prices' is a fallacy in the end, it's just a
matter of groups having collective power over another, it's not really
economically efficient.

Either A) all Americans form a 'super powerful buying conglomerate' which is
10x more powerful than any healthcare provider, thereby forcing 'amazingly low
prices' (which basically socialized medicine) - or B) we let the 'aggregate
market demand' determine price, which is basically 'one price for all'.

America should probably follow one of the European examples where they have a
public/private mix. I respect that some people just want full control and want
to pay for that, it's fine, but there needs to be a socialized component more
efficient than Medicare.

I'm not sure if Canada or UK are the best examples for America. Germany,
Netherlands or Switzerland might be better.

------
jjwhitaker
This may make pricing more transparent but it isn't going to help anyone
unless action comes from regulation or something. Martha may check which local
hospital has the best pricing for an anticipated upcoming medical need but in
the moment the ambulance will take her to the closest and she'll be charged
bankruptcy levels for care because the system itself is broken.

It'll help further see how broken the system is, but this does nothing to
actually change it. It'll be held up by lawsuits for a while then either
dropped when politically viable or used to prop up a 2020 plank without
anything to actually stand on.

If Trump wanted to do something positive he'd bring back the individual
mandate and try to reverse the loss of insurance and cost spikes since he
signed the 2017 tax bill and other legislation aimed at destabilizing the Us
healthcare system. He won't, because the GOP won't, because their goal isn't
to help Americans, just the wealthy and corporations like the for profit
groups running the detention centers at the border for $750/kid per day sans
soap and toothbrushes.

------
dragonwriter
The headline “Trump Signs Executive Order Compelling Disclosure of Prices in
Health Care” is a lie [0] and unsupported by the body of the article. Trump
did not sign an executive order compelling disclosure of prices in healthcare
(nor is that even possible, that's not how EOs work), and the body of the
article does not support the claim that he did. He signed an executive order
directing various government agencies to propose regulations consistent with
existing law which would do that (which seems unlikely to be possible; to be
both possible and necessary that would require a federal law to exist
_permitting_ the executive to require such disclosure without itself
_mandating_ it; if such a law did exist, you'd expect the EO to have cited it,
which it didn't presumably because it doesn't) and also directs agencies to do
some other, more likely to be possible, things (e.g., write reports
identifying who the agencies think we should blame for the absence of price
transparency.)

It's perhaps worth noting that this EO explicitly described itself as a
follow-up of the report produced by the Administration as an outcome of the
last EO Trump issued on this issue.

Actual EO text appears to be here: [https://www.whitehouse.gov/presidential-
actions/executive-or...](https://www.whitehouse.gov/presidential-
actions/executive-order-improving-price-quality-transparency-american-
healthcare-put-patients-first/)

Though the official text will be whatever is published in th Federal Register,
not what is on White House public info pages. When it is published, it should
show up here: [https://www.federalregister.gov/presidential-
documents/execu...](https://www.federalregister.gov/presidential-
documents/executive-orders/donald-trump/2019)

[0] propaganda rather than clickbait, I suspect—its a lie to shape opinion of
the large number of people who will only see the headline rather than one to
get people to click through to read the article.

~~~
coldcode
Exactly this. Forcing companies to show pricing is not something a EO can do.
It could direct Medicare to indicate the prices it is willing to pay for
example, but not to require corporations to do the same. That would require
actual legislation.

That said it's a good topic to wish for.

------
anovikov
We saw what happened to airlines when they allowed 'comparison shopping' and
internet search engines did that for us. Ugh. I'd much rather not have the
same thing happen with hospitals. For that matter, i'd much rather remove it
back for airlines too, as would every middle class passenger (someone who
isn't bothered by extra $30 in ticket price, but can't yet afford a private
jet).

I already see people thrown out of ER room handcuffed because someone with a
loyalty card of a higher priority level called in :)

~~~
amanaplanacanal
Extra $30? Prices were a _lot_ more expensive than that. Ticket prices are
about half what they were in 1979.

~~~
anovikov
If you guarantee me 32'' pitch on all flights, 50lb of check in luggage,
ability to change and return any ticket, any time, and good food and wine on
every flight in economy, i sign to pay 2x.

After all, we have more or less this in premium economy when you have it on
the flight (unfortunately it's on just a few, and business is, too drying up),
and it's MORE than 2x more expensive.

What airlines have become is just an insult to the human dignity. No industry
should operate that way. If you are concerned with what comparison shopping,
price optimized on the Internet, and free competition done to the taxi
drivers, turning them into precarious, powerless and poor Uberists, why aren't
you concerned with the 'demand side' of the same problem? Much less
healthcare. I'd absolutely hate to get any treatment in a system which is
'optimized' in the similar manner.

------
luckydata
This will do exactly jack squat to control prices, but it MIGHT make enough
people that are not paying attention to start thinking about what's going on
with healthcare in this country and why it's so expensive.

Every time I go to the doctor in the US I wonder WHY they are doing what they
are doing, WHY they want to see me two weeks from now even if I have a chronic
condition that's perfectly managed already and hasn't changed in years...

I never met so many unethical individuals like since I moved to the US and
started going to the doctor.

