
A bipartisan plan to end surprise ER bills - jseliger
https://www.vox.com/policy-and-politics/2018/9/21/17887692/voxcare-surprise-er-bills-senate
======
ericd
How about a law stating that a medical provider has to charge everyone the
same price for the same service?

This would eliminate the many-to-many negotiation problem that contributes to
absurdities like Duke University Hospital having 1,300 billing clerks for 900
beds ([https://www.pbs.org/newshour/economy/why-does-health-care-
co...](https://www.pbs.org/newshour/economy/why-does-health-care-cost-so-m)).
It would also make it much easier to estimate costs before going to a
provider, because instead of having 1000 different prices, that service will
have one price (albeit with some variability depending on what's actually
done).

If you paired it with a law that mandated that hospitals publish their prices
for services in a simple JSON format, such that companies could use it freely
to create price comparison tools, suddenly you'd make it much easier for
market forces to push prices down to sane levels. It's insane how difficult it
is currently to figure out how much even routine and planned operations like
delivering a child will cost, and as a result people don't bother to even try,
so there's no incentive for hospitals to keep their list prices anywhere near
the realm of sanity.

~~~
IncRnd
> It's insane how difficult it is currently to figure out how much even
> routine and planned operations like delivering a child will cost, and as a
> result people don't bother to even try

In my real-life experience, that is false. When my wife was pregnant we asked
the doctor if we could pay upfront. She said yes, gave us a price, and
explained what that would cover. We paid her; the delivery was at the
hospital, and everything went well.

~~~
ericd
Was the doctor's quoted price the same as the all-in price? In our case, the
OB's bill was something like 10% of the final total, which was close to 6
figures, despite being bog standard.

~~~
IncRnd
Your total seems to be one to two orders of magnitude greater than what we
paid. We fully prepaid, and there were no complications. However, I wasn't
talking about cost but replying to the assertion that one could not forecast
costs.

I replied to, "It's insane how difficult it is currently to figure out how
much even routine and planned operations like delivering a child will cost,
and as a result people don't bother to even try". Your post seemed to refute
that as well.

------
lutorm
How about everyone gets to bill through the _hospital_ instead of every person
who tangentially heard of you one way or another sending you their own bill.
If the hospital is in-network, they bill based on in-network rates, and all
those "providers" can take up their bill with the hospital (who at least knows
they're there, unlike the patient).

~~~
arcticbull
How about the state gets a bill for everyone and the risk is distributed over
the population minimizing the cost and improving efficiency? This happens by
maximizing the risk pool size and eliminating waste from marketing and
executive compensation (and the claims denial department). This happens to
also incentivize the state to ensure everyone gets the preventative care they
need, and line up incentives re: legislation (for instance around cigarettes
and alcohol). Then we can call it “what every other civilized country does.”

~~~
tomp
How do you then provide higher-quality but more expensive healthcare to those
who can afford it?

~~~
arcticbull
You provide the same high-quality healthcare to everyone because nobody is
better than anyone else on account of wealth. Wealthy people don't suddenly
need different healthcare when they make money.

~~~
tomp
Why not also provide the same high-quality cars, housing, jobs etc to
everyone?

Hint: communism doesn't work.

Also, the reality is you have to prioritize. A public health-care system has a
limited amount of money (by definition) and needs to spend it in a carefully
balanced way. E.g. you'd rather operate/save a kid than a 90 year old person.
Another example is, governments "advise" citizens to do preventative exams
based on cost-efficiency, not on "best quality healthcare" \- it's simply
unrealistic to perform a mammography on 50% of the _older than 25_ population
every year. But if someone _wants_ to do that, and _can pay for the costs
themselves_ , why would I, you or the government limit their freedom?

~~~
int_19h
The system described above, as applied specifically for healthcare, works
wonderfully for _most_ in countries that use it - significantly better than in
US, anyway. That alone is already a reasonable answer to your "why?".

But also, there's no reason why you can't have private insurers providing
better options _on top_ of a public system. In fact, most countries do exactly
that.

------
mberning
Care in the US is quite good, but the billing is the most opaque thing
imaginable. I went in for a skin biopsy and got a bill from 3 different
people. Why? I don't take my car to the shop and get a bill from 3 other shops
in town. Ridiculous. I really think the onus should be on the provider to
issue a single bill and provide up front pricing.

~~~
paulie_a
I received a bill 9 months after a procedure. After I had already received a
dozen other bills for various other services pretty much immediately and paid
immediately. My nuanced argument was "you waited 9 months, fuck off". I never
heard anything more about that one.

~~~
fyfy18
That sounds more like a scam. Is there any way to verify the bill is
legitimate?

~~~
paulie_a
It definitely was legitimate.

------
vidanay
It's a decent start, but it doesn't really do a whole lot for "transparency",
it simply caps the charges against some completely unknown and somewhat
arbitrary number.

~~~
MBCook
Hopefully the insurance companies would demand some transparency.

At least when it comes to ERs transparency isn’t exactly useful. Most people
don’t have time to go shopping around between them, all transparency does this
let you know you’re being billed $1700 for a Band-Aid instead of billing code
B736.21.

This clearly isn’t a fix to the problems of the healthcare industry, but it
certainly sounds like a nice step up.

While I understand the logistics behind it, the idea that you can go to a
place, pay your bill, then have eight different people bill you for the same
service just feels like an absolute scam.

Yes, one was the doctor, one was the lab, one was the hospital etc. and they
may work for different companies and even in different buildings it’s just
that they all HAPPENED to be in that one building that one day if that one
time.

But you don’t go to a restaurant and get separate bills from the establishment
and the waiter and the cook and the group which buys ingredients.

“We couldn’t have told you how much that Caesar salad would have cost, it
depends on complex negotiations with your dietitian. Had it been at least 30
days since your last consumption of Californian arugula?”

~~~
nradov
Insurance companies do have negotiated prices with all their network providers
for all applicable billing codes. And insurers do often provide those numbers
to their plan members, at least partially. The trouble is that you can't
always know in advance which billing code a provider will actually submit on
the claim, and some providers are out of network without negotiated prices.

~~~
hakfoo
>The trouble is that you can't always know in advance which billing code a
provider will actually submit on the claim,

That seems like the billing system itself is conceptually faulty. Like a
supermarket where the same gallon of milk costs different prices depending on
which shelf you took it off of.

~~~
nradov
For a given customer, the "gallon of milk" costs the same regardless of which
shelf it comes from. But if you come in to buy milk and end up buying
champagne instead the price will be different.

Billing amounts are calculated based on specific unique procedure and modifier
codes. The coding is typically done by trained coders using the doctor's notes
as a reference, and the coders select the most expensive codes that they can
legally justify. Many doctors aren't even aware of their billing rates for
various procedures. In some cases the doctor won't know which specific
procedures will be needed until she gets into it and sees what's going on, at
which point it's too late for price estimates.

Payers (insurers) are trying to fix the billing system by moving away from the
fee-for-service model and toward value-based care (payment for meeting care
quality goals) or various forms of capitation (flat payment per patient per
year regardless of which procedures are needed).

------
Crontab
Radiologist and anesthesiologists are the vultures of the healthcare industry
- they are often out of network and they hide behind the scenes at hospitals
and outpatient surgery centers.

~~~
plink
The anesthesiologist for a family member's out patient tonsillectomy was the
sole out of network component in the procedure. When they remonstrated that we
should have known, I responded that maybe we should have checked if the
orderly, the valet, et cetera was in-network.

------
SilentM68
I have not read through the entire article, so don't know if what I'll state
is covered, however, I have experienced something similar with Kaiser, though
not with ER, but with regular Doctor's visits. They just send me a surprise
from time to time, and the latest one is $175.00 for a visit. This is,
literally, something that just keeps happening. Somebody on their end messes
up, or somebody does some sort of funny business, and patients get unforeseen
bills. I wish somebody would investigate them and force them to get their act
together. I mean it's convenient that they have all facilities in one place,
but they are really expensive and their billing practices are inconsistent.

------
thomasfedb
In Australia ED is free, paid for by state governments. We spend ~10% of GDP
on healthcare, the US spends 18%. We have a private system, but it has to
compete with free, and that's stiff competition.

------
subhobroto
Excellent! This is action.

Not the best action (more below) but _anything_ else is wildly better than the
situation we have in the current U.S. Healthcare system

Change needs to happen to the U.S. Healthcare system so that surprise billings
just stop. This change is not going to happen on its own without people
driving change.

The issue at hand is that Healthcare costs in the U.S. are all over the place.

Same place, same doctor, same procedure on the same person on the same day can
yield massively different invoices depending on whether the person is insured,
where they work, what kind of insurance they carry!

Hospitals wield a lot more power than you and I would guess.

An example: [https://www.publicintegrity.org/2015/06/15/17474/profit-
hosp...](https://www.publicintegrity.org/2015/06/15/17474/profit-hospitals-
mark-prices-more-1000-percent-because-theres-nothing-stop-them)

As a person who's extremely passionate about driving change in the U.S.
Healthcare system, I communicate a lot with people who have fallen on hard
times due to an enormous medical bill.

Here are two scenarios for you:

[https://www.quora.com/Recently-my-husband-visited-the-ER-
in-...](https://www.quora.com/Recently-my-husband-visited-the-ER-in-the-US-
due-to-almost-bleeding-out-were-citizens-and-have-insurance-The-bill-
is-24-000-USD-We-do-not-have-that-kind-of-money-What-can-we-do)

[https://www.quora.com/Why-did-the-doctor-charge-
me-3600-hr-t...](https://www.quora.com/Why-did-the-doctor-charge-me-3600-hr-
to-drain-my-swollen-elbow)

When people ask me what I think is "wrong" with the health care in the USA, my
answer surprises them:

Nothing is wrong with the health care in the USA. It is one of the very best
in the world for those who can afford it.

The issue is that one should not have to look unexpectedly to a life
completely ruined because they suddenly fell sick or got into an accident -
they should be able to pick up their lives when they need to do it the most
and go on from there.

My hypothesis is that a system where everyone pays the same rate regardless of
whether they are insured or not would head us off to a much better direction.

I invite your feedback on:

[https://www.quora.com/Would-a-completely-free-market-
healthc...](https://www.quora.com/Would-a-completely-free-market-healthcare-
system-with-zero-government-involvement-and-no-subsidies-for-anyone-work-
better-in-the-long-run)

[https://www.quora.com/In-the-US-the-majority-of-people-
under...](https://www.quora.com/In-the-US-the-majority-of-people-
under-65-years-old-have-health-insurance-through-their-employers-What-is-the-
logic-behind-tying-health-insurance-to-an-employer/answer/Subhobroto-Sinha-1)

~~~
Gibbon1
Feedback I have is health insurance should work like other insurance where if
there is a dispute the claimant has defacto sue the insurance company. They
can't just turn around and bill insured if the insurance denies.

------
qwerty456127
> So far, things have turned out fine — I’ve only been billed a $150 copayment
> for my ER trip...

Copayment should be eliminated too. Paying for an insurance I want to be sure
that if something happens to me I don't have to worry about anything, even
about having spare $150.

~~~
BurningFrog
Copayments are essential to keep bored and lonely people from going to the
doctor every day for nothing in particular.

AFAIK, only the UK has a zero copayment system among the government run health
care systems.

~~~
qwerty456127
In the Czech Republic copay is optional (depends on the insurance company and
the plan, not really widespread, the majority of people don't have copay) and
nobody seems to be misusing this. You can also just buy insurance that is
going to cover almost everything (and with no copay) for reasonable money
without even having a job (if you actually have a job the insurance costs you
and the employer a fixed percent of your salary). Some times the laws change
(just to get changed back some years after) and compulsory copay gets
introduced but it always is just ~$1 (which would be enough to repel bored
grannies and homeless alcoholics that just want to hang out if there actually
were any, but in fact there don't seem to be any actually misusing hospitals).
Hospitals don't look and feel as fancy and cozy as they do in the USA and a
stationary patients' diet is a disaster from the dietary value point of view
but in every other aspect everything works amazing.

~~~
BurningFrog
So it sounds like the Czech Republic has some kind of private health insurance
system?

~~~
qwerty456127
All (AFAIK) the health insurance companies in the Czech Republic are private
(public actually, but not state-owned) corporations that are regulated heavily
but in a very reasonable client-oriented and a little bit socialistic way.
Every person is legally obliged to have a paid health insurance but the
coverage is the same while the cost is a fixed percent of their income to be
paid on monthly basis so poor people pay less and get the same service. People
that don't have legal regular local income (e.g. foreign students) must buy
insurance approximately the same way tourists do when traveling abroad
(everybody else can also go and do this and it's as easy as buying a cellphone
subscription, that's almost a free market).

------
DeonPenny
Thanks god. I hate this so much

------
jlg23
As a German who had to take US-americans to the ER twice, once in Germany,
once on Curacao, my observation can be summarized as "WTF?".

In both cases the patient initially refused treatment out of fear to receive a
high bill. Both bills ended up being about 50 USD (a few stitches in the first
case, lab analysis to confirm it were kidney stones in the second case).

In the first case, the patient's spouse told me not to worry, it ain't too
bad. But she would stay with him to make sure he does not fall unconscious
("uhm.. ok...."; I got a taxi to pick them up for a trip to the ER); in the
second case I ate my dinner while watching the guy scream in pain - being a
doctor's child helps with that .. he finally agreed to let me take him to the
ER.

Dear US-americans doctors, you lost me. Where again was the exit ethics took
during your education?

~~~
0xB31B1B
The doctors don’t create the bills, or even really influence billing. The
billing issues are caused by hospital administrators who are mostly MBAs or
Policy masters, and they’re negotiating with MBAs in insurance companies.

~~~
ChristianBundy
Do you think that the doctors or hotel administrators have more power?

~~~
briandear
Doctors typically don’t work for hospitals. Their services are billed
separately.

------
arcticbull
Stop applying duct tape to a ridiculous system. Its time to offer a public
option like every other country in the OECD. That’s how you solve this. This
is sheer stupidity all the way down. How are so few of you mad as hell getting
the worst deal in the OECD? I’m mad _for_ you.

It’s like watching someone hit themselves in the face with bare knuckles, stop
and say you know what this needs? Boxing gloves, then it won’t hurt as much.
Like, you’re right, it won’t hurt as much, but why are you doing this to
yourself?

Either this is a free market and we allow the market to sort this out,
allowing people to die and go broke in the process, or we say this is a public
good that deserves a public solution. A whack-a-mole based patchwork of legal
impositions on the market is not a solution to anything. It just encourages
the captains of the insurance industry to find the next loophole to exploit
(or go out and create them by lobbying) to ensure profits keep going up
quarter over quarter, until they’re whacked back down again. Then in 6-18
months were right back where we started.

~~~
Gibbon1
We used to have a free market and it sucked. So they took the worst part of it
and slapped a national insurance program over it and that's Medicare. And now
50 years later the rest of the market sucks.

------
arkades
> The policy proposal, which you can read here, essentially bars out-of-
> network doctors from billing patients directly for their care. Instead, they
> would have to seek payment from the insurance plan. This would mean that in
> the cases above, the out-of-network doctors couldn’t send those big bills to
> the patients, who’d be all set after paying their emergency room copays.

I do love "sensible policy changes" that work by extracting money from
physicians to cover patient bills rather than actually fixing the systemic
dysfunction.

If you're the surgeon to hand, you don't get to refuse to do emergency
surgery. You _have_ to take care of that patient, ethically and legally. Oh,
turns out they're out of network, and their insurer isn't obligated to give
you a dime? Awesome, free surgery!

Here's a sensible solution: when it comes to emergency-based care, insurers
must accept all comers as in-network. There's no such thing as "out of
network" emergency-related care.

But hey, insurers have powerful leverage and a near-monopoly. What're the odds
we'd take a slice off _their_ profit margin?

~~~
godzillabrennus
People should demand an end to private insurers. Makes zero send to have
middle men who profit off denying care.

~~~
leetcrew
idk about you but i have a zero premium plan with $2300 max out of pocket for
in-network services. all i want is a foolproof way to ensure all my providers
are in-network.

~~~
antoniotamer
How can such a plan exist? Or am I missing something?

~~~
throwaway2048
You are missing the fact that its basically his employer self insuring, as a
form of unpaid compensation. The only thing the insurer is doing is acting as
a billing agent.

~~~
zrail
It’s not self-insurance, necessarily. When OP says “zero premium” they mean
(even if they don’t know it) that their employer is paying 100% of their
premium.

------
TuGuQuKu
Fuck the "bipartisan plan". M4A now.

------
anon7429
Non-Americans may not realize: In America, going to the ER, it's possible and
often happens that someone can be billed any random, unlimited amount for 10
seconds of interaction: $3,150 for "consultation." Yes. Heck, you don't even
need to be seen to be billed. As soon as they collect personal information,
despite not being seen, they can and do still try to bill you randomly
regardless. One ER in the Bay Area has a security guard whose job it is to
collect Social Security or tax identifiers from people before they can speak
to anyone in the hospital.

