
Hospital prices are about to go public in the U.S. - SQL2219
https://www.ajc.com/news/national/hospital-prices-are-about-public/2jXYHgoR5CObBj6fSJQQUO/
======
bookofjoe
Pro tip: I was a neurosurgical anesthesiologist at the University of Virginia
Health Sciences Center for twelve years (1983-1995). Every now and then I'd
get a call from our billing office that they'd received a letter from a
patient I'd cared for who was too poor to pay what our department had billed
(usually many thousands of dollars: I had NO IDEA what our charges were, BTW,
nor did any of my colleagues in the department). Every time that happened, I'd
go over to the billing office and — without bothering to read the letter —
tell our billing chief to waive all anesthesia-related charges. In other
words, by my initialing a form we had, their balance due us was 0. Try it, you
never know, it might work for you.

~~~
tomohawk
If you are a patient in this situation, there are advocates who can help you.
One thing to try is to ask the billing department if they will "accept
assignment". What that means is that instead of billing you their fake rate,
they would instead bill you as if you were an insurer.

IMO, it is incredibly unethical and dishonest for these medical corporations
to charge different fees depending on who you are. Prices should be
transparent, and should be the same for everyone.

Some may argue that an organization representing a large pool of people should
be able to achieve economy of scale and a better price. This seems false to
me, as in reality there is only one pool of people and care provider provide
care to that one pool. Its time to kick the middlemen out.

~~~
cheez
When you remove the middlemen, what will you replace them with?

~~~
lallysingh
Tiny bits of software.

~~~
cheez
What's the purpose of the software?

~~~
RhodesianHunter
Replacing the middle men

~~~
cheez
Is the software written by people who would not profit from the software?

~~~
50656E6973
Could be an open standard

~~~
cheez
This is quickly degenerating into... an xkcd comic

------
karmelapple
I was in a hospital in Singapore recently, and the prices for doctor
consultation fees, staying in a room, and even certain tests were listed right
at the front of the emergency room desk.

After the patient I was with was stabilized, the nurse confirmed with us
verbally what the rough cost should be for the rest of what the doctor
prescribed, and asked if we wished to proceed. We could have said no and gone
elsewhere if we wanted, since the patient at least was relatively stable and
we knew what was wrong.

I want this experience to be the norm in the USA.

~~~
Holybeds
Where I live you know the cost before you go to the doctor since you will only
pay a symbolic sum of 30 USD even if the visit ends up with something like a
life long cancer treatment. If you need medicine you will pay at most 120 USD
per year regardless of the costs.

The idea that your access to healthcare should be linked to your own or your
parents financial is crazy.

~~~
miketery
I agree in principal to an extent - however economics need to be tied to the
end product somewhat. Otherwise many people would opt for $100k healthcare
cost (at the expense of the public) to extend their life for a few more
months, this is not reasonable. Resources are finite - therefore we need
appropriate allocation.

In the end I agree that a basic safety net is necessary and serves a greater
good - providing things like normal checkups, preventative services, and acute
trauma care is reasonable. However $200k for a second heart surgery for
someone who hasn't taken heed of earlier exercise or diet advice by a
practitioner should not be supported.

~~~
jlebar
Serious question: Do you live a perfect life? Do you exercise daily? Do you
never eat processed meat (linked to cancer)? Do you never drink soda (linked
to metabolic syndrome)? Do you not smoke? Do you not drink any alcohol (linked
to cancer)? Do you live close to your work so as to minimize the time spent in
a car (car accidents are a major cause of preventable death)? Are you not
overweight, even a little? And so on.

Do you think that someone who follows _all but one_ of those rules still
deserves healthcare? All but two? What's the moral difference between someone
who smokes and someone who hasn't taken heed of diet/exercise advice after
getting heart surgery? Where do you draw the line?

It's easy to say, "I don't want to pay for the healthcare of some hypothetical
'slob'". But make it real, consider what this actually means, and I think it's
not something most of us want.

None of us is perfect. I'm sure that even olympic athletes occasionally eat
bacon. Let he who is without sin cast the first stone, right?

~~~
antisthenes
> Do you think that someone who follows all but one of those rules still
> deserves healthcare? All but two? What's the moral difference between
> someone who smokes and someone who hasn't taken heed of diet/exercise advice
> after getting heart surgery?

Yes. Yes.

Moral difference no idea, but neither one should expect to have society foot
the entire bill for their bad habits.

> Where do you draw the line?

Probably around morbid obesity that's unrelated to genetic/chronic issues.

> Let he who is without sin cast the first stone, right?

By setting an unreasonable standard and saying no one under it has the ability
to cast judgment is extremely anti-intellectual. If 2 people were telling you
about health habits and one of them was an olympic athlete (who occasionally
ate bacon), and the other was a random overweight person from the street,
whose advice would you give more weight to?

~~~
jlebar
> Probably around morbid obesity that's unrelated to genetic/chronic issues.

The jury is still very much out on how common this is, isn't it? Who is going
to make the decision of whether I am "at fault" for my obesity?

Also how many people _actually choose_ to be morbidly obese? Like, suppose I
am genetically predisposed to like "unhealthy foods" (scare quotes because we
don't really know what that means). Does that excuse my obesity as genetically
caused? How are you going to tell the difference between someone who
"selfishly likes" unhealthy foods and someone who can't help themselves? More
to the point, _is there a difference_?

> By setting an unreasonable standard and saying no one under it has the
> ability to cast judgment is extremely anti-intellectual. If 2 people were
> telling you about health habits and one of them was an olympic athlete (who
> occasionally ate bacon), and the other was a random overweight person from
> the street, whose advice would you give more weight to?

In the face of this claim that my argument is anti-intellectual, I think I get
to be pedantic and say that this counter-argument is a straw-person and
equivocates.

I am saying that I don't think an Olympic athelete should pass _moral
judgement_ on other people. But of course an expert can pass _intellectual
judgment_ on ideas (e.g. "candy is healthy").

I can't believe I'm here as an athiest defending Jesus, but there you go. :)

~~~
antisthenes
> Also how many people actually choose to be morbidly obese? Like, suppose I
> am genetically predisposed to like "unhealthy foods" (scare quotes because
> we don't really know what that means). Does that excuse my obesity as
> genetically caused? How are you going to tell the difference between someone
> who "selfishly likes" unhealthy foods and someone who can't help themselves?
> More to the point, is there a difference?

I'm sorry but this is insane. Are we just abolishing any notion of personal
responsibility whatsoever? I can't and won't argue from that first principle
so we're going to have to disagree here fundamentally.

What if I can't help myself but grope women? What if I'm genetically
predisposed to violence? Or kleptomania? Those things also impose a heavy cost
on society, but if I _just can 't help myself_, am I really at fault?

> How are you going to tell the difference between someone who "selfishly
> likes" unhealthy foods and someone who can't help themselves? More to the
> point, is there a difference?

Of course there's a difference. If your willpower is not sufficient to correct
your obesity, then you should take other, more radical steps that do. And if
you don't, then you're just selfishly externalizing your problems to society.

> But of course an expert can pass intellectual judgment on ideas (e.g. "candy
> is healthy")

Good, at least we can agree on something. So to answer the first part of your
post, you should ask an expert on obesity. I'm not one, so if their judgment
differs from mine, I'll stand corrected. But until then, I'll be of the
opinion that most obesity cases are not genetic.

~~~
jlebar
> you should ask an expert on obesity. I'm not one, so if their judgment
> differs from mine, I'll stand corrected. But until then, I'll be of the
> opinion that most obesity cases are not genetic.

You're saying you have no expertise in this, haven't spent any time reading
the literature or consulting with experts, but you nonetheless are going to
continue having a strong opinion on this question? What is the basis for this
opinion on a question of fact? Hopefully it's not than the fact that fat
people are icky and so must be morally at fault for their failings?

~~~
antisthenes
I can ask you the same thing, but in reverse. What is your strong opinion on
believing that people should have no responsibility for the obesity, when we
know it is caused mostly by over-eating?

Why do you presume people are completely hopeless at controlling what they put
in their stomach?

How many experts did you consult with to form _your_ opinion?

~~~
jlebar
> What is your strong opinion on believing that people should have no
> responsibility for the obesity, when we know it is caused mostly by over-
> eating?

We don't know that obesity is caused mostly by over-eating.

Many basic questions about diet are unsolved, including the reason(s) that
some people gain weight while others don't and the reasons that the vast
majority of people can't lose weight. We just do not know to what extent do
genetics, gut flora, lifestyle, and diet affect weight. We also don't know
what makes for a "good" diet, or whether the same diet is good for everyone.

This is not obscure knowledge. Literally if you google "what causes obesity?"
you'll get pages like this: [https://stanfordhealthcare.org/medical-
conditions/healthy-li...](https://stanfordhealthcare.org/medical-
conditions/healthy-living/obesity/causes.html)

> How many experts did you consult with to form your opinion?

I spend a lot of social time around doctors, and I read a fair amount of
medical literature (for someone who isn't in the medical sciences, anyway).

I am not claiming to be an expert, but I am claiming to be somewhat informed,
yes.

I am also claiming, more strongly, that _before we as a society punish someone
for causing something_ we'd better be pretty damn sure that the person
actually did cause the thing, with mens rea and so on. I am claiming that the
scientific evidence is not there for obesity.

~~~
antisthenes
> We don't know that obesity is caused mostly by over-eating.

No, that part is obvious and we do know that more calories results in more
weight. There's no debate. The only debate is in what causes over-eating.

> Many basic questions about diet are unsolved, including the reason(s) that
> some people gain weight while others don't and the reasons that the vast
> majority of people can't lose weight. We just do not know to what extent do
> genetics, gut flora, lifestyle, and diet affect weight. We also don't know
> what makes for a "good" diet, or whether the same diet is good for everyone.

Also flat out not true. You're creating some ridiculous standard for
"knowledge" when in reality, you only have to have "good enough" knowledge in
order to be healthy and not obese. Most people can easily adhere to, but for
whatever reason, don't.

> This is not obscure knowledge. Literally if you google "what causes
> obesity?" you'll get pages like this:
> [https://stanfordhealthcare.org/medical-conditions/healthy-
> li...](https://stanfordhealthcare.org/medical-conditions/healthy-li..).

Yes, and? The answers are not equally weighted. Just because there are 3
answers, doesn't mean each answer is equally responsible in the cause of
obesity.

> I am not claiming to be an expert, but I am claiming to be somewhat
> informed, yes.

I am claiming the same. My parents are biomolecular scientists and for them it
is not contentious that overeating causes obesity. If we're giving weight to
anecdotal evidence, I'm entitled to at least give my own evidence the same
weight as you do yours.

> I am claiming that the scientific evidence is not there for obesity.

And there are people claiming that anthropogenic global warming is a myth,
despite scientific evidence otherwise. However, I'll take claims that are true
(overeating causes obesity - replicated many times), over claims that may or
may not be true.

Please realize that you're in the minority on this, but the science is already
settled. It's ok to admit that you're wrong.

~~~
jlebar
>> Many basic questions about diet are unsolved, including the reason(s) that
some people gain weight while others don't and the reasons that the vast
majority of people can't lose weight. We just do not know to what extent do
genetics, gut flora, lifestyle, and diet affect weight. We also don't know
what makes for a "good" diet, or whether the same diet is good for everyone. >
> Also flat out not true. You're creating some ridiculous standard for
"knowledge" when in reality, you only have to have "good enough" knowledge in
order to be healthy and not obese. Most people can easily adhere to, but for
whatever reason, don't.

OK, this is a concrete claim that we can test: "most people can easily adhere
to a 'good enough' diet/lifestyle to avoid being obese".

If this were true, then there would exist a protocol that "easily" results in
lasting weight loss for most people, right?

Does such a protocol exist?

------
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, this (first step of an)
anti cartel measure brings tears of joy. 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. It’s rather sad,
that it didn’t come from the industry itself - but I guess that speaks volumes
already. Florida faced a dilemma with their incredibly broken public school
system many decades ago and was stuck in a political gridlock as no party
agreed on any measure the other would propose to improve the situation.
Finally, the only item both parties did agree on, was to grade schools. Just a
single simple letter, a search for more light. The result of a little bit more
transparency caused a chain reaction of consequences leading to higher quality
of service overall. I hope that similarly this move will spark a
quality/performance re-orientation and help create more Surgery Centers of
Oklahoma. It’s high time.

~~~
epmaybe
Something I worry about, and that maybe you can help shed some light on, is
what the ramifications of such a move would be.

You mentioned the grading of schools leading to higher quality. Do we know if
any metric suffered as a result? One guess I have is that teachers started
teaching for the test rather than for the foundation.

Take that same question and apply it back to the issue of hospital cost. If
there's more transparency, the obvious conclusion is that there will be
increased competition and an overall lowering of costs for patients. Does that
come at the cost of quality of care? My gut says no, but my brain says that
hospital administrators are incredibly talented at cutting costs. Maybe we
have other safeguards such as HCAHPS to prevent the worsening of quality.

And as my own comment on this situation - how does this move fit into the
insurance realm? My understanding is that hospitals will display the
overinflated prices, but not the individual insurance negotiated prices. So
how does this increased 'transparency' help?

~~~
tachudda
I suspect that with teachers teaching to a test, it improves bad teachers and
holds good teachers back a little.

~~~
galangalalgol
It accomplishes little. The tests are a subset of the things the students
should have been learning anyway. The idea was that by measuring performance
teaching could be improved where needed. The actual result was that the "help"
given to classes with bad scores has been to overtrain some tiny neural nets
to respond to very specific stimuli without teaching them anything beyond the
specifically measured behavior. Even the students that pass often haven't
mastered the material. They just can take the test. We opted to replace
accountability with process and reaped the usual results.

------
mwerd
This won't help consumers. The prices (both charges and what Medicare pays)
are already effectively public: [https://data.cms.gov/Medicare-Physician-
Supplier/Medicare-Pr...](https://data.cms.gov/Medicare-Physician-
Supplier/Medicare-Provider-Utilization-and-Payment-Data-Phy/utc4-f9xp)

The problem, as some other comments point out, is that they're way too
complicated. The link I posted, for example, is just the provider charges. A
hospital visit typically has a facility claim and at least one provider claim.
Depending on the type of service received and the agreement between insurance
and facility, the facility fees can be billed a variety of ways (diagnosis
related groups, ambulatory payment classifications, or HCPCS). Each provider
that sees you or performs labs, x-rays, etc can bill separately, and each
could have a separate or no contract with your insurance. The latter is how
surprise 'out of network' bills happen.

It's a total mess and hopelessly complex for the average consumer.

~~~
m1sta_
> It's a total mess and hopelessly complex for the average consumer.

Sounds like something the people on this forum can help improve.

~~~
pjc50
It's not a technological problem but a political one: the obfuscatory pricing
is deliberate.

Maybe you could have "fighting hospital billing as a service", but that's
definitely going to need a chunk of human labour on top of whatever AI
assistance you apply.

~~~
dig1
Is there any way this could be represented via interactive graph? We were able
to tame much complex stuff than deliberate obfuscation by people not aware
what tech can do.

I guess there is not enough incentive ($$) to solve this problem.

~~~
willvarfar
The $$ is being made by the hospitals

See [https://www.vox.com/health-
care/2018/12/18/18134825/emergenc...](https://www.vox.com/health-
care/2018/12/18/18134825/emergency-room-bills-health-care-costs-america) to
start digging into the mess

------
codingdave
I'd be happier to see regulated business practices. While I agree that the
prices are a problem, I've felt more pain from bills that keep coming in for
more than a year after a major event. And when I go to complain, they say that
someone made a mistake, the insurance took a long time to respond, or some
other excuse. Give me a final bill with all charges within 30 days, then 30
more days to resolve any issues with that bill, and then let the billing end
so we can move on with our financial lives without wondering if one more bill
is going to show up next week, tied to my credit record.

~~~
sturgill
I currently use hospital billing as an example when explaining the halting
problem. You’re never sure if you’ve paid off an incident or if another bill
will show up in a few months...

~~~
mgr86
Before we were married my wife had an MRI. Having not met her deductible they
sent her a bill for 1.5k. Not ideal but we were able to afford it and paid the
bill. 364 days later we received another bill for roughly the same. We thought
there was an error. After months of back and forth, even after they had told
us for 2months that “they took care of it and we would not be charged” we
ended up having to pay another $500. This whole process was beyond
infuriating.

The other bill apparently came from the Dr who read the MRI. The fun part was
we were never contacted by that Dr about the results. She eventually left the
hospital and she canceled our follow up appointment.

------
refurb
My guess is that eventually the govt will step in and start regulating prices
if providers don’t.

One interesting idea (not well thought out at all) would say that all prices
need to be +\\- 50% of what Medicare pays.

Medicare pays $20,000 for stent placement? Great! You can charge whatever you
want up to $30,000.

A lot of effort goes into setting Medicare rates (and they are based on self
reported costs across the country), so forcing providers to be in the ballpark
of those might help.

It wouldn’t solve the issue, but it would eliminate those ridiculous “why do
you charge $10,000 for an MRI when the clinic down the street charges
$1,000?”.

~~~
pkaye
If you look at healthcare vs GDP, the US is way above the line compared to
comparable countries. [https://www.healthsystemtracker.org/chart-
collection/health-...](https://www.healthsystemtracker.org/chart-
collection/health-spending-u-s-compare-countries/#item-relative-size-wealth-u-
s-spends-disproportionate-amount-health)

I think scaling the average costs from other countries accounting for GDP
would be a good way to set the rates.

~~~
AmericanChopper
This is one of those nice ideas that has some pretty serious hidden costs.
You’d struggle to compare healthcare in the US to other countries, because the
quality of healthcare available (talking about availability, not
accessibility) in the US is generally superior to other countries. So you
could end up simply eroding the quality of care in the US. Another thing
people tend not to talk about when discussing healthcare in the US is how much
the US contributes to medical research and innovation. No other nation on
earth even comes close. If you adjust the system so much that you remove the
incentive to carry out that research, then the quality of care in literally
the entire world would suffer.

~~~
torgian
I disagree about quality/availability. In Japan, Taiwan, Mainland China,
Thailand; I’ve had amazing health care for the fraction of the price. Shit, a
full cancer check only cost me 90 dollars in Japan. Getting my eyes fully
checked for retinal tears cost me nothing due to national insurance in China.

In some cases, _maybe_ the US has better care. But the cost of that is just
way too damn high.

Yes, medical research in the US is superior, but that shouldn’t be at the cost
of peoples’ lives.

~~~
AmericanChopper
In the developed world, the price of routine checkups are not what people
would generally be referring to when discussing _quality_ of healthcare.
Generally speaking, the US has the best facilities, technology, expertise and
pharmaceuticals available. Which is why people come from all over the world
for procedures that simply aren’t available elsewhere. Again, I’m not talking
about the problems with accessibility, merely talking about available
treatments.

Reducing investment in medical research will absolutely come at the cost of
people’s lives. More people’s infact, as anybody will die from a terminal
illness that doesn’t have a treatment. As an example the US market constitutes
something life 70% of _global_ pharmaceutical profits.

~~~
lostlogin
This weird argument pops up regularly. In relation to New Zealand (where I am)
it’s argued that the US is subsidising the cost of drug scripts. It’s beyond
me quite how NZs drug buying agency is running roughshod over the rights of
drug companies that have multiple insurance companies in the US that are
bigger customers. What’s the agenda behind this argument?

~~~
mikestew
The U. S. is the last place drug companies can get away with it, is what the
agenda is. Americans are suckers for a good capitalist argument. “U. S.
customers pay more because they have to subsidize those filthy socialists.”
Imma gonna have to call bullshit. You’re telling me you sell to NZ at a loss
because...New Zealand tanks will roll up to your doorstep if you don’t? Does
New Zealand even own a tank? No, you sell to NZ because you somehow figured
out how to profit from doing so.

But as we see above, plenty are willing to carry the water of the poor,
downtrodden drug companies.

~~~
AmericanChopper
>No, you sell to NZ because you somehow figured out how to profit from doing
so.

The incremental cost of selling drugs you’ve already developed is quite low,
so of course they can still profit from them in less profitable markets. But
it’s the US that’s paying for them to be developed. This isn’t even up for
debate, R&D in the US dwarfs everywhere else.

------
mikedilger
I actually stiffed a doctor once because he refused to give a price up front
and when I got the bill it was outlandish. I also made a huge scene in the
intake/waiting room about this. I was leaving the United States at the time so
I didn't really care about my credit record.

To be slightly more honest: he wasn't the doctor assigned to me on intake, he
was another doctor from another hospital across the street as a consultant
IMHO trying to get onto my case so he could bill me.

~~~
QuantumGood
Had new insurance and a sore shoulder. Was billed ~$1,400 for a physical
therapist to examine it ("evaluation"). No treatment. Very little covered by
insurance.

The next day had a chiropractor treat it and shoulder was fine. $25 with
coupon. Funny part is, as it was new insurance, I spent over 30 minutes with
insurance rep _in advance_ on phone going over options and trying to get an
idea of likely costs.

When I had a heart problem and no insurance, we called providers all over town
(Minneapolis) to try to get prices in advance. Most would only give estimates
over a wide range. Some flat out said it was there policy to _not_ give
estimates. Eventually found a cardiologist who worked basically free ($30 plus
donation). I bought a Kardio to record my own ECG so I can have more data to
improve my communication with cardiologists, who are (understandably) a bit
alarmist about what can go wrong and tend to err on the side of (expensive)
caution without sufficient data.

Feels like a broken system.

~~~
arethuza
So you have insurance but it doesn't cover stuff when you are actually ill?
Does your insurance policy actually spell stuff out so that you can predict
what will or won't be covered?

Note: I'm from the UK and find the stories about US healthcare insurance
grimly fascinating....

~~~
sbov
Not just health insurance, but healthcare is crazy too.

Spent a total of 36 hours on the phone with the hospital to figure out how
much something would cost because I knew I had to pay out of pocket. And they
weren't even right when they finally gave me a number.

Had a doctor remove a cotton ball from my ear in the hallway. Charged me 2.4k
for that. Didn't have insurance either.

My wife's friend delivered her own baby in the hallway and they still sent her
a bill for delivery.

My wife had her gall bladder removed, supposedly the most common surgery.
Surgeon charged 25k, hospital charged 65k, anesthesiologist charged 3k, and a
doctor that talked to her for 25 seconds charged 1.5k. Insurance and the
hospital argued over the bill for almost a year, during which time the
hospital kept sending me payment due notices.

No one in this industry has my sympathy.

~~~
lotsofpulp
I couldn’t even get the billing codes for a routine ultrasound. And no one
will ever respond to you in writing for anything.

------
phkahler
One thing I advocate is fixed pricing. It's great to put prices online, but as
long as insurance companies and such get to make deals there will be no real
transparency or competition. The one downside I see to enforcing the prices is
that it would ruin this ability to offer a break to people who need it.

On the other hand, with enforce posted prices those prices would come down to
levels similar to what insurance companies pay so the sticker shock to those
uninsured would be significantly lower. Still, there will always be those in
need.

~~~
ethbro
It's a good goal, but this is a very complex system.

For example, if published prices were brought down to slightly-above-insurance
rates, fewer people would buy insurance.

Consequently, insurers would have less bargaining power, further erroding
their price advantage (and financial solvency).

As an end result, absent regulatory mandate, non-high deductible plans would
cease to be market viable.

Providers, insurers, and patients are in a zero-sum competition for the same
dollars.

The ultimate question is -- do we want the US medical system to look like the
US air travel system?

On the whole, it seems like it would be better than what we've got. But I
think we could do better (specifically: smooth boom/bust cycles, increase
healthy competition)

~~~
pavel_lishin
> _For example, if published prices were brought down to slightly-above-
> insurance rates, fewer people would buy insurance._

Would they? I don't buy insurance so my doctor visits are only $20 - I buy
insurance so that if something catastrophic happens to me, I'm not on the hook
for hundreds of thousands of dollars.

Even if the cost of (e.g., brain surgery, emergency appendectomy, resetting
shattered bones) was the same as what insurance pays, I _still_ wouldn't be
able to afford it.

~~~
ethbro
I would hazard to say that both of us aren't in the demographic where $20
matters.

But for a lot of people, $20 vs $250 is the difference between going to a
doctor and not.

Separate from that there's the catastrophic vs no coverage argument. If you're
struggling to make rent at the end of the month, it's probably a smarter
personal bet not to buy insurance.

But patients without at least catastrophic are corrosive to our medical
system, and what the ACA mandate was targeting.

Personally, I think the ACA mandate for a catastrophic policy, with
preventative care included, and direct cash subsidies to people at the poverty
line (to cover routine care) is the best solution.

I'd expect the ACA designers considered this, and only broadened the mandate
requirements as a horse trade to insurers for assuming the risk of offering
marketplace plans.

------
kurthr
Presumably, this is based on ICD10 codes... but there can be 30 different
services tied to a code. You still won't know what code is being charged until
after the service is rendered, and if it's rack rate you won't know the actual
rate your insurance will be charged, until THEY tell you... because that is
proprietary information (just like the reason why your treatment was denied
coverage).

Imagine you have diabetes and want to know which provider or insurance company
will give you better endocrinology rates... it's the best case treatment
knowledge scenario, but you can't figure anything out without knowing the
secret negotiated rates for each possible coverage pair.

~~~
Scoundreller
Are people really billed based on diagnostic codes? If true, it’s not what
ICD-10 was designed for.

Patient A can recover from the same procedure for the same diagnosis much
quicker and with fewer interventions than Patient B. Would insureco get billed
the same for both?

~~~
wslack
They aren't. Prices are based on the HCPCS codes (CPT for clinical charges).
For example, a 99213 is a return office visit.

~~~
kurthr
Providers often enter ICD-10 codes (required by Epic) and do not know HCPCS or
CPT... so how could they tell you what you will be charged? There isn't a way
(that even educators know of to get those codes or the pricing)... the prices
are handled by billing, which is a separate department and you can't reach
them by phone. They will call you back (within 30days), but they do not leave
messages.

Clinic and hospital in the heart of silicon valley.

------
mc32
This is a start but will be useless unless how these published prices are
arrived at are regulated so they can’t be gamed behind discounts, copays,
deductions, insurer discounts, tacked on items, etc. It’ll be like buying a
mattress and trying to do price shopping.

The published prices will need to have a readily useful and predictable
meaning and interpretation.

~~~
moonka
Exactly. As it is, everytime we end up with a sizable bill I call and ask for
a discount, and right away they tend to give a 10% pay in full discount. I've
seen this through different providers and insurance plans. I would have never
thought about it until someone suggested it to me.

~~~
Fjolsvith
Hah, yeah, I even pad my product prices so that when I run a sale, I still get
my profit.

------
stickfigure
The next logical step is to require written estimates in advance, just like
the auto repair industry.

~~~
alexis_fr
and require the same price for lone customers as what is negociated with
insurances.

~~~
redisman
and then strangle the parasitic insurance companies that are paid handsomely
by the consumer to build pointless bureaucracy and safeguard their market
position

~~~
lotsofpulp
Considering the patients have no idea what is going on and therefore no way to
tell if what they are being sold by medical care providers is appropriate or
not, insurance (who also have doctors reviewing the cases) is actually the
only entity that is auditing the work of the medical providers to make sure
they’re following the proper procedure and prevent overcharging.

------
hedora
Just in time for end of year tax donations, and on a related note, I’m a big
fan of RIP medical debt. They buy up medical debt for pennies on the dollar,
then forgive it.

It’s too late to prevent credit score dings, but at least it gets rid of
collectors for someone.

By law, when debt is sold to collectors, the person that owes the debt should
have the option to pay the price offered to the collector. In the current
system, hospitals are just paying shady crooks to borderline-illegally hassle
people.

------
gorbachev
This is almost completely meaningless unless it's paired with some serious
help in figuring out the total cost of a visit.

Every service that offers this sort of price transparency I've seen so far
lists the prices for single insurance billing codes at a time. A lay person
isn't going to understand the total cost of the visit from that, because
there's no way to figure out which billing codes are going to be make up
everything that's been billed for different types of visits.

An average price also means absolutely nothing, if the variance is significant
or the medical care depends on circumstances and can, as an example, vary from
a single day hospitalization to a 2 week hospitalization.

While this is positive progress, I would really appreciate more effort put on
actually reducing the prices themselves.

I guess the more expensive hospitals could see patients choose less expensive
hospitals, and forcing them to lower their prices, but I'm not too optimistic
of that happening in any meaningful way.

~~~
pcurve
"A lay person isn't going to understand the total cost of the visit from that,
because there's no way to figure out which billing codes are going to be make
up everything that's been billed for different types of visits."

Another problem is, for many, you won't even know what your ailment and
treatments will be until after.

~~~
whatshisface
> _Another problem is, for many, you won 't even know what your ailment and
> treatments will be until after._

Progress is progress, even if it's not perfect. Many people get diagnosed and
treated on separate visits, and many more have long-term illnesses that they
know relatively well. Soon there will be a proliferation of guides for common
long-term illnesses like diabetes, detailing what billing codes you can
expect. Eventually, I hope to be able to put a condition (say, pregnancy)
along with some personal information into a computer, and get out the flow
matrix telling me the probabilities of all possible futures and the costs of
each. That's a long way off, but this is the first step.

When medical costs are being discussed, the relatively rare situation of being
rushed in to a hospital unconscious for doctors to do a series of completely
unpredictable procedures on you tends to get focused on almost exclusively. In
reality, a huge fraction of medical expenses go to (comparatively) predictable
things like cancer treatments, where an operation will be scheduled out two
weeks in advance. Even a day's notice would be enough time for price selection
to happen, if all you had to do was look at a list of providers, prices and
success rates.

------
dakom
How about transparency of medical records - i.e. if I provide some
credentials, can I definitively get a copy of my medical history so that I can
easily take it with me to another country/hospital?

By definitively I mean within some federal regulation or system that doesn't
depend on an employee at a particular hospital getting around to it on their
coffee break.

~~~
trevyn
You certainly can under HIPAA, and I’ve done this several times without
unreasonable delay. If you’ve had issues, I’m sure the “sternly worded letter
from a lawyer” approach would get the gears turning.

~~~
dakom
Thanks! Are they all interconnected, so that if I use a service like
[https://www.medicare.gov/manage-your-health/medicares-
blue-b...](https://www.medicare.gov/manage-your-health/medicares-blue-button-
blue-button-20) I will get the collected records from different doctor visits
at different hospitals?

~~~
nradov
They are not all interconnected. Most providers have some sort of connectivity
to a regional health information exchange network, but there are a lot of gaps
and interoperability problems.

Blue Button 2.0 is helpful but currently it only gives authorized providers
access to your Medicare claims (if you're a Medicare beneficiary), which have
limited clinical value. Getting a copy of your full chart requires going
through other channels.

------
txcwpalpha
I take issue with this headline. Hospital prices are _already_ , by law,
public in the US. The new rule makes it required to post them _online_ ,
whereas previously you might have to call/email the hospital to get the price
list rather than looking at their website.

This is an important distinction, IMO, because I have seen people saying that
this is an important step because "insurance/patients can now negotiate easier
with a set price list". The issue with this is that, like mentioned above, the
public has already had access to these price lists, so this new rule changes
nothing in that regard.

The new rule might make it easier for insurance companies or those collecting
pricing information to scrape the price data from the hospitals' websites,
which is a good thing, but overall I think this new rule is being overblown in
terms of the actual impact it will have.

~~~
keerthiko
If the only access you have to a price list is through a private comms
channel, what guarantee do you have that you are receiving the same prices and
service for a given price as someone else?

If the prices were available through a centralized third party (government
health agency or similar) then sure, it's not much of a difference, but if the
only way before was by directly contacting the hospitals, then it being
available online is a big difference in the actual "public" nature of the
information.

Also, calling or writing snail mail to multiple individual hospitals for price
lists is a barrier in 2018 that not only dissuades, but is possibly physically
not viable for affected people.

In my opinion, being posted online is rightfully the baseline for information
to be considered "publicly available" (but probably not sufficient) today.

My heuristic is if you can't find out a piece of information by visiting a
public library within 5-10 minutes, it's not public information.

~~~
txcwpalpha
There's nothing in this ruling that requires the price list, even online, to
fit within your heuristic.

The hospital could choose to place the price list at a url of blahblahhospital
dot com / 3424kjfksm34. And to get that URL, you have to call the hospital and
ask for it. There is nothing in the rule going into effect on Jan 1 that says
they have to plaster the price list on their front page or on Google.

For that matter, they still could give separate price lists to different
parties, as long as said price lists are 'online' (eg price list for you is at
our_prices dot html, whereas someone else's price list is at our_other_prices
dot html).

And, beyond all of this, is the fact that even if you do get access to the
price list, it is meaningless to you as a patient. The article discusses this.
As a patient, if you want to know an actual realistic estimate of your costs,
the only way to get that is to call/go into the hospital and ask, or to go
through your insurance company estimator, both of which are already available
and aren't changed by this new ruling.

Your points are all legitimate and ones I agree with, but I just don't think
this new HHS rule does anything to meaningfully address them.

------
clavalle
One way we could wheedle useful information out of this is how the published
prices relate to other providers, especially if there are huge discrepancies.

Telling me an average MRI has an average list price of $1000 at provider A
tells me nothing. But if provider B says theirs is $10,000? That could be
pointing to something important.

~~~
jahbrewski
The ability to “shop around” for cheaper care sounds fantastic. But could that
system actually work for healthcare? Is there anything intrinsic to healthcare
that limits the ability of a free market in that arena (morally, economically,
etc.)?

~~~
clavalle
>Is there anything intrinsic to healthcare that limits the ability of a free
market

Oh, lots (the biggest fundamental failing being that a person will generally
pay anything to not die or be in pain -- its why extortion and robbery can
never lead to an efficient market). But examining costs doesn't mean we have
to apply a market-based approach to controlling those costs.

------
timtaco
I was curious at what determines medical prices after recent stay in hospital,
my bill was bizarre and it seemed that different hospitals charge
substantially different amounts. So I wrote a medical pricing app to explore
hospital bills and medicare reimbursement

I still don't understand why pricing so different throughout the country, but
at least there is a pretty app to visualize it

[https://itunes.apple.com/us/app/u-s-medical-
prices/id1376580...](https://itunes.apple.com/us/app/u-s-medical-
prices/id1376580121)

------
surfmike
Should be extended to require: * Prices _actually_ paid vs. list price for
procedures * All-in prices for the ten most common/expensive procedures (e.g.
all associated costs of a heart surgery).

------
sharemywin
Now if we could just get some kind of all payer system in place. so everyone
pays the lowest prices offered. but I guess its a start. The problem is
there's not enough competition and not enough schools and we don't allow
doctors from other countries to test to become a US doctor. with out basically
starting over.

[https://innovation.cms.gov/initiatives/Maryland-All-Payer-
Mo...](https://innovation.cms.gov/initiatives/Maryland-All-Payer-Model/)

------
yodsanklai
Some anecdotes related in the comments are scary. I'm wondering, how is the
situation for a software engineer working in a big company (say GAFA in
silicon valley). Suppose you broke a leg skiing, and need surgery and various
medical exams. How much are you expected to pay? what's the administrative
overhead? same question for dental care.

~~~
randomacct3847
completely depends on your insurance plan...something like this will
definitely be covered, but how much you will pay depends on your deductible,
how much you’ve already contributed to your deductible, what copay or
coinsurance you need to pay once you meet it, and your out of pocket max (max
you will pay for anything in a given year)

I have supplemental “accident insurance” since I’m relatively young and
healthy and the biggest reason why I’d end up in the ER is due to a physical
accident. With this insurance it covers more of what I would pay in this
situation than my insurance would alone.

~~~
lotsofpulp
Also if someone out of network walks into the room.

~~~
randomacct3847
Yeah that’s a big one. Also if you have an emergency and go to a in network
facility your doctor might be out of network. Most decent insurance plans do
say that in emergencies they treat in network and out of network care equally,
but definitely not all plans work like that.

------
weliketocode
It's hard to believe how little progress has been made with medical billing.

My last standard annual physical was billed at $2.6k, had 30+ line items, and
despite being covered my insurance left me with an out-of-pocket of $200+.

I guess I'll take this as a win, albeit small.

------
pcurve
fyi, Medicare made their reimbursement data available some time ago, including
billed vs reimbursed.

[https://www.cms.gov/Research-Statistics-Data-and-
Systems/Sta...](https://www.cms.gov/Research-Statistics-Data-and-
Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-
Data/Inpatient2016.html)

CEDARS-SINAI MEDICAL CENTER in CA billed on average $2.8 mil for one heart
transplant (nearly 50 performed) while Tufts Medical only billed $586k on
average for similar number of procedures.

They were reimbursed $345k and $280k per procedure respectively.

Insurance companies should follow suit.

------
throwawaywhynot
I like to see when title mentions the country. National news websites
typically don't include the name of the country, which is a definite
inconvenience on global communities like hn and some subreddits

------
epsontmt88vi
Can anyone recommend some resources to read up on the US healthcare system? I
am looking to spend a good week studying the subject so I can have a more
informed opinion on the subject.

~~~
conanbatt
To have a truly informed opinion, I recommend The economics of Healthcare
class on Coursera.

Its only a couple of hours to understand why pricing is so complicated in the
US, and why the problems people focus on are usually the wrong ones.

~~~
epsontmt88vi
Thanks.

------
Dowwie
EMR, Health Information Exchanges, teams of analysts organizing standards for
information exchange, and mandates for upgrades should have set the stage for
transparency beyond published fictional information by providers.

Would someone please comment about these projects? The affordable care act
gave more than a billion dollars away for people to work on the exact same,
redundant projects in regions across the United States. Did these initiatives
reach production and are they running today?

~~~
nradov
Yes EMRs have been widely deployed, and the majority of providers are now
connected to some sort of HIE. This has helped to improve care quality
slightly by reducing medical errors and preventing the need for duplicate
procedures. However it hasn't had much impact on billing or insurance issues;
those will have to be addressed separately.

------
ilaksh
I work for a startup with two people and the other guy can't pay a real salary
or benefits. So I can't really afford to live in nice areas of the US or
really even afford the health insurance and medication for just me even after
subsidies. If I needed to visit a hospital in the US without insurance, I know
I would be bankrupt.

So my solution is until business starts making money I am going to continue to
live in Mexico and get Mexican health insurance.

------
intralizee
This is honestly something I look forward to witnessing. Currently it's hard
to find detailed financial information for how much a person with whatever
diseases ends up being covered per year with costs. I think transparency about
coverage is necessary for people being unfairly handled by providers based on
their condition being minuscule compared to another disease with a larger
population that has better coverage because more advocacy.

------
aj7
There is a similarly useless drug price list. What is needed is crowd sourced
discount pricing of the insurance companies, per hospital. Leaks would be
welcomed.

------
kozikow
It's funny that co-pay I am paying for a service in the USA is comparable to a
full private treatment with the same quality in Poland, where I grew up.

~~~
Scoundreller
It can be difficult for a patient to determine quality of care.

And difficult to compare country against country.

Poland is similar to USA in cardiovascular care, but much worse in cancer :
[https://en.m.wikipedia.org/wiki/List_of_countries_by_quality...](https://en.m.wikipedia.org/wiki/List_of_countries_by_quality_of_healthcare)

~~~
TheDong
I'm curious about the quality of that source actually.

Based on the pdf linked from the OECD page [0] it looks like they're measuring
the reported incidents of cancer based on medical records.

The medical records for the US may be skewed because they only cover the well-
off (after all, the poor can't afford healthcare), while in other countries,
like Poland, everyone rich and poor receives care and are included in the
statistic.

Also, the numbers on wikipedia are stale, but they don't seem to have changed
that much on the OEDC website. The ux is garbage so I didn't click around that
much.

[0]: [https://www.oecd.org/els/health-systems/Definitions-of-
Healt...](https://www.oecd.org/els/health-systems/Definitions-of-Health-Care-
Quality-Indicators.pdf)

------
onetimemanytime
List price $72,588.00

Insurance co pays $5600

OK, maybe I am exaggerating a bit but this is useless. Someone brought
unconscious to the hospital should pay reasonable and common fees when they
leave the hospital, not whatever the hospital dreams up. What the insurance
companies pay the hospital for the procedure, maybe with a 20% increase should
be it for everyone.

~~~
pcurve
Sadly, I've seen worse billed/reimbursement ratio in reality.

------
mattferderer
I wonder if the prices listed will be shown in a manner that is legible by the
average citizen or if they will be so convoluted that no one will be able to
make sense of them.

Reading the article it seems as this will be the case. Hopefully that changes
down the road.

------
noddy1
Has there been any precedent of patients saying to the hospital at the start
of a visit "I agree to pay 1.5x the medicare reimbursement rate and no more,
if you don't agree to this I will go to the next hospital"?

------
stuaxo
Ah, always a surprise to entrenched businesses when freer markets are
introduced.

------
SQL2219
Now this is the way it should be:

[https://surgerycenterok.com/pricing/](https://surgerycenterok.com/pricing/)

~~~
assblaster
These prices seem reasonable, even though the cost is in the thousands of
dollars.

The question is what happens when you try to get your insurance company to pay
this quoted price.

------
deytempo
Why the hell would you allow automatic playing video ads that crash the mobile
browser? What a shitty site

------
SlowRobotAhead
It’s funny how long it took me to figure out the rule, is being pushed through
by Trump’s HHS appointee.

Some of the only info I could find on him by name is how much of “a distaster”
he would be published around the time he was appointed.

I’m getting real sick of what constitutes professional journalism. I don’t
like Trump, but when accomplishments are effectively hidden, and all
speculation is unabashedly negative - there is a problem.

------
aceon48
Its about damn time

