
Emergency room patients can face steep bills even when treatment is declined - jseliger
https://www.vox.com/2018/5/1/17261488/er-expensive-medical-bill
======
spsrich
Any parent has similar stories. Consumer law does not seem to apply to doctors
and hospitals.

Imagine if you took your car into the shop - there is no price list, they
won't give you an estimate, and for weeks after they send you random bills
without indicating what it's for?

This affects everybody in the US, and I don't understand why it's allowed to
continue, except the medical industry has bought off all the politicians

~~~
lr4444lr
That may be changing soon: [https://www.infectiousdiseaseadvisor.com/practice-
management...](https://www.infectiousdiseaseadvisor.com/practice-
management/medicare-requiring-hospitals-to-post-prices-online/article/761266/)

~~~
mazelife
I think price transparency is a bit of a red herring. That's not to say I
don't support the idea of requiring hospitals to be upfront about costs, but
it isn't going to fix issues with ER visits referenced in the Vox article.
Emergency medical treatment is not really a consumer good, where if you don't
like the price your can shop around or just decline to spend money. What's
more, there is massive information asymmetry. If a physician diagnoses you
with X and recommends treatment Y, you're not in a position to evaluate
whether there's some cheaper option Z instead. Price transparency is great for
elective care, but most medical treatment is not elective in nature.

------
Ensorceled
I recently had a spot appear in my vision. Went to my GP same day, the
receptionist called around to get me into a local optometrist who determined
it was a detached retina, she called and got me into the local hospital as an
emergency case. It was busy but I got my first treatment that evening.

The entire journey, my green OHIP card was all I needed, no insurance forms,
no pre-approvals, no extra charges. 5 hospital visits with 3 treatments so
far.

I'm flabbergasted when I talk to American friends and family and they all seem
to think two things:

1\. Canadian health care "is terrible, people die waiting in emergency rooms"
2\. The US system is by far the best and that's why it's so expensive

~~~
mfoy_
You forgot:

3\. Canadians pay for their health care in tax, anyways.

(However: [https://www.investopedia.com/financial-edge/0411/do-
canadian...](https://www.investopedia.com/financial-edge/0411/do-canadians-
really-pay-more-taxes-than-americans.aspx))

~~~
seymour333
You forgot:

3\. This is actually a good thing, because we get health care when we need it
and aren't exposed to crippling debt?

(your system entirely indefensible from every possible view point)

~~~
refurb
_aren 't exposed to crippling debt_

Whoa there. My family has a good friend whose child was born with a severe
genetic disease in Canada. They are paying a ton out of pocket for care for
their child since the gov't doesn't pay (night nurse, some physiotherapy).
Both parents are having to work full time just to pay the medical bills.

For your average Canadian everything gets paid for, but if you have special
needs, you're sometimes on the hook big time.

~~~
seymour333
I think you're using an outlier to compare to an entire population, the
argument doesn't really hold up.

(indeed, it's unfortunate for your friend and I'm sorry that they're in that
situation)

For the average person though (which, when we talk about American healthcare,
is largely who we are discussing), and a for the majority of the population,
things work out very differently. Myself and the members of my family have had
countless hospital stays, ER visits, surgeries, checkups, ambulance rides
(approx $300 flat fee), assessments, scans and x-rays. All without any of us
carrying any debt or dealing with any related financial hardship (lower tax
bracket, so no special benefit plans or anything).

Friend's kid's appendix needed removal, multiple night stay at the hospital.
No cost. What does that look like in America?

I had a deviated septum and didn't breath great. I breath just fine now after
my totally covered septoplasty. What does that look like in America?

Kids recently got strep throat and needed a doctors appointment to get a
prescription for antibiotics ($42 to cover the prescription) What does that
look like in America? (honestly I'm curious about this one, would it be more
than a couple hundred dollars for that?)

edit (spelling)

~~~
redblacktree
> Kids recently got strep throat and needed a doctors appointment to get a
> prescription for antibiotics ($42 to cover the prescription) What does that
> look like in America? (honestly I'm curious about this one, would it be more
> than a couple hundred dollars for that?)

It will depend upon your insurance plan, but this situation is pretty
comparable. You'd likely pay a $20ish copay at the doctor's office and $20ish
at the pharmacy.

------
Talyen42
Hospital corporations and insurance corporations are not your friend.

You shouldn't have to do this in a first world country, but:

* Go to the ER without ID

* (optional) Ask how much it will cost

* (optional) They do not give prices, as a matter of policy

* They must treat you by law

* Afterwards, offer a cash payment you deem reasonable

* They will accept or decline it

Transaction complete.

For non-emergency care and prescriptions, get cash quotes up front, pay in
cash, and order discount online prescriptions from canada, a first world
country.

For chronic medical conditions, leave the US and immigrate to a first world
country.

~~~
saalweachter
Important note on ER care.

The job of the ER is to prevent you from dying, not fix you. If you are
injured in a way that requires an expensive surgery and therapy to fix but
won't actually kill you if left untreated, even if it cripples you, they are
not obligated to fix you under the law.

~~~
swarnie_
How did your healthcare system get messed up to such a level? This is criminal
in western Europe.

~~~
lr4444lr
It goes back to WWII when we had a strange price controls on labor. Health
insurance was a way for employers to provide employ compensation circumventing
that. Originally it was quite manageable, but as with any system where neither
the consumer nor the producer of the good/service has any incentive to keep
down costs, it spiraled out of control.

Also, president Richard Nixon effectively linked national health care with
socialism as part of Cold War propaganda. (That said, he did offer
comprehensive health reform too that in a number of ways was more dramatic
than we achieved under president Obama, but the congress killed it.)

------
clarkmoody
Plenty of anecdotes in this thread, predictably. Let's talk about why things
are so messed up.

The thing to realize here is that total government provision of healthcare is
probably cheaper than the way the US does it, but that doesn't mean the market
has failed. Healthcare in the United States is anything but a free market.
It's the worst of all worlds: special interests extract rents through
government regulations (drug patents, occupational licensing, handouts to
insurance companies in legislation); the government effectively controls
prices through its own payment programs; the whole system is over-regulated to
an absurd degree. There is no price mechanism to help consumers or producers
make proper choices.

So when someone says something like, "the free market can't effectively
provide healthcare," I would kindly ask where they see a free market
healthcare system. This sounds like a No True Scotsman argument, but it's not.
You can't label something so ridiculous as US healthcare as "free market"
without either total ignorance or intent to deceive.

~~~
assblaster
This poster gets it right 100%.

In an ideal hospital, you should only have doctors, nurses, nurse assistants,
nurse manager, accounting, pharmacy.

Think of all the unnecessary healthcare MBAs that siphon off enormous amounts
of resources to generate as much profit as possible to be shared with other
healthcare MBAs.

Think of all the suppliers of healthcare goods that try to patent and profit
off of unnecessary medical "inventions" which do not make a difference
compared to what was done previously.

Think of all the government bureaucrats paid to ration healthcare resources by
underpaying for services which burden hospitals and doctors to raise charges
for private insured.

Think of all the patients who don't give a crap about their health and refuse
to correct their chronic conditions and rather go to the ER when things get
really bad.

Think of all the lawyers who profit off of bad outcomes (not malpractice
necessarily) which forces hospitals and doctors to practice defensive
medicine.

Making everything single payor won't work, because guess what, there will
still be a private insurance system for the people who can afford it vs the
system for the rest. It doesn't fix anything.

~~~
uberduber
You do need _some_ administrators, like the receptionist, someone to manage
the janitorial staff, etc. There's now something like 18 administrators for
every doctor in a hospital. I think it was barely 5-6 years ago I was
complaining because the ratio was 10 to 1. Their salaries are also pretty
high, typically in the $250k range.

~~~
assblaster
Those are all relatively low level though.

I think the boom has been in pay and employment of hospital CEO, CFO, CTO,
nurse directors, nurse compliance officers, legal, billing departments and
supervisors of supervisors.

The people who actually deliver care, ie doctors and nurses, are being
perpetually marginalized.

------
toomanybeersies
How can people read and hear about stories like this, and even possibly think
it's OK or even normal?

How do lawmakers in the USA convince people that this is acceptable? I have
never directly paid a single cent for healthcare, and neither has anyone I
know. When I had to get 6 stitches in my forehead at 2 AM on a Sunday morning,
it cost me nothing. When my friend needed to get the tip of his finger
reattached, it cost us $5 for parking. When my brother spend almost a week in
hospital after coming off his motorbike, requiring surgery on both his knees,
it cost him a grand total of $0 out of pocket.

Are people just so blind to how extortionate healthcare is in the USA?

The argument that I pay for my healthcare in my taxes doesn't hold water
either. I pay less tax in Australia than I would in California, and I get free
hospital care as part of that. I don't have health insurance and see no reason
why I would purchase it either.

~~~
nickjj
It's because most people in the US are brainwashed (note: I live in the US)
into thinking paying ~$450 / month per adult for basic health insurance with
high deductibles is a bargain because it "saves" them from $100,000+ hospital
bills in an emergency scenario. Meanwhile they are still losing ~40% of their
income to taxes if they own a small business with no insurance applied.

The messed up thing is, the US also offers "catastrophic" insurance for about
$150 / month but they only allow people under the age of 30 to apply for it.
But at the same time I'm pretty sure hospitals are forced by law to perform
emergency surgery on you regardless of whether or not you have insurance
(don't quote me on this).

In 2017 I had to spend thousands of dollars in tax penalties for not having
insurance. Welcome to the US!

~~~
ajross
> into thinking paying ~$450 / month per adult for basic health insurance with
> high deductibles is a bargain because it "saves" them from $100,000+
> hospital bills in an emergency scenario

It is, though. Insurance is expensive, but it's not a scam. That money tends
to go mostly for care, overall. Someone has to pay it.

It's true that on the whole, the US tends to overpay for care and that other
systems tend to get similar results for less cost. But that's a constant
factor on the insurance payment.

Obviously many of us think making this an individual burden is a bad idea:
obviously it's regressive and burdensome for the bottom of the income
distribution, and more subtly it's a moral hazard for the healthy, who are
tempted to forego insurance figuring that they don't need it and thus pushing
the cost of providing care disproportionately onto the sick and the elderly.

But again, someone has to pay it. There's no magic wand here that makes health
care cheap or free. Health care is expensive, someone's got to write that
check.

> In 2017 I had to spend thousands of dollars in tax penalties for not having
> insurance. Welcome to the US!

 _Because someone has to pay it, and you didn 't!_

~~~
nickjj
> It is, though. Insurance is expensive, but it's not a scam. That money tends
> to go mostly for care, overall. Someone has to pay it.

Yes but the govt already takes a bit over 40% of my income (I run my own
business). I'm certainly paying my share. It's not my fault that the govt
would rather use those funds on non-healthcare related things.

I'm all for a true universal health care for everyone, but if you're already
taxing me so hard, I shouldn't have even more taken away from me. That's
unreasonable.

> Because someone has to pay it, and you didn't!

I would bet anything the amount I paid in penalties is more than what most
people pay to be insured just going by the average income in the US compared
to the "assisted pay" discount you get for having a certain bracket of income.

I don't even make that much either. I'm in the "typical software developer
income" bracket, but I'm self employed so I have no help or matching from an
employer. I'm essentially paying both halves with no benefits (health or
retirement).

And to top it off, if I get into medical trouble I'm left hanging.

~~~
waisbrot
> I'm certainly paying my share.

That seems very hard to determine, especially as a business owner. What's the
value to you of safe shipping lanes to get raw materials to you? What's the
value of employees not worrying about being executed by warlords? What's the
value of having US customers who can afford your products?

I don't think you can say what your "fair share" is as some limit for what you
pay. Rather, the amount the businesses are taxed has to be a matter of
pragmatism.

> I would bet anything the amount I paid in penalties is more than what most
> people pay to be insured

One would hope so. That is the point of penalties, after all.

~~~
nickjj
> That seems very hard to determine, especially as a business owner. What's
> the value to you of safe shipping lanes to get raw materials to you? What's
> the value of employees not worrying about being executed by warlords? What's
> the value of having US customers who can afford your products?

I am a freelance web developer and online teacher. I have no employees or
physical goods.

About half of my customers are from the US and I am in a hyper competitive
world wide market.

------
avs733
"Hoboken University Medical Center, where Pell was seen, declined to comment
on the bill. The hospital did, according to Pell, reverse the entire balance
after Vox began inquiring about the fees."

I'll bet the hospital sees that as 'fixing the situation' and all I am left
wondering is how many other people don't have Vox reporters sending emails for
the same type of treatment. I'm hoping the CMS plan [0] to require published
prices might help this type of nonsense just a little.

[0] [https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-
rele...](https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-
releases/2018-Press-releases-items/2018-04-24.html)

~~~
maxerickson
I doubt it, hospitals were already required to make those prices available,
the change is that they have to make them available on the internet.

 _While hospitals are already required under guidelines developed by CMS to
either make publicly available a list of their standard charges, or their
policies for allowing the public to view a list of those charges upon request,
CMS is updating its guidelines to specifically require that hospitals post
this information. The agency is also seeking comment on what price
transparency information stakeholders would find most useful and how best to
help hospitals create patient-friendly interfaces to make it easier for
consumers to access relevant health care data so they can more readily compare
providers._

One reason to doubt it is that an awful lot of people live within reasonable
distance of 1 hospital, and almost everyone else lives near busy hospitals.

~~~
ceejayoz
> While hospitals are already required under guidelines developed by CMS to
> either make publicly available a list of their standard charges...

This requirement is useless, though. The "standard charges" don't reflect
reality. My wife receives regular infusions in an infusion center. They bill
$3k to insurance each time. Insurance pays about $400, which the hospital
happily accepts. That $3k number is what an uninsured patient would be asked
to pay, and it's the number they'll list as the standard charge, but _it 's
complete, invented bullshit_.

~~~
maxerickson
The new requirement is the same in that regard.

It's a good talking point though, several people in this thread are excited
about the potential for it to bring about change.

~~~
jrs235
Will publishing prices just cause more price inflation though? Similar to what
happened with CEO compensation when companies became more transparent about
their compensation?

------
mfoy_
As a Canadian, we have our own share of problems with our health care
system... but thank goodness _this_ isn't one.

------
ClassAndBurn
No other industry entirely hides the end price you'll pay, or even an
estimate, until after you have gone through the service. It's a sad state of
affairs but not something we have to be stuck with; most of the time we could
get these numbers ahead of time.

ER visits are difficult in their own ways; you can be brought in unconscious
and go through treatment you can't agree to, you can be close to death and the
time it takes to check costs could impact if you live or not. This means you'd
want to do something like fixed costs for these services but with good medical
coverage for everyone those fixed costs could be what people do in place of
insurance.

I don't have an answer other than universal healthcare. There are reasons that
this can't happen at the moment and it's still difficult to implement in a way
that works across the board. This is a hard problem and will take a lot of
effort to get right

~~~
humanrebar
> I don't have an answer other than universal healthcare.

What about requiring published price lists? Maybe you need twelve procedures
because you're in bad shape, but at least the bill won't be arbitrary.

~~~
DoctorOetker
something like a chargemaster?

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

That said, mandatory transparency (from both the hospitals as the
insurance/healthcare plans on what exactly happens in what scenario (say x-ray
for possibly broken elbow), and the current rate/probability of scenarios)
should be requisite, but that is only a necessary condition. The behaviours of
the medical industry should also be binding.

------
paulsutter
I paid $5500 last year for an unnecessary emergency room visit (doctor sent me
down to get a scan).

They wired me up to machines and made me wait 5 hours for the scan, then 3
hours to get discharged. They wouldn’t let me leave until the doctor on duty
wrote up her treatment recommendation. Even though I was just there for a
scan.

No insurance last year so after my “35% cash payer discount” it came out to
$5500 after the many parties in the ER sent me separate bills. Scan was $2000
of that, but I could have paid $600 across town.

Don’t go to the ER unless you’re unconscious. It’s that rare case where you
are paying AND you are the product.

~~~
softawre
I think the concept of not going to an emergency room unless it is an actual
emergency is well known?

~~~
paulsutter
The doctor sent me there. Gave me a slip of paper and said “give this to the
ER desk to get a scan”.

So I did what he said.

------
sandworm101
I cannot get over how odd "in network" is for everyone outside the united
states. For emergencies we all just go to the nearest hospital. They see us.
They treat us. Or they stabilize us and discuss whether we should transfer to
another hospital for better/faster treatment. There is no discussion of in or
out of networks.

Stories like this make me very happy that I no longer live in the US. The
constant fear of a surprise medical bill is a stress I don't need.

~~~
assblaster
Insurers offer guaranteed patients to hospitals and doctors in exchange for
reduced payment rates. In other words, they hospitals make their money off of
volume. This is why there are networks of providers.

If you prefer, you can visit any hospital you want in the United States, as
long as you pay for the medical care. Why should hospitals accept low
insurance payment from insurers who do not give them a benefit of increased
patient volume?

~~~
sandworm101
More questions that we never bother asking. There are fixed rates agreed
nationally, not backroom deals between corporations.

------
awicz
“While we cannot comment on rates for emergency room services..."

Why not?

~~~
c0nfused
Typically, the rates negotiated with the various insurance companies are
basically secret. No one wants to share the data and there is great incentive
not to.

If you are in the insurer side, you think you have a competitive advantage
compared to company Y. Sharing what you are paying per procedure is bad
business

If you are on the Hospital side, you want to make sure the insurers keep
paying more, and publishing means a quick race to the bottom.

This means that in most cases in america, you cant know what something is
going to cost until after you get billed. Its great for literally everyone
except the consumer.

~~~
andruby
My personal opinion is that this should be illegal. Prices for the same
treatment should be equal regardless of patient or insurer. The insurance
repayment policies could differ, but at least the base pay won't seem
completely made up.

Disclaimer: I only lived in the US for a year.

~~~
toast0
The base rate is the same (in theory), but insurance policy A is only going to
pay 18% of procedure Z and policy B will pay 27%; uninsured patients will be
offered a 50% discount if they pay promptly, otherwise the bill will
eventually be sold to collections for 1% if it's not paid)

------
corpMaverick
Similar thing happened to us.

My 3 year old son hurt his arm. It was after 7pm so we had to go to the ER. We
see a nurse, she didn't check anything. X-Rays and then they gave us a
hospital room. Immediately I realized we were getting into a spending black
whole. After 30 seconds I told the nurse we wanted to leave. My son wasn't
crying and he was climbing a chair using his "hurt" arm. They wouldn't let us
leave. After hustling with them we left. we got a $1,500 USD bill that we had
to pay because we didn't know what to do.

------
justherefortart
Just don't pay it. That's the solution.

Hospitals have these bullshit inflated fees, once they accept the insurance
payout that is all they're getting from me.

They're all "non-profits" that scam the system by writing all this shit off as
goodwill or bad debts.

~~~
assblaster
The insurer only pays part of the bill because you entered into a contract
with the insurer that specified that as such.

No insurer pays 100% of every medical bill, no matter what, with no
expectation of copay or deductible. Even if you had that sweet deal, you would
be paying premiums that nobody could afford.

Do you have a right to receive services from another human without appropriate
payment?

~~~
ThrustVectoring
They're not talking about the copay or deductible. They're talking about
"Hospital believes that the services provided should cost $X, insurance
company believes that a reasonable price is $Y, you now owe the hospital $X -
$Y".

~~~
assblaster
That's the problem! Hospital overcharges because government pays less than the
cost of delivering care, so costs have to be recouped from other sources:
privately insured, and uninsured.

The one caught in the middle is the individual who gets screwed by both the
hospital and insurer/government.

------
esbranson
For all the people railing against hospital corporations, please note:

1\. Los Angeles County, of 10.1 million people, runs its own hospital system.

2\. New York City, of 8.6 million people, runs its own hospital system.

3\. Colorado, of 5.6 million people, runs its own hospital system.

Etc etc. (All of them quickly add up to the population of Canada.) They still
do these horrible things we're talking about here, even though they're
ultimately accountable to the people and must do what our laws says they must
do.

And we think we're gonna suddenly be like Canada, like magic? If so, get the
five people running the LA County hospitals to do so. (Yes, five people
represent 10.1 million people, lol.) And the same goes for NYC and CO and the
rest.

------
noetic_techy
I know everyone loves to push for a single payer system, but we could have the
best of both worlds if we transitioned to the Singapore model.

[https://www.vox.com/policy-and-
politics/2017/4/25/15356118/s...](https://www.vox.com/policy-and-
politics/2017/4/25/15356118/singapore-health-care-system-explained)

------
ThrustVectoring
Balance billing is complete bullshit. My long-term plan to deal with it is to
move to Texas for their superior creditor protection laws, retire off of
retirement accounts + annuities + owning primary residence, have zero assets
that creditors can go after, and tell the hospital and insurance company to
figure it out because they are legally unable to force me to pay.

------
piyush_soni
Ok, mine is way less than her, but at one of the ER in Wisconsin, they sent me
a bill of $400 for literally telling me that I have no disease and sending me
back. Out of that, the insurance paid $300, and I paid 100 out of my pocket.

I had gone to ER only because it was at an odd time and no other hospital was
open.

~~~
assblaster
Why didn't you just wait to see your primary physician?

~~~
falsedan
Lay people don't have the training to determine if an ailment is life-
threatening or not; that's why they pay for insurance, so they can see a
medical professional who is qualified to say if you could die or not.

~~~
assblaster
You can say that about 100% of medical complaints.

Emergency rooms should be for emergencies. You yourself will know if you are
about to die.

~~~
piyush_soni
You mean one should wait until the signs show with certainty that they're
about to die before going to the ER? That'd a bit of a stretch :). Of course,
I went because I thought it was an emergency (though I can see your definition
of 'emergency' is quite different from mine). It's not like I went because I
had cold.

------
Carlton87
There is an easy way to avoid this, don't go to the Emergency Room unless you
have an Emergency.

~~~
ishansharma
I guess the point of the article is exhorbitant fees. An ice pack and a
bandage in ER don’t have to cost $5k plus.

~~~
Arnt
What is it that does cost $5k? Keeping a mostly-unused tomography machine and
crew ready in case someone at the ER needs it? Insurance premiums charged per
patient who walks in the door?

We get these complaints in Germany too (where I currently live) BTW. "A five-
minute drive with an ambulance shouldn't cost €500!" someone complained to the
newspaper here recently. It doesn't, what costs €500 is keeping enough
ambulances ready that one can arrive within x minutes with y% probability, for
IMO overcautious values of x and y.

~~~
tunbgeetf
€500 is still something many people can pay in Germany, 5k isn't something the
average American can foot (with no treatment to boot). It's not at all a
comparable complaint.

IIRC an ambulance ride in the US is 10-20k, that's indicative of just how much
more medical care costs over there.

~~~
JesseWright
I have never heard of an ambulance ride costing anywhere _near_ $10K-$20K. The
average, out-of-pocket price of an ambulance ride is much closer to $1000 -
and often less. New York's 2012 fee schedule offers a good example:
[https://www1.nyc.gov/assets/fdny/downloads/pdf/about/fee-
sch...](https://www1.nyc.gov/assets/fdny/downloads/pdf/about/fee-schedule-
ambulance.pdf)

