
A Common Blood Test Can Cost $11 or Almost $1k - pseudolus
https://www.nytimes.com/2019/04/30/upshot/health-care-huge-price-discrepancies.html
======
roganartu
As an Australian living and working in the US with a wife who has a chronic
medical condition that costs our insurance company on the order of $100k/yr
for her regular treatments, all I can say is "Almost $1k" sounds like a gross
underestimate.

An anecdote I like to share with friends back home is related to a routine
blood test that she has every few months. The price the provider bills varies
significantly, but one time they billed $2900. Our insurance paid them $27
like they usually do and the remainder was written off.

Imagine being sick, having no insurance, maybe no job, and receiving that bill
in the mail with absolutely no way for you to know that they would probably
accept over 100x less than billed. I can understand why medical expenses are
the #1 cause of bankruptcy in this country.

~~~
ajmurmann
This econtalk episode[1] provides some interesting background on how this
happens with medication. There are man-in-the-middle companies (Pharmacy
Benefit Managers - PBM) that negotiate plans with pharma companies. These
companies get paid a commission based on the delta between list price and the
deal they got. The Pharma companies need these deals, so both benefit by the
pharma company increasing list prices every year and then cutting better deals
to those PBMs. If someone is offering a generic that's cheaper, there is less
incentive for PBMs to add them to their plan, because the prices are too cheap
to begin with and they have a smaller market share initially. It's all a giant
Rube Goldberg machine of a mess.

EDIT: One more interesting detail from the podcast and the book it's based on:
Those deals between PBMs and pharma companies are secret. Not even the
insurance companies know the details of what's in there.

It's also fun to point out that typically this is everyone involved in a
consumer getting their drug: * the consumer * the consumer's employer who
selects the insurance * the insurance * a PBM who get a Pharma benefit plan
for the insurance * the Pharma company that manufactures the drug * the
pharmacy you actually buy the drugs. On top of that the actual payment
apparently happens often months after you received the drug.

Edit2: Clarifying "PBM"

[1][http://www.econtalk.org/robin-feldman-on-drugs-money-and-
sec...](http://www.econtalk.org/robin-feldman-on-drugs-money-and-secret-
handshakes/)

~~~
BurningFrog
And what's the root cause of this absurd arrangement that doesn't exist in
unregulated markets?

~~~
danmaz74
These things happen all the time in real world free unregulated markets. The
seller looks at you, tries to understand how much you can afford and what are
your alternatives right then, and to get the highest price possible.

If you are desperate and your life is at risk, they can literally strip you
naked - just see how many unscrupulous people become rich during wars.

When you are in a medical emergency, and you need a treatment right there and
right then - no time to shop around - why should an unregulated, shareholder
value maximising business, not extract from you as much as you can afford?

~~~
anonuser123456
>When you are in a medical emergency, and you need a treatment right there and
right then - no time to shop around - why should an unregulated, shareholder
value maximising business, not extract from you as much as you can afford?

In a free market, you'd also have choice via competition to drive that price
down. Right now, hospitals can literally veto their competition by claiming
"there isn't enough demand to justify another hospital in this area". So bing,
no new hospital, no competition.

And of course, this assumes your provider is out to screw you at every turn.
This turns out to not be the case for obvious reasons; your provider still
wants your business in the future. In the case of a single hospital/provider
(a la regulation) they've got your business no matter what.

Competition is a key force in markets, and regulation in the medical industry
provides huge barriers to competition.

~~~
dragonsngoblins
> In a free market, you'd also have choice via competition to drive that price
> down

Not really though. Like, if I am having a heart attack the correct answer to
"Which hospital do I go to?" is always going to be "The closest one equipped
to handle it". Well technically the one I get can to the fastest that can
handle it but you see my point.

This kind of choice via competition would work for things like optometrists
and GPs (assuming you live in an area with more than one general practice) but
just plain doesn't for emergencies.

~~~
BurningFrog
Yeah, the moment you have a heart attack is not the time to start comparison
shop. This is the argument everyone always brings up all the time, because
it's so obvious.

An because it's so obvious, people will want to be prepared for it. By having
insurance ( _real_ insurance, not the bizarre "health insurance" construct we
have today), or subscribing to some service like you do for when you car
breaks down etc.

I'm not sure what exactly would happen, but I'm _certain_ it won't be that
people will just never think about this until they all, one by one, have a
medical emergency and have to unexpectedly pick a hospital on the spot.

~~~
dragonsngoblins
Right, but what I'm saying is even if I did my comparison shopping before hand
it doesn't matter because unless I stay within a certain radius of the
hospital I've chosen I can't then it is kind of moot.

Because if hospital B isn't my choice but I'm closer to it when the emergency
happens I am going to hospital B

------
notjesse
I kind of want these issues to continue and get worse. Because then we will
have a healthcare revolution, rather than more bandaid policy fixes.

It seems like the US healthcare system is too far gone, and we need to hard
reset it. Anyone who lives in another developed nation would be absolutely
outraged if they had to deal with half the things Americans do when it comes
to healthcare and the respective insurance.

~~~
gizmo686
How many people are you willing to let die to get to that revolution.

Then, once the revolution comes, how many people are you willing to let die
while you iron out the operational bugs in your new system.

Fixing the US healthcare system is going to be like changing an engine mid
flight. It will require long term planning and consist of a lot of bandaids
and ducktape while we work on it. Unfortunately, our political system is by-
polar, so plans need to be designed not by what will work best, but by what
cannot be dismantled when leadership changes.

~~~
notjesse
I'm not sure it needs to be like that.

Most developed nations have a public health system. Akin to how the US has
public schools and emergency services.

The revolution could be the government bitting the bullet, and spending a
fortune on bootstrapping a public health system that undermines insurance and
private health.

Yes, it will hurt that sector a lot, it won't happen overnight, it will cause
huge deficits, and it will inevitably cause higher taxation. But it's
ultimately what needs to be done. We just need to give up on the sunk cost
fallacy and go with proven models.

~~~
saagarjha
Any plan like that is going to have a portion where you convince the part of
the country openly hostile to it that you're not bringing in socialism.

~~~
jakeogh
Having the gov decide who gets what care is incompatible with a free society.
Alfie Evans is a striking example.

~~~
lazyasciiart
A "free society" doesn't require that parents be given free reign to torture
their children. You may wish to argue whether that's what was happening, but
that's the reasoning the state gave for their actions. If you'd like to argue
that a free society _does_ require this, go ahead, but I don't think most
people agree.

------
zaroth
The simplest and most common sense medical reform I can think of would be to
make it illegal to charge a different price to two different patients,
regardless of insurance carrier or self-insured, for the same medicine,
procedure, or equipment at the same facility.

There should be the Price. The amount that insurance Covers. And the remainder
is the Patient Responsibility.

Either that, or a cash patient cannot be charged more than the Medicare
allowed amount for the same procedure.

Insurers should not be horse trading to pay more or less for one procedure or
another. And if you happen to be treated by someone who is out of network, you
shouldn’t be paying an exhorbinant price on top of that higher copay or
deductible.

The entire concept of negotiated rates is a fraud IMO, and could be reformed
with a simple regulation that would I think be supported by a vast majority of
Americans.

Price changes should have to go into effect for all patients at once, and be
published in some ledger at least some number of days ahead of time.

~~~
spockz
This is kind of what we have in The Netherlands. Insurers make standard prices
in collaboration with a large part of the healthcare providers. Healthcare
providers have to bill using the exact code of the treatment and that amount
cannot be more than the agreed amount.

This leads to funny things like there being Treatment X variant A-E for
getting a different price for the same treatment based on some arbitrary
thing. It also means that now the insurer knows exactly what has been done
because the bill says replaced filling on 3rd upper molar with this and that
material etc. Before it was just “filling”.

Also if you want to provide better care and need more time or better materials
to do that you can only do it within the determined budget and they are quite
tight.

~~~
zaroth
I don’t necessarily want to standardize care, I want to standardize pricing.
Of course there will always be minute variations in a procedure, but the law
is not an algorithm.

You can have different levels of materials with different prices, but two
people still need to see the same price if they choose the same thing, or
substantially the same thing.

Of course some people will game the system trying to make infinite variations,
but at least that one apply to common blood tests and office visits, MRIs,
X-rays, plenty of stuff is standardized.

So what you are describing sounds a step beyond what I am thinking, which is
just a standard published price list which is actually the price, and not a
published book price which is an absurd ripoff, and then a secret price which
everyone with insurance x, y, or z pays.

------
jonwachob91
>>> In Tampa, FL the a basic metabolic panel could cost you either $11 or $440
[paraphrased from a graphic in the article]

No properly functioning market behaves like this.

~~~
nsxwolf
We’ve been fighting a hospital on an overcharge that drained our HSA account.
Every person we talked to has been utterly flabbergasted that we are
complaining because “it says here you owe $0”. They can’t get it through their
heads that the insurance paid them with our own money, and that we’d like to
be refunded the overage.

It’s just a confusing concept to these people. This is what happens when most
people use someone else’s money to pay for things. Nobody knows or cares what
anything is supposed to cost.

~~~
dnadler
Your insurance has access to spend your HSA? That's certainly not how mine is
set up, and I'm surprised that's even possible. Did you give them your account
number and authorization to spend your money?

~~~
nsxwolf
Yes. I think the arrangement is technically called an “HRA”.

~~~
pishpash
That's just a fancy name for self insurance, i.e. no insurance. Somehow
wrapping it in yet another siloed tax advantaged vehicle makes it sound
better.

~~~
nsxwolf
You understand why I would have an interest in what my medical procedures cost
then, yes?

~~~
pishpash
Of course. Even with a run-of-the-mill HSA + HDHP, you're basically partially
self-insured and tasked with the thankless job of insurance administration.
You can see there is something scammy about these things (in practice if not
on paper) when they are so enthusiastically pushed by the healthcare industry.

~~~
nsxwolf
Seems to me like having a lot more people being interested in the prices of
things could only be a benefit.

~~~
EvanAnderson
You can be interested in the prices, but you won't find anyone interested in
telling you the prices. You will also be met with complete incredulity when
you ask about prices. (If you're asking about prices for a procedure or
treatment related to your child you will also be shamed for "putting a price"
on your child's health.)

~~~
flowersjeff
Totally agree with you.

Adding to this: Oftentimes there isn't a single person in the place that even
knows what X costs...and hasn't a clue how to determine that number.

Years ago, I was between jobs and asked for the 'cost'. The reply I got was
"$20", a typical copay at the time. When I explained my situation and was
asking for the actual out the door costs...20 bucks. They really didn't even
understand how to approach my question (could see it in their eyes/response).
When I asked for another person in the office - 20 bucks. Hell, even the Dr
told me 20 bucks. The bill I received was not 20 bucks - surprise surprise.
And what could I do really - hold them to the 20 bucks? Where was my
'proof'...

Many of the people doing the admin work simply are not trained nor equipped to
understand the gravity of the position. They can set you up on a calendar and
fill out a postcard - beyond this, and there's problems. And why should they?
They are being paid to be calendar/postcard filling person only.

The system itself was designed weirdly to begin with, it assumes that you are
a wage earner of a large company that is paying insurance as an employment
perk. If you deviate from this model - then these sub-systems don't know what
to do.

~~~
pishpash
They know what to do. But they are selectively "dumb." Do you think a doctor
who runs a clinic and their employees, accountants, medical procedure coders,
and insurance claims people don't know a thing or two about costs? How do they
stay in business?

But if they told you some four-digit number you'd bolt.

We like to hold medical professionals in high esteem, but these days it's also
a business transaction. They know this. As such they are very much a part of
this very large problem.

------
httpz
I once got a blood test in California. Nothing special, just a regular checkup
recommended by my doctor. The blood testing company later sent me the bill. It
was originally $950 and some pre-arranged deal between my health insurance and
the testing company discounted most of it. My insurance covered part of the
rest and I paid like $50. It's not like my insurance paid $900, they just had
a pre-arranged deal with the testing company to have a huge discount, which
makes me think the actual cost of the blood test is nowhere near $950. If I
didn't have insurance I still would've had to pay the whole $950 out of my
pocket.

~~~
seppin
> It's not like my insurance paid $900, they just had a pre-arranged deal with
> the testing company to have a huge discount, which makes me think the actual
> cost of the blood test is nowhere near $950. If I didn't have insurance I
> still would've had to pay the whole $950 out of my pocket.

How on earth is this type of pricing legal?

~~~
flowersjeff
It's legal because when you tell people you know that this has happened to you
- unless it happened to them personally as well, they will just assume that
you don't know what you're talking about or confused.

And so this practice thrives.

------
pkaye
There are a few websites where you can order your own tests. You pay for it
online, a doctor automatically authorizes the test and then you go to a Lab
corp office and get your blood drawn. The basic tests can be quite cheap. Like
a "chem 26" test is $55. [http://www.healthcheckusa.com/heart-disease-
cholesterol-test...](http://www.healthcheckusa.com/heart-disease-cholesterol-
tests/heart-health/super-chemistry-heart.aspx) Its amazing how much hospitals
are marking up these tests.

~~~
bubblethink
I'm surprised this isn't a common thing with some big company/startup doing
precisely this. All these tests that don't need specialized equipment at the
point of the test (i.e., blood or other fluids as opposed to fancy imaging)
can be easily outsourced to pretty much anywhere else in the world. Is there
some law preventing this ?

~~~
pkaye
Blood tests are commonly outsourced by many hospitals but they subsequently
mark them up to cover their other costs. But you cannot outsource them to
other parts of the world as many tests are inaccurate if the blood sits around
too long in transit. Lastly is the problem of interpretation of the results. A
person on this website might be bright enough to figure it out but there are a
significant number of people who just can't. So once you bring in the doctor
costs start rising up. Then you have people for whom even $55 is unaffordable.

~~~
bubblethink
>there are a significant number of people who just can't. So once you bring in
the doctor costs start rising up.

I'm assuming that the patient cannot read the results. i.e., They go to the
hospital. Doctor asks for the tests. Patient gets the test results from their
lab of choice and go back to the doctor with the results. This is a fairly
common model, at least elsewhere in the world. Labs and hospitals are separate
entities, and the first visit to the doctor is just a consultation with
nominal costs. Doctor's costs don't kick until the test results are back.

~~~
pkaye
I've seen this model in the US also mostly with small clinics.

------
specialist
I was billed ~$4,600 for a $40 blood test. The reason given is the testing
company was out of network. Even so, my insurance offered $400, but was
refused.

I previously worked for a company owned by Quest Diagnostics, so have some
insight into the parasitic nature of these lab companies. (The other titan in
the USA is LabCorp.) Once a facility is up and running, they basically print
money. Some wags even created "speedometer" dashboards to show real time
revenue per minute.

------
dlevine
For a while, I had to get blood tests every month or so for a drug I was
taking. Usually I went to a discount provider (labcorp), and paid like $30 for
the bloodwork (maybe it was actually less).

One time I went to UCSF hospital, and they ended up billing me several hundred
dollars. For the exact same lab codes. Actually, I think they billed well over
$1000, but my insurance company at the time allowed several hundred in
charges.

I called them up, but they were unwilling to negotiate. I ended up paying,
because I figured that it wasn't worth fighting it.

One time several years back I fought a fraudulent charge from a doctor who
billed me for a more expensive procedure than the one he actually performed
(this practice of "upcoding" is actually pretty common). I eventually got them
to remove the charge after a lot of complaining to the doctor and talking to
my insurance company, but it wasn't worth the stress involved for the amount
of money I got back.

------
phkahler
The solution is simple and I've posted it here many times. Rates for services
need to be fixed by the provider and the same price charged to all payers
including insurance companies. Posting those prices is a bonus, but the
insurance companies alone will force competition among providers.

~~~
specialist
The surprise in surprise billing is the issue here.

I'm a life long patient, so not my first rodeo (dozens of blood tests). I had
no idea it was possible for a lab to "out of network", so would never have
occurred to me to ask. But at some point the rules changed. And no one thought
to tell me, as they're supposed to (eg verify insurance coverage before doing
any work).

Surprise!

------
golover721
Having just gone through a situation with a family member who had to go to the
ER, have a variety of tests done, be admitted to the hospital for a few days,
and be seen by a specialist in the hospital. This definitely hits home. What
makes it worse is that it will be months before we know the total cost for us.
The ER doctor, the labs, the hospital, the specialist are all separate legal
entities. Each potentially with their own staff filing claims to the insurance
company. What a crazy system we live with.

------
systemtest
I live in the Netherlands and recently had a basic blood test done to diagnose
a lack of energy. Having a high income I had to pay full price but it only
cost me €89 so that seems fair. The GP was able to draw the blood and then
sent it to a hospital laboratory.

Living in Europe is pretty great. Healthcare mainly is based on income here,
if you are low income you pay next to nothing if you are high income you pay
up to €5000 per year in tax and insurance. I think that's fair as it makes it
accessible for everyone.

~~~
microcolonel
> _Having a high income I had to pay full price but it only cost me €89 so
> that seems fair. The GP was able to draw the blood and then sent it to a
> hospital laboratory._

If that was more than a handful of tests (usually separate drawings), then it
was probably still subsidized. I think the out of pocket prices are in the
same range though, at a private lab clinic, here in Southern Ontario.

The reason insurers end up paying $1,000 for this service in the most
expensive places is mainly that insurance is ubiquitous in some places. If
nobody asks the price, how can it stay down?

~~~
systemtest
I believe I had three drawings. It was a basic test for not much more than
iron levels and such. The €89 is what the hospital will receive in total for
the research. Because the amount is lower than the yearly healthcare
deductible (€385 up to €885), you will have to pay for it yourself.

There is an online calculator with the maximum amount a hospital may charge
for its services:
[https://www.diagnostiekvooru.nl/tarieven](https://www.diagnostiekvooru.nl/tarieven)
(use the checkboxes for whatever you want tested, apologies for it being
Dutch).

This is the maximum amount the hospital may charge by law, the insurance
company can lower this by up to 10% by negotiating the rates.

~~~
microcolonel
I don't think there's any equivalent price control on private purchase of
tests here, the prices are in the same range, maybe a bit less depending on
where you go.

------
hermitdev
Honest question: why cant the US Fed go after the hospitals, insurance
companies and pharma companies for price fixing/collusion/anti competitive
pricing?

Seems to me that all of the warning signs are there, is it corruption in the
regulatory agencies?

I don't buy that it's purely regulatory overhead. That you see this price
gouging at supposed nonprofit hospitals as well, it can't be purely rampant
unchecked capitalism when you have 15x markup from the pharmacy.

One of my pet peeves with US medical is how the billing is handled. Visit the
ER? Get ready for an untold number of bills. One from the hospital, another
for imaging, another from the pharmacy, yet more from specialists, radiology,
etc. There's no one clear bill about what you owe. This is due to most of
these technically being subcontractors. Yet, I dont know of any other industry
where I have to pay subcontractors directly, rather than paying the contractor
at once instead.

~~~
zip1234
Well, I think requiring published pricing in a standard format would go a long
ways. Right now, people have no idea how much anything will be. If there was
published pricing, there could be a shopping app or something of the sort.

~~~
coenhyde
Right. I'm for socialized healthcare. But if you're going to have a free
market approach at least make the market forces applicable. Pricing for all
services should be published in a standard format and then everyone should be
charged the same price, regardless of who is paying.

------
natmaka
I'm a French expat in China (Shanghai), in 201901 I had to obtain an
electrocardiogram. A high-end hospital would do it for 1500 to ~3000 RMB (the
local currency, 1 RMB is ~0.15 USD). I took the path used by locals, and had
it done without any fuss or appointment for ~40 RMB.

Details: the hospital would do it after an "initial out-patient visit" costing
"1,000 to 1,800", the ECG price is "500", and those are "estimated prices
((...)) subject to change."

~~~
baybal2
I had to pay ~1000 in Shanghai just to have a doctor prescription for
loperamide...

They claimed you can get high on it if you drink a bucketload of it.

I wish I knew Chinese better

~~~
AFascistWorld
You went to clinics? Majority of Chinese clinics and private hospitals are
price gouging quacks.

~~~
baybal2
I went to one of few genuine clinics there, and I think the only one with
service in English

1000 is in Chinese yuan

------
RcouF1uZ4gsC
>The Trump administration may eliminate this secrecy, making numbers like the
ones in these charts more common and easier to find. As The Wall Street
Journal has reported, the administration has asked for comments on a proposal
to require doctors and hospitals to publish negotiated prices.

I really hope this goes through. Right now, the opacity of prices for health
care is a huge problem.

~~~
michaelmrose
Any particular reason for not just fixing the current situation by declaring
by fiat either

\- It costs exactly $20

\- It costs not more than $30 allowing negotiation

\- You may only charge one price for all customers

\- You may not charge more than some n percentage over the national average in
the last business quarter

~~~
wtfrmyinitials
Prices set by fiat cannot possibly react quickly enough to changes in the
market

~~~
mbesto
Precisely what changes in the market are you referring to?

Prices negotiated between payer and provider today are already 1 + N year
length contracts. Having one transparent national price list would 1000x
easier than the hundreds of thousands of healthcare administrators that exist
today whose sole job is to negotiate and determine price lists.

------
sershe
Ok so dumb question I always wanted to ask, about the arbitrary prices. Let's
say I have no insurance and I collapse on the street, get rushed to the
hospital and revived, after which they send me a bill for $10k. I didn't agree
to any treatment; I didn't sign anything. What prevents me from saying that I
won't pay it - not in "send it to collections" way, but in a "this is a
fraudulent bill" way, like I don't owe anything at all? If the hospital can
claim by fiat the price was $10k after the fact, how come I cannot claim by
fiat the price was $100, or send the hospital a counter-bill for $9900 for
having had the privilege of touching my chest? I mean, a car dealership cannot
send me a bill after the fact for an extra $10k for driving off the lot?

(Semi-)serious question, actually. What would they do? There's no contract.

Even if I did sign something in an emergency, I can claim to not have been
capable enough to reason about it, due to shock/mental issues given the
emergency; and anyway does all this paperwork (that having good insurance I
sign without reading) actually say "I agree to pay whatever you charge me"?

------
virtuallynathan
FWIW, this test can be bought from LabCorp for a bit more than $10, which is
close to "at cost".

~~~
code_duck
However, the way the US medical system works is a doctor decides that you’re
going to get a test, and then they perform it and bill you with no agreement
or warning about what the price will be.

~~~
pauljurczak
Not really. The doctor prescribes the test, but you decide where the test is
done. Make sure the lab is listed as a preferred provider by your insurance
plan. Good rule of thumb is to stick to major labs: Labcorp and Quest. Be very
suspicious about local hospital lab, which usually will be much more
expensive.

~~~
code_duck
How about when you’re hospitalized? I don’t think had that choice when I was
visiting Mayo as an outpatient, either. Perhaps theoretically. I have seen
this option with my local physician, but it’s not as if there’s more than one
lab in town that I can choose, especially with the restriction of insurance.

~~~
pauljurczak
You are right. When you are hospitalized, you are in their clutches. I asked
them once about getting my own Ibuprofen tablets instead of being charged $2
each. They refused.

~~~
code_duck
Two dollars is a bargain. What I’ve seen is being charged six dollars for the
tablet and $80 for someone to give it to you.

------
bichiliad
I'm lucky enough to have parents that both work in the medical industry. I had
a pretty routine ear checkup in which the doctor decided to use an endoscope
to confirm my sinuses weren't inflamed. I got a surprise ~$400 bill for that
particular part of the procedure, the majority of which was not covered by my
insurance. My parents both advised me to literally just ask for a break and
see if it would work — allegedly it's successful more often than not. It's
extremely upsetting to think of that sort of knowledge being required to
navigate healthcare.

------
legulere
That clearly shows that there is a market failure in the US healthcare system.

------
javchz
Just hope that even with the Theranos thing, R&D investment doesn't stop
flowing for better price testing.

It's incredible how a little health problem, can kill your finances so
quickly, even if it's for something simple, but doctors have to discard so
many other things (which I'm grateful to live in a time, where those things
can be a reality... just hope for a more accessible solution).

------
typenil
I recently tried to find out what I'd be charged for a standard office visit.
There was literally no one at the provider or my insurance company who would
tell me what it would cost - even though I have a high deductible plan and
would be paying 100% of it.

Eventually I got a "guesstimate" of $200-300 for the visit. I cancelled the
appointment.

------
jokoon
I asked a lab how much it was to test for lead or other metal, apparently it's
30 euro per element.

Not sure if I'm going to do it, or if there is an ideal moment to do it so I
can have a positive.

------
billylb42
There are multiple complex problems here. I think one of the more interesting
is one of agency. The person picking the procedure is often not the person
paying for it.

------
lucio
[https://www.youtube.com/watch?v=CeDOQpfaUc8](https://www.youtube.com/watch?v=CeDOQpfaUc8)

------
aosmith
All of this back door negotiating needs to go away, it's stupid & costly.

------
cosmodisk
As someone who lived only countries with free public health service,these
numbers are appalling.Not the numbers per se but rather lack of competition
between healthcare providers.

~~~
notjesse
That's the problem. As a healthcare consumer, there is no way to discern
between costs of providers. Just that some are "in-network" (meaning your
insurance works with them and they agree to your insurance's rates) and "out-
of-network".

It is extremely difficult to determine how much things will cost in the US
system ahead of time and there is no reasonable way you can "shop" around for
better prices when it comes to healthcare.

It's like you go out for dinner, but the restaurant won't tell you how much
things cost, just that you should definitely order X,Y, and Z. And all the
restaurants in town have the same policy. You order it, and then they mail you
the bill 2 weeks later. Only for you to find out the exorbitant costs. Plus,
they decided to charge you for the extra ketchup you requested.

~~~
cosmodisk
Publicly available pricing won't solve it all,as it can't be always easy to
define how much a treatment would cost without actually doing it,however it
would benefit a lot to ensure better prices.There must be a very strong
lobbying programme going on against it if they are considering changing the
law.

~~~
gizmo686
>it can't be always easy to define how much a treatment would cost without
actually doing it.

Actually, it can be very easy. Quote a price prior to treatment and you are
not allowed to charge more. Providers will lose money on some treatments, but
on a large scale that can be predicted and rolled into the average price.

If there is a small provider, or particular treatment with high financial
downside risk to the provider that the uncertainty is potentially crippling
for the provider, then the provider can take out insurance to cover their loss
if the treatment turned out to be far more expensive than originally
anticipated.

~~~
Spooky23
In my state, movers are regulated like this. The result? Everything has a 30%
error margin.

That approach is why the $10 test costs $400. Medicaid mandates $10.01
payment, and selling it to someone for less than that is a crime (fraud).
Everyone else gets a percent off of list.

~~~
gizmo686
Everything already has an error margin. The difference is that the entire
error margin is paid by the unlikely few who turned to cost more than
expected. The point is to reduce risk by spreading the cost between those
unlucky enough to have incurred extra with the rest of the patients.

If the actual cost of covering the unexpected costs is less than the margin
they are tacking on, then that is simply over charging, and is not
meaningfully different from the overcharging they can do anyway.

~~~
Spooky23
Show me an example of a price ceiling that doesn’t raise prices.

~~~
gizmo686
Interesting complaint. The common downside of price ceilings is that they
prevent raising prices, leading to shortages.

Regardless, I am not proposing a price ceiling, I am proposing determining the
price prior to rendering services.

~~~
Spooky23
They do that too, but given a ceiling of $1, the vendors who sold the widget
for $0.95 will raise the price.

------
danieltillett
I have to say as an outsider that the USA healthcare system is a monument to
US ingenuity. I doubt there is another peoples in the world that could
construct and keep partly working such a complex, inefficient, and byzantine
apparatus.

~~~
DoreenMichele
We have a super secret medical club we almost never talk about in such
articles and discussions: The military.

The article below estimates that _7.3 percent of all living Americans have
served in the military at some point in their lives._

[https://fivethirtyeight.com/features/what-percentage-of-
amer...](https://fivethirtyeight.com/features/what-percentage-of-americans-
have-served-in-the-military/)

A married military member gets "free" medical coverage for their spouse and
children. The ridiculous cost of having babies as a civilian is some minor out
of pocket expense, medically speaking, for military members. It's common for
people who aren't planning to make a career of it to try to get the kids out
of the way before they exit the service. If you put in twenty years or more
and retire from the military, you have lifelong medical benefits for you and
your dependents.

Most articles about the problems the American medical system is rife with seem
to not bother to delve into what goes on in the military medical system, what
percentage of our medical system it constitutes, etc.

It actually makes me a little nervous to leave this comment. It makes me
wonder if I am going to mess up the super secret club or something. Because
it's really bizarre how we seem to completely leave out the military medical
system entirely from any analysis of the American medical system.

~~~
kn0where
That said, the VA is a poorly managed and IIRC poorly funded agency. Lots of
dysfunction in how we provide healthcare to veterans. That’s not to say we
shouldn’t try—we need to try harder.

~~~
rockinghigh
The VA may be poorly run but it is not poorly funded. For FY2020, their budget
will be $220 billion. See
[https://www.va.gov/budget/products.asp](https://www.va.gov/budget/products.asp)

