
California lawmakers introduce plan to end surprise ER bills - howard941
https://www.vox.com/2019/2/24/18236482/zuckerberg-hospital-surprise-bills-california
======
geebee
I spent a night once in the ER for observation. I never got anything but
Tylenol, though I think the concern that led to the overnight stay was
reasonable. The bill was $16,000.

This was certainly a defensive, risk-averse treatment, but I think it was a
reasonable decision. I think my insurance paid about 8,000. The magic words on
the bill were "Patient is nor responsible for the difference between the
amount paid by insurance and amount billed". This is because I went to an in-
network hospital with a contract.

I talked about this with some of my physician friends, and they told me this
is typical. In fact, the original bill doesn't represent what they expect to
be paid. It represents an extreme position taken to start negotiations with an
HMO or other insurance company.

Here's the trap: if you don't have insurance, you are not just hit with the
high bill that represents what the hospital would pay an HMO, you're hit with
he wildly inflated bill they send to an HMO in anticipation of being paid much
less.

So if you don't have insurance in the US, you're doubly hosed. I know I'm
supposed to hate my HMO and all, but to me, this is a bit like belonging to a
union. As part of a powerful group, I have someone not just paying the bill
but knocking it down for me. I may not like being part of a group plan, but on
my own, I'm toast.

Unfortunately, this story shows that you can still end up on the wrong side of
this billing practice even if you do have insurance, because some hospitals
remain out of network for all insurance, and if you're incapacitated or simply
don't have the plan in front of you and a couple hours to research the billing
practices of various hospitals as your head is bleeding and you're being taken
to the ER, you can end up in a similar situation to an uninsured person.

It turns out that it may in fact be impossible to insure yourself against
ruinous bills. Nicely done, there.

~~~
gowld
If you don't have insurance you can negotiate your bill. The problem is that
people don't understand that, that Americans hate negotiating, and that
negotiating the price of something _after_ you bought it (or even after you
need it) stinks.

~~~
tome
Why aren't there services that negotiate people's medical bills, for a fee?

~~~
jjoonathan
Because "negotiating" the blank check that you already signed does't work.

Yes, it works if they have actually stuck you with a bill that exceeds your
net worth and expected income, but in that case you can't afford and/or don't
need a negotiator -- you just default. It also works if you've stirred up a
media frenzy, but you can't turn that into a business model for obvious
reasons. The only place it does reliably work is in the imagination of those
looking to downplay the severity of the current state of affairs.

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lykr0n

      Second, the bill would regulate the prices that the hospital could charge for its care, limiting the fees to 150 percent of the Medicare price or the average contracted rate in the area, whichever is greater.
    

Seems like this will start to solve the chicken and egg problem. Hospitals
charge more because insurance will pay more. Insurance costs more because
hospitals charge more.

~~~
gowld
"150%" smells like a made-up number. Unless providers have some freedom to
_raise_ Medicare prices (which they don't), this effectively means that
Medicare sets prices for everything. I'd rather see laws that strengthen
consumers control over their insurance options (improving the power of the
demand side of the market), including price disclosures, than pushing the rope
from the back end without any competitive market forces influencing prices.

~~~
heydenberk
Have you ever tried to be a conscious consumer for health care? How about for
serious health care for a life-threatening of life-changing issue like cancer
or childbirth? I never understood the desire to offload any of this cognitive
load to the consumer, many of whom are going through the most difficult times
of their lives.

~~~
lewis500
The weird thing is that, even though a lot of policy is oriented toward making
you a conscious consumer (high deductibles, coinsurance) in many cases you
just can’t do it,at least not very well.

My wife got an allergy test at a local allergy clinic, but she had 20%
coinsurance so we tried to figure out how much it would cost. Everyone there
treated us like garbage. Even when we called the billing department in advance
they told us there was no way to know in advance how much the basic allergy
test would cost until she saw the doctor. So we went to the clinic (stupidly),
and the nurses just acted like we were crazy. Finally one did tell us what the
bill would be:$12k. I had researched these tests online and was floored;
that’s way more expensive than it should be, and the doctor who gave her a
referral had told us it would be a reasonable price. So we were in the awkward
position of just leaving the appointment. The doctor then basically talked to
us somberly like we were the poorest people on earth, and said “listen, most
of the test is for allergens that don’t exist in northern California.” If I
just give u the local ones it’ll be like $1800.” I started laughing. Later on
I read an NPR story about a lady who had a$48k allergy test from there. Just a
complete scam, much worse than a car dealer because at least there they will
tell you a price and they will not sell you ten extra useless cars evenif you
don’t explicitly say “don’t give me ten superfluous cars for no reason.”
Anyway, we got the limited test, and at the end the doctor said “listen I’m
not supposed to do this, but given the financial hardship I’ll make an
exception. If I don’t put the results in the system you’ll only be charged for
the visit.” And he just wrote the results on a yellow notepad paper and tore
it out for us.

Tldr we were treated like annoying busybodies for asking the price at an in-
network facility, and then treated like indigents when we balked at paying way
more than anywhere else charges, for totally bs procedures.

~~~
ams6110
This is a pretty good anecdote that supports why I don't go to doctors.

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thorwasdfasdf
Finally, we see legislators doing something good for a change: "“These
practices are outrageous,” says Chiu(Assembly member David Chiu) , who
represents part of San Francisco in the Assembly. “No one who is going through
the trauma of emergency room care should be subsequently victimized by
outrageous hospital bills.”

So, they introduce a bill that will reduce patient billing abuse in CA.

Based on the article, it seems like Zuckerberg Hospital was especially
egregious in abusing it's patients with billing.

I hope they can continue to crack down on Hospital overbiling.

~~~
gumby
> Finally, we see legislators doing something good for a change:

Come on, we don't need this invective. Sure, I can find a reason to be
outraged every day by some legislative decision someplace but in the main, we
still have roads, air traffic control, health and safety rules etc.

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mc32
And that happened to people with private insurance (SF General was “out of
network” for the two examples.) But upwards of $20 thousand for very simple
things is outrageous,

This has to become a national effort to curb these exploitative and unfair
billing practices. It’s simply outrageous.

~~~
jdavis703
San Francisco General Hospital is focused on serving the public, i.e. those
without private health insurances. Per Wikipedia:

About 80 percent of its patient population either receives publicly funded
health insurance (Medicare or Medi-Cal) or is uninsured. SFGH also cares for
the homeless, who make up about 8 percent of its patients.

They effectively use the high rates for privately insured folks to subsidize
their public mission. Of course this all speaks to a really broken health care
system, but it's not like uninsured people would have been charged even more
than $20k.

~~~
mc32
This the Robbin Hood approach to a problem. How on Earth does a public
hospital think it’s ethical to exploit people like this and think it’s okay to
do because I’m helping someone else?

~~~
gowld
It's price discrimination and it's how most businesses operate because that's
the only viable option in many industries.

~~~
r00fus
It’s only a viability issue because everyone does it.

Regulation can help here.

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admax88q
Negotiating the cost of life saving treatment, checking in-network vs out-
network, vs in-network with contract, shopping for different insurance
providers.

The amount of mental energy that Americans spend on health care just seems
absolutely nuts to me. How much productivity does your country lose because
people have to spend time even thinking about things like this?

~~~
andrepd
It's beyond ridiculous that the richest country in human history cannot even
ensure health treatment to its citizens, when countries with 1/20 of its
GDP/capita manage that. Goes to show that "economic growth" by itself means
nothing, if it does not even translate into something so basic as health care.

~~~
sorenn111
which country has universal healthcare with 1/20th of US GDP per capita?
genuinely curious

~~~
HarryHirsch
I think he's talking about Cuba.

~~~
NoGravitas
Most likely. Cuba's kind of an outlier in having an extraordinarily good
medical system relative to its GDP, but it's proof at least that, given
political will, it's possible.

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

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Animats
Some years back, the California legislature passed a bill which limited what
hospitals could charge uninsured patients to the Medicare reimbursement rates.
Schwarzenegger vetoed it.

~~~
masonic
CA has been under single-party control since then. What's the barrier since
then?

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fmajid
I kinda feel bad for Mark Zuckerberg. He donated a massive amount of money to
the city-run hospital in a bid to improve his image (like Mark Benioff did
with the state-run UCSF Children's Hospital), and it turns out they are even
more rapacious than him and now his name is being dragged further in the mud
thanks to them.

This incident does illustrate how corrupt health care is in the US, and public
institutions are just bad as private ones.

~~~
heavenlyblue
Well, or he could have done some research before donating that money.

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sivanmz
California protections against balance/surprise medical billing are not
enforceable when an employee is covered by a "self-insured" or "self-funded"
employer plan. California doesn't regulate that plan, and also cannot
intervene in the billing between the provider, patient and insurance. Most
medium to large employers are using such plans which means that employees are
not protected from such billing.

[http://www.insurance.ca.gov/01-consumers/110-health/60-resou...](http://www.insurance.ca.gov/01-consumers/110-health/60-resources/upload/AB-72-Fact-
Sheet-Consumer_Protection_for_Surprise_Medical_Bills-rev2.pdf)

"Does the New Law Apply to Everyone? The new law applies to people with health
insurance policies or plans regulated by the California Department of
Insurance or the California Department Managed Health Care that were issued,
amended, or renewed on or after July 1, 2017. It does not apply to Medi-Cal
plans, Medicare plans or “self-insured plans.”"

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dsfyu404ed
Preventing attempts at collections (like this law does), insurance reform,
"medicare for all", etc, etc. are nice but they don't address the root
problem. Costs are out of control. Until we find a way to control costs we
will still pay way too much. All that changes until then is who pays what
amounts and the point at which payment is made. The hospitals are just going
to shuffle around who pays what in order to make up for the income they're not
getting from surprise bills unless there's something (actual competition, a
government payer who won't put up with that crap, etc,) to stop them.

Sure this is a step in a good direction but there's only so many band-aids you
can apply to a gunshot wound. While unscrupulous practices like this bill
takes aim at should be weeded out it strikes me as hopeless in light of the
bigger picture.

~~~
zaroth
The problem is two-sided. Yes the costs paid by the hospital, and the cost of
the techniques and tools used by the hospital are all too high, because the
system does not properly incentivize finding lower cost solutions that may be
equally effective and safe.

In this case the problem is exacerbated by the way that privately insured
patients are being exploited to subsidize publicly insured patients;

“A hospital spokesperson initially told Vox that the hospital’s focus is on
serving those with public health coverage, even if that means offsetting those
costs with high bills for the privately insured.”

It should be illegal to charge two different people different prices for the
same procedure at the same hospital. At a more granular level, it should be
illegal to price discriminate on anything that can be itemized.

The middle and upper class patients are exploited to pay for publically
insured patients who get service below cost which the hospital can’t legally
turn away.

~~~
exabrial
> It should be illegal to charge two different people different prices for the
> same procedure at the same hospital

I think you're close to a solution with minimal regulatory intervention (Which
so far has only made things even more expensive: ACA for example).

I'm curious how this would be reconciled with insurer networks though. A cost
savings to insurers IS to have networks and discounts.

~~~
larkost
Two comments: 1\. The ACA has by all accounts kept the growth of healthcare
costs in check. Yes they have gone up, but at not nearly the rate they were
going up before it, let alone the increased rate that most expected. If you
start getting into the details this makes a lot of sense, but those details
often get lost in the conversation about mandatory coverage (and the subsidies
to make that possible on the low end).

2\. This sort of cost savings to the insurers is more moving the costs to
other people, thus negating most of the cost savings incentives.

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BrainInAJar
What about just eliminating medical bills entirely?

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sivanmz
These laws don't apply to employees covered by employer self-funded plans,
which are predominant. California can't enforce them in most cases.

