
Show HN: We structured and compared hospital chargemaster prices - aguynamedben
http://pricemed.org/procedures/transfusion-of-blood-or-blood-products
======
GauntletWizard
This is the kind of data that is needed for true transparency, and true
medical reform. Prices will be gouged so long as you can't compare;
Realistically, this still has a long way to go (Because I'm certain that a lot
of these differences are in part due to one procedure being billed as many
different codes under the current US regulatory mess), but it's a good step up
from what we've had available in the past.

~~~
cookiecaper
The only thing that's going to matter in effectively reforming medical cost
structures in the U.S. is getting a critical mass of people who are shut out
from medicine due to the insurance scam. While there are presently _some_
people who are in a bad position, it's not enough people to really mount a
meaningful united front. Sure, people are upset, but not enough people are
upset in the right way to really make policymakers fear for their careers
and/or lives.

Huge swaths of "money" in the medical industry are the result of paper
pushing, pure and simple. No one is spending their own money, or even really
"real" money: the doctor's bill will say something outrageous for the cash
price, because they know the insurers will demand a large reduction, and even
though they write "$40,000" for something, they don't actually expect anyone
to pay that directly. They expect you to either call and get a "cash payment
discount", i.e., something close to what they charge insurance companies
(which is still really high, because insurance companies aren't spending
"real" money either), or to use your insurer to "pay" the bill.

Remove the lecherous middle-men who do nothing but shuffle numbers around and
we can start making progress on medical pricing. This is not the ONLY cause of
high costs, but it is easily the largest and most perverse problem point,
because this type of billing completely destroys all conventional rules of
supply and demand.

Interestingly, the Affordable Care Act does the opposite of this, and
strengthens the lecherous middle-men to the point that it will be illegal not
to give them money (the government will forcibly take the money from you in
the form of a "tax penalty" if you do not voluntary sign up for "medical
insurance").

~~~
001sky
This is a generalized problem with insurance, tho. Ie, if you had a likely
expense, you would plan for it (house, college, etc). You buy insurance
precisely because you don't think you'll need it.

So, the people that need to use it are always going to be a small group. The
people that don't have it, another group. The people getting screwed (on the
sharp end) are the subset of those where there is overlap. This will always be
a small number (by math).

That being said, for everyone is paying into the system but its more death by
thousand cuts. As long as pricing is opaque and uncorrleated with out-of-
pocket marginal payments, there will be a problem. The cleaner solution is
simply to remove the facade of pricing a-la-carte services.

The problem there, is two fold: (1) how to control the inevitable buracracy
with a huge budget making life or death decisions; and (2) how to incentivise
research and science/product development without the cash cow of monopoly
pricing (patents are useless if selling is illegal).

While these problems seem to be solvable, they are daunting and not simple. In
a world where the NSA is spying on every electronic communication over the
internet, perhaps even more so. Ie, a world where privacy and trust is being
undermined by those seeking to entrench their own power. Its harder poltically
to delegate more responsibility to the "government".

~~~
cookiecaper
I agree that this is how insurance works. Normal insurance is a hedge against
anamolous disaster. Medical care is something that practically everyone will
need at one point or another, i.e., it is not an anamolous disaster, and
therefore insurance is a problematic billing model from the get-go.

We should start by saying that insurance is often considered a perverse
industry because their incentives are inverted. Normal businesses make money
by providing a product or service to clients, and the incentives are therefore
aligned. Insurance makes money by explicitly NOT providing a product or
service in exchange for your money; if they have to give you the thing you've
paid for, they are less profitable. The more frequent claims against a
particular insurer are, the more incentive they have to make things difficult,
because some people will ultimately give up and that'll be one less (or
lessened) payout that the company must supply. As medical insurance policies
will likely have several claims per policy per year, they have an incentive to
be the worst type of insurance.

Most people with home insurance will never use it, because their house is not
likely to get robbed, or catch on fire, or encounter even more esoteric
occurrences. Considering the multi-hundred-thousand dollar investment most
people have in their homes, a nominal fee of a few hundred bucks per year is
entirely reasonable to protect that asset.

The opposite is true of medicine. Most people will get medicine sometime, and
it's not uncommon to need access to medicine several times per year (even
excluding the chronically ill). Even car insurance will often go several years
without being used, but not medical, especially not if you have a policy that
covers multiple people (policy holder + spouse + dependents).

Insurance simply _does not work_ for services that are commonly required, and
that's what it boils down. There is a major feeding frenzy operating on the
backs of the nation's health, and everyone is pointing the finger at the other
entity, and again, there's more to it than _just_ insurance, but insurance is
now and always will be the most major cause of problems in this industry. The
only way to bring it back to sanity is to expose it to true market forces; the
clientele must spend their own money to receive medical services, and
therefore medical providers must set prices within an affordable range or go
out of business. The leeches who do nothing but sit there and push paper must
be removed, plain and simple. No amount of whining about how it will put some
people out of work, etc., can be tolerated on this. The fact is that insurance
is a very, very bad thing to have so deeply ingrained in our medical system,
and we won't see major improvement until those people go away.

Other countries have band-aided it by saying "OK, I see meidicine 'costs'
inordinate amounts of money, we'll just write what is effectively a blank
check to the industry", but that's not how we should do it in America. We must
accept that market forces must dictate the prices, that hospitals the size of
universities are probably not plausible, and that the whole industry must be
brought back down to earth. The industry is obviously not going to like that,
but it must be done. We need some ballsy politicians who can make it happen.

~~~
001sky
_the clientele must spend their own money to receive medical services_

The flaw / issue with this, is that sick people are in no position to
negotiate. People that are sick are desperate for the drugs. People that are
not sick dont really need them. that is ill suited to the simplification
required of econ 101. In econ 101 you want the price to converge to the
marginal cost of supply, not converging to the marginal amount of residual
equity / net worth of the patient's bank account (that's the hold up problem:
give me all your money or you die). Imagine if you had to negotiate the price
of a fire-department visit with your house burnging? Its just not a service
that is ever going to fit the framework (in particular, the behaviour
assumption of non-opportunim) of the typical econ 101 course.

That being said, I agree with your analysis of the insurance model when
applied to "scheduled maintenance" type services. Opaque pricing and a culture
of witholding service is particulary innappropriate here. Assuming that
chronic and life-threatening services are another matter, that still leaves
the issue of everything in-between. The issue there is that there are life-
style type elective surgeries and treatments that some may want access too
(the rich) but not be willing to subsidze for others (the poor). So there is a
basic triage of the types of health care, and they all need to be thought
through from a sociological perspective as well as just an economic and
medical/technical one.

------
tryitnow
This is a fascinating data problem. I noticed a lot of the price distributions
are non-normally distributed (specifically with a strong positive skew for the
least consistently priced procedures). You guys should have fun with this.

Who will be the primary users of this information? It seems that insurers
already are aware of chargemaster prices and ignore them since they're going
to be bargained away.

Employers seem not to care to dig into how much their insurers are paying
(employers just care what premium they'll have to pay).

Finally, it seems like consumers can't really use this data since they're
pretty much locked into their plans anyways and will go wherever is most
convenient.

Now given changing consumer behavior, I could see consumers maybe using this
so they have to pay less of a deductible, I could also see insurers working
with consumers to steer them to the best prices - saving both the insurer and
the consumer money. However, this will require overcoming consumer attachments
to preferred providers (a challenge for older adults, not so much so for
younger ones who often don't have a relationship with a doctor). It can be how
surprising how quickly people can overcome sentimental attachments when their
money is on the line though, so who knows.

------
atldev
Background on the chargemaster story that broke in Time Magazine. (So glad it
was covered by The Daily Show or I would have missed it):
[http://healthland.time.com/2013/02/20/bitter-pill-inside-
tim...](http://healthland.time.com/2013/02/20/bitter-pill-inside-times-cover-
story-on-medical-bills/)

~~~
aguynamedben
Here's the Jon Stewart segment: [http://www.thedailyshow.com/watch/mon-
may-13-2013/bi-annual-...](http://www.thedailyshow.com/watch/mon-
may-13-2013/bi-annual-competency-round-up)

Some other links to more info are at the footer of the page. There was an
interesting US Senate hearing with Steven Brill, the author of the Time
article.

------
aantix
Love this!

If there's some unstructured data that you're having trouble taming, contact
me. I have a ton of experience with Mechanhcal Turk and can give you some
advice on how best to structure your HITs to extract the data that you need.

jim.jones1@gmail.com

------
chime
One suggestion: The dropdown for "Find a Hospital" needs to show the location
too. I tried searching for "St. Anthony's" near my town and multiples ones
from all over the country showed up. I put in my zip code but it did not
filter the results. I have no idea how to look for St. Anthony's near 33708 or
not. I don't know if it is St. Anthony's Medical Center or Health Center or
Hospital. But there's only one St. Anthony's here in St. Petersburg, FL.

~~~
gknoy
When I entered a zip code, it showed a map w/ nearby hospitals. Perhaps they
have no data from yours?

------
babby
Some tweaks to the design would help!

At the top of the page, the search boxes are mis-aligned to the text above
them. Fix that. They could also take up more horizontal space, or simply be
aligned better.

Add an extra ~3-10px of horizontal padding to table cells (td's) Table
headings should be text-align: center except for the longest field (hospital).
Also, vertical-align: middle on table headings.

Link color on the tables could also be darker.

Add left-margin/padding on the (?) question mark icon at the top right of
fields.

Font size on the search drop downs could be bigger.

May want to try the font "Open Sans", too, on the tables.

Add a hover effect for all links and buttons. It's kind of nuts that you could
overlook that.

Add a focus effect for all inputs. Also make input font color brighter, and on
focus, make font color darker.

On the "worst hospitals" table, the percentages could use a + sign before them
like "+97%".

------
pc86
It looks like the sorting is off. It's saying that Cedars-Sinai is the worst
priced hospital for the linked procedures, but at "only" a 99% marked over the
average $1,300 even though there are many in the $3-5.2k range.

------
HarryHirsch
This is all great, but cost isn't the only metric, there is also such things
as readmission rate &c. Two weeks ago or three a fellow, a physician, made the
front page of HN who listed prominently listed _prices_ for his hospital, but
you had to go digging for readmission rates.

That guy was on a mission, and his mission wasn't to improve public health. If
his mission was that he would have listed the other important metrics. He
knows all about them, he is a physician, after all. This sort of dishonesty I
cannot stand.

~~~
eruditely
It seems you're implying malevolence and unless the other metrics
substantially were worse than the other hospitals.

~~~
HarryHirsch
No one knows about his motives except that person himself, but it is
indisputable that a public figure such as he has responsibilities to society,
and he does not fulfill them.

------
hkiely
No one pays chargemaster prices. The reason hospitals set the prices so high
is because they are the starting point for negotiations with networks and
insurance companies. Even consumers without insurance typically don't pay
chargemaster prices as hospitals normally have cash pay discounts. As payers
begin to contract with ACO's, I think we'll likely see a shift to a more
standard shape bell curve if reform is working.

------
donquichotte
Great idea! There seems to be a minor flaw in the data though, the Healdsburg
District Hospital appears do be doing many procedures for 1$.
[http://pricemed.org/hospitals/healdsburg-district-
hospital](http://pricemed.org/hospitals/healdsburg-district-hospital)

------
jmcgough
Really cool!

One thing - the google map always sets California as the state, even when I
look at hospitals in other states.

------
patmcguire
Isn't the chargemaster price mostly unrelated to anything?
[http://runningahospital.blogspot.com/2013/05/useless-
noise-f...](http://runningahospital.blogspot.com/2013/05/useless-noise-from-
cms.html)

------
davemel37
I'm confused... This is assuming a procedure in facility A by Doctor B is a
commodity and is no different than the same procedure in Facility C by Doctor
D. Am I missing something?

~~~
wffurr
For many procedures, that's true so long as they're competently executed,
which we should expect so long as the doctor is licensed to practice.

To really make buying decisions for your own health care procedures, you would
want user reviews in addition to prices, just like you see on every online
storefront.

------
ljoshua
I love it, thanks for sharing. Where did you get the original data from? (I
thought chargemasters were relatively guarded secrets?)

~~~
jparker165
raw California chargemaster data was in excel files at this gov't website:
[http://www.oshpd.ca.gov/chargemaster](http://www.oshpd.ca.gov/chargemaster)

outside of California, the data from a release by Medicare:
[http://www.cms.gov/Research-Statistics-Data-and-
Systems/Stat...](http://www.cms.gov/Research-Statistics-Data-and-
Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-
Data/Inpatient.html)

------
NKCSS
Very cool. I wished this would be done for hospitals in .NL as well.

------
bezdekt
Very cool. Does anyone pay the chargemaster price though?

~~~
ars
No, no one pays that.

And I don't think the chargemaster price is even correlated with the final
price, so it's not even useful as a relative measure.

I wish it was a real price though - maybe this site could push hospitals that
way. But I doubt it because the reason hospitals are able to afford Medicare
prices is only because they overcharge the rest, and the prices are made
opaque specifically so that that people do not complain about that.

The only way to make transparent healthcare prices is to raise medicare prices
so that everyone pays the same, but that'll never happen. So what happens is
that insured people pay an extra premium to help out the rest.

Airlines do the same thing, and they too have very convoluted hard to
understand prices.

~~~
rdl
Yeah, I get the feeling one could fix healthcare overnight by allowing any
private person to pay cash at Medicare prices, or a low multiple (1.5x?). I
guess there would still be prescription drugs and devices to deal with,
though.

~~~
DanielBMarkham
Another idea: make it illegal for anybody but the patient to pay for their
healthcare. Insurance pays the patient, who then pays the hospital. If the
patient doesn't like the service, or feels they're getting ripped off? They
probably won't pay as much.

~~~
rdtsc
Bush or Clinton, I forgot who basically was pushing that. Create high
deductible plans, add tax benefits attached to them (tax sheltered health
saving accounts) so that people are more directly involved in shopping for
prices and it was being sold as that would drive the prices and competition to
get better.

~~~
rdl
Yeah, I think the HSA was one of G W Bush's best accomplishments (and,
probably, one of the only net-positive accomplishments other than helping in
Africa somewhat), which is why I'm sad the new health reforms are basically
incompatible with the HSA concept.

As I see it, there are basically two separate ways to make healthcare work --
expose consumers to prices AND give them the tools to make decisions (with
subsidies, etc. if we want to let poor people consume more health care than
other things, as a matter of policy; I don't think that's an economic
argument), or have an external entity with the correct incentives acting on
the consumer's behalf. Medicare seems to mostly work on the latter model.

It's clearly possible to screw up both ways, but an even surer way to screw up
is to do neither/both-partially.

Ending employer deduction for healthcare (and/or making it deductible for
individuals) would be a huge step, too (in either model). I see no actual
upside to employers paying for health care vs. individuals or the state at
all.

------
bdcravens
Lung transplant: 0 results

~~~
joshwa
[http://pricemed.org/procedures/transplant-of-
lung](http://pricemed.org/procedures/transplant-of-lung)

~~~
bdcravens
Didn't see that earlier - and there's only one listing. $413?? More like
$143K.

