
Insured, but Still Owing $109K for a Heart Attack - tim_sw
https://khn.org/news/a-jolt-to-the-jugular-youre-insured-but-still-owe-109k-for-your-heart-attack/
======
jtokoph
> UPDATE: Monday, shortly after publication and broadcast of this story by
> Kaiser Health News and NPR, St. David’s said it was now willing to accept
> $782.29 to resolve the $108,951 balance because Drew Calver qualifies for
> its “financial assistance discount.”

Sounds all fine and dandy until you realize that these charges will just be
made up for by people that aren't able to get NPR to publish a story about
them.

~~~
opencl
There is a whole industry of "medical billing advocates" you can pay to find
what is likely thousands if not tens of thousands of dollars of completely
made up charges on any given US hospital bill and "negotiate" them away. You
don't necessarily need press coverage though it obviously helps.

Hell one time I got a $15k bill for something insurance should have covered.
Called the hospital, turns out insurance had covered it and I didn't actually
owe any money at all. How many people get this kind of stuff and just pay it
anyway?

~~~
acomar
Yea, but to hire a medical billing advocate, you need: 1)
knowledge/information that they exist and that hospital bills are BS, and 2)
money to pay the advocate AND the reduced bill. If the final bill is $800 and
the advocate gets a cut of the savings, how many people in dire straights are
likely to be able to afford that? Keep in mind, most Americans don't have 1k
in savings, living pay check to pay check _because they have no choice_.
Facing a 100k bill, people are more likely to wait for the collector to show
up and then declare bankruptcy, facing damage to their already poor credit,
garnishment of already subsistence wages, etc..

I'm much less worried about the folks who pay it anyway than I am about the
folks whose lives are destroyed by an industry predating on people in the
worst of circumstances.

~~~
benmowa
sounds like an opportunity....

~~~
acomar
For what? Lay out a business plan in this area for me that doesn't take money
from the worst off.

~~~
PurpleBoxDragon
If you make money off them but save them more money than you costs, it is
still towards their benefit. The only problem occurs when you start working
with the hospital to create even more arcane bills that you get into immoral
territory.

~~~
acomar
That's exactly the circumstance I outlined previously. This plan has you
taking the debts of somebody who cannot afford to pay, reducing them to
something above the actual cost, then asking them to pay the higher amount.
You are making money from the least able to pay and profiting from a system
driving people into bankruptcy. I cannot imagine starting such a company
without serious empathy issues.

------
rdtsc
> St. David’s HealthCare defended its handling of Calver’s bill and sought to
> blame the school district and Aetna for offering such a narrow network.

So while dying of a heart attack he should have been negotiating with the
ambulance driver, the paramedics, the nurses, each intern and doctor to make
sure they are "in-network".

> St. David’s said it was now willing to accept $782.29 to resolve the
> $108,951 balance because Drew Calver qualifies for its “financial assistance
> discount.” I

You can pay $100k or just $700, whatever is cool with us. I guess, go to the
media and try to shame everyone involved is your best hope? I can see if they
did this to people buying luxury suites or yachts. Doing this to people who
are dying of a heart attack is particularly disgusting. And it's not like
anyone involved is going to be punished for this practice or learn a lesson.
They'll turn around and do the same thing to the next patient.

~~~
sturgill
I once got cut by a skate playing hockey. Showed up at the hospital pulsing
blood from my leg. My first question to them, “Do you take X insurance?” Only
after they assured me that my insurance would be accepted did I drag my bloody
leg into the care room.

Turns out the doctor that the hospital assigned to me did _not_ take my
insurance.

I got billed the full amount, yelled very loudly at lots of people, and when I
“resubmitted” the claim ended up paying like $50 out of pocket. I’m pretty
sure that every item in the hospital is purchased by a separate company and
that the Venn diagram of approved insurance companies never intersects.

My dad is a nurse and I grew up hearing how insurance was destroying health
care. As a free market libertarian, I have no idea what to do about it. But
next time I need stitches I think I’ll just opt for the super glue in my
workshop...

~~~
RyanCavanaugh
It's not a free market if you (literally) can't walk away from the
transaction. Trying to apply free market principles to non-free markets is
what got us into this mess in the first place.

------
treyfitty
My father had a heart attack 4 months ago, and he’s been in and out of the ICU
for 3 of those months. Everyone likes to think “oh, I’m insured. I’ll be
fine.” But let me tell you, you won’t be fine. 3 months of ICU at Robert Wood
Johnson was billed for $4Mn. BCBS-NJ only paid out $750k. The headache begins
there- from a personal financial standpoint, and Tri-party incentive
standpoint. Ignoring the difference of $3.25Mn “owed” to the hospital
(technically, this $4Mn is an exaggerated number by RWJ to recoup as much as
they can), the insurance company is essentially denying basic/reasonable
services. The doctors have been fighting with insurance to get him to an
LTACH, but the most they’ll pay for is a nursing home.

Insurance is a business. They aren’t looking out for you, or your loved ones.
I hate to sound cynical, but boy, these past 4 months have shown me the
deepest, ugliest side of commerce that inevitably results from aligning
incentives with profits.

~~~
lotsofpulp
Health insurance companies' profit margins are restricted by law, whereas
Robert Wood Johnson and its executives and doctors profit margins are not
restricted. If anyone is on the patient's side from a cost perspective, it's
insurance, and the ones benefiting from higher pricing and unnecessary
procedures are the providers.

~~~
acomar
I've suddenly started seeing this take all over the place and I have no idea
where it comes from because it doesn't make sense. That the insurance
_companies_ profit margins are restricted means rather little because
executive pay isn't capped: if they earn too much money, they can simply pay
bonuses to raise their expenses. Or cut shareholders a check. Or. Or. Or.
Tangentially, this is why "non-profit" doesn't mean what people think it
means.

And despite what caps exist (can you point me to resources on this topic?),
the industry is enjoying record profits right now. That's not to say hospitals
aren't as well, but I'm puzzled that so many people seem to want to point the
fingers at _doctors_. Doctors and nurses actually provide the care. If there's
anyone I'm less worried about making a little more, it's the people actually
doing the work. The administrators and the corporations that set and negotiate
prices with the insurance companies though... I'm with you there.

Lastly, the incentives of insurance companies do _not_ align with the patients
unless you ignore most of how the industry works. Insurance companies make
money when they're able to _deny_ you coverage or require you to pay more out
of pocket (in vs out of network). That doesn't align with patients at all.

There should not be a profit incentive in health insurance.

~~~
jhayward
> _I 've suddenly started seeing this take all over the place and I have no
> idea where it comes from because it doesn't make sense. That the insurance
> companies profit margins are restricted means rather little because
> executive pay isn't capped: if they earn too much money, they can simply pay
> bonuses to raise their expenses. Or cut shareholders a check. Or. Or. Or.
> Tangentially, this is why "non-profit" doesn't mean what people think it
> means._

This is not correct, as I understand it. Under the ACA (Obamacare), health
plan providers had to ensure that at least 80% of premiums were paid out for
patient services. That leaves 20% for overheard, including profit and
compensation.

The "trick" here is that service providers (doctors, hospitals, MRI
facilities, labs, etc.) are _not_ limited in this way (except by "usual and
customary" terms where applicable), and there are LOTS of layers of providers.
So in the end you can get many multiples of actual costs by simply washing the
underlying treatment or service through 5 or so layers of providers.

~~~
jfk13
> This is not correct, as I understand it. Under the ACA (Obamacare), health
> plan providers had to ensure that at least 80% of premiums were paid out for
> patient services. That leaves 20% for overheard, including profit and
> compensation.

Doesn't this imply that it's in the interest of health plan providers for
patient services in general to be as expensive as possible? That means
premiums will have to be correspondingly high, and the 20% available for
profit and compensation will be larger.

~~~
mrguyorama
That's been one of the biggest complaints about Obamacare, yes. Other than the
"I shouldn't have to pay for my neighbor's wellbeing" complaint

~~~
gowld
How is an 20% cap worse than no cap? Obviously if this scam works it would
also work with less regulation.

------
lainga
_After a reporter made inquiries, St. David’s said collection efforts were put
on hold, and a hospital representative called Calver, offering to help him
apply for a discount based on his income._

I refuse to believe that the US medical system is run by humans, and not
trolls we pulled from under a nearby bridge.

~~~
HarryHirsch
No, it's run by people like George Shultz, who himself pays for an on-call
boutique physician, while the plebs can get their medical testing for cheap
from Theranos. When the grandson, who was a Theranos intern, becomes concerned
because Theranos' numbers are not better than throwing darts on a board the
grandfather becomes enraged, arguing that his investment and his reputation
are being threatened.

------
maxxxxx
How is a regular person who has other things to do than to read and
understated all the details and traps of his health insurance supposed to
navigate this insane system?

From what I read going to a hospital is pretty much a gamble that has a
certain probability to bankrupt you and there is pretty much nothing you can
do about it.

There should be bipartisan agreement that these practices are just not
acceptable and that there must be a way for a patient to get binding
information upfront.

~~~
0x7f800000
Yes, I demand full and final information about what the heart attack I am
currently suffering is going to cost me to be treated at this hospital.

If I think you are trying to extort me, I am just going to go to another
hospital.

~~~
krupan
I'm actually not sure if you are being serious. If the information on costs
for emergency services were clear and available up front people could shop
around ahead of time and basically write up a living will saying, if I have a
heart attack, take me here.

Insurance companies are the reason the costs are not clear and up front.

~~~
burkaman
Are you serious? You think every American should be required to write a living
will for them and their children listing every conceivable illness and injury
by individually researching all the medical options in their area? And what,
update it weekly as they follow the markets? Should they keep up with the
latest medical research so they know what the newest drugs and treatments will
cost? What about vacation, do you need to do a week of research to prepare for
a weekend trip to NYC?

~~~
krupan
"listing every conceivable illness and injury"

No. Just the ones that are true emergencies where you won't have time to do
any shopping around ahead of time. Why is this such a hard concept? Think of
all the times you've seen a doctor in your life. How many of those were super
time critical? Big accidents and heart attacks are. Having a cold or flu
isn't. Heck, even cancer isn't super time critical, you could take a few days
to shop around treatment centers. Shopping around for most medical care
shouldn't be that weird of a concept.

Another option would be to only have insurance for those critical time
sensitive events, then you don't have to be super price sensitive for those,
and the free market could drive down prices of all the other medical care we
get.

~~~
burkaman
Ok, here's one list, I'm sure it isn't comprehensive:
[http://ourmed.org/wiki/List_of_medical_emergencies](http://ourmed.org/wiki/List_of_medical_emergencies)

So for each item on this list you'll need to find out every possible treatment
and drug and what they cost at every hospital within ~50 miles. Make sure you
look up allergies and any side effects when combined with medication you
regularly take, you don't want to be in a situation where you listed Hospital
X for meningitis, but their cheap drug can't be combined with your asthma
medication, or whatever.

And again, how often do you update this will? And what about travel?

Is there anything else in your life that you shop around for in case of
emergency?

~~~
krupan
Your google skills are strong. How many things on that list need treatment
within minutes?

"Is there anything else in your life that you shop around for in case of
emergency?"

Have you never heard of Preppers? But seriously, yes, I shopped around a
little for a fire extinguisher in my home, I shopped around a bit for a good
first aid class so I'd have some skills. I have spare batteries around the
house in case the power goes out and shopped around for a flashlight. I have
practiced changing a tire for my car just in case. I have a little food stored
up in my house.

Why is preparing ahead of time completely off the table for people when it
comes to medical care?

~~~
zaarn
>How many things on that list need treatment within minutes?

Let's go down the list for things that don't need treatment in minutes:

\- Malaria

\- Rabies

\- Salmonella

\- Lyme disease

\- Malnutrition and starvation (though you'd rather have this taken care of
fast if possible, in severe cases minutes would count)

\- Attempted suicide, non fatal (though only if you aren't up for anything
else as a result of said attempted suicide, you'll be fine if you don't get
immediate treatment)

\- Psychotic episode (under supervision)

\- Suicidal ideation (if you're under supervision)

\- Smoke inhalation (in very very minor cases)

\- HELPP syndrome (doesn't seem to be very dangerous in the minute range
though you'll want treatment either way)

\- Priapism (although it is very painful)

\- Sexual assault (before you downvote consider that sexual assault is
generally not fatal itself and you don't need urgent medical attention, though
urgent psychological attention is, in general you'll survive if you need more
than a few minutes to the hospital)

Most of these come with a few ifs, notably that no other medical emergency
coincides and some depend on severity, the rest of the list is to my knowledge
pretty deadly if you don't get it taken care of as quickly as possible and for
half the list it is likely you'd be either in extremely severe pain,
unconscious, non-responsive, dying or a combination of the previous in any
order.

------
csomar
Looking at the bill, here is some ridiculous: NaCl (basically salted water)
costing around $300/liter.

That's outrageous. These guys are protected by your politicians and make use
of mercenary tactics. Villains in doctors clothing.

I'm for free markets but we are kinda going over the limit here. Maybe have
fixed rates for emergency where you can't get the approval of the patient.
Maybe give the patient the possibility to pay for these ridiculously priced
items after.

I mean if I get you 1l of NaCl we'd be cool. And fix the rates for emergency.

~~~
jhayward
Retail cost for Lactated Ringer's solution, injectable (basic saline fluid for
IV) was over $40/liter in qty 12 liters about 3 years ago. I can imagine it
has gone up since then.

The use of the health care system to extract every single excess dollar from
the middle class extends to many, many layers of the supply and service chain.
It may be that the saline was "merely" marked up by a factor of 2x.

~~~
csomar
Seems like the problem is broadly in the medical sector (including
pharmacological). There is 0 reasons why it would cost over $1. Maybe $2. $40
is still way ridiculous. I mean in a competitive market.

~~~
jhayward
The problem is there will never be a truly competitive market in most health
care products and services. Necessary regulation creates too many barriers to
entry and competition, and the ultimate consumer has very little demand
flexibility or even choice of provider.

What is needed is a monopsony buyer who can negotiate in this arena on a more
even footing. In other words, single-payer.

------
ako
The US is proof that a free-market system for healthcare does not work. This
is also illustrated by all the stories here.

For free-market to work, a consumer needs to be able clearly understand what
he is buying and how much it will cost before he consumes whatever he buys.
This allows him to shop around, and find the best seller and price.

The current system just drives prices up instead of down, as the seller, who
is in it for the profit, can set his prices after the goods have been bought.
Ofcourse prices will go up, there's no competition anymore, as the buyer has
already consumed the goods.

Trying to make this transparent before an operation would not work. It would
just turn healthcare into another IT project, where seller will offer you the
lowest prices, and then come up with extra-work that also needs to be done.
Image being operated on, and the surgeon informs you they've discovered some
required extra work, asking you if you will agree with the additional cost...

It's clear to me that healthcare and free-market are an incompatible
combination, it needs to be heavily regulated, and probably single-payer.

------
donretag
"Calver asked whether his health insurance would cover all of this... The
hospital told him not to worry and that they would accept his insurance."

From my experience, it is completely legal for any medical practitioner to say
they accept an insurance even though they really do not.

~~~
lacker
From my experience, no human at the hospital has any idea whether they will
accept your insurance or not. The doctors certainly don't. They just report
things into the bill-processing system which occasionally delivers patients a
crazy $100,000 bill.

~~~
dboreham
They have no idea if the insurance company will pay. I know this from personal
experience where the hospital explicitly called insurance co to ask if a
procedure would be covered, received confirmation that it would be, AND the
hospital recorded the call. But coverage was subsequently denied.

------
dcosson
I feel like whenever I hear crazy stories like this about healthcare it
usually involves these weird in or out of network issues. I'm certainly not an
expert on healthcare, but is there no way to attack the problem from this
angle?

If you have a hospital with a certain list price for a particular procedure,
why is it legal for them to charge one insurance company 5% of that price and
charge another insurance company or someone without insurance full price? It
seems like exactly the kind of scenario that price discrimination laws are
meant to prevent.

Similarly for the insurance plans themselves, why can you sell basically the
same plan to employees of a large company for much cheaper than you sell it to
employees of a small company? (This one might need to be a new law specific to
insurance companies, because clearly there are many other products that give
group discounts when selling to large companies, but I think health insurance
should be treated differently).

I'm sure I'm missing what some of the downsides might be, but it seems like
making these kinds of backroom network-based deals illegal in health insurance
would go a long way in making prices more understandable/predictable, and that
might allow for more fair competition on price to emerge.

~~~
FireBeyond
> I feel like whenever I hear crazy stories like this about healthcare it
> usually involves these weird in or out of network issues. I'm certainly not
> an expert on healthcare, but is there no way to attack the problem from this
> angle?

Because hospitals, and physicians, have decided that, for the most part, it is
better for each of them for physicians to be "independent contractors", so the
situation of "your hospital is in network, but your physician was not".

Or for me, most recently, going to my doctor for a checkup on my hypertension
at an Urgent Care/Family Practice hybrid. Facility? In network?
Physician/Assistant? In network? Lab in the same building (to be clear, it
wasn't a multi-tenant complex, this was a medical practice) that they sent me
for CBC draws? Out of network. Boom, hundreds of dollars in lab bills.

------
quickben
All this is a bit surreal (Canadian here), but it prompts the question: why
won't people sue in a class action to refund money they gave to the insurance
in the first place?

I realize it's a complex subject, but at the end of the day, the insurance
companies advertise and sell: insurance.

~~~
lotsofpulp
Any insurance policy will have clearly stated the difference between out of
network and in network benefits.

~~~
chrisbennet
But you can't always pick your providers. Example: You go to emergency room
that is in-network. A month later you get the bill for the doctors that
treated you - who aren't in-network.

 _" A new study that looked at more than 2 million emergency department visits
found that more than 1 in 5 patients who went to ERs within their health-
insurance networks ended up being treated by an "out-of-network" doctor — and
thus exposed to additional charges not covered by their insurance plan."_
[https://www.cnbc.com/2016/11/16/many-get-hit-with-
surprise-o...](https://www.cnbc.com/2016/11/16/many-get-hit-with-surprise-out-
of-network-bill-after-emergency-rooms-study.html)

------
krupan
Here's the deal. Insurance is a simple concept. Take house fires. They are
fairly rare, but they do happen. We could all just save up enough money to
cover a house fire ourselves, or, since we know that house fires are rare, we
can pool our money together as friends and neighbors and when one of us in
that pool gets unlucky and has their house burn down, it can be covered by
insurance. A lot of us pay a little money for peace of mind that if a rare
catastrophic event does hit us, we'll be OK.

This same concept applies to some medical issues, but there are a lot of
medical issues it does not apply to. Getting a routine infection and needing
antibiotics? _Everyone_ is going to need that. It makes no sense to pool our
money and pay out for the rare person that needs money for that. How many
other medical expenses are like that? Even things that are rare for a group of
20-year olds like heart attacks are actually a lot less rare (more common than
house fires, probably) for an older age group. So while it might make sense
for a group of 20-year olds to pool money together to pay for the rare heart
attack amongst that group, it might not make any sense for an over-50 group of
people to do that same. It definitely doesn't make sense for a 20-year old to
join that group. Yet this is exactly what we do. We all pool our money
together and use it to pay for _every_ medical expense that comes up. Minor
infection? Use insurance! Need a couple stitches? Use insurance. Routine
screening? Wow, didn't see that coming, good thing I have insurance.

This is insane, and this is the root of all our problems.

~~~
alphabettsy
I completely disagree. The reason insurance pays for the small things is to
encourage people to seek treatment early because it’s cheaper in the long run.
Almost nobody would pay hundreds for a cancer screening like mammogram or
colonoscopy that they don’t believe they need, but catching these things early
is orders of magnitude better both for health and financial outcomes.

Insurance covering a minor infection prevents needing to handle a major
infection. Your system assumes humans are rational and a good judge of risk,
something that has proven to be untrue countless times.

~~~
krupan
Yes, humans are shortsighted and stupid. That's why we need state-sponsored
medical care. Run by humans.

~~~
Terr_
Not sure if you're joking, but that's a pretty lazy fallacy of composition
there.

Ex: Human memory sucks, but you can generally trust the immutability of books,
despite them being written and copied and bound and distributed and sold by
humans.

It's all about using strengths in the right direction and order to sidestep
weaknesses.

~~~
krupan
Fallacy of composition says I look at a few stupid humans and decide that all
humans are stupid. That's what the person who I was replying to was doing in
reply to my original post. I was trying to point out that if their supposition
is true then we are all screwed no matter what.

Fortunately their supposition is false. Humans are not generally shortsighted
and stupid, if you give them a chance.

~~~
Terr_
> Fallacy of composition says I look at a few stupid humans and decide that
> all humans are stupid.

No, a fallacy of composition would be "the organization is stupid because its
employees are stupid", or "metal boats are impossible because metal sinks in
water." It involves something which is _composed of_ the smaller pieces.

What you're describing is more like a hasty generalization, where individual-
qualities within a sample lead to a conclusion about individual-qualities
shared by the entire population.

> I was trying to point out that if their supposition is true then we are all
> screwed no matter what.

And -- even if their supposition is true -- I disagree!

Metal boats _can_ float on water, even though individual metal pieces sink.
Institutions _can_ solve problems, even ones that individuals humans suck at.

------
keithnz
From outside of the US, it baffles me ( and I'm sure others ) why the US
doesn't embrace governement based healthcare. We pay the same kinds of tax
rates etc and don't have to pay for health insurance on top of that(though you
can get extra health insurance for pretty cheap if you want). It's kind of
like governement education which the US does pay for up to a certain point.
Not only is it worth educating your population, it's worth looking after their
health as well.

The amount of misery and unpayable debt it seems to cause people who live in
the US seems really unecessary. Not to mention nearly everyone in good heealth
has a certain level of anxiety about whether their insurance is good enough
and will cover them.

Mind you guns also seem unecessary yet the general response to that seems to
be, It's ok, we will live with our fear and everyone should be carrying guns
and make it so everyone needs to be prepared to kill other people in gun
fights. If you get wounded of course, then prepare for living the rest of your
life in medical debt.. :I

~~~
dragonwriter
> From outside of the US, it baffles me ( and I'm sure others ) why the US
> doesn't embrace governement based healthcare.

The US has had majority public support for fully-public healthcare for at
least ~30 years.

What it has lacked—even among politicians championing “healthcare reform” like
Bill Clinton and Barack Obama—is politicians willing to challenge the
insurance industry even with the backing of majority public support.

------
kimsk112
> Industry analysts and consumer advocates say St. David’s has a reputation
> for exorbitant billing and for trying to collect big payouts as an out-of-
> network provider.

Sounds just like St. David’s Medical Center in Austin, TX is run by crooks. I
like the take-home message that "Faced with a surprise bill or a balance-
billing situation, don’t rush to pay any medical bills you receive."

~~~
lacker
More specifically, it is run by HCA Healthcare, a for-profit company listed on
the NYSE.

------
mabbo
If you owe a 6-figure amount of money because of a health issue, you don't
actually have health insurance.

~~~
lotsofpulp
You do, it just doesn't cover you at all medical providers in all 50 states.

~~~
mabbo
If you send me a bill for anything over $100,000, you might as well send me a
bill for $10 trillion. It doesn't matter, I can't pay. I'm bankrupt now.
Great, you get my house and my retirement savings.

The point of insurance is to prevent that from happening. I pay a small amount
so that if I get unlucky, I'm not ruined. I don't care if "oh the bill was
actually much higher before" because the number never mattered- me being
ruined is what mattered. If I still am, then the insurance did not do what I
wanted it to do.

------
mnm1
The insurance company is basically saying, you should still choose the in-
network provider even if you are unconscious or don't have a choice or we'll
fuck you financially. I've had this happen to me, appealed, and after many
months, actually won. In my case I was unconscious and the ambulance and
hospital were out of network. I was lucky the hospital was willing to wait
over a year and not send it to collections. It was hell. Why the fuck isn't
there a law against this kind of shit? Do we expect people who are unconscious
or having a heart attack to say, "oh no, take me to an in-network provider so
I don't go bankrupt?" Fucking absurd the healthcare in this country and the
lack of proper regulation. How long are we going to allow these insurance
companies to get rich while people die and go bankrupt?

~~~
dragonwriter
> The insurance company is basically saying, you should still choose the in-
> network provider even if you are unconscious or don't have a choice or we'll
> fuck you financially.

Actually, they are saying if you choose to cut premium costs by selecting a
narrow provider network, well, there's a reason _why_ the premium costs are
low.

> Why the fuck isn't there a law against this kind of shit?

Because Republicans actively oppose any attempt at health security, and
Democrats keep ignoring the majority support for single-payer that polls have
shown for close to 30 years in favor of Rube Goldberg solutions that keep
private insurers and this type of network-based limitation as central
features, despite the fact that hey have less public support and are thus more
subject to being politically sabotaged before passage (Clinton) and after
(Obama).

Though there's signs of potential for that to change on the Democratic side in
the near future...

~~~
mnm1
Your first point is simply not true. There is no plan that covers every ER and
every hospital. Even on the top plans, there are in-network and out of network
providers. So once again, we're back to making decisions while incapacitated
or unconscious. No matter how carefully you chose your plan and how much you
pay, you're still fucked. Not to mention that almost everyone is stuck with
the plans their employers choose. Even the platinum level ACA plans, however,
are like this. That's what I'm talking about above, BTW, as well as equivalent
plans provided by corporations. It's simply impossible to get a plan that
covers everything and therefore prevents you from going bankrupt in all
situations.

~~~
dragonwriter
> Your first point is simply not true.

My first point is what the insurance company is _saying_. It's absolutely true
that they are saying that. (It's also a true claim; your argument that all
provider networks are limited such that the risk of similar problems exists at
some level in all insurance plans is perhaps pedantically true, but not
necessarily relevant—e.g., it may be that the only reason the care from the
profile provider in this particular case was out of network was that the
district's individually negotiated narrow network plan excluded providers that
would have been included in standard plans this insurer offered in the area.)

> Not to mention that almost everyone is stuck with the plans their employers
> choose.

That's factually false; only 49% of Americans are covered by insurance
provided by an employer (either their own or as a dependent) health insurance,
and not all of them have no other practical option than that plan, so, no
“almost everyone” is not stuck with their employer's plan choices.

But, in any case, the employer's plan choice is exactly what the insurance
company is highlighting as the issue in this case.

------
alkonaut
There are midterms coming up. Vote for change and don’t vote for anyone who
took one cent from the insurers.

~~~
swebs
And here's a handy list of all representatives and how much they took from
healthcare lobbyists.

[https://www.opensecrets.org/industries/summary.php?ind=H&cyc...](https://www.opensecrets.org/industries/summary.php?ind=H&cycle=2018&recipdetail=S&sortorder=A&mem=Y)

~~~
DesiLurker
whats amazing to me is how little money it takes to sway a politicians vote.
yes there are big numbers in the list but most of them are 10s of thousands.
its just amazing that they are willing to put their conscience aside and
condemn people to bankruptcy or worse for that little. for the worshipers of
free market they sure are selling themselves off cheap.

~~~
whamlastxmas
The problem isn't that they're bought with $10k. They're approached and told
"Take this money or we'll give your competitor $5 million to campaign and take
your place". And they know they follow through with the threats, so they take
the $10k.

~~~
DesiLurker
but even that should ultimately bid-up the bribes after all its a 'free
market'!

------
ThrustVectoring
This is why I plan on moving to Texas: creditor protection.

At any point in time I could require medical services and have medical service
providers simply decide that I owe them a truly massive amount of money. The
only route I have to mitigate that risk is through creditor protection laws.

In Texas, wage garnishment is limited to child support, unpaid taxes, and some
other limited categories that medical billing doesn't have access to.
Creditors can sue you, but they can only seize bank accounts, brokerage
accounts, and the like - your primary residence is completely exempt, as are
employer-sponsored retirement plans and IRAs.

So my emergency medical debt plan is to liquidate all taxable investments and
close out bank accounts, send the cash from that to pay down a mortgage, and
tell them to pound sand. The only real consequence is having to head to
Walmart each month to cash paychecks and mail out money orders to pay bills.

~~~
robin_reala
You might be better moving to a country with a nationalised health system and
avoiding this mess entirely.

~~~
ThrustVectoring
It's _significantly_ easier to move between US states than it is to emigrate.

------
megamindbrian2
Another easy solution, file for bankruptcy. No sane judge will kick a family
out of their house over a medical bill. That would be counter productive to
their recovery and cause undue hardship. If you don't see the utility in
bankruptcy, just remember our President has used it several times over
decades.

Edit: it's also known as unsecured-debt, which means the worst thing anyone
can try to do to you is ruin your credit score. This isn't worth dying over
and America is designed to bear the cost.

~~~
chatmasta
Bankruptcy really is the ultimate medical insurance. In fact, when so many
people don't even have $2k in liquid assets, it almost makes more sense to
skip paying _actual_ medical insurance, and just declare bankruptcy in the
event of massive medical bills.

What that doesn't help with, though, is something like being diagnosed with a
chronic condition where pills cost $800 a pop.

~~~
megamindbrian2
I've read that it can only be done once every 7 years.

~~~
tluyben2
What happens when you do it more often? You have no money so...

~~~
megamindbrian2
I think it was just from the credit score side, maybe it takes that long for
it to be discounted from your credit score.

------
paulcole
Went to the ER on the advice of my doctor. Went to my insurance's website to
find an ER that accepted my insurance.

Got there and asked at admittance, "Do you take my insurance?" Was assured
they did.

Got a big bill a few months later and it turned out the doctor working in the
covered ER was not covered by my insurance.

~~~
petelevinea
Exact same thing happened to me. I went last April and just now got it all
"fixed". I ended up negotiating with the hospital, the contracting company for
the hospital's ER department, and my insurance on the phone at the same time
to reduce the cost to what the contracting company's ER doctor on staff would
normally bill the insurance company and paid that out of pocket.

I guess you have to ask if the doctor who may or may not see you depending on
what you're in for also takes your insurance? I don't even know.

------
jim-jim-jim
Just cut the gordian knot and nationalize the system already. It's a political
no-brainer. There are very few Americans, even conservative ones, who are in
love with the intricacies of paying medical bills. The only people beholden to
the status quo are those paid to defend it.

------
cmurf
FTA _St. David’s is out-of-network on his school district health plan_

So apparently the "max out of pocket" on the cover sheet of your plan is b.s.
and only applies in-network. I guess good luck having in-network coverage if
you're on a vacation and have an emergency.

~~~
woobar
Yeah, out-of-network coverage (if provided) is often limited by terms like
"the usual, customary, and reasonable amount". When a provider charges
unreasonable amount the insurance will not have any contracts that enforce the
cost of services. And the patient left holding the bag. ;(

My guess is in a situation like this I'd get the reasonable amounts for
services provided from my insurer and use them as a basis to refuse any
unreasonable charges.

~~~
nerdponx
The whole warped part of this is that the consumer has no way to anticipate
cost in advance, and often the individual providers (doctors, nurses, etc.)
don't either. Shouldn't the burden be on the insurance company to investigate
and discourage excessive billing? Or are they too strict as it is, leading
providers to play games with billing?

~~~
woobar
I think in this particular case insurance did investigate actual (or within a
reason) costs and paid them. But there is no business relationship between the
insurance company and an out-of-network provider. Should they go to the court
on behalf of the patient? As a customer I'd like this. But it looks like
combining health and legal insurances.

Another option is maybe to require that language on the "patient
responsibility form" to include the blurb about fair prices. For instance:

In the event that my health plan determines a service to be “not payable”, I
will be responsible for the complete charge and agree to pay _the usual,
customary, and reasonable_ costs of all services provided.

~~~
nerdponx
Is there an analogy in the car insurance world? Let's say I know nothing about
cars and I get in a collision somewhere far away from home. I need a repair th
let's say I know nothing about cars and I get in a collision somewhere far
away from home. I need some bodywork and a replacement for the flimflam
crankslap in the engine. The shop knows that I don't know anything about cars,
and they know that I am covered by insurance. What is stopping them from
charging me an exorbitant rate for a new crankslap, and then me getting
screwed when the insurance won't cover it?

~~~
woobar
> What is stopping them from charging me an exorbitant rate

Nothing. That's why everyone always asks for a good and trustworthy mechanic.
Or an HVAC repairman.

------
digitalneal
I just don't see what value private health insurance companies bring to the
table anymore. They are not helping get the best coverage for their patients
and they squeeze the crap out of the care-givers until its hardly worth their
time.

------
huangbong
Crazy that you need to make national news to pay a medical bill fairly in this
country.

------
tim333
There must be a better way. I'm in the UK where the NHS is kind of flawed but
at least they don't bill you like that. I'm kind of a believer in customer
satisfaction as a guide to how to run things and it seems highest in hybrid
systems like Singapore.

------
NTDF9
Has anyone in the US considered flying overseas to get treatment done? Many
hospitals in third world countries are cheaper and more humane.

Sure, you lose out on the ability to sue them if things go awry but where is
the tradeoff between six figure debt at an old age vs paying $10000 to get the
whole thing done?

~~~
amichal
Not intentionally but this happened to me. I have bad adult asthma and spent
6hr in an my in network ER (on the advice of my pcp) a couple of years ago.
Got some meds a chest X-ray (turns out I had pneumonia!) and got sent home
stablized. my bill for the 6h (with BCBS insurance) was ~$3k. Last year I was
in Japan for 2 weeks and again got sick. After avoiding it for a few days I
again went to the ER and got the same treatments/test (this time it was only
the flu). Bill (no insurance at all) $200. Round trip direct flight to Japan
from my house is $1300 and takes less then a day. Makes me think what I might
want to do next time...

------
mikekij
*Disclaimer: I'm not attempting to support HCA's billing practices here."

HCA has profit margins around 10%, which do not appear to me to be exorbitant.
([https://investor.hcahealthcare.com/press-release/hca-
reports...](https://investor.hcahealthcare.com/press-release/hca-reports-
first-quarter-2018-results)) While this patient's experience is clearly out of
whack, and the $19k for a $1,500 stent thing is nuts, this points to a larger
pricing / business model issue within US Healthcare. Typically, a few medical
specialties (Surgery, Imaging, Rad Onc) have high profit margins, but are
offset by losses in other departments (ER).

~~~
krupan
Thank you for pointing this out. How many medicaid patients paying below cost
does it take to drag down profits from the occasional 1000% markup that the
hospital gets away with?

~~~
mikekij
Can't tell if you're being sarcastic or not, but yes, there are patients that
pay (or are charged) a 1,000% markup, that in turn offsets patients not paying
anything. I'm not saying the problem is the patients paying nothing; the
problem is that the payment model is broken.

~~~
krupan
I think you just said what I was trying to say. Thanks!

------
honkycat
Working as intended.

Here is the thing: This hospital is a vampire. They WANT to send you to
collections. They WANT to take your house and everything you own.

~~~
ThrustVectoring
It's Texas, they can't actually take your house.

------
megous
'We saved your life so that you can spend the rest of it in indentured
servitude.'

------
kbos87
I have a relative sick with cancer right now and I’m seeing this first hand.
Hearing stories like this you hope it’s a one off, but it’s absolutely the
norm of how insurance companies operate.

My aunt is still employed, fully insured, and every day is a fight between her
and her insurance company. They randomly deny claims for chemo treatments, and
put her through invasive procedures to verify the disease after doctors
formally diagnosed her.

The list of landmines they strategically place that could cause her to lose
her insurance seems to only grow. This payment isn’t made on this date?
Insurance gets cancelled. This form isnt filed on this day three months from
now? Insurance gets cancelled. Forget the fact that she is too sick to work;
her insurer is already busy trying to figure out how to not pay.

Unless you are wealthy enough to pay for everything yourself, everyone in the
US should expect to be left behind by the health insurance they’ve paid their
entire life for as soon as the insurer can figure out how to do it.

------
cimmanom
I thought this was one of the things the ACA was supposed to prevent, with
out-of-pocket maximums?

~~~
luminaobscura
out of max doesnt apply to balance bills since it is not insurance's
responsibility.

~~~
cimmanom
Then what's the point of an out of pocket max? Shouldn't it _make_ the bill
the insurer's responsibility?

------
scarejunba
Well, it doesn't have to cost that much to take care of a heart attack. Remove
the AMA from the equation and it'll clear up. The real problem is that we
restrict the supply of doctors.

Without that, competing hospitals can arise that will compete on price.

~~~
maxxxxx
Why don't they compete now or why can't you even get a price upfront from
them?

EDIT: I am responding to a comment that the AMA is the problem. Maybe the AMA
is a problem but it has nothing to do with hospitals not competing over
prices.

~~~
jjeaff
You can get a price upfront in my experience. Especially for standard
procedures. And definitely for outpatient stuff.

But it isn't reasonable to expect upfront pricing in things as complicated as
heart surgery. Or where you are going in for unknown problems. There is no way
to know what complications may arise or additional procedures, x-rays or scans
may be required.

~~~
eric_the_read
I was having trouble sleeping for a while; at one point my doctor recommending
I go on oxygen for a while until she could figure it out. I called the company
that provided the oxygen, and asked how much it would cost. Nobody knew. I
called back 3 times, and still nobody could tell me. I called my insurance
company; they couldn't tell me either. I ended up electing not to use it
(which turned out to be perfectly fine), but it does seem like this was a
fairly standard procedure, for outpatient stuff, and nobody involved knew what
the prices were.

~~~
maxxxxx
That matches my experience. Or you get quoted $100 and charged $3000 which
after some back and forth turns into $50.

------
elorant
40k for four plastic tubes. Why on earth are medical supplies so fucking
expensive?

~~~
CommieBobDole
Because the markup is arbitrary. An NPR article notes that the average price
paid for the stents by hospitals is $1,153.

[https://www.npr.org/sections/health-
shots/2018/08/27/6408918...](https://www.npr.org/sections/health-
shots/2018/08/27/640891882/life-threatening-heart-attack-leaves-teacher-
with-108-951-bill)

~~~
ReverseCold
First reaction: Hmm that's not so bad.

Second reaction: It doesn't seem as bad because it's put in context of "40k"
\- in reality that's still pretty bad.

------
maxerickson
The way out of this for the US is to have _lots_ more doctors.

So tax hospital revenues (yes, revenues) to fund residencies and have an
objective standard for accrediting medical schools, where meeting the
objective standard automatically qualifies the seats.

Of course patients will then be paying for the residencies, but that's fine,
it even makes sense.

Having more nurse practitioners and physicians assistants would also help, but
doctors lobby against them starting independent practices.

------
geggam
Reads like a breaking Bad prequel in the making

------
smittywerben
When you are out of network then you are responsible to submit the claim to
insurance. I paid < 1% in the end for a 5-figure bill in similar
circumstances.

The scary part is you must carry this risk to your insurance who can then deny
the out-of-network claim.

Am I misunderstanding something here, or is everyone else not understanding?

------
faragon
How it can be that inefficient? It looks like a monopoly or corruption. In
Europe medical costs are way lower (not what the user pays, but the actual
cost).

------
armanini_io
Only in US.

~~~
cabaalis
There are different horror stories from different systems. Bottom line is that
access to health care professionals and equipment is a scarce resource, and
any resource management process whether through governmental regulation, or
individual funding, insurance program, etc will be faced with managing access
to that resource one way or another.

~~~
TomVDB
And in some systems, horror stories are way more common than others.

The simple fact is that I don't know anybody from my European family or
friends who would willingly switch their system to the US one. And as a very
well insured employee in the US, if, hypothetically, I had the option to use
my European health care in the US, I'd switch immediately a well.

~~~
h4b4n3r0
>> I'd switch immediately a well

I doubt it. _Someone_ needs to pay for it, so this switch would have to imply
a 20% tax increase. Unless you’re paid peanuts, it’s not worth the tradeoff.

~~~
TomVDB
> Someone needs to pay for it

Or you could pay less for it.

There are many studies that show how the US system has incredibly high
overhead that simply isn't needed.

Just an example: in the US, a primary care physician usually has a nurse and
somebody who handles paperwork, insurance BS, and what not. Most European
countries simply don't have this, mostly because there is no insurance BS to
deal with.

There is insurance related overhead every step of the way.

And that's not including the free-for-all pricing of $500 saline bags.

Your 20% tax increase is ridiculous. It doesn't have to be nearly that high
(and it isn't.) And even though I'm in the highest tax bracket, I'd gladly pay
5% more if it meant quality medical care for everyone without any risk of
bankruptcy.

~~~
h4b4n3r0
Once again, US share of taxes in GDP is 26%. Denmark: 50.8, Sweden 49.8,
Germany 44.5, France 47.9, UK 34.4. So weighted by GDP it does cost quite a
bit.

~~~
didroe
Why are you quoting figures for the entire tax take in a discussion about
healthcare? To give you some perspective, the healthcare-only figures for
those countries are US: 16.8%, Denmark: 10.3%, Sweden: 11%, Germany: 11.2%,
France: 11.1% and UK: 9.9%. Data here:

[https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS?year_...](https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS?year_high_desc=true)

~~~
h4b4n3r0
Because OP wanted to "switch" to European socialized insurance, without also
"switching" to their levels of incomes and taxes as well. Of course their cost
of labor is lower: they socialize a bunch of costs that would otherwise need
to be recouped through the earnings of doctors, nurses, administrative
personnel, etc. On top of that they get US drugs for a fraction of the cost,
and don’t do any serious pharma research (because there’s quite literally no
money in it, given the cost of drugs). It’s not a valid comparison. My point
wasn't that US healthcare is not expensive, anyone with any brain at all can
tell that it is. It was that you can't pick and choose, and on balance, even
with the more expensive healthcare, the US is a "better deal" for the vast
majority of people who comment on this site.

------
psycombi
I a non-immigrant here in SA's medical/emergency system is fully corrupted and
broken. Citizen's of USA are not standing up/protesting this issue which can
virtually affect everyone. Why are citizens sleeping? Same surgery with more
experienced docs and equipment are done in 10-20 times less in my and the rest
of the countries in the world. It's time to wake up USA

------
sigvirt
Propublica [1][2] has done some investigation into the amount of waste,
beginning with a 2012 report by the Institute of Medicine of the National
Academies. The unnecessary costs amount to roughly 5% of US GDP. For
comparison: the defense budget is about 4.5% of GDP, and Social Security
Disability Insurance outlays are about 5% of GDP. NASA's budget is about 0.1%
of GDP.

A number of other commenters have castigated politicians on suspicion of being
in the pocket of insurance companies or health care companies. Sure such
things may happen occasionally. More certainly, politicians and bureaucrates
are regularly attentive to the budget and financing of the government.

If medical care was cost efficient, it would 1) reduce GDP and the appearance
of economic growth, and 2) wreck the back office math concerning whether the
federal government can afford the deficit and the interest on the national
debt. Elimination of mass incarceration and criminalization would cause a
similar dilema. US economic growth has been 2-3 percent in recent years. If
that were negated by substantial reduction of waste-masquerading-as-
productivity, then the federal budget could not be financed without massive
cuts or dramatic manipulation of interest and inflation rates.

There are others who potentially benefit from denial of treatment or claims
beside the insurance company. Beside the doctors, medical institutions, and
insurance companies are another set of actors: the benefits management and
payment processing companies, who often profit per transaction. Some of the
calculus in this camp can be seen in [3]. This part of the system (and others)
can benefit when a patient is denied or discouraged from or uninformed of
curative treatment and manipulated into some ongoing palliatve therapy -
despite the possibility of greater overall long-term cost. The cash-flow gets
distributed differently than curative treatment, and there are more smaller
on-going transactions enabling a higher percentage of skim.

[1] Sep 2012 - [https://www.propublica.org/article/a-costly-equation-
medical...](https://www.propublica.org/article/a-costly-equation-medical-
dollars-wasted-are-greater-than-the-u.s.-defense)

[2] Nov. 2017 - [https://www.propublica.org/article/a-hospital-charged-to-
pie...](https://www.propublica.org/article/a-hospital-charged-to-pierce-ears-
why-health-care-costs-so-much)?

[3] Nov. 2017 - [https://www.bnymellon.com/us/en/what-we-do/business-
insights...](https://www.bnymellon.com/us/en/what-we-do/business-insights/the-
saga-of-medical-claims-payment-processing.jsp)

------
aaroninsf
Here is a reminder that in the US, we pay much more and receive far worse
outcomes than any other first world nation, by any metric you care about: life
expectancy; infant mortality; incidence of chronic disease; obesity; incidence
of addiction; etc.

Then consider we are the only first-world nation in which medical bankruptcy
is not just a thing, but a profound source of anxiety and genuine risk.

What do we get in exchange for worse care, worse lives, and risk of financial
ruin...?

A "free market" like the one functioning in OP's case. Oh, and in the time
_since_ the ACA passed? Record private industry profits.

It's not just Trumpism sh-tcanning this country.

~~~
PeekPoke
This is why it's good to be English - our national health service fixes you up
and sends you on your way without providing you with a bill.

~~~
wang_li
Unless the NHS has no approved treatment, in which case you die instead of
being able to go abroad for care.

~~~
DanBC
If the NHS has no approved treatment you can go abroad or you can pay
privately in the UK.

What conditions are you thinking of that don't have "approved" treatments?

~~~
wang_li
Within the NHS specifically, there was the recent case of Alfie Evans[0],
where the medical practitioners said there was no hope for him and the family
wanted to take him abroad for care. The NHS and the UK legal system decided
that his best interests were to die in the UK. His family was not allowed to
take him for additional care.

0\.
[https://en.wikipedia.org/wiki/Alfie_Evans_case](https://en.wikipedia.org/wiki/Alfie_Evans_case)

~~~
Thlom
That isn't really an issue with the NHS. If it's an issue it's with the UK's
family law which recognises that the parents of a child doesn't always act in
the child's best interest and allows the state to intervene.

------
ypeterholmes
Our system is an ongoing tragedy.

------
Talyen42
.

~~~
whymsicalburito
I agree, but why no credit cards? Just keep them on autopay and get free
points right?

~~~
mikeryan
This is what I do. I did reach a point in my life though where I could manage
this.

------
donclark
I curious to know the details of his health. He just did an IRONMAN 5 months
before. Why was he unaware of the status of his clogged “widow-maker” artery?
Why was his artery clogged? high cholesterol? What does his diet consist of?

Use of ultrasound imaging to measure the thickness of the inner walls of the
carotid arteries that supply blood to the brain. Increasing carotid artery
intima-media thickness, or CIMT, indicates a build-up of fatty deposits, known
as plaque, in crucial arteries to the heart and brain. Plaque build-up in the
arteries, which is usually affects adults, can restrict the flow of blood,
causing heart attacks or stroke.

~~~
stan_rogers
There's not always a lot in the way of warning signs, and people tend not to
get casual arteriograms just for kicks. The apparently-healthy suddenly
dropping dead isn't exactly a rare phenomenon, and "being in shape" can be
misleading. Jim Fixx[1] was kind of the poster child for this sort of thing;
his death pretty much kicked off the over-40 checkup routine.

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

~~~
AstralStorm
Unfortunately you can't really get a heart arteriogram done as a checkup and
anything else is actually guesswork.

Both MRA and CTA are really expensive.

Bloodwork can point to problems but there is still a plenty of differential
diagnosis involved... You need a bunch of history (main factors are currently
age and family history) to reasonably evaluate risk using e.g. European joint
guidelines.

You can perhaps guess better based on local doppler USG of some big extremity
artery or of carotid. Doppler of heart is not precise enough to show anything
useful.

