
Hospitals Must Now Post Prices. But It May Take a Brain Surgeon to Decipher Them - wjossey
https://www.nytimes.com/2019/01/13/us/politics/hospital-prices-online.html
======
yason
Any business that can afford to splice, destructure, and recompose their
pricing into undecipherable mess is a strong sign they're doing too well, and
have an unhealthy stronghold on their customers.

If the markets are free enough I'd imagine some hospitals coming up with
reasonable price lists that amortise the variance between successive
operations and between the hospital and the patient. Most calls are routine
anyway.

Even car repair shops are able to quote rough price ranges even if they face a
lot of unknowns. They will call you back if they find something else, and at
least locally should the mechanic commit to a fixed offer he's only allowed to
deviate from it by X percent. And routine jobs are generally advertised with
fixed prices. The shops will undoubtedly swallow some of the accidental costs
themselves to provide tighter quotes which is what customers like.

Surely treating a human patient is more involved than that but the mechanism
for pricing doesn't need to be. The hospital can calculate how much extra they
need to add in the fixed prices to be able to "insure themselves" against the
rare pathological case, to some extent. There's always the route of escalation
from a routine operation to operating an acute trauma, but I can't imagine
that would be common enough to explain the inability to provide reasonable
quote ranges.

~~~
viggity
"splice, destructure, and recompose" \- this gives the impression that they're
making complicated on purpose. In this regard you're giving them way, way too
much credit. I can practically guarantee they're just dumping a report (or
more likely a union of several reports).

It is a giant bureaucracy that has had zero price pressure to force them to
simplify. It is a function of 30 years of new inventions, complicated laws and
IT as an afterthought. It akin to asking the IRS exactly how many taxable
transactions exist. They have no effin' idea. They'll just push the 74,000
pages of the tax code at you and say "you figure it out"

------
DigitalSea
This seems like a great opportunity for a company to invest serious time and
money into creating a better-centralized database which will allow people to
decipher and compare prices. It sounds like a highly-complicated task, but if
someone can pull it off, that would be huge.

~~~
wjossey
The opportunity is likely more B2B than B2C, where insurers are more apt to
negotiate down prices if they see they are "overpaying" based on comps.

GoodRx already does this somewhat with prescription medication, by getting
pricing data on prescriptions from local pharmacies.

Perhaps, based on the GoodRx model, the opportunity is to improve price
pressure on recurring procedures for patients who require ongoing dialysis
treatment, dermatology care, physical therapy, etc. For emergency based care
in hospitals, I still don't think it's a major net-win for consumers, as you
don't care enough to ask about price when your leg is broken.

~~~
elyobo
As a non American, based on what I've heard of the US system, I would
absolutely ask about price for any medical treatment in the US if I was still
physically capable of asking.

Haven't broken a leg, so can't be sure whether I'd be functional - probably
depends on how bad the break is :D

~~~
ceejayoz
You can try, but the answer is likely to be “we don’t know, ask the billing
department afterwards”.

~~~
elyobo
Ha, yeah, I can imagine :-/

------
AndyMcConachie
Americans must think markets are like Gods. If we could previously say, "Kill
'em all and let God sort them out." Now we can say, "Starve them all and let
markets sort them out."

The only difference is in who we outsource our morality to. Either way we, as
mere mortals, are not responsble for determining morality. Or quite literally
in this case, who gets to live and who gets to die.

The markets will fix it. Believe in the markets. They are our saviours and
they are a fickle beast that we mere mortals cannot understand. Their actions
are mysterious and their outcomes capricious, but we must believe because they
are the one true God.

~~~
conanbatt
MArkets are people. When you make your rhetoric on markets what you are
actually raging against is the desire of human beings: that is what you
despise.

~~~
andyjsong
Don't hate the player, hate the game.

~~~
salawat
That's a copout if I've ever heard one.

A few years ago, there was a game some adolescents would play where they would
run up to an unsuspecting person person and bludgeon them as hard as possible
to knock them out. There have been variants of the same pattern of behavior
except involving strikes to other areas.

It is _absolutely_ justifiable to hate a person for engaging in a _game_ that
involves inflicting harm on others. This attitude to hate the game rather than
those forcing it on everyone else just seeks to divest blame from the actors
that perpetuate the malignant activity, to an assumption that "the game" is
some mysterious standalone force that subverts the will of the participants
and justifies their innocence.

In short, "the devil made me do it" is not an excuse for poor moral choices.

Lets take it even further.

I have a game.

I'm going to get all the lifesaving equipment I can, and open a facility. This
facility is going to specialize in a particular type of highly asymmetric
transactions, and I'm going to do everything I can to inflict the greatest
financial harm I can, because gee, the way we keep score mandates I do so to
keep the game going.

It's a hard realization to come to, but as human beings and individuals, our
_collective_ behavior is dependent and a composition our individual choices.

And for a not insignificant portion of our population, we have succeeded in
allowing it to scrape together a world around itself where maybe it takes a
week to explain the technicalities, but it doesn't take a layman more than an
a 15 minutes to come to the conclusion there is something seriously wrong.

This is one of those cases where rationalization has been left unchecked or
unquestioned for far too long.

To wrap around to the true meaning underlying your aphorism, which is diluted
without context:

Don't hate the market participants for participating in the market; but feel
free to call out the hypocrisy of dealing in grievous financial harm in trade
for necessary care. If you can't question or shame the actions of the ones
perpetuating the status quo, you'll never change a blessed thing.

Mrs. Bloom in Accounting is still a part of it. Even if she'd rather not think
about it.

~~~
mrguyorama
I agree with most of your post but do you have any evidence that "the knockout
game" was an actual thing and not just a few unconnected instances played up
with scaremongering?

------
droithomme
I've checked out the price lists from the hospitals in my area. They are
useless. It's clearly a case of malicious compliance, and it seems to have
been done universally and consistently across different markets, suggesting a
criminal conspiracy to evade the law.

Hospitals are already dangerous to go to since either the hospital is not
covered by any given insurance plan, or the doctors at the hospital are not
covered. It's pretty much impossible to get taken to a hospital that actually
accepts your insurance and be treated by doctors who also accept your
insurance. This has been bifurcated so precisely that it also indicates an
intentional and designed conspiracy.

~~~
rjtavares
> It's clearly a case of malicious compliance, and it seems to have been done
> universally and consistently across different markets, suggesting a criminal
> conspiracy to evade the law.

Do you really believe this is a conspiracy instead of, you know, healthcare is
complicated and the US market isn't working?

Knowing something about hospital pricing, I looked at Johns Hopkins Hospital
pricing and it looked perfectly legible. Item pricing in healthcare is pretty
useless, that's just how it is.

~~~
smileysteve
> Do you really believe this is a conspiracy instead of, you know, healthcare
> is complicated and the US market isn't working?

Yes -- and I think it's pretty well documented. Though less conspiracy and
more regulatory capture. Between several insurance companies - patients,
doctors, and hospitals - , "not for profit" ever expanding and state sponsored
hospitals, medicare, lost bills, medical debt, and somewhere in this, medicare
and medicaid.

~~~
rjtavares
Hence the "US market isn't working" part. None of that is new and it all
explains perfectly why the price listings are useless. Which is why suggesting
a criminal conspiracy to evade the price listing law is ridiculous.

------
motohagiography
These price lists look like "malicious compliance."

Based on the quality of published data, one could rank hospitals in order of
probable honesty. Crowd sourcing estimated bills based on price data vs.
actual bills would provide another metric.

If we in tech treated hospitals as being engaged in predatory wealth
destruction, we could probably make a dent in the harm they cause. The most
authoritative data could come from medical bill debts in collection, with
signals in regard to how likely a given hospital is to make an egregious
claim.

------
dmitriid
I'm baffled that in comments people in all seriousness say things like "a
great opportunity for a company to invest serious time and money into creating
a better-centralized database" and "a great opportunity for startups who does
price/cost aggregation and comparison".

Are you serious?!

It's not even like trying to cure the symptoms of a disease. It's like trying
to treat a symptom of a symptom with essential oils.

~~~
mac01021
What's the underlying disease?

And, even if this isn't the path you'd like our healthcare system to take,
isn't this new state of affairs a big opportunity for some startup?

~~~
dmitriid
The underlying disease is the healthcare system in the US. No amount of
startups will fix that.

~~~
DennisP
Of course, but it's going to take a long time to really fix that. In the
meantime, scraping some websites and aggregating their data could help.

------
leovander
_The data, posted online in spreadsheets for thousands of procedures, is
incomprehensible and unusable by patients — a hodgepodge of numbers and
technical medical terms, displayed in formats that vary from hospital to
hospital. It is nearly impossible for consumers to compare prices for the same
service at different hospitals because no two hospitals seem to describe
services in the same way. Nor can consumers divine how much they will have to
pay out of pocket._

I took a look at the Vanderbilt charges[0] mentioned at the top of the
article. If they could at least provide proper medical codes for procedures
like they did in the drugs export, that would make it a lot easier to cross
reference procedures/etc. between hospitals.

You can look through my comment history on my complaints about it, but if
these csv files or pdfs were generated with jasper reports or mirth connect
(any other integration engine), its a shame that they missed out on either one
extra column or one extra join to get all their corresponding codes in their
exports.

To the other comments' points, yeah someone could go ahead and start cross
referencing codes, if they were all there, but the problem is that most
systems are usually behind in code systems (e.g ICD9 vs ICD10) or they are
made up using their own internal codes. You might end up with yet another set
of standard codes that you would have to map to the official codes.

Here are some value sets[1] that are listed on the HL7 site. If anyone did
want to tackle this problem, start there to at least get a baseline in the
types of labels/descriptions you will be seeing across the board.

[0]
[https://finance.vumc.org/chargemaster/](https://finance.vumc.org/chargemaster/)

[1]
[http://hl7.org/fhir/us/core/terminology.html](http://hl7.org/fhir/us/core/terminology.html)

CPT - [https://www.ama-assn.org/amaone/cpt-current-procedural-
termi...](https://www.ama-assn.org/amaone/cpt-current-procedural-terminology)

SNOMED - [http://www.snomed.org/snomed-ct/get-
snomed](http://www.snomed.org/snomed-ct/get-snomed)

ICD-10 - [https://www.icd10data.com/](https://www.icd10data.com/)

RXNORM -
[https://www.nlm.nih.gov/research/umls/rxnorm/](https://www.nlm.nih.gov/research/umls/rxnorm/)

~~~
cinquemb
Having had some experience with both SNOMED and RXNORM (for scraping and ETL
for updates), you need login credentinals for both and I'm not sure how much
they cost.

Also they come in some large zip files (some are nested) so if you want to
process it efficiently you should probably think about reading a particular
file located inside, write to disk, process it, and deleting it and move on to
the next without extracting it as whole.

------
mbrumlow
Why do we always act like brain surgeons are any smarter than -- well any
other type of surgeon?

It seems to me it is mostly a dexterity thing. Much like a good butcher.

Don't get me wrong. I am not trying to put down brain surgeons, I just think
their job is less brain power and more physical performance.

~~~
yason
Not necessarily smarter than... other scientists:
[https://www.youtube.com/watch?v=THNPmhBl-8I](https://www.youtube.com/watch?v=THNPmhBl-8I)

------
Nelkins
This article strikes me as unnecessarily negative. This only began to roll out
as of Jan 1, and the dust is still settling. Even if it's not perfect, it's
still an improvement over the previous situation and I'm sure it will be
iterated on.

~~~
sam_goody
It's a NY Times about something the Trump administration did. Relatively
speaking, its surprisingly positive.

There is a benefit to publicize the program and its shortcomings, so I am
happy they wrote it up.

------
sbr464
Here is the link to Vanderbilt's pricing [1] mentioned in the article. Has a
few CSVs and PDFs, also Johns Hopkins[2].

Searching google generically for the term "chargemasters csv download" seemed
to uncover a few more hospitals.

Interestingly, I tried searching for "chargemaster" on Google Datasets
search[3], and it only came back with one file. I think this shows the work
needed to be done in this area (datasets search).

[1]
[https://finance.vumc.org/chargemaster/](https://finance.vumc.org/chargemaster/)

[2] [https://www.hopkinsmedicine.org/patient_care/billing-
insuran...](https://www.hopkinsmedicine.org/patient_care/billing-
insurance/billing/charges-fees.html)

[3]
[https://toolbox.google.com/datasetsearch/search?query=charge...](https://toolbox.google.com/datasetsearch/search?query=chargemaster&docid=05ZyhHyKdkjXc1p3AAAAAA%3D%3D)

------
TheChaplain
This is a great opportunity for startups who does price/cost aggregation and
comparison.

------
shishy
In case anyone was curious, there isn't a centralized list of everything yet.
All the chargemasters are posted on the individual hospital websites.

~~~
wjossey
I have a feeling some of these non-profits that are mentioned will take a
crack at creating a centralized index. But, it sounds like it'll be a
borderline impossibility to make it accurate and useful.

To me, the argument that people can "shop around" for healthcare is just
peculiar. For elective / non emergency scenarios, I get it. Dentists, for
example, are more likely to face pricing pressure, given that dental work
tends to be non-emergency. However emergency care, which is where insurance
really matters, is by definition an emergency. If you cut off a finger, you
don't call ten hospitals to find out who will stitch it on the cheapest. You
head to the nearest hospital so you don't lose your finger!

I'm generally quite sympathetic to Hayekian economics, but the model doesn't
strike me as universal (which doesn't make it flawed, just not some grand
unified theory). Behavioral economics change during time sensitive & life
threatening situations in a way that "throw the rulebook out the window", so
to speak.

~~~
dantheman
Most healthcare costs are not emergency care; its probably somewhere from 2% -
10% of healthcare costs: [https://www.politifact.com/truth-o-
meter/statements/2013/oct...](https://www.politifact.com/truth-o-
meter/statements/2013/oct/28/nick-gillespie/does-emergency-care-account-
just-2-percent-all-hea/)

------
sbr464
Here's all of the California data:

[https://oshpd.ca.gov/data-and-reports/cost-
transparency/hosp...](https://oshpd.ca.gov/data-and-reports/cost-
transparency/hospital-chargemasters/2018-chargemasters/)

[https://data.chhs.ca.gov/dataset/hospital-annual-
financial-d...](https://data.chhs.ca.gov/dataset/hospital-annual-financial-
disclosure-report-complete-data-set)

~~~
aboutruby
Read a random one, "Kaiser Foundation Hospital - San Francisco", Common25 is
quite readable. but "CDM" is exactly as described in the article, it's
basically an endless list of codenamed items.

> Emergency Room Visit, Level 2 (low to moderate severity) $1,185.00

> Emergency Room Visit, Level 3 (moderate severity) $2,105.00

> Emergency Room Visit, Level 4 (high severity without signigicant threat)
> $3,263.00

> Emergency Room Visit, Level 4 (high severity with significant threat)
> $5,009.00

I guess that's the very minimum base price, quite offensive for an european
like me.

~~~
tyfon
Yes, here the emergency rooms are not allowed to even ask for name in case it
will be a deterrent for an illegal immigrant to seek health care.

Health care is a basic human right.

We had an incident where a hospital here tried to charge an illegal for giving
birth. It was an uproar in the news for weeks and the bill was dropped and
hospital fined.

------
sbr464
Found this github repo[1] about a proposed schema etc, and a wikipedia article
about chargemasters[2].

[1]
[https://github.com/docgraph/Hospital_Charge_Master_Data_Sche...](https://github.com/docgraph/Hospital_Charge_Master_Data_Schema)

[2]
[https://en.wikipedia.org/wiki/Chargemaster](https://en.wikipedia.org/wiki/Chargemaster)

------
aub3bhat
Soon there will be Lemonade style app driven per hospitalization insurance on
top of normal health insurance where for elective procedures you will be able
to protect yourself from surprises like balance billing etc.

------
edoo
A step almost. The price charged to direct payers will not be the same price
billed to anyone else, so fraud is still abound.

------
coldtea
Nothing that a few convictions of hospital executives / accountants for fraud
can't fix.

~~~
matis140
Seem to remember insurance sets pricing somehow not the doc/hospital? One of
the reasons they don't have an answer to that question is it depends on what
your insurance carrier negotiated with the care network the doctor is probably
loosely affiliated with because it was required by whoever now controls the
administration in the builsing they currently work...except more complicated
and less direct with lots more opportunities for people to pad the price
another few % for each layer of abstraction because abstraction is always
free.

------
username3
Priceline for hospitals, when?

~~~
onetimemanytime
Heart attacks, for one, don't wait for them to accept your offer. Also when
you call 911 they decide where to take you.

These lists are useless. God knows how many of those charges will they tack on
your appendectomy, from unwrapping the syringe to administering the $4 pain
killer.

What we need is is a simple list like some surgery centers have. This
operation will cost this much and includes everything.

~~~
DennisP
Most hospital visits are for non-emergency care. Even for emergencies, I've
put several people in ambulances over the last couple years and the drivers
always asked which hospital we wanted.

You're certainly right about needing total costs.

------
freewilly1040
I wonder how they got the raw hospital price data, is it published anywhere?

~~~
joecool1029
Just run a search for '<your local hospital name> chargemaster'. I found my
hospital's price sheets in xlsx format easily.

Just had a CT done a couple weeks ago for abdomenal pain, $750 without
contrast according to the sheet (if I did not have insurance).

I looked into costs for past procedures I had done in high school. I had
kidney stones at 16. Lithotripsy was required which alone would have cost
~$65k according to the sheets. Tallying up the other minor stuff like meds and
facility fees would have brought me close to $100k.

Now you argue, 'well insurance pays less'. Of course they do. But I had
experience in my mid-20's having to use hospital services without insurance.
Rabies shots came to around $17k billed, I paid around $2k, and spent a year
fighting to have my credit brought back to normal (hospital never applied a
payment from a CDC program then reported me to collections).

~~~
codegladiator
> Rabies shots came to around $17k billed, I paid around $2k

Am I understanding something wrong or what ? Rabies vaccinations are something
about $10 in India. I knew prices are up in US but this seems another level.

~~~
ashelmire
Yeah, this is real. Cheaper to fly to India if you don’t have insurance and
need medical care.

