
Insured price $2,758, cash price $521 - prostoalex
https://www.latimes.com/business/story/2019-07-29/column-could-our-healthcare-system-be-any-dumber
======
johnwheeler
I took my 4 year old to the ER because he had a 103 fever. The doctor put an
ear thermometer to him and told me to give him some childrens ibuprofen. The
visit lasted all of 5 minutes. The cost: $756.00.

I refused to pay it. It was the first time I did not pay a debt and the first
time I was sent to collections. I refused based on principle, and not because
I couldn’t afford it. Collections called me for about 3 months, and every time
someone called and said, “is this John Wheeler”, I would never confirm and
then go about asking why they are calling for John Wheeler. Eventually, the
calls stopped and the collection agency wrote it off to their unpaid reserves
(I’m assuming), I never received a ding on my credit report.

Everyone is always asking why US healthcare is so expensive. People blame it
on the insurance companies and the hospitals, but my theory is it’s the
providers.

I worked at Vanderbilt on their payroll system, and I would regularly see
general practitioners making $350,000 a year, and this was 15 years ago! It
wasn’t uncommon to see teaching doctors getting paid a million dollars.

~~~
avocado4
[https://www.politico.com/agenda/story/2017/10/25/doctors-
sal...](https://www.politico.com/agenda/story/2017/10/25/doctors-salaries-pay-
disparities-000557)

Providers are the core problem. Various doctor associations (AMA et al) have
strangled supply side of healthcare through State licensure and scope of
practice laws.

Just read medical forums to get an idea of what an average doctor thinks about
competition in the form of midlevels:

[https://www.auntminnie.com/Forum/tm.aspx?m=581583](https://www.auntminnie.com/Forum/tm.aspx?m=581583)

"Don’t teach your mid levels procedures... Ultimately, a mid level that can do
procedures, even easy ones, are your competitors."

[https://www.auntminnie.com/forum/tm.aspx?m=581130](https://www.auntminnie.com/forum/tm.aspx?m=581130)

It's not politically talked about because it's much easier to blame
corporations than your neighborhood doctors. There's enough leeches downstream
too (insurance, pharma, PBMs, administrators, etc) but gatekeeping at the
supply side is what's making it possible.

~~~
evrydayhustling
That forum is amazing! Thanks for the primary source! That said, two
quibbles/questions:

Those same threads have logins like "indebt4life" and "kids2feed", which
matches what I've heard from doctor friends: the length and cost of medical
training and insurance are so brutal that the folks gatekeeping are themselves
in an unhealthy lifestyle and don't want it to get worse. In other words, and
benefits of gatekeeping accrue to the school and hospital complex more than
the individual practirioners.

Separately, what's the breakdown of specialist labor costs vs drugs and
equipment? My experience has been that the crazy bills are for stuff , not
people.

~~~
hakfoo
We see a lot of people trying to justify medical salaries due to the cost of
education and malpractice insurance, but an integrated program could work
around that.

We should treat it like the infantry. If you want to drive a tank and blow up
people, you don't apply to a college and get a Doctorate in Blowing People Up.
You don't buy insurance to cover if you blow up the wrong people. You join the
army.

I'd like to see health care reform inspired by military structure. A high-
schooler eager to get into medicine joins the Health Corps, and gets their
education covered in exchange for n years of working in state-run facilities.
There's strongly restricted legal recourse if the Health Corps hospital cuts
off the wrong foot-- here's $500 and a really nice wooden peg.

As a self-contained system, I could also imagine it working around some of the
structure that's restricting the industry. I'm picturing programmes to advance
in both through direct study and training, and where appropriate "field
promotions" (think of the 20-year term nurse who knows more than most of the
doctors from experience, but will never be able to escape their position
without expensive and onerous formal training/certification)

~~~
lallysingh
Would that end up also being single payer?

~~~
radicalbyte
If you wanted to do it cost effectively, yes.

I have experience of single player (UK) and private insurance based but
properly managed by the government (NL) and can tell you that single player is
much cheaper to run. When I moved to NL about 15 years ago the UK was spending
the same per capita on the NHS as The Netherlands spent from the central
government to cover the shortfall to the insurers.

In 2019 there isn't as much difference: a significant amount of providers in
the UK have been privatised which increased costs whilst at the same time the
NHS budgets have been systemically strangled in real terms - something like
annual 2% budget increases against annual 15% cost increases thanks to
demographics and lifestyle choices.

So in short: single payer is great but the second the Republicans (or whatever
the "don't tax the rich" party is at the time) get to touch it they'll ruin
it.

------
Stratoscope
Beyond opaque and variable pricing for the same service, there is also the
question of whether something simpler would do the trick.

Some years ago, I thought I might have broken my finger. I went to the doctor
and it was actually the physician's assistant who saw me. I'd explained at the
front desk that I had a high-deductible policy and I would be paying in full
for the visit.

The PA said "Usually we would send someone for an X-ray, but since your
insurance won't cover it, there is a quick test we could do and it would just
be part of this office visit."

He opened a drawer and pulled out an instrument and asked me if I knew what it
was. Being a musician, I said "Yeah, that's a big tuning fork. And with those
weights on the end it must vibrate at a very low frequency."

He said, "You got it! The idea is we get the fork vibrating and then hold the
end against your finger. If it's broken, it will hurt like the dickens, so
just holler and we will stop and you go get that X-ray. If it doesn't hurt
much, it's just a sprain, so take it easy and you should be fine."

We did it, and my finger was fine. Saved me a bunch of time and money!

Edit: Thank you everyone for the lively commentary! I would like to mention
something that I forgot at first (it was ten years ago) and your comments
reminded me of.

The PA didn't pull out the tuning fork until going through a complete set of
manual range-of-motion and "does this hurt" tests. All indications were that
my finger was not broken, it was just a mild sprain. I'd only gone to the
doctor in the first place out of the proverbial "abundance of caution".

So it was _my_ decision not to get the X-ray. Please, everyone, do not blame
this on the American medical insurance system! I could have easily afforded
the extra $150 for the X-ray, and of course I still had that option _after_
the tuning fork test. But since both the PA and I were both so sure at this
point that it was just a sprain, I figured I would same both time and money by
skipping it.

It was my call how to proceed with this very minor injury, no one else's.

~~~
erikig
Out of curiosity, why would it hurt a lot more if a bone was broken?

~~~
Pfhreak
Having a bone in my hand set without anesthetic, I suspect it's because when a
broken bone becomes rapidly agitated it's causing a bunch of nerves to fire
their pain signals. The tuning fork most likely resonates the bone rapidly --
if things are just sprained, the whole bone vibrates. If the bone is broken,
it grinds against itself.

------
drblast
Insurance is _not_ supposed to make routine things more affordable. It's
supposed to spread the risk of catastrophic loss from unlikely events around
to a large group of people so you don't have to worry about losing your house
if you get struck by lightning. Everyone needs routine medical care at some
point so an insurance model doesn't work there.

You don't have gas or grocery insurance, do you? If that were a thing would we
all expect to pay less for gas and groceries, or would we just be tacking on
overhead for routine expenses for no reason?

Using insurance for routine, affordable expenses is one of the problems. But
it's a race to the bottom where insurance companies win, because everyone in
the U.S. thinks "good" insurance pays for everything and makes a 17% profit
out of nothing.

In addition to the transparency the article advocates for, we'd probably be
way better off with a universal health care stipend and very high deductible
insurance for rare catastrophic events. Insurance should not be involved in
routine care.

~~~
habitue
There's still a benefit in insurance for routine procedures to balance costs
between the young and old. (As long as young people are required to have
insurance)

~~~
rossdavidh
...but the fact that the median income of young people (at the beginning of
their career, whatever it is) is much lower than old people, pretty much
nullifies this. If you want to balance out the costs over a person's life,
there are much better ways than making the coffeeshop barrista subsidize the
middle-manager's health costs.

~~~
entee
The reason this logic fails is because income and healthcare costs are on
different curves but of similar (or far greater in the case of healthcare)
magnitude.

Say you start out your career making $30K as a barrista and end up making
$150K as a middle manager in your 60s. A single surgery can be $150-$300K and
you're more likely to have them when you're older. Cancer patients can cost
millions in a given year, again you're more likely to have that as you get
older. I don't have the number for a diabetes patient off the top of my head
but I think it's 10s of thousands a year.

The income growth curve is far shallower than the healthcare cost curve, and
the healthcare cost curve is essentially unbounded whereas for most people
income doesn't go all that high. Remember median income in the US is something
like $55-$60K. Most people won't ever see 6 figures and if they do, they'll
see the very low end of that.

------
nonbel
It has been good practice for awhile now to claim you have no insurance even
if you do: [https://selfpaypatient.com/2015/05/12/insured-but-not-
lettin...](https://selfpaypatient.com/2015/05/12/insured-but-not-letting-the-
doctor-know/)

Once you know the cash price then you could later say you got insurance but
not vice versa.

~~~
mxcrossb
It seems like someone could start an insurance company, where all customers
had to claim they had no insurance, but then sent the bill to be reimbursed.

~~~
nonbel
That sounds like it would be about 10x cheaper, but I am sure some regulation
is preventing that.

------
gok
The "insured price" contributes to your annual out-of-pocket maximum. Care
providers want insured patients to hit their cap as soon as possible so that
the patients' marginal cost of care drops to zero. Once this happens, they can
get patients to keep getting expensive treatments "for free" while the care
providers can continue to bill insurance companies whatever they can get away
with.

------
crazygringo
(American here.) Funny, my last several doctors visits the cash price has
always been higher than the negotiated price.

These are all for services in the $150-300 range, and I was told upfront what
the cash price would be, but they couldn't tell me what my negotiated plan
rate was. (I inquired because I have a high deductible plan so I'll pay in the
end no matter what.)

The negotiated prices were all at least 1/3 lower, and the most expensive one
turned out to be free because it was classified as preventitive.

So it's even worse because you _never know_. It's certainly not a rule _at
all_ that cash prices are lower.

~~~
nonbel
> Funny, my last several doctors visits the cash price has always been higher
> than the negotiated price.

There is nothing funny about it. Once you tell the provider that you have
insurance, the price they can quote you is in their contract with the
insurance company. You need to go somewhere new and tell them you do not have
insurance to get the real price.

~~~
crazygringo
They didn't have to check that, and certainly didn't. They knew the prices off
the top of their head.

The doctor had no idea what health plan I had or even if I had one -- they
leave that up to their staff to sort out, they couldn't care less personally.

~~~
nonbel
Then they are just quoting you the "insurance price". Think about it, how
could it possibly be more expensive to cut out the middle man?

~~~
crazygringo
Um, no. My original comment explained, their cash prices are _higher_ than the
prices through insurance. (Also there's no single "insurance price", they're
different for each plan they accept.)

And honestly, that's _supposed_ to be one of the points of insurance prices,
that they negotiate prices _down_ by providing volume.

So there are clearly different economic factors at play, in different doctor's
offices and hospitals. I'm just making the point it's not always the case that
the cash price is cheaper -- it can be more.

I don't need to "think about it", it's just the facts.

~~~
nonbel
There is a "cash price" in many contracts between the insurance company and
provider. _If you tell them you have insurance_ the provider must quote you
this inflated price.

You need to go to a place that does not know you have insurance, say you do
not have any, and then get the cash price from them.

~~~
crazygringo
How do you know that? I'm looking online and can't find any mention
whatsoever. What's the contract term for it? And what percentage of health
plans in the US does that apply to? And how often do doctors actually follow
that?

In my case, the doctors in this office are certainly unaware of anything like
that. Like I said, the doctor quotes the cash price, which is standard for the
office, not having the slightest idea of which insurance I have.

You keep insisting there's this separate higher cash price, but I'm explaining
to you the fact that in this case, there obviously isn't, in practice.

~~~
nonbel
Read here: [https://selfpaypatient.com/2015/05/12/insured-but-not-
lettin...](https://selfpaypatient.com/2015/05/12/insured-but-not-letting-the-
doctor-know/)

How can it otherwise possibly make sense that they charge more for not having
to deal with insurance company bureaucracy?

------
ikeboy
>The near-total lack of transparency in healthcare pricing is a key reason we
have the highest costs in the world — roughly twice what people in other
developed countries pay.

Nope. We pay around what you'd expect given our consumption in other areas.
See [https://randomcriticalanalysis.com/2018/11/19/why-
everything...](https://randomcriticalanalysis.com/2018/11/19/why-everything-
you-know-about-healthcare-is-wrong-in-one-million-charts-a-response-to-noah-
smith/)

------
mewop
ITT: people who assume doctors are accountants and go home in their sports car
every night to tweak their prices and count the stacks of 100s they made that
day

The reality is is doctors often have no control over cost. Yes, if you are the
increasingly rare private group that is physician owned you do but certainly
not if you are employed. These are 100% set by the bean counters who are paid
twice my salary and have no idea about what we do on a day-to-day basis.

I have no idea what my services cost and for ethical reasons I don't want to.
That inflicts bias and can lead to misdiagnosis.

I sacrificed 10 years of my life and took on over $275,000 of debt that
continues to grow thanks to compound interest. I live in an average house and
drive an average car because I have this debt to pay back.

Daily I am responsible for not harming dozens of patients while trying to make
their lives better. With each decision I make I have the risk of being sued
and losing everything I have worked for. All the while, my mid-level providers
work relatively liability free because they work under my license and their
mistakes are on my back. Adminstration pushes for higher numbers of patients
andmore uncompensated work. When was the last time you spoke to a lawyer on
the phone or had them complete a 5 page document for free?

Think twice before you criticize doctors and the sacrifices we have made. I
didn't do this for the money, I assure you.

------
pkaye
My understanding is the insured patients are subsidizing all the others
covered by medicare, medicaid or those uninsured.

~~~
devoply
Why? Why are insurance companies not demanding cash price and reducing
premiums? There should be lawsuits against hospitals, this seems like
something which is generally considered highly illegal at this sort of
scale... charging different customers different prices -- especially when the
ones paying more are more than capable of taking hospitals to court.

~~~
dantheman
The 80/20 Rule could be one reason -- the more they spend on health care, the
more they can spend on other things.

[https://www.healthcare.gov/health-care-law-
protections/rate-...](https://www.healthcare.gov/health-care-law-
protections/rate-review/)

~~~
devoply
Sounds like the government needs to sue both insurance companies and hospitals
for collusion to stop this.

~~~
kaibee
It's extremely unlikely that there's actual collusion. But actors acting in
their selfish best interest can definitely look like collusion.

------
astrodust
Wouldn't it be nice to have an ultrasound and not know the price, nor care?

That's what countries with single-payer are like. America needs to give up on
this nonsense. There should be riots.

~~~
aianus
As mentioned below, the price doesn't matter when nobody is available to see
you.

Also, the opportunity cost of sitting around with a broken hip waiting to be
seen can be higher than going to a privatized country/province and paying for
the surgery, in which case you're a super-sucker who paid extra taxes for
decades just to end up paying out of pocket for surgery anyways.

Anyways, the US system is probably worse overall but it can work quite well
(better than socialized medicine) for upper-middle-class people and above
which is why it's still around.

~~~
velcrovan
Funny, I have a sister in Canada and a sister in Switzerland, neither of them
have had trouble getting ultrasounds. My wife's grandmother is also in Canada
and was treated the same day for her broken hip.

I'm really sick of being told things are impossible in the US that are normal
in other developed countries.

~~~
aianus
I live in Canada and have waited 4 months for a specialist at great personal
cost (but not financial cost).

I have also seen my mother suffer for 6 months on a surgery wait list and then
recover slowly and painfully in a room with 4 other people who were constantly
screaming during the night. And she was a lucky one because the hospital was
so overcrowded that other patients were living, sleeping, and recovering in
the literal hallway. Google "hallway medicine Ontario" to see I'm not making
this up.

It's not a perfect system by any stretch and it's much better than nothing but
I bet upper-middle-class and above citizens in the USA enjoy better care.

~~~
johnpowell
I live in the United States and in June of last year I was told to make a
appointment with a ear, nose, and throat doctor. So I called and was told the
earliest they could see me was in October.

I started chemo before my original appointment with that doctor. (Yes, it was
mouth and neck cancer)

------
truthseeker1
Most of you who attack doctors have no idea how this complex health care
system works. Doctors are UNDERpaid. A majority of the billing goes to
overhead for the hospital facilities, nurses, labs, meds, administrators, etc,
with doctors getting much less than 10% of the revenue even though they are
responsible for generating most of it. Your resident doctor friend (who has
way more qualifications than your software engineer friend - including top
tier college, and medical school) gets paid about 60-70k a year for working at
least 80 hours a week. Yes, the man or woman who assists in your brain surgery
after your aneurysm popped gets paid less than your uber driver for 7 years
time, and he sacrificed his/her best years to be a sleep deprived medical
student and then brain surgeon working under constant rush and stress, as
their 300k med school debt accumulated under high compound interest.
Meanwhile, your mediocre software engineer friend graduates debt free, gets
paid 160k out of college to build the next best sexting app, at a company with
free lunch and gym.

Also, don't forget about the malpractices. 10 years down the line, your
radiologist friend gets successfully sued for 11 million dollars bc the
parents of a child for whom they read a chest radiograph decided to sue
because lawyer convinced the parent and jury that radiologist was at fault for
not saying the heart is enlarged and somehow that is responsible for all the
kids ailments later on in life (the truth is much more complex than that). The
radiologist probably got paid 7.50$ for that read, btw. This is actually a
true story, look it up in the Boston Globe. Now all providers are on edge and
overdiagnosing and overordering everything - who would want to miss a
diagnosis.

------
kevindong
I'm dealing with an insurance mess right now. I got a physical at a in-network
doctor a month ago and they sent my blood sample to an out-of-network lab. My
insurer sent me a statement last week saying that $444 of the $954 bill is
eligible for payment. However since I hadn't met my deductible for out-of-
network spending yet, I would have to pay that entire $444 on top of the $510
that they wouldn't cover even if the sample had been sent to a in-network lab.

I believe/am hopeful that since I live in New York, which prohibits out-of-
network providers from surprise billing patients without the patient's
informed and explicit consent that the procedure would be considered out-of-
network [0], that I ultimately won't be held liable for the bill.

Fortunately as a software engineer, I can trivially afford to pay the bill in
the worst case. But I shudder to think of the consequences for someone in a
much less privileged circumstance.

[0]:
[https://www.dfs.ny.gov/consumers/health_insurance/surprise_m...](https://www.dfs.ny.gov/consumers/health_insurance/surprise_medical_bills)

------
axaxs
I write this very candidly, and many on HN would likely constantly argue if I
always chimed in with my personal views. I am a very conservative person, and
always have been. That said, I will vote for anyone who promises single payer
healthcare. Our healthcare is completely broken, and I feel honestly that
anyone defending it is either being paid or brainwashed.

------
kazinator
The cash price being lower is lucky. Sometimes uninsured cash prices are
jacked up due to collusion with the insurance racket.

We see a hint of that here: "Cigna gets a contractual discount of just over
$1,000 because it’s, well, Cigna." In this particular case, the negotiated
discounts didn't bring the price below the cash one, but in many cases it
will.

~~~
vonmoltke
I recently had a "$140" blood test that Cigna declined. I was billed $6.48
(which is what Cigna would have paid if they accepted). I'm pretty sure I
would have been charged more than $6.48 without Cigna involved.

------
erikig
I'll start by saying I agree with the premise of the article - transparency of
pricing is not just helpful, it is necessary.

However...I can also understand why paying by cash should much cheaper Adding
another company or companies into the transaction, trying to standardize the
various medical procedures, invoicing and managing co-pays, deductibles etc
adds a significant amount of overhead.

One would hope that the insurance companies would leverage the volume of
transactions and the pools of clients to get price improvements but this is
not the case.

~~~
colbyh
Yeah I think the big problem here is related to the scale, not the fact that
it's cheaper when you pay in cash. But that insurance would pay $500 (after
negotiating the price down) and then push a > $1k charge to the patient when
the clinic would have been ok with a $500 payment up front is just wrong.

It's also worth noting that many clinics, if not most, won't actually try to
collect the balance here. They'll often go through the motions and forgive the
balance after some number of attempts to collect.

------
rolltiide
It's random from a user experience perspective.

There are many times when a practice will quote you a much higher cash price
just because you don't have an insurance company negotiating for you.

I have privileged foreign friends with private "worldwide insurance" from a
European provider, but it is just a reimbursement scheme. So they appear
uninsured to American providers and have to float potentially extremely large
costs which might not actually get reimbursed.

And then things like birth control aren't insured by their "worldwide
insurance" nor some dental work deemed cosmetic, and these people aren't
surprised their great "worldwide insurance" doesn't cover those things because
their state run insurance wouldn't cover those things either, but confused why
the cost is so high in America.

I have to tell them that "privileged" people in America don't pay those costs,
and explain to them how dangerous or ill-advised acting uninsured in America
is.

~~~
nonbel
> things like birth control aren't insured

Why would you use insurance for something you know you are going to need? I
got new glasses and an eye exam and they were surprised I didn't pay via
insurance? Why would I want to pay extra to insure for something I know I will
need to get? This makes no sense at all.

~~~
rolltiide
privileged people have the option of using pre-tax + employer funded FSA/HSA
accounts, where a wide array of hygienic purchases, medical purchases and even
copays can be paid for and further subsidized.

These are part of your overall “insurance package”, in conversation this is
typically called being insured with no regard to whether an insurance company
is actually picking up the tab.

~~~
nonbel
Wouldn't the "privileged" prefer to have actual money they could spend as they
want instead of be forced to use it for a single purpose, including the extra
cost of a middle man? It sounds like some sort of tax scam.

~~~
rolltiide
The pre-tax portion naturally comes out of the part of your paycheck you
otherwise wouldn't be able to use at all.

The level of discount would therefore be linked to your marginal income tax
level, alongside how much your employer contributes to it.

The max a person can contribute to these in 2019 is $3,500 and $7,000 for
family.

It is a privilege extended by the federal government.

~~~
nonbel
Thanks, what do you mean "otherwise wouldn't be able to use at all"? You mean
the government gets it?

~~~
rolltiide
Yes correct

------
elihu
The opposite also happens, where the uninsured price is a lot more than the
insured price.

I was in this sort of situation once. I needed a CT scan, but it was on a late
friday afternoon, and the hospital couldn't get prior approval from the
insurance company. They quoted one price that they would bill the insurance
company if it was approved, and another much larger priced that I would have
to pay if the insurance company rejected the claim. (I ended up getting the CT
scan the next day at a hospital that charged a lot less. I think it was
covered by insurance.)

The thing about this that's bad is that it's over-charging the people least
likely to be able to repay, and (if they can come up with the cash) they're
effectively subsidizing the insured customers. This is the other side of
narrative that poor people are driving up health care costs for everyone else
because they don't pay their bills.

------
fulldecent2
If you have a similar story: stop reading, open a court case in small claims
court and come back to post about it. You will get all the support you need
here from extremely qualified people, including specific filings you should
make and also answers to every question you will have.

------
IronWolve
If you have to go to minor emergency clinics that are popping up all over, say
you dont have insurance and want the cash price, its 1/4th the cost. If you
pay with insurance and have a co-pay or a yearly deductible its just not worth
it. Then pay with your HSA card.

------
SI_Rob
How long has it been broken like this? By my count, at least 346 years,
reckoning from the premiere of The Imaginary Invalid by Molière.

The opening scene features the protagonist iterating over a series of
rationalizations for reducing his medical bills to 1/3 of the list price. That
this scene was expected to be received by an audience which could relate to
the necessity of performing these sorts of arithmetic gymnastics (though
perhaps exaggerated for comedic effect) suggests that this was already a well-
established norm in 1673:

SCENE I.--ARGAN (_sitting at a table, adding up his apothecary's bill with
counters_).

ARG. Three and two make five, and five make ten, and ten make twenty.

"Item, on the 24th, a small, insinuative clyster, preparative and gentle, to
soften, moisten, and refresh the bowels of Mr. Argan."

What I like about Mr. Fleurant, my apothecary, is that his bills are always
civil. "The bowels of Mr. Argan." All the same, Mr. Fleurant, it is not enough
to be civil, you must also be reasonable, and not plunder sick people. Thirty
sous for a clyster! I have already told you, with all due respect to you, that
elsewhere you have only charged me twenty sous; and twenty sous, in the
language of apothecaries, means only ten sous. Here they are, these ten sous.

"Item, on the said day, a good detergent clyster, compounded of double
catholicon rhubarb, honey of roses, and other ingredients, according to the
prescription, to scour, work, and clear out the bowels of Mr. Argan, thirty
sons." With your leave, ten sous.

"Item, on the said day, in the evening, a julep, hepatic, soporiferous, and
somniferous, intended to promote the sleep of Mr. Argan, thirty-five sous." I
do not complain of that, for it made me sleep very well. Ten, fifteen,
sixteen, and seventeen sous six deniers. "Item, on the 25th, a good purgative
and corroborative mixture, composed of fresh cassia with Levantine senna and
other ingredients, according to the prescription of Mr. Purgon, to expel Mr.
Argan's bile, four francs." You are joking, Mr. Fleurant; you must learn to be
reasonable with patients; Mr. Purgon never ordered you to put four francs.
Tut! put three francs, if you please. Twenty; thirty sous. [Footnote: As
usual, Argan only counts half; even after he has reduced the charge.]

"Item, on the said day, a dose, anodyne and astringent, to make Mr. Argan
sleep, thirty sous." Ten sous, Mr. Fleurant.

(the above is just the first half of Argan's recitations - they go on for
another paragraph or two!)

------
randyrand
This ridiculous symptoms come from ridiculous regulations and their unintended
consequences. Apart from emergency care, I think the health care industry
actually needs very little regulation.

------
maerF0x0
This adds to my recent thought stream that it ought to be charge 2 people a
different price for the same thing (basket of things) ...

Why is it that someone who is a new customer for service X gets a sweetheart
deal but those of us who have faithfully paid for months/years are charged a
premium?

Why is it that 2 people in a hospital pay entirely different prices for the
exact same thing?

on and on the insanity goes.

I am, of course, not talking about packages/bundles etc. Yes it makes sense
that someone who buys 10 could get a better price than someone who buys 1.

~~~
lotsofpulp
Price discrimination yields the most profit for a seller. You want to be able
to capture all that each person is willing to pay, because your cost of goods
sold remains the same.

Also the new customer doesn’t permanently get a sweetheart deal, it’s always a
temporary incentive to join, which doesn’t seem unfair to me at all. However,
as a buyer, if you’re not always shopping around, expect to pay more than
someone who does. That’s just how the game works.

~~~
maerF0x0
> That’s just how the game works.

I agree that you're talking about an optimal analysis of the current game.

However, one of the roles of government is to alter games which are suboptimal
for society. For example cartels are illegal despite them being optimal for
the sellers.

------
yencabulator
Relatively routine outpatient surgery:

    
    
      Doctor's fee $750
      Anesthetician's fee ~$150
      Hospital facility fee ~$24,000
      Hospital facility fee, cash price ~$9,000

------
intopieces
What’s a little tricky here is that the cash price is only $521 _because_ the
insured price is $2,758. If the patient were able to choose the cash price or
the insured price, the cash price would be much higher.

One of my family members once told me he is against socialized medicine
because it subsidizes the bad choices of the poor. True enough, but that’s no
different from the current situation (since hospitals can’t refuse to treat)
except that the one we have is opaque.

------
bobharris
I always got a kick out of the DO's in training at a WA DO school telling us
they were all on WA medicaid, as they didn't have another option in which to
obtain healthcare.

Huh, that's odd.

A friend who asked how much the retina re-attachement would cost. Weighing her
options.

I'm just sad that healthcare seems like such a luxury.

I do enjoy stories of friends not just being complacent. Going out of country
for dental procedures. Getting good results for 1/10 the price.

------
chiph
It really helps to be a shrewd negotiator when it comes time to pay your bill.

[https://youtu.be/pY-BGNjI2Rg?t=281](https://youtu.be/pY-BGNjI2Rg?t=281)

Should you have to do this? No.

No one in American healthcare knows how much it costs to deliver care. And as
a result, the bills are more like: "They look rich. Let's see if they'll just
pay it."

------
techie128
Having lived in the US for over a decade, I am disappointed with the system. I
also notice that nobody in this thread, so far, has talked about liability and
the overly litigious aspect of the American society. There are so many lawyers
that are willing to file malpractice lawsuits against anybody in the medical
industry which also raises costs overall.

~~~
greedo
Malpractice costs are a relatively small proportion of the total costs for
healthcare[1]. Probably around 3%. Doctors love to complain about being sued
and about the high cost of premiums, but being able to sue for malpractice is
the only recourse a patient has when a doctor or medical practice screws up.

[1]
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3048809/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3048809/)

------
kazinator
A lot of this is explained by Camels and Rubber Duckies.

[https://www.joelonsoftware.com/2004/12/15/camels-and-
rubber-...](https://www.joelonsoftware.com/2004/12/15/camels-and-rubber-
duckies/)

------
aj7
I’ve been purchasing drugs entirely by cash, optimizing markets as best I can,
for about 7 years now. I began when I discovered my employer’s drug plan,
Optum, was charging me significantly higher prices than the the spot prices on
the open market.

------
lxe
Are "cash" prices always cheaper than what's billed to insurers? What if one
starts an "alt-isurance" company that just gives people cash for their medical
bills that operates completely outside the medical industry network?

~~~
chiph
We already have that .. sort of. They're called Health Savings Accounts and by
law they're tied to high-deductible policies. Mine is $2500, so I'm on the
hook up to that amount. With some caveats, such as payments for drugs, etc.
The good news is that money is yours to keep and use (only!) for health
related expenses. So unlike a FSA the balance will roll over to the next year
and continue earning interest.

The other trend along these lines are concierge doctors. They don't accept
insurance, and typically operate on a subscription basis (X dollars per
month).

------
newshorts
I wanted to level the playing field a few years ago and built the site below.

It aims to present users with the highest quality and lowest price hospitals
in your area:

[http://myhospitalscore.com/](http://myhospitalscore.com/)

------
sjg007
I paid like $3k for hearing tests for my kid because my insurance wouldn't
cover it. This was at a world famous California children's hospital.

------
mnm1
So if the cash price is five hundred something can the lady in the story
decide to pay that now instead of her insurance deductible? If not why not?

------
luminaobscura
1\. Forbid different pricing for different payers.

2\. All prices have to be posted on your website.

3\. Patient has to agree on the bill beforehand.

(ER is the exception obviously)

------
neonate
[http://archive.is/U1psP](http://archive.is/U1psP)

------
radley
I have a prescription that was $35 with Anthem and $17 with Blue Shield. With
cash: $12.

------
ilaksh
This type of thing is one of the main reasons I moved to Mexico.

------
entee
It's important to remember that an insurance company has very little to zero
incentive to lower costs. The only incentive an insurer has is to ensure costs
are predictable. It doesn't matter if costs go up 20% next year as long as
they know costs will not go up 25%. The extra cost gets shunted into the
premium.

There is no party in the current healthcare system whose incentive is to lower
prices. Medicare/Medicaid can achieve low costs by fiat, but it's broadly
accepted that the whole system as structured today couldn't operate on those
prices [1]. This means private insurance picks up the delta.

Doctors, Hospitals, Pharmacies, Drug companies, Medical device companies all
have zero incentive to lower prices. You might think technology that makes
doctors visits (to pick one example) would just win out in the marketplace,
but there's a flawed assumption there. Most people are insured, so most people
are paying the insured cost. For something like a doctor's visit, you pay your
copay (say, $25) and the insurer pays the rest (lets say up to $70). Assume
you could get an app or a technology that gets that price down to $35. This
would be a huge achievement and you'd go out of business because it's more
expensive than what the consumer sees.

Ah yes, but maybe you can pitch to insurers, surely they would love a lower
cost! Probably not. You're small so you can't reduce their costs across the
board. Even if you succeed, they have caps on how many profits they can take
(usually something like 15-20%) so if you drop their costs, that might
actually force them to refund customers. Good, but not the primary driver for
profitability.

Let's even grant that the above isn't true. You're still a small player, you
basically need to fit inside their (extremely cumbersome) protocols to be able
to bill them. Now you have to do all sorts of billing and management, maybe
you need to hire extra staff to run billing. That $35 now financially doesn't
make sense, maybe it's now $55. Still cheaper but now you're in the system and
don't have much of a competitive advantage that's visible to the consumer. Now
you differentiate by offering better services, maybe a good online portal,
that costs more engineers, and now we're back up to $70. Insurer doesn't care
much, you're just another provider, they'll pay, you'll make money, and we're
back to square one.

We're not even considering the, "Is the cancer doc that costs 25% less the
same value as the other guy?" problem, which is damn hard on its own.

Healthcare is really hard, and the incentives across the board are perverse.
I'm increasingly skeptical a solution that doesn't dramatically reshape the
market is likely to make a difference.

[1] [https://www.healthcarefinancenews.com/news/mgma-majority-
pra...](https://www.healthcarefinancenews.com/news/mgma-majority-practices-
say-cost-care-outweighs-medicare-reimbursements)

------
minikites
I don't see how mandating clear pricing is supposed to address medical
inefficiency. If it threatens your life, you're going to pay no matter what,
or in other words, demand is inelastic. Insulin is often used as an example of
an inelastic good in Economics 101. I'm not sure how people are supposed to
comparison shop for hospitals in an emergency situation and even for elective
procedures, lots of hospitals in an area are often owned by the same
overarching company and it's not difficult to collude. For "the market" to
work, we would need to let people die, which is not very popular among society
at large.

~~~
wrs
No. For the market to work, substitute goods would need to have transparent
pricing so the customer can choose with price in mind. Most ultrasounds —
indeed, most entire hospitals — are pretty close to identical goods. Everyone
will die without food, but supermarkets don't take advantage of that fact to
mark up food by 500%.

~~~
minikites
It's easy to evaluate the quality of an apple and there are dozens of
substitute goods (other fruit). It's not easy to evaluate the quality of an
ultrasound machine, the staff required to operate it, and their interpretation
of the results. Depending on the medical issue, there may not be a substitute
good (procedure).

Medicine does not work with market principles.

~~~
wrs
I disagree, I would think that imaging centers produce comparable results. On
the medical side, the substitute good isn't a different procedure, it's the
same procedure done by a different provider.

Most people do not currently make any of those evaluations anyway, so as far
as the consumer is concerned, they are _de facto_ substitute goods since they
have no rationale for making a choice.

