
Bringing transparency to ER prices, one hospital bill at a time - smacktoward
https://www.cjr.org/q_and_a/sarah-kliff-vox.php
======
ForrestN
Kliff's approach to covering healthcare is nothing short of miraculous. She's
killing it on all fronts—dominating the beat as far as traditional reporting
techniques, innovating new ways (like this) to unearth information, and on top
of it, communicating an intricate and sometimes abstract area of public policy
in a way that anyone can understand and relate to.

In general, I think vox.com is underrated. But Kliff in particular stands out.

~~~
joe_the_user
While Kliff's work seems good, the title has the "Helping X, one Y at a time"
problem.

The actually state of affairs is that arbitrary hospital bills are a problem
that won't be solved one hospital at a time but rather are going require
regulation, not just on all hospitals but of health care broadly.

~~~
tialaramex
The one Y at a time approach brings _transparency_ as mentioned in the title.
Once there's transparency the conversation is more likely to be about the
facts because that's what everybody can see.

When you don't have transparency what happens is that everybody can bring
their own anecdotes, maybe baseless, and you can watch as a group "wins the
argument" based on claims _you_ know are spurious, because even though their
position is unsupportable on the facts, nobody had those facts.

So, you're right that Kliff's work doesn't itself fix the problem, but what it
does is document the problem unmistakeably so that this thread has fewer
people saying "I don't think that can be right, my friend's sister knew
someone who worked in an ER and they never charge that much".

Back in technology the Certificate Transparency system doesn't itself solve
any problems per se. But it delivers transparency, and that has allowed clean-
ups to happen in years that would undoubtedly have taken decades to complete
without transparency.

It still requires a Will in the right place to solve the problem, for example
CT's effectiveness is in good part dependant on Mozilla. Would Google step up
to the plate and do the same job if Mozilla didn't exist? Maybe, or maybe for
political reasons as a for-profit they would fail. Certainly Symantec's
leadership believed that going over our heads to Google management would get
them what they wanted, but unless what they wanted was "Get out of this
business" that does not seem to have worked.

But the good news is that for healthcare Americans can vote to put that Will
in place in your country.

------
halflings
I moved to the US about a year ago.

Went to ER for the first time ~3 months ago. I was charged about $4000 for:

\- Cleaning a wound (with water/desinfectant).

\- Some antibiotics.

\- A band-aid and gauze.

I get how, with labor cost and all, that might cost $200. Maybe $300? I have
no idea how this can cost $4000.

~~~
outworlder
I got an abdominal ultrassound, because some of my bloodwork was off and the
doctor wanted to confirmed my liver was ok. Very routine. So I agreed. 15
minutes from the time I got to the reception desk to the time I was out of the
door.

Hospital billed $6000 (already negotiated down with insurance). Insurance paid
around $4000. They wanted me to pony up 2k. Told no. Went to collections,
negotiated to just under 1000. According to the line items, doctor took ~$100.

I have no clue why this was so high. My wife did pelvic ultras-sounds at
another hospital (so not exactly the same procedure), but was billed $300.

The only reason I can think of is the 'name' of the hospital. It's in the Bay
Area and shares the name of a well known university.

Had I known, I would never have gone there. That incident caused me to ditch
my plan and go with Kaiser. It's been ok so far. No ultra-sounds, but I got a
sleep apnea exam and a cpap for about 150 - and that was disclosed upfront.

~~~
rdtsc
Ultrasound is a quick and relatively simple procedure. They could get a few in
the ER and a few technicians on staff. Then doctors are encouraged to say
bloodwork is off let's do an ultrasound and there you have it - $4k / 25
minutes. Bill the insurance and keep raking in the money.

Normally I'd say that's far fetched but after having relatives advised to get
unnecessary surgery I wouldn't be surprised.

~~~
HeadsUpHigh
I'm not sure what you mean by the doctors being encouraged but unless the
doctor ordering the U/S is getting a cut then there is no direct incentive.
But I don't know how your system works so I might be wrong.

~~~
citrablue
In some emergency departments, the physicians participate in profit sharing. I
know of a few EDs where they add up all the revenue, subtract all the costs,
and divide the rest into each doctor's paycheck based on how much that doctor
billed each month.

------
erentz
For the past three weeks I’ve been going through a flare up of an autoimmune
neurological condition. It’s been terribly painful. The treatment is high dose
IVIG or plasmapheresis. Unfortunately my insurer doesn’t want to pay. I’m told
if I had almost any other insurer they would. This has left me trying to find
out just how much I’d have to pay out of pocket for either of these services.
But absolutely no one knows and no one will work it out for me. All I know is
it will be somewhere between $30k and $60k from various guesses that have been
offered.

Pricing in the US health system needs regulation. The best option would be all
providers must charge the same rate to all customers. Then I could look up the
price and know it’s been prenegotiated by big insurance companies.

~~~
ekarulf
I get IVIG 3x / week for a primary immune deficiency I’ve had since birth. For
my dosage, it’s billed weekly at a rate of ~$32K of which my insurance company
pays around ~$3K.

I hit my max out of pocket the first month of each year and the rest of the
year is “free.”

I know that all the IVIG pharmaceutical companies offer a “I can’t afford
this” option if you’re going out of pocket.

Good luck, it’s stressful to get but it’s a miracle blood product for those
who need it.

------
esotericn
The practices espoused here confuse me quite a bit (essentially, variants of
not being quoted a price before a thing happens).

In the UK it's common to, say, go to a pub and buy a pint. It's not usual to
ask for the price first. It's possible a bar could decide to quote me 500 quid
after pouring. I'd obviously decline and walk out.

How is it any different in the healthcare case? If you've made an honest
effort to determine a price, been told it'll be about X, and then receive a
bill for 10x, it sounds like a scam that cannot be enforceable.

~~~
LeftTurnSignal
You forgot the part about forcing you to sign paperwork saying you'll pay
everything insurance doesn't before you see anyone.

That's how I went from being told I was only getting charged $100ish and wound
up being forced to pay $600.

------
joecool1029
Heh, funny they brought up the rabies vaccine anecdote. I was jogging and had
a bat fly into my eye one night. This was during a period in my early 20's
when I didn't have health insurance. My bill was around $14k for the
immunoglobulin and vaccine series.

I paid somewhere around $2k out of pocket for ER fees. There was a program
through Sanofi Pasteur and the CDC to pay for it for people under a certain
income threshold. Seems it's bad press if Americans catch symptoms of rabies
and die, since prevention is straightforward... and it is such a deadly
disease.

The kicker was, around a year after this... the hospital reported me to
collections for nonpayment of the full amount. I begged the guy that I
submitted the application to, to provide me with a record of being covered
under this program. Thankfully he violated HIPAA law and did it. Provided me
with a complete report of everyone paid under the program that month.

The hospital's response was to tell me to immediately destroy the document,
citing privacy law, and to tell them where I got it from. I explained that I
would not be doing that, and that I would go public with the situation to as
many sources as possible. The next day the hospital had a meeting with their
vice president and the head of their pharmacy department. Within the week, I
had collections removed from my credit reports.

------
wonderwonder
Anecdotal story, a few years ago my dad had a heart attack. He was self
employed, living the american dream so no insurance. He had to stay 2 nights
plus ambulance ride. Total bill ~80k. I kid you not, 3 days after he got out
my mom shattered her wrist and was taken to emergency surgery. ~40K. They
wracked up a bill slightly less than their mortgage in under a week.

Of course they could not pay and the hospital dropped it down to something
affordable over a long period of time. How could the hospital expect anyone to
pay either of the bills? Don't get me wrong, hospitals and doctors do amazing
things and deserve to get paid well, but their has to be some sort of reality
applied to the billing process or they are just breaking people.

~~~
olliej
That’s easy - medical debt isn’t written off by bankruptcy. So they’re pretty
much guaranteed unending money.

~~~
victor106
Source?

“Medical debt can be completely discharged if you qualify for Chapter 7
bankruptcy or you can pay it over three to five years through a Chapter 13
repayment plan”

[https://www.thebalance.com/tactics-to-deal-with-medical-
debt...](https://www.thebalance.com/tactics-to-deal-with-medical-debt-960859)

------
viburnum
Just nationalize the whole damn thing already.

~~~
novalis78
...and make it 15 times as expensive, unfortunately.

~~~
smacktoward
This is the exact opposite of the truth. The US spends a disproportionately
high amount on health care compared to other industrialized nations, and
receives worse outcomes from that expenditure to boot. See
[https://www.healthsystemtracker.org/chart-
collection/health-...](https://www.healthsystemtracker.org/chart-
collection/health-spending-u-s-compare-countries/) for details.

------
calebm
I consider myself a "pragmatic libertarian", and by "pragmatic", I mean I'm in
favor of legislative intervention when the free market often goes awry.
Examples of this would be combating monopolies (since I don't want feudal
system 2.0) , preventing immoral practices (like child labor), and controlling
prices when there is no competition at work, such as utilities. It seems that
with hospitals, there effectively is no competition-driven pricing pressure
due to unpublished pricing. This seems like a place ripe for legislative
intervention... but perhaps the medical industry is so bad that it would be
better to just nationalize it.

~~~
bakenator
The US government has put in place extremely heavy barriers to open a medical
care facility. If we were to allow people to open facilities that compete with
hospitals, we would very quickly see advertised prices and dramatic price
drops. The medical cartel and all its bizarre non-market activities are a
result of the existing legislation in place.

~~~
masonic

      The US government has put in place extremely heavy barriers to open a medical care facility
    

That's not true at all. The federal government wouldn't gave any reason to
intervene unless you end up falsely billing a Federal program like Midicare,
Medicaid, or VA.

The reason for consolidation in ERs is _cost_ \-- uf you run an ER, you are
obligated to treat anybody who cones in without regard to ability to pay. It's
a money pit in many urban areas.

~~~
trhway
Certificate of need. For example:

[https://www.vox.com/policy-and-
politics/2018/7/31/17629526/m...](https://www.vox.com/policy-and-
politics/2018/7/31/17629526/mri-cost-certificate-of-need-north-carolina-
lawsuit)

------
User23
The medical profession's billing practices make used car dealers look
reputable.

------
jhinra
I love that Kliff gives a shout out to Kaiser Health News’ Bill-of-the-Month
feature ([https://khn.org/news/tag/bill-of-the-
month/](https://khn.org/news/tag/bill-of-the-month/)), which is a really
similar project. I wonder if these two projects were independently inspired?
Either way, totally a good thing to get more public visibility into medical
billing.

------
hedvig
Standardize the bill format across all providers, and provide EDI billing
option, or a digital copy, and then we have something very easy to parse and
store and make comparisons. Barring that, develop OCR parser. There's probably
just a few programs that hospitals use that generate the bill paper so most
formats could be profiled.

------
jolmg
> If you are bitten by a raccoon, you can’t really decide not to get the
> rabies vaccine. It’s literally a life-or-death situation. But the price is
> incredibly high. We had a bill from someone who had gotten a rabies vaccine
> at an emergency room

What the... I'm pretty sure vaccines only work to prevent illnesses and are
very much useless to treat them. I mean they're supposed to be small
quantities of the virus or bacteria that causes a given illness to train the
immune system to defend itself. Why would you add more of the rabies virus
when you might potentially already have more than you can handle after being
bitten? I thought she was just giving a bad imaginary example, but she says
she "had a bill from someone who had gotten a rabies vaccine at an emergency
room". Could she have misinterpreted why the vaccine was administered? but why
would anyone need a vaccine in an emergency?

~~~
mintplant
This is referring to postexposure rabies prophylaxis (PRP); see
[https://www.cdc.gov/rabies/medical_care/](https://www.cdc.gov/rabies/medical_care/)
under "Postexposure Vaccinations":

> Rabies postexposure prophylaxis consists of a dose of human rabies immune
> globulin and rabies vaccine given on the day of the exposure, and then a
> dose of vaccine given again on days 3, 7, and 14.

------
airstrike
> If you are bitten by a raccoon, you can’t really decide not to get the
> rabies vaccine. It’s literally a life-or-death situation. But the price is
> incredibly high.

This, to me, is a perfect example of why healthcare should be subsidized by
the government (either directly or through a government-backed insurance plan
that you receive as a fallback).

Health isn't a good or service you choose to purchase. Demand is perfectly
inelastic and everyone is subject to emergencies no matter how healthy their
habits are.

~~~
robertAngst
That sounds great, but our US government has failed us for 30 years on
healthcare.

Not sure why anyone thinks that tax dollars would make the problem better.

~~~
astrodust
Something like 40% of Americans already receive "government health care" in
some form or other. Any government employees, military, police, teachers, fire
fighters, and so on, receive health care. Anyone who qualifies for Medicare
does.

Just push that number to 100%.

~~~
maxxxxx
The funny thing is that a lot of Medicare recipients or soldiers are adamantly
against "socialism" in the form of government healthcare.

~~~
astrodust
Fox News is a dangerous drug.

------
kayhi
I can really relate to this problem as it also exists in scientific chemicals
and supplies.

------
randyrand
While it wouldn’t be my first go to, I have to wonder if complete 100%
deregulation would be better than what we have today.

~~~
MichaelApproved
Why would you even entertain that thought? When has anything even remotely the
size of healthcare been 100% deregulated and successful?

Why go for such far out nonsense like this when there are perfectly good
examples of successful healthcare models in other countries.

~~~
randyrand
> When has anything even remotely the size of healthcare been 100% deregulated
> and successful

Plenty. The electronics market huge and barely regulated. The hardware for
smartphones are cheap and amazing, televisions, etc. Automobiles are huge and
relatively unregulated. It's not a great comparison, but your question was
bad.

The size of the industry has nothing to do with whether or not it should be
regulated.

The reason to entertain this thought it because deregulation is part of the
solution to high health care costs.

~~~
MichaelApproved
> electronics market huge and barely regulated.

"Electronics market"?! That's like calling healthcare the "service industry".

> Automobiles are huge and relatively unregulated.

This is laughable. Air bags, seat belts, emissions, break lights, tires, and
more. Cars are one of the most regulated industries out there. From how
they're built to how they're sold (manufacturer can't own the dealerships).

> It's not a great comparison, but your question was bad.

Your attempt to add something meaningful failed.

------
smacktoward
As the person who submitted this story, I have a question: why was Sarah
Kliff’s name removed from the headline?

I submitted it with the same title it carries at CJR, which includes her name.
The story is a profile of her and her work, so removing it makes the headline
less informative, not more. And she’s not a celebrity, so mentioning her by
name doesn’t make the headline any more clickbaity than it would be without
it.

Is there some reason HN believes she deserves to have her name struck out of
the title of her own profile?

~~~
robertAngst
I find HN borderline propaganda.

Its the only educated place on the internet, but the front page and comments
is what HN whales decide.

~~~
devwastaken
I would save the word propaganda for what it's meant to mean, and not for
dissatisfaction in the bias of a platform.

