
The Company Behind Many Surprise Emergency Room Bills - petethomas
https://www.nytimes.com/2017/07/24/upshot/the-company-behind-many-surprise-emergency-room-bills.html
======
coreyp_1
I am having problems with my insurer at this very moment. I went to an in-
network hospital for an ER visit, which turned into an 8-day stay (yes, it was
serious). Evidently, _none_ of the doctors at the hospital are in-network,
however, (claims from various technicians are still "in processing", so I
don't know how they will turn out) despite the fact that the hospital itself
is definitely in-network. I had no choice as to what doctors came in, and,
yes, I can now see them billing $600 for a 1-minute visit ($600 per visit, &
they came every morning).

This is ludicrous! I have insurance, & still this will completely drain me
financially. I'm at the point where I almost think it would be easier to
declare bankruptcy and start over!

~~~
narrator
When I had back surgery, there were all these therapists coming in the moment
I got out of surgery trying to get their 1 minute in. It was throughly
ridiculous. One of them was attempting to do physical therapy and pulled on my
leg a little and put me into so much pain I went into shock. She probably got
her $600 bucks.

I am with Kaiser now and it is the most BS free medical experience I have ever
had. To fix healthcare without single payer the government should just make a
law that medical insurance can only be offered by hospital chains and the
doctors and specialists cannot bill insurance separately, but must be paid by
the hospitals. This is how Kaiser works. That way the hospitals can pay a fair
market rate to doctors and not have them demanding a surprise emergency room
rate from distressed patients.

~~~
parmta
I work in investment banking and cover hospital facilities (i.e. the "hospital
chains"). You are right that the Kaiser model, or what the industry calls
fully integrated systems, can often produce more efficient healthcare. For
people that aren't as familiar with the healthcare system, I thought it might
be helpful to provide a brief overview of why that is the case.

Since the ACA, there has been an emphasis on shifting from a fee-for-service
model (FFS) to a value-based care model (VBC). Under a FFS model, doctors and
hospitals are paid for each service they provide and make their profit from
the margins built into the prices they charge for their services. In an ideal
VBC world, doctors and hospitals are paid a certain amount for each patient
they cover, and don't make additional revenue when they provide services to
patients.

You can immediately see the incentives in each model. In a FFS world, doctors
and hospitals are incentivized to give you the most care possible at the
highest possible prices. For example, you could see how a doctor could be
motivated to give a patient an unnecessary MRI. In a VBC world, the best-case
scenario for the doctor is that he never sees you, and that you never enter
the hospital. Each time you receive care, he spends time and money providing
that care, but doesn't get paid any additional money for it. In other words,
his margins decrease when he provides care (or, as those in the industry think
about it, his medical loss ratio increases). When you become sick, the doctor
would prefer that you seek care in a setting that is as low-cost as possible -
via telemedicine, an urgent care center, or his office. That way, he keeps
more of the monthly premium.

Practically, though, in the VBC world, the doctor probably wants to see you
once or twice a year, to make sure you are healthy and that you are taking
preventative measures to avoid becoming sick and utilizing healthcare. That
investment of resources can help reduce your need for healthcare in the
future, protecting his profit margin going forward.

So in a perfect VBC world, everyone's incentives line up. You spend as little
time in the hospital or at the doctor as possible, and check in every once in
a while to make sure you are healthy. Doctors and hospitals make more money
when they don't have to treat you, and want to keep you out of the healthcare
system.

The problem is, the current system is a mix of FFS and VBC. Most hospitals and
doctors aren't compensated on a fully capitated basis (capitation is a concept
that, in layman's terms, measures how close the system is to VBC vs FFS - more
highly capitated = closer to VBC). Under FFS, doctors don't make much money
providing preventative care, so there is no incentive to keep people away from
the hospital. Unless you are a member of a system like Kaiser, you are most
likely covered by a plan that is partially capitated - your insurer may share
profits over a certain % with your doctor as a reward for keeping you healthy,
but still pays for services on a FFS basis. Often, this profit sharing does
not compare with the potential revenue from providing additional acute care
services, so the old FFS incentives are still at play. (Hence the $600
1-minute consultation.)

Now, wouldn't it be great if every health system operated like Kaiser, where
all the incentives are aligned and the objective is to keep people out of the
healthcare system? Yes, but the answer is not as simple as requiring
healthcare systems to provide insurance. In fact, Kaiser is one of the only
success stories involving provider-sponsored health plans (Presbyterian in New
Mexico is another).

The reason why many of these provider-sponsored health plans fail is twofold:

First, most healthcare in the US (70% I believe - but that is from memory) is
provided by regional or community healthcare systems. These systems only serve
certain communities (their primary service area, or PSA) and therefore certain
populations. These populations are often not of significant enough size to
provide adequate risk diversification for healthcare systems that provide
insurance plans. One of the key reasons insurance works is risk
diversification - but these hospitals can't diversify their coverage beyond
their community's population. In fact, one of the most common criticisms of
Kaiser from the investor community is that its membership is too concentrated
in California - and Kaiser has over 10 million members on the East and West
coasts.

Second, these systems often don't have the capability to price their insurance
and healthcare services correctly to account for the levels of risk embedded
in their insurance plans. Sometimes that is due to lack of actuarial
experience, sometimes that is due to lack of risk diversification causing risk
to exceed estimates, and sometimes that is due to existing healthcare prices
driving up costs to a level beyond where they can reasonably charge premiums.
Also, it is hard for these systems to predict who will enroll in their health
plan, and what their overall risk level will be after enrollment season. There
are companies dedicated to helping systems operate provider-sponsored health
plans (e.g. Evolent), but this has proved to be a difficult problem. For
examples of premier systems getting this wrong, look up Partners (they own
Mass Gen), Catholic Health Initiatives, Northwell, Banner Health.

While this is a hard problem to solve, and I don't have the answer, you are
right that the Kaiser model has in many ways proven to be more cost effective
than FFS or other capitated models. It might be a good intermediate step for
some of the larger systems. But there is still a lot of work to do to fix the
system, and even solutions that sound good on paper have unintended
consequences (for example, if you move to a single payer system to reduce
prices, would lower drug prices disincentivize pharma R&D, hurting development
in the US and the rest of the world? Would medical device companies making
prosthetics go out of business if prices decreased below their cost levels?
etc.).

Hopefully this was helpful to people who aren't as familiar with the way the
system works. A less-than-perfect analogy I often use is:

The old FFS model is a "supermarket" model: the supermarket makes money by
selling you as many gallons of milk as possible, and pricing the milk at a
premium to their cost. The higher they can price the milk, or the more milk
they can convince you to buy, the better off they are.

The current model is a "Costco" model: you pay a recurring membership fee to
Costco, and can buy their products at a lower price, but (let's assume) you
still pay a slight margin on those products to Costco. So, Costco would love
to have as many members as possible paying membership fees - and, in fact,
could offer its products close to cost if there were enough members who didn't
use the store. But, they would still prefer that members use the store as much
as possible, and buy as much product as possible at the highest allowable
margin for Costco.

The "ideal" VBC model is a "Netflix" model: you pay a recurring membership fee
to Netflix, and can stream any of their videos for free. Netflix starts out
the month with its $10 of revenue from your membership, and each video you
stream causes them to incur streaming costs and royalty payments, reducing
their margin on your $10 throughout the month. From a pure profit perspective,
Netflix would love to have millions of members who never used the service,
allowing Netflix to keep 100% of their membership fees. However, in order to
grow and be successful, Netflix needs members to use and love the service, so
it "invests" some of its membership fee by streaming videos to users. If users
are going to stream, Netflix would prefer that users stream its proprietary
content, which is lower-cost for them to provide. (That last part of the
analogy is stretching it a bit, but meant to demonstrate that for the health
of the system, some utilization is required, and the provider would prefer
that utilization to be as low-cost as possible.)

~~~
arcbyte
I appreciate the time it took you to explain all that. You did a good job.

I am in the opposite camp and don't have the time to write out my position to
the extent you did. However, I'd just like to take a moment to point out the
ludicrousness of calling something that isn't Fee For Service "Value Based",
as if there's anything in the world more "value based" than paying someone for
the value rendered in a specific service.

~~~
parmta
Thanks. I would be interested to hear your perspective.

I agree that "value based care" is probably not the best name for a fully
capitated system. (Population health might be closer, but still not perfect.)
By definition the "value" of something is whatever someone is willing to pay
for it. A doctor's reimbursement rate is negotiated with the insurer, so there
is an explicit agreement to pay that rate for that service. And by being a
member of that health plan, the patient explicitly agrees to pay whatever
deductible or copay is required by the plan, based on the rate the insurer
negotiated with the doctor. So in a FFS system everyone has actually agreed to
pay the price that is charged.

The problem is that as a patient, it is hard to tell how much a medical
service will cost before receiving it. In a grocery store, you can look at the
price of milk and decide whether it is worth buying. But there are all sorts
of reasons why price consciousness is harder with healthcare (for example:
emergency care, lack of price transparency, agency issues). And so the idea of
value is harder to measure from the patient's perspective, which is why value
and price paid may not exactly match.

------
rwmj
Over here (in Europe) we get the impression that US has such a crazy
healthcare system. Why aren't people marching in the streets? Is it not as
crazy as it sounds for most users? If you're taken to ER how are you supposed
to know if the doctors are all part of "your network" (whatever that even
means)?

~~~
istorical
Because those in the middle and upper class have employer-paid health
insurance which protects from the worst of bills. You only go bankrupt if
you're uninsured and usually only those in the lower-middle or lower class are
uninsured.

And those in the lower echelon of society economically are those least able to
have the time or money to march or lobby for change.

~~~
godot
I went to ER a couple of months ago for a relatively minor issue and stayed
for a few hours total. This was in-network hospital, doctors and so on. Purely
by co-pays this ended up being a ~$800 bill after all the insurance kicked in.

If I didn't have a comfy software engineer salary, and instead lived paycheck
to paycheck, this would've been devastating, even with insurance.

~~~
SilasX
Which is ridiculous. We're at the point where the insurance is just covering
the cost of the overhead that necessitates having insurance in the first
place. There's no way the real charge should be $800, let alone co-pay.

~~~
chimeracoder
> Which is ridiculous. We're at the point where the insurance is just covering
> the cost of the overhead that necessitates having insurance in the first
> place. There's no way the real charge should be $800, let alone co-pay.

You're right. Of course the private insurance premiums have a negative
expected value. Aside from insurance always having a negative expected cash
value by definition, private insurance premiums are literally used to
subsidize care of Medicare, Medicaid, and uninsured patients.

------
sixdimensional
In a past life, I worked in health insurance fraud detection.

Everybody should know, the health insurance system in the US is fundamentally
broken and has been almost since its inception in the early 20th century. The
lack of adequate consumer protection, transparency, health systems and
appropriate government regulation, in addition to organizational oversight,
has lead to a situation where we have poor systems that can easily be
exploited. And they are exploited.

What the third party care outsourcing/billing company mentioned in the article
(Emcare) was doing sounds like upcoding. They bill the highest cost service
they legitimately can to maximize profit. In this case, as a third party
billing organization, they both want to maximize the profit for their customer
(the hospital system), but also for themselves, as they surely take a cut as a
middle man.

Likely, they were operating within the gray area where illegal upcoding has to
be proven in a court of law. It is an expensive process, that requires review
and comparison of huge amounts of medical records with claims to determine
whether the more expensive procedure billed was medically
necessary/appropriate, or if it was egregious. That legal process does pan out
sometimes in the end, but it can take years and just adds even more overhead.

Coding correctly, fairly and getting reimbursed correctly and fairly is
incredibly complex. There are an enormous number of combinations of services
(usually represented by codes called HCPCs and CPT codes) and diagnoses
(ICD-10... which has 100,000s of codes), as well as all different regulations
and scenarios for settings of care (inpatient, outpatient, doctor's office,
etc.).

Props go to the hospital system for taking back their coding after they
realized what the third party was doing, but the reality is, it was probably
financially benefiting the hospital system too.

Every technology that I know of has been tried to address these issues, such
as data mining, machine learning, rule-based expert systems, etc. and none of
them has addressed the root cause, which is the basic system is fundamentally
flawed.

All the politics you see about US healthcare in the news are, in a way,
representative of the root problem - how big and complex the systems are now,
how much money they represent, and how many interests are involved. We have a
tangled web.

I don't know the solution (and many have been proposed).

~~~
snuxoll
> Props go to the hospital system for taking back their coding after they
> realized what the third party was doing, but the reality is, it was probably
> financially benefiting the hospital system too.

I doubt the hospital system got anything from it, physician groups usually
keep all their revenue from professional services claims - the hospital gets
paid whatever they do for their facility claim regardless of what the
professional claim pays.

~~~
sixdimensional
It's possible you're right. Without knowing the details of the relationship,
you never know.

The reason I say that is the article points out another glaring issue - the
shortage of ER docs that we are currently facing. I know this first-hand, as I
have a family member who is one and is working harder than ever.

Some of these arrangements are to make up for the shortage, and the hospital
systems and physician groups are often working in partnership... so it could
be there was benefit for both since the hospital system needed coverage for
their ER (due to physician shortages), and Emcare is providing the physicians.
Without the physicians doing the services in the hospital, there would be no
facility claim either...

~~~
snuxoll
> It's possible you're right. Without knowing the details of the relationship,
> you never know.

This is true, and being a mere software developer I'm in the dark on the
contents of any of the contracts my parent company has with facilities either.

> The reason I say that is the article points out another glaring issue - the
> shortage of ER docs that we are currently facing. I know this first-hand, as
> I have a family member who is one and is working harder than ever.

Insert my standard rant about restricted med-school/residency admissions and
cost of tuition here.

~~~
sixdimensional
It's sad but true that we are getting to a point where all we have are
standard rants about these topics, but can't find the solution. I'm guilty of
the same too.

Stalemate.

We need to go through Kurt Lewin's change model process - "unfreezing, change,
and refreezing" and find something better. It's like, we need agile healthcare
or something - fail fast and iterate faster... without costing people their
lives or their savings.
[https://en.wikipedia.org/wiki/Kurt_Lewin#Change_process](https://en.wikipedia.org/wiki/Kurt_Lewin#Change_process)

------
pascalxus
So, basically, if you visit any emergency room then your handing them a blank
Check and they can write whatever number on there they want. That's egregious
beyond belief. I'm never one to call for legislation and price controls, but
in the face of such adversity, I think it may be our last hope. I think they
should either provide a quote before they offer the services or there should
be a law limiting the amount that can be billed per service.

~~~
madengr
Yep. Took my wife to the ER last week for suspect appendicitis or
diverticulitis. Last time this happened a CT scan alone was $3k ($11k prior to
insurance reduction). My HDP is $4,500 OOP max per family member; $8,500 for
family.

What really pisses me off is that the HSA max contribution has not kept up
with family OOP max. I contribute the max every year and can't end up with
$8,500 saved.

I had a decent insurance plan prior to Obamacare. Now it's 3x as much and a
HDP. Don't even have dental insurance anymore; use the HSA for that. Work for
a Fortune 100 Company too.

~~~
e40
_Work for a Fortune 100 Company too._

Your HR department is shit. I manage a 30 person company and our benefits are
better than what you've mentioned.

~~~
madengr
Yes, no argument there. I work for Fortune #75 (hint; it's probably hanging on
your wall). Lost dental insurance last year, vision the previous year, and
switched to an HDP the year before (with massive premium increases every
year). But hey, the stock price was at an all-time high on Friday.

Funny thing about HR directors is that they don't last more than 1 year before
rotating out. Don't want them to become too attached to the people they are
there to screw.

~~~
SpaceRaccoon
>I work for Fortune #75 (hint; it's probably hanging on your wall).

Honeywell; thermostats?

~~~
swampthinker
HON stock did just hit an all time high.

------
canhe
Canadian here. Had a pain in my right side for about 3 weeks (thinking muscle
pull). Called Doctor's office at 10am had appointment at 11am, had exam and
referred electronically to local hospital for X-Ray, had X-Ray at 11:45am, out
the door at 12pm. Doctor called me personally the next day to say it's
probably a muscle pull and call back in a couple of weeks if still sore.

$0 out of pocket, just showed my government issued card everywhere.

Couple of years ago my father was in an ICU for two weeks with Parkinson's
related complications. That one had a $0 out of pocket bill as well. The ICU
was in a world class university teaching hospital.

System works here. Sure people can cite edge cases, but they are relatively
rare. The single payer, $0 out of pocket system also encourages pro-active
care as opposed to waiting until the problem is severe, which in turn keeps
costs down.

Wouldn't trade our single payer, socialized medicine for anything. There's
reason why Tommy Douglas, the father of Canadian socialized medicare, was
voted the greatest Canadian of all time by the public in a recent CBC poll.

(Shameless plug: software industry is booming in Toronto and there's lots of
jobs. Just sayin'...)

~~~
refurb
_System works here. Sure people can cite edge cases, but they are relatively
rare._

Not sure these are just "edge cases"...

[http://www.cbc.ca/news/canada/british-columbia/patients-
live...](http://www.cbc.ca/news/canada/british-columbia/patients-lives-ruined-
as-hip-surgery-waits-grow-1.2976196)

~~~
mahyarm
Lets compare the 'horrible edge case' rate of the USA compared to Canada now.

~~~
refurb
How about we compare Canada's edge cases to countries other than the US. How
does it stack up?

~~~
canhe
I would suspect not too badly.

------
chimeracoder
If you want to understand how medical billing works and _why_ these
ridiculously high bills get created, there's a lot of important context that
this article unfortunately leaves out.

Large hospital systems accept patients who have a range of payers (Original
Medicare, Medicare Advantage, various Medicaid plans, private insurance, and
uninsured patients). On the aggregate, they want to make sure that their
entire system is cashflow-positive - however, they do that in a rather
roundabout way, because they only have the ability to negotiate with some of
their payers, whereas the others are able to set their rates at whatever price
they want.

Medicare and Medicaid set their reimbursement rates by fiat, and providers
have essentially no ability to negotiate those. Except in critical access
areas, Medicare actually reimburses much less than the marginal costs of care
for its patients (7% in the aggregate)[0]. These rates are so low that
Medicare actually has a separate program to pay extra money to hospitals that
treat a lot of Medicare patients - otherwise, they would literally go under.
The reason they provide this money as a separate program and _don 't_ count it
in claims is entirely political.

As a result, providers present very large bills to everyone else (privately
insured and uninsured patients) to make up for this loss - you can't stay in
business if you're literally making a loss on every patient! Uninsured
patients see the large bill and assume they have to pay the entire amount
(they don't!), and private insurers end up negotiating that down to some
multiple of what Medicare pays.

A typical insurer will negotiate an agreement like, "we'll pay 350% of what
Medicare pays for this category of services".

[0] This is not looking at any markup that the hospital provides - we're
talking about how much the hospital has to pay _its_ suppliers. So, for a
hypothetical vaccine that costs $100 wholesale, Medicare might reimburse $93,
which doesn't even cover the cost of the equipment, let alone the entire
hospital infrastructure (wages, etc.).

~~~
joe_the_user
_We 're talking about how much the hospital has to pay its suppliers_

Except suppliers can engage in their own fiat prices, as the OP demonstrates.

But your narrative does show the basic situation - where you have an elaborate
_digraph_ of buyers and sellers, most of which have a more or less
monopolistic position. These monopolistic suppliers initially/formally set
their prices based on "what they could possibly imagine getting", expecting
regulators/down-stream-buyer to be the ones who will push things back into
sanity (or not).

American health care, of course, has bounced from regulatory regime to
another, with all of the players having to adjust. And moreover, all the
players are now adept at adjusting, able to switch gears to leverage whatever
ad-hoc cost reductions might go with any new system (cautious enough to lay-
low when the new system comes since they know the politicians need to point to
gains but will move on - see the way Obamacare worker great for two years,
etc, etc).

And with all the bouncing, the situation has gotten only broadly more
catastrophic. Health care was ~18% of GDP a year or two ago and no doubt is
higher still.

Not only does health care have a problem but the four or eight cycle of ad-hoc
fixes to health care has itself broken. Which might relate to the general
breakdown of the countries political system, and so-on. I assume when (part
of) Rome fell apart, no had seen an empire disintegrate on quite those terms
(where a lot of civilization still remained on higher terms than Rome's
neighbors). Perhaps our descendants will look back on this era in similar
terms.

~~~
chimeracoder
> Except suppliers can engage in their own fiat prices, as the OP
> demonstrates.

Those aren't fiat prices by any stretch. Aside from the fact that there is a
competitive market of providers, patients don't have the obligation to pay the
entire billed price (a key point which this article does not mention). That's
neither a monopsony nor a monopoly.

Medicare, on the other hand, _is_ a legal monopsony over its patient
population and _does_ set its prices by fiat. (There is no competitive market;
patients can opt to receive their Medicare benefits privately, but they cannot
opt out of Original Medicare entirely. Similarly, most providers cannot
legally opt out of accepting Medicare, in practice).

------
toss1
Start with the fact that even the hospitals _themselves_ do not even know the
cost/price of their procedures and goods.

Notice here, in 2013, an article about how "For the very first time, the
federal government is publicly releasing the "rate card" (the full charge
before insurance company discounts) prices hospitals throughout the nation
charge for the one hundred most common procedures and services."
[https://www.forbes.com/sites/rickungar/2013/05/08/the-
great-...](https://www.forbes.com/sites/rickungar/2013/05/08/the-great-
american-hospital-pricing-scam-exposed-we-now-know-why-healthcare-costs-are-
so-artificially-high/#3a56feb53bff)

Yet two years later, a CEO of a hospital cannot even get the costs at the
hospital of which she is CEO: [https://www.nytimes.com/2015/09/08/health/what-
are-a-hospita...](https://www.nytimes.com/2015/09/08/health/what-are-a-
hospitals-costs-utah-system-is-trying-to-learn.html)

Price discovery, the most basic element of a free market, is literally
impossible, even for expert executives within their own organizations. Vast
price discrepancies exist for procedures just a few towns apart. Discovery for
consumers in advance is impossible, and of course absurd in the situation
where you are being rushed to the nearest hospital in an emergency.

Do not let anyone get away with claiming that this is somehow a "Free Market"
until reliable prices, and outcome rates (with case difficulty information)
are as easily available as prices and reviews on Amazon.

------
sol8
The entire pricing scheme is an elaborate sham if you ask me. My wife had to
have surgery. A outpatient laparoscopic procedure that required cutting a
tendon. The time she spent at the facility (from the when they took her back
and discharged her) was about 3 hours. A month later we got a statement
showing they tried to charge $67k and were denied… followed by a separate bill
for $7.5k We ignored the bill and contacted Anthem who said the hospital
didn’t code it correctly. Anthem said they would resolve it. A month later…
another attempt to charge $67k another separate bill for $7.5k. Again we
repeated the same process. This time it appears it went through. Final total
when they “coded it correctly” was $74k.

I have a friend who had to have an emergency appendectomy this year. She paid
$1500 for it after insurance. My father had knee surgery he says they tried to
charge the insurance company $64k for it.

At this point I think the pricing is all arbitrary. It’s about them trying to
charge what they think they can get away with and sticking you for the rest.
Kind of like raising the price so you can offer a deep discount later on. I
think the real price of the surgery (without insurance) was probably the
$7.5k.

I can think of no other business where you agree to have work done without an
agreed upon price. The insurance company will tell you it’s covered but the
hospital you go to may decide to play games with you. At the very least I
suppose they are just hopping you pay so they can collect interest on your
money on it before sending it back.

~~~
21
> I can think of no other business where you agree to have work done without
> an agreed upon price.

You can't really compare this with other businesses. Unless you want the
doctors to stop the moment they hit your negotiated price (like lets say a
building constructor would).

However you should be able to get a rough quote for the procedure (assuming no
unexpected complications).

And I agree with you in general, US health care is a total scam (very high-
quality to be fair).

~~~
sol8
That's good point. I wouldn't expect pricing to function like that, especially
in life or death situations. In our case, this was a surgery that was planned
and scheduled a month in advance and at no time was a price ever mentioned.
Just a letter from Anthem saying it was covered. We didn't start to see
anything on the monetary side until after it was all said and done with. In
advance of the procedure I tried to find some pricing data on the surgery but
struck out. Apart from some articles about hospitals in California publishing
prices for procedures, I could find nothing for the east cost.

------
occultist_throw
Does anyone know if a lawsuit has been lodged questioning these practices?

I've always thought that my informed consent should also apply to cost of
procedure - I have a right to say "NO" to something in the medical
establishment. And had I known the price and the success rate, I would have
said "No".

Now, I'm not asking "What is my exact rate?", although that would indeed be
nice. But given minimal complications, I should be able to get a range of what
to expect.

~~~
advisedwang
Price transparency is pretty meaningless for ER care. Anything that is serious
enough for an ER visit probably distracts you from making good economic
choices, plus it's likely impractical to change ER (plus you'll pay for that
ambulance ride!)

Further, it shouldn't be necessary for people to be making financial decisions
in the middle of medical emergencies, even if it was easy.

~~~
sigstoat
> Anything that is serious enough for an ER visit probably distracts you from
> making good economic choices, plus it's likely impractical to change ER
> (plus you'll pay for that ambulance ride!)

there are all sorts of folks using ERs for non-emergency issues, simply
because ERs are required to treat everyone.

both of my trips to the ER (subluxed knee; particulate matter lodged in my
eye) would've been amenable to at least a few moments of financial
consideration, had any information been available to me.

------
dsfyu404ed
Every time I read a story about ER-billing I have to fight the urge to spend a
few hundred bucks on the materials and equipment required to produce "official
enough looking" forms of ID.

Seems like getting a hospital to think they treated someone who doesn't exist
is a better bet and no more stressful than getting your insurance to cover
things to the extent you are lead to believe they would be covered

~~~
mahyarm
They do check IDs at hospitals. I remember sitting in one and the person next
door having a conversation about how their ID was fake / not theirs.

------
siliconc0w
Similar experience where I went to an ER and like six people interacted with
me for less than 1-2 minutes apiece plus scans and an unneeded IV which came
with a generous offer of Opioid pain meds when I specifically said, multiple
times, I wasn't in pain. I got like seven different bills, each for
randomint(0,1000). Worse, after wasting a day there - all they could do is
just refer me to a specialist. The bills didn't even really explain what they
were for, they just kept coming for almost a year after - apparently one for
every person who may have looked in my direction plus each scan or test.

So I switched to Kaiser which is slightly better from the billing side but
feels pretty mediocre care-wise. I don't hear back from the GP about
questions/tests ordered and I've waited literally all night just to get
something for a bad cough.

Healthcare in America is truly and thoroughly fucked.

------
vladgur
This is no longer legal in some states, including California...
[http://www.huffingtonpost.com/entry/surprise-no-more-
balance...](http://www.huffingtonpost.com/entry/surprise-no-more-balance-
billing-from-docs-in-california_us_59567da0e4b0da2c73232bd7)

Im curious how many supporters of GOP's free market rhetoric would support
regulations around these practices once they are hit with a surprise bill like
that

------
Fej
We will have our universal healthcare, eventually. More and more people are
scorned every day by the perils of our system. The Democrats couldn't manage
to pass a public option during Obama's honeymoon period but the country might
be ready for it once the pendulum swings back in 2020. Even my somewhat
economically-conservative father admits that it is inevitable.

These next two to four years are going to suck, though.

I am a New Jerseyan and the medical industry is going to fight tooth and nail
on this. My district swung (!) and even the Democrat won't endorse single-
player.

Hopefully we can effect change as the Boomer leaders die off, at the very
latest.

------
notadoc
What are the specific benefits to having an immensely expensive administrative
bureaucracy lodged between the actual patient and actual health care provider?

This should be easy to answer and explain.

~~~
Chardok
Shifting costs from the hospitals and insurance to the patients, plain and
simple.

This is merely the tip of the iceberg for what for-profit healthcare is
developing into. You cannot have sound medical decisions being made when money
is so deeply intertwined in the process.

~~~
notadoc
I would highly recommend every patient asks their doctor(s) about health
insurance and their opinions of it. You will get an interesting earful.

------
RyanMcGreal
Seriously, America: how is _ANYONE_ still arguing against universal, single-
payer health care?

~~~
Tempest1981
Healthcare is 1/6 of the US GDP, and they have good lobbyists.

------
thingschanged
In any other field all of these billing scams would be a federal crimes.

Congress could solve this issue overnight by passing a 1 line law:

If a patient is using services that is not covered by their insurance, or if
they have no insurance, no medical service provider can change more than the
official medicare standard rate for any services rendered.

Problem solved.

~~~
mahyarm
That quickly becomes single payer, since prices will be set to a price ceiling
of whatever medicare (the gov't) sets it at. Good luck!

------
zippergz
I feel like there must be something I'm missing here. Isn't providing health
care the core purpose of a hospital? Why are they outsourcing that?
Outsourcing might make sense for ancillary stuff (e.g. running the cafeteria),
but I'm confused why they'd look to outsource their core job. And if the
outsourcing company can do it so much more efficiently, why don't they just
open their own hospitals and take all of the profit?

~~~
adolph
Think of a doctor as being an specialist independent contractor affiliated
with the primary business.

Imagine if you would, a small hospital. They probably don't see enough
patients with diagnosis X to keep staff specialized for X busy year round.
There is a doctor in town that specializes in X. This doctor needs a place to
get their patients stabilized and where the doctor can see the patients
periodically. When one of the patients needs hospitalization, the doctor can
write an admission order telling the hospital to take care of a patient in a
certain way. When somebody comes into the ER and the generalist/hospitalist
discovers that person has condition X, then the hospital knows they can call
on the doctor to consult with them on how to treat X.

A historical artifact of the hospital/physician relationship is that there are
separate billing streams for each side. There is just enough information
sharing so that the doctor's billing system knows who the patient is and it is
up to the doctor to claim that certain actions were performed for a valid
medical reason and documented.

The current state ranges from very arms length relationships to total economic
integration, which is rare enough to have a term for it, Single Billing
Office.

[http://healthaffairs.org/blog/2016/05/09/the-tangled-
hospita...](http://healthaffairs.org/blog/2016/05/09/the-tangled-hospital-
physician-relationship/)

------
todd8
I have learned, directly from people that would know, that even in affluent
cities in the US one-third of the people having surgery do not have insurance
and simply refuse to pay any of their hospital bills. In some cities,
hospitals have virtually no paying patients.

This surprised me, but I suppose it makes sense that cost have to be born by
those of us that have the means to do so.

------
nfriedly
One thing to keep in mind: when you go to the emergency room as a relatively
well-off individual who has insurance and pays their bills, you're not only
paying for your emergency room visit - you're also paying for the visits of
people who don't have insurance and can't afford to pay their medical bills.

------
Ricky789
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(CYBERDON@CLERK.COM; +1 912 388 3132) for your credit score & credit report
issues, he is a true credit specialist. Just drop him a mail or text him on
the above contact and be happy you did.

------
throwrow
Some out of network providers send bills to patients but don't collect. Some
even tell the patients not to worry about it, although I believe this may be
illegal.

In theory, the high reimbursements are so out of network doctors can get paid
market rates. There's also a fair amount of propaganda from insurance
companies on this issue which makes the reality hard to discern. Yet they pay
10-20% on average of the bills they receive, so it's just another way to
punish the patient while both the insurance company and doctor are taken care
of.

------
hermitdev
Dear NYT, Spokane is not rural. It may not be the metropolis you're accustomed
to, but rural it is not.

------
rconti
At least the hospital in Newport took back their coding/billing into their own
hands.

~~~
bdamm
What was the result?

