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Thoughts on Insurance (ycombinator.com)
518 points by akharris on June 29, 2017 | hide | past | web | favorite | 413 comments



> After paying for broker commissions, fronting costs, reinsurance, customer service, claims processing, there’s often around 50% of the original premium dollar left to pay claims – which is the primary purpose of an insurance company.

What about shareholders? One of the biggest problem I have with insurance companies as for-profit enterprises is the inherent conflict of interest that comes from trying to service claims and customers as best as possible and turning a profit for shareholders.

I've always felt that insurance companies should be run as not-for-profits, or at the very least co-ops..

Don't get me wrong here, still pay the employees and the executives competitively (you want things to run efficiently and by talented teams so you need to attract top talent), but otherwise the whole enterprise should be working hard to make sure every other dollar goes to helping the customers who pay the premiums, and that's it.


Something this article did not cover and which is often overlooked is that insurance companies invest the premiums they receive in order to help defray the cost of claims. Companies that are both talented and ethical will get a good rate of return on the investments, thus serving as good stewards for the money.

I am not a fan of general health insurance. I think the government should provide universal basic health care and there should be health insurance for emergencies and the like.

I don't think it matters so much whether it is a for profit business or a not-for-profit or a co-op. It will basically come down to: Are they actually ethical? Are they actually talented at what they do? Is the model of policy any good?

Those will be problems regardless of the form of the organization.

(Background: I worked for a big insurance company for over 5 years. As an employee there, I was sent by my employer to a local technical college to get training to do my entry level job. At least while there, this training entitled me to the spiffy title of "Certified Life and Health Insurance Specialist.")


This is one of biggest misnomers when we talk about health insurance. We buy life insurance but don't plan to die once a month. We buy car insurance but don't plan to crash once a month. We buy health insurance and although we don't plan to go to the ER once a month, we may plan on seeing a primary care physician once a month whether for a chronic condition or maintenance or mental health or... Insurance is intended for unexpected things not expected things.

I think the way to fix this is similar to what you said. Primary care should be provided for everyone and the way you drive that cost down is by using more PAs, CRNP/other nurses and having only one actual Dr. for oversight and tougher cases. There are huge system costs that can be removed just by focusing on things like treatment compliance, pre-habilitation, healthy lifestyle, good mental health, etc.


Imagine if you paid for gas by using your auto insurance card? And also used insurance to cover normal car maintenance such as brakes, tires and oil changes. Now the co-pay on a tank of gas would be about 40 bucks, and if you tried to buy gas without insurance it would cost a couple thousand to fill the tank. But the insurance companies get a discount, and only end up paying 5 dollars per tank.


Yes, I basically agree. I posted this link about Direct Primary Care elsewhere in this discussion:

http://micheleincalifornia.blogspot.com/2017/01/direct-prima...

Direct Primary Care is on the rise in the U.S. It is a saner solution than Obamacare, which forces premiums up crazily for everyone and is a terrible model. If we, as a nation, want to insist on market based solutions instead of the government playing a more central role, then Direct Primary Care is a far saner answer. You pay for basic care out of pocket in a way that helps keep costs down and you get insurance for actual unexpected emergencies and major health events.

The other problem with health insurance is that it doesn't serve the preventive role that car insurance serves. Car insurance is required by the state you live in and the details vary by state, but if you get too many tickets or have too many accidents, your premiums go up. So, it serves as a deterrent to bad driving behaviors. Furthermore, it doesn't just cover your losses. It covers damages done to other people. If you get in an accident and are found to be at fault, your insurance pays for their repairs.

Unlike car insurance, health insurance does not play a real role in pressuring people to behave more responsibly. So far, we have found no means to really do that effectively. Health issues are far more complicated than safe driving issues. You don't drive 24/7, but being alive 24/7 impacts our health for good for ill and in ways we don't completely understand. So it is a very hard problem to solve.

What we do know is that when people do not have access to basic health care in an affordable manner, health outcomes are worse and, thus, more expensive. So we need to find a means to get health access to more people in a way that is preventative. Direct Primary Care and government funded services seem to do that. Health insurance really does not.


It is interesting and that is one thing that I didn't mention. You can do primary care as free or a HSA path. I think the states should offer an HSA so it isn't dependent on your job. Then you can use it for dental or checkups or whatever.

I think the only way to handle the the deterrent/incentive piece is to find a metric that can be used. BMI is worthless as people vary too much. The best thing in my opinion is HA1C levels, but use it as a discount on your premium. You can't cheat A1C and most of our chronic diseases and inflammation causes are caused by poor diet. This forces people away from that if they want the discount. The only problem is high carb diets are cheap (rice/pasta) and healthy diets are expensive (lean protein/vegetables).

The biggest thing we need to change is to remove all the middlemen from the system. Each takes a cut and adds to the cost without having value. The biggest problem with health insurance is it isn't event driven like death or a crash. How do we stop everyone from being on the cheap plan for emergencies and then switching to the best if they get cancer? (Although one piece may be in the incentivizing better diet reducing cancer risk). I do keep wondering if it makes sense to flip it and make that the emergency part is tax based and mostly free to the person. You can then make the deductible based on the person maintaining healthy stats. Never go to the doctor and eat junk? You pay 25% of the total cost. Eat healthy and go for routine check ups? You pay 5% of the cost. Tough to know without running numbers.

All tough questions with no easy answers.


My home insurance in Sweden was a co-op, and they'd pay back any profit they ended up making as a refund https://en.m.wikipedia.org/wiki/Länsförsäkringar


Is there a practical difference in cost though? A Dutch insurer (Univé) used to do the same, but in practice there turned out to be no significant different in total amount of money spent by customers. Even though they gave their profit back to their customers at the end of the year, they couldn't compete on price.


One big non-profit player will drive all the prices down thanks to competition.

There is no reason for private insurance to be more expensive if they have non-profit competitor. If this competitor was to disappear, on the other hand, the costs would probably sky-rocket.


Or not, because the for profit businesses might be more efficient, since they have incentive to be.


This is popular wisdom but experience show the opposite: for profit insurance companies tend to be less efficient. I am not sure what the reason behind is.


I live in Sweden too, and Länsförsäkringar weren't cheaper than the alternatives for the things I looked at (car insurance, home insurance).

That's just looking at the premiums though, there's no way to see any potential refunds and take those into account.


I just looked it up again for my car insurance.

I pay 758 SEK per month now and with Länsförsäkringar I'd end up paying 968 SEK for the same coverage. I do have a 10% discount on my current insurance due to having several policies at the same company. That's still less than the difference though, so Länsförsäkringar would have to refund me around 1200 SEK per year to break even.

That would be around 10-15% of the entire yearly cost, and I don't think they can promise those kinds of refunds year over year.


I'm with Länsförsäkringar because, for me and my situation with cars and houses and everything else I've got insured, it was cheapest.

But you cannot just compare for price; you also have to compare for cover and självrisk etc.

Pretty much all insurers bend over backwards to avoid paying out. I have no idea if Länsförsäkringar is particularly good or bad in this regard.


> Is there a practical difference in cost though?

There has to be since no shareholders are involved assuming the rest of the setup is the same. If they are not cheaper then it's more likely that the coop is badly run which sadly is not uncommon.


There's at least one other alternative. The NFP uses the excess to pay better wages across the board. Thus benefiting every community those wages are spent in, which will usually be local (both to the business and it's clients).

Monies move toward local, low cost and essential spending as opposed to remote, high cost and luxury spending that one would expect to dominate with dividends paid out by for profit businesses.


For me getting a home insurance for my rental apartment in Sweden, Länsförsäkringar in my region (They're split up in regions) was the cheapest one at the time I was looking.


My home and auto insurer, Amica, is mutual company today. I'm not sure if there's a difference between a mutual company and a co-op.


A co-op could be a mutual company (i.e. owned by its customers) or it could be owned by its employees. It's an umbrella term for both.


Ah, makes perfect sense.


A lot of life insurance companies (e.g. the Prudential) started as mutuals. In the UK in the 90s there was a wave of "demutualisation" where the customers decided they'd take a one-off payment in return for handing control over to shareholders.


I don't know if it was done similarly in every case in every country, but my experience is that the customers became shareholders (with an option to sell the shares immediately, which I guess almost everyone exercised).


Came here to say this. Probably most of the insurance companies were mutuals prior to demutualization.

Probably the biggest consumer-owned business we have today would be Vanguard, when it comes to investment funds, but for a variety of reasons most industries have shifted to the corporate model.


That's one of the hardest questions to answer. In order to generate profits for shareholders the carriers have to generate return on their float. That was "easy" during the big bull market that started in the 80s, but has become increasingly difficult.

There are a number of very large and successful mutual insurance companies - take a look at USAA. They also happen to enjoy some of the highest customer satisfaction ratings in all of financial services.


USAA is still affected by many of the same forces that affect for-profit insurers. USAA has changed a lot in the last 20 years as they've opened up to more members.


I guess I don't really see your point.

Suppose we take two situations:

#1 As described in the article, between the premium and the actual claims pool there's 50% lost to all the entities involved -- from brokers up through reinsurance companies and back down to the entity that actually cuts the claim check. But further suppose that all these companies happen to be co-ops and so no dollars are lost to passive investors.

#2 There's a vertically integrated insurance company that is highly efficient. It only sells directly and doesn't use commissioned salespeople. It has overhead of only 25% and pays a 10% of revenue dividend to its shareholders, leaving 65% of premiums to pay claims. This enables the company to offer lower premiums for the same coverage.

Is #1 somehow morally superior to #2? Do you think it is impossible for #2 to exist?


I think Sebastian is introducing an orthogonal perspective, which has nothing to do with morals. The theoretical ideal is that an insurance company nets zero profit while operating at maximal efficiency. Introducing a third-party (investors) that benefit from extracting revenue is a form of overhead that decreases that potential efficiency. This isn't all bad though. Likely, if it were not for the investors, the company would never exist, so they should have rights to a piece of the pie. Unfortunately, the trade-off introduced is conflict of interest.

Investors reward behaviors that maximize revenues be it through cost-cutting, premium hikes, or benefit reductions (or potentially the opposite assuming sales increase enough.) Granted, some of the more negative actions might cause customers to move from one provider to the next because of free markets and whatnot, and theoretically, the market should reward the company that provides the best balance for customers... except that almost all insurance companies are owned by investors, and over the long run, these investors incentivized to maximize revenue in prisoner's-dilemma-like fashion.[0]

So... I'd argue introducing investors over the short term is a fantastic idea, but at some point, it's probably wisest give them a heap of profits, and turn off the tap. Otherwise, the company will turn into yet another publicly-traded monstrosity with a mechanical conscience.

[0]: https://en.wikipedia.org/wiki/Tacit_collusion


I think your example is overly simplistic, but I understand what you're saying...

To stay at that level, I would say that while there's nothing inherently bad about #2 it would be better if 75% remained to pay claims, and then they would not only offer lower premiums but better coverage.

And as someone else said, this isn't about morals, it's about priorities.. An insurance company should exist primarily to protect it's customers.

That said, if investors were contractually bound to accept only a fixed return over a period of time (almost like a bond or a GIC or something?) and had no voting power or influence in the direction of the company, that could work?

My issue is less about "investors" and more about focus and priorities I suppose..


I once read an interesting story about the host* business. Apparently the dominant player is a for-profit business.

The competition is convents around the country that have traditionally supplied them to parish churches. Here you have organizations that are as non-profit as they come -- convents aren't like many hospitals where the CEO and other high level employees are raking off a huge salaries as quasi-profit. And the motives and priorities couldn't be any purer, their work is essentially in the service of what they consider the glorification of God.

Yet they are being out-competed by a for-profit company that explicitly tries to make on every sale in order to compensate the owners.

How do you explain this if you view profit as deadweight loss that can only be at the expense of customers?

Edit: https://www.vice.com/en_us/article/vvaeyb/the-surprisingly-c...

*The bread that is used during Catholic masses.


So first off, you're adding additional meaning to my statements by saying things like "you view profit as deadweight loss", which is not what I said at all (or if that's what you understood, then my apologies).

Secondly, I don't really think I need to disprove your anecdotal scenarios (which aren't really apples to apples anyways) in order to stand behind my statements..

I will say this: I did originally say that executives and employees should be well-compensated and that the company, while not profit-driven, should still be making enough money to attract top talent and be competitive in the market.

My idea was never about running an insurance company like a charity or a tiny unsophisticated business (as in your host example), it was just about not prioritizing shareholder profits over the core business service provided to the customer (i.e. providing coverage and paying claims), which is what many publicly-traded insurance companies do today.


> Do you think it is impossible for #2 to exist?

not the OP but, in the long term, yes, I do believe a for profit entity is at odds with that. Shareholders clamor for more profit and will not be content with no growth.


Shouldn't we expect plenty of revenue growth since the efficiency edge over competitors means they can charge lower prices? 10% of a growing revenue stream looks like a recipe for pretty happy shareholders.


You can certainly expect it short to medium term yes. Longer term I don't think so.


Lemonade is a NYC based insurance start-up that is doing this idea but one better. They are building two halves of the business: a for-benefit corporation that is the insurance carrier, and a for-profit, broker side that takes a flat 10% commission on premiums. They are getting great traction in the few states where they currently sell insurance

https://www.lemonade.com/blog/its-not-our-money/


In CA there is heavy competition between not-for-profits and for-profit. Kaiser and Blue Shield are both not-for-profits. I'm not sure why you would pick a for-profit here given those options


Blue Shield of California lost their tax-exempt status in California a few years back.


They lost their ca tax exempt not for profit status but they are still not for profit... which means they pay normal taxes and still operate as a non profit, which is actually pretty amazing in my opinion.

They also limit net income to 2% of revenue and refund anything more.

https://www.blueshieldca.com/bsca/bsc/public/member/mp/conte...


How is that still a thing? The LA Times article mentioned that they've never had status with the IRS and that they lost status with the California taxmen.


Ah. "Not-for-profit." Yeah. Right. How many millions do the execs get in salary? Those are costs, not profits, right?

edit: typos


Not for profit doesn't mean that the people doing the work don't get paid. It means that the entity doesn't exist to payback a financial return to its investors.

Think of it this way, a not-for-profit insurance company has to pay its executives, staff, and so forth, while a for-profit insurance company has to do all of that and show a return for its investors.


I think you missed the point he was making.

When an exec makes 22 million at a for-profit company which produces dividends that might make its way into your 401k people have a hissy fit.

When a not-for-profit company pays their execs that much, those same people don't even know, because it's "not-for-profit" they assume it's more charitable somehow.

I don't think it was the reality that the prior comment lamented, but people's perception of it.

There have been moments in my life where I've wanted to smack smug idiots who, when asked what the do, say "I work for a non-profit doing X." As if that makes them better than the rest of us.


I think in insurance, there should be two separate pools of money, one for the insurance fund itself, and the other for managing the fund (management of the risk model) and making profits for the owners of the insurance company. These should be separate items on your insurance bill, and no money should ever cross the line from one pool to another.


In a for-profit company, there's a group of people at the top who are paid handsomely for cutting costs (i.e. stock-based compensation). This doesn't exist in NGO's, and so for large organizations with lots of cash flow, bloat balloons exponentially (because the default, human loyalty of an employer is to their employees, not their customer)


NGO are trying to cut cost down. They tray to focus to their mission as efficient that they can. Doctor without Border is faster in some case than public emergency service.

The difference is that what is seen as cost, private company often see the product they deliver as a cost.


Is generating enough income to give a profit to investors so different from generating enough income to meet operating expenses. Even without investors, if I was working at an insurance operation I'd feel a conflict between trying to be good to customers and trying to keep the lights on.


Insurance companies used to run as mutual companies. Part of insurance is investing all that money. A lot of mutual companies become pseudo public companies so they could access cheap capital then grow faster. Of course once nationwide grew as big as they did they went private.


There are alternatives.. we are setting up an insurer with a new business model in the UK.

We earn a flat fee every time we settle a claim for members of our community - they provide the funds to cover for each other.

No conflict of interest, fair pricing, everything instant.

Have a look. insureathing.com


Interesting, but the variable premium scares me. Is there no limit on liability? What happens if lots of people claim in the same month?


If there are outliers and the premium would skyrocket we cap your premium at market rate through an agreement with a reinsurer. It's a standard financial tool insurers are using as well and costs us next to nothing.


Aren't car-insurances sort of co-op's? Atleast I've read verbiage in my California car insurance policy from Farmer's that indicates that the insurance policy is really owned by the pool of users taking insurance and Farmer's is just a manager taking a government controlled percentage for their operating costs + profit.


In your case, that's true. Farmers is a reciprocal, meaning that the policyholders own it. Not all car insurance companies work this way.


I believe that Farmers is owned by Zurich Insurance.


I feel like this is the case for a lot of big industries in the US. Insurance, especially health insurance. Personal banking with credit unions. Maybe even pharmaceutical companies.


Disclosure: I've worked in both P&C and Reinsurance for several years. Also on Wall Street for a couple years. Also in Healthcare for a couple years.

Overall I think this is a nice briefing on the state of the insurance market in the modern economic landscape. It is extensively regulated with rates set and various nuances. All of this, of course, comprises part of a grand "data set" that looks quite appealing to modernization.

Unfortunately, I think there should be a strong expectation that the market (industry) will both be openly hostile to "disruption" oriented attitudes a la Uber, but laugh at any ability to raise capital to compete at any meangingful level.

I applaud your interest in perhaps improving a legally sanctioned form of graft (I prefer Mutual Organizations myself). Conversely, my experience leads me to laugh a little because I've seen the numbers and the complexity behind the scenes. I've got no interest in the industry beyond the paycheck it provided, but it is quite fascinating in numerous respects. Just the naming conventions alone once you get to Bermuda is a trip. Good luck.


I agree with you that there are going to be challenges in building these companies, but not all of existing players aren't as openly hostile as I think you expect. I've spoken with a lot of P&C folks at different companies, and they know things will have to change, they're just trying to figure out how.

Some of the more forward thinking companies are actively investing in new models and companies. I think that's going to accelerate.

Even without that, over time, new models and companies will succeed. Some of these are going to look like stock insurance, some will look like Mutuals and reciprocals, and some will solve insurance like problems in new ways.


We certainly agree on the bulk of your points (see my top-level post elsewhere in this thread). There is opportunity, though in my opinion, a really good way to get there is to work with an incumbent on a "modern" strategy. That's really hand-wavy, I know, but you gotta find the guy who's willing to piss off its brokers and start there.


We're doing much that at Neos at the moment. We've taken a series A mostly funded by a couple of big insurance companies who are interested in what we can introduce to the market.


Are you the guys using smart home (is that the right word?) devices to try and mitigate homeowners claims by preventing or catching problems as they occur (presumably to respond quickly and limit the extent of damage)? If so, that's a pretty good idea. Carriers already give discounts for things like alarms, sprinklers, etc, but virtually none partner directly with a company that can better assure the quality of monitoring. I'm sure there's a privacy hurdle to work on, but it has to do something to loss activity, right?

Best of luck!


We are indeed. Out philosophy is that its better for everyone to prevent a claim before it escalates into one. To that end we provide smoke, flood, motion, and door sensors, along with an (optional) camera. We've got some other cool things in the pipeline capable of not only detecting problems but also responding to them before they become a crisis.

You're definitely right that there are privacy issues to be answered but we try to be as transparent as possible about what we're doing with customer's data, and by being stringent about who has access to sensor data.


There are a few unresolved issues with the preventative / home sensor approach.

1. Sensors dramatically increase the acquisition cost for a policy.

2. It is unproven that sensors will mitigate losses. We all see the potential but there just isn't data there to tell us that.

If I could prove #2 then #1 becomes simple math, if the CBA is there then incumbent carriers will adopt it. It's just not there yet to justify doing outside of startups and market tests.

3. When carriers pick a partner and get into the preventative game then there's some liability that opens up if things go wrong. One could argue that the carrier is already covering the risk - this just means the preventative offering has to line up with coverage being bought.

4. Last but not least, the biggest source of losses is CAT related in property. Sensors will get at the second tier water and fire - again loss avoidance has to justify the sensors unless the preventative side is an ongoing fee service.


Sensors definitely increase the acquisition costs, although at least early on there's customers who see them as a benefit they're willing to trade the usual cashback/discounts/etc for, so its not as bad as you might think. We're also looking at ways to reduce the cost of sensors over time.

As for proving that sensors mitigate losses, even in our initial beta period we've seen a couple of potentially large escape of water claims avoided by early detection of a leak, and that's before we start introducing truly preventative measures as opposed to just detection. We're very focused initially on escape of water because those are in fact the largest source of losses in the industry - fire is fairly rare, theft tends to be pretty cheap to handle claims for, but a leaking dishwasher left while someone is at work for the day can easily require replacing everything on the ground floor of a small house.


So I wanted to try Neos after meeting a Zoopla exec who said they had invested.

But when the premium came out at over 4x my existing renewal quote I became less enthused.

And then I saw the Excess Charge (for making a claim) was £1,000 vs the £250 norm, I ran away to the nearest comparison site to find vanilla home insurance.

I think the conversion process might need looking at to make the benefits less nakedly focused on cost.


Give us another go in a few weeks - our initial trials we were partnered with Hiscox, and were bound to only their (really expensive) policies.

We're now in the final stages of rolling out our own policies which are much more competitive - quoting on my own house has our policies coming out cheaper than my current home insurance policy, with much better service.


Awesome, looking forward to using something that adds value beyond 'invisible protection'


Are you able to completely offset the sensor costs against the loss avoidance?

Do actually observe a different risk profile in the type of customer willing to pay for a proactive service?


As appliances become smarter, there's probably a monitoring play there too - maybe some coverage that blends the concepts in product warranties as well as home warranties.


Thanks for responding. The whole motivation of why I wrote my post was, to paraphrase "You're late to the party, there are already extremely competent experienced players already working hard in what you think is ideal." Seeing your quick input pretty much affirms my impression that yes, improvements can be made but it's hilarious to think a couple years of outside study might reveal some kind of gem.

As in, there are already block-chain based deployments going for portions of the industry. That's some pretty aggressive shit in my opinion. These are also industries with loads and loads of proprietary data that simply can not afford to play fast-and-loose with integrity.

That's why Cyber Insurance now exists. Even the Industry itself knows how to layer risk models.

Hey though, if somebody wants to march into Stalingrad in the Winter and prove me wrong, they can reap the rewards. Full stop.


When I started with Neos I was genuinely surprised at quite how on the ball the insurance industry is. I'd had the same impression that it was a bunch of people stuck in the 90s throwing together spreadsheets and hoping for the best. What I've actually seen is a lot of companies providing some pretty advanced technology (just a single example, a company which given an address can return the projected cost in claims over a year, broken down by types of claim), and a lot of people who's entire job is to take large amounts of data and extract insight into people's behaviour from it, it really wouldn't surprise me if some of these data teams are on a par with Google's ad-targeting teams.

Having said that, there are a great many advantage to doing greenfield development in an industry full of entrenched companies who've been around for a long time, mostly around the level of complexity. We can get away with much simpler solutions because we're currently super focused on home insurance so don't need to deal with all the edge cases around providing fifteen different types of cover.


Since you should know, is TFA's description: "Reinsurer – There are companies that purchase insurance risk from carriers." a conventional way to put this? ISTM a reinsurer is paid to take risk, which is the opposite of how one thinks of purchasing.


The relationship between a carrier and the reinsurer is a bit of an odd one, with the relationship in my experience being more symbiotic than the description gives the impression of.

At least in the case of the company I'm at the details of the policies we write, and what feeds into the pricing, is worked out in conjunction with the reinsurer. They then agree to buy any risk we take based on that model. It is definitely a case of the reinsurer buying that risk from us though, the best way to think of it is that if a reinsurer believes the model is correct they also believe that on average they'll end up making a profit on the risks they buy, and indeed that if we didn't sell the risk to them that we would make that profit directly.


You're correct. They sell a product.


The biggest problem I have with insurance is the inherent disproportionate power relationship between the company and their customer.

Essentially, the moment a customer becomes more trouble than they are worth, they are dropped. This is true with other types of industries, but if your health insurance drops you when you get cancer, you can't get more health insurance, and you die.

Same with house insurance, car insurance, ect...

And it causes death or financial disaster all too often.

Some would argue that "this doesn't happen" or "it's illegal".

1) It happens ALL THE TIME.

2) It's illegal, but if you don't have the means or education to fight it. You are pretty much done.

It's the fundamental nature of insurance companies to milk healthy customers while dropping unhealthy customers. It's just too tempting and they are too protected by our legal system for them to not do it.

I know this is pessimistic, but as long as you realize this fundamental imbalance in the relationship with you and your insurance companies, you can mitigate it to a certain extent.

But, really, the only way to completely mitigate it is to be so rich that you don't even need insurance.


Or to be socially-connected to organizations that the health insurance company doesn't want to piss off. My family wasn't rich at all growing up, but we never had a problem with health insurance, because my mother worked for the government. The one organization that insurers will never piss off is the federal or state government, because then they will lose the right to do business in that state.

I do think that this increasing preference for the rule of power over the rule of law is pretty disturbing, and makes a mockery out of the claim that we live in a democracy. Sure we do...if you have leverage over the companies that would violate your rights. But that's the very definition of corruption, when you need to rely on inside information, relationships, or other proprietary tools to get people to do what you want, rather than your rights as a citizen.


> Or to be socially-connected to organizations that the health insurance company doesn't want to piss off.

This is definitely true, and it seems like social media and sites like this or Reddit have the potential to bring this power to many more people. Companies behaving badly stokes online lynch mobs like nothing else, just look any recent stories of Uber on HN or United on Reddit.


The challenge is that these mobs are essentially random, and the public's attention span is short. So if your company does something evil, there's basically a 1% chance that you will face a company-ending event, and a 99% chance that it will never come to light. And even if your company doesn't do something evil, there's still maybe a 0.25% chance that you will face a company-ending event, because online lynch mobs don't really care about facts. So it doesn't act very well as an incentive.

Just look at the recent Monsanto news, where they knew that Roundup causes cancer, sold it anyway, and paid off the EPA to bury the investigation. There've been news stories, but no major social media outrage. Probably we've just been conditioned to expect no better of Monsanto.

The advantage of a real legal system that's accessible to all is that there're procedures for finding out the truth of any accusation, and then if it is true, there's enforcement teeth behind it. (Or used to be, at least; I think many companies are now using the bankruptcy/reorg shield to avoid court judgments.) Mobs are a poor substitute for that.


Some more info about the Monsanto thing, which I hadn't heard about; I believe this is what the parent is mentioning:

https://mobile.nytimes.com/2017/03/14/business/monsanto-roun...


The other challenge here is that it's hard to vote with your feet in insurance because you might have employer provided insurance that gives a specific company a monopoly, have fewer options for other reasons, or face turning a condition acquired while insured into a pre-existing condition (might be relevant under Trump's attempt at reform).


Insurance company executives pull the political marionette strings via campaign finance (in the U.S.). I would surmise the worry of "pissing someone off" dynamic is exactly the reverse.


Possibly at the federal level. At the Massachusetts state level, the teacher's union (which my mother was part of) pulled the marionette strings; basically all local politicians were in the pocket of the MTA.


Don't forget the police union.


yes, insurance companies are very corrupt. I would say they are inherently corrupt given their place and power in our system.

I don't have a solution other than don't get sick or have a car accident.


I do! End health insurance companies as we know them. Institute universal coverage, mandated by law. It doesn't have to be single payer or free at point of care, but it has to be universal coverage.

It's not a trivial problem, but it's also largely a solved one. The US just hasn't implemented any of the models that work elsewhere.


That addresses healthcare, but health insurance is just one slice of the insurance market.

I'm not aware of a general solution that covers all cases, but in auto insurance we found that the model of replacing underwriters with crowdfunded groups works.


Here in BC only the province is allowed to provide primary car insurance. Our current provincial government is incredibly corrupt and incompetent, including with regards to the provincial insurer specifically, but I'll still take it over private insurers I've had to deal with before.


I'll take advantage of us having the top commentthread to pose a question to the HN audience:

Would you rather live in a society where everyone has a right to medical care regardless of their social standing or financial wherewithal, but some people will die because of bureaucratic incompetence or because the person who could've saved them has no incentive to? Or would you rather live in a society where medicine can work miracles, even the most debilitating ailments can be cured, but only if you happen to be rich?

The former is (to a first approximation) what you get with European-style single payer. The latter seems to be where American health care is headed. There's no situation where everybody can be saved, simply because we're all going to die in the end anyway, but the distribution of who dies and from what can be changed by different policies.


"Would you rather live in a society where everyone has a right to medical care regardless of their social standing or financial wherewithal, but some people will die because of bureaucratic incompetence or because the person who could've saved them has no incentive to? Or would you rather live in a society where medicine can work miracles, even the most debilitating ailments can be cured, but only if you happen to be rich?"

Is this honestly a question?

There are way more non-rich people who need health insurance than there are people who may die because of "bureaucratic incompetence" or lack of incentive(what? do people really need money to not let someone die?).

The way you phased it the former is obviously(to me at least) better than the latter one.

It also sounds like you think medical research advances only in countries with the latter style of health insurance. Do you really think medical advances happen only in America?


I'd love to see you and chimeracoder (sibling comment) fight it out, because his comment was exactly that medical advances happen because of freeriding off the American system, and without the American system, those advances would not happen.


The idea that the American system is pulling the rest of the world up by its bootstraps is in my belief absurd.

Copied from earlier comments by me:

let's go through a quick run-down of the 'major' pharmaceutical companies of the world, and where they are headquartered.

Company Revenue (USD) Headquarters

Novartis 53.6 Bn Switzerland

Roche 47.8 Bn Switzerland

Sanofi 36.9 Bn France

GSK 34.9 Bn UK

AstraZeneca 26 Bn UK/Sweden

Bayer 43.4 bn Germany

Baxter 15.3bn US

Pfizer 49 Bn US

Merck 42.23 Bn US

BMS 18.8 bn US

So, 4 of the top 10 pharmaceutical companies by revenue are headquartered in the US. By Revenue, those 4 account for 125.3 Bn out of a pie of 367.9 Bn; or 34%.

It is not easy to get a list of the number of drugs under clinical trial, or the number of drugs that were recently brought to market by various manufacturers; and, as a side matter, a number of the more innovative drugs brought to market recently were all developed by small pharmaceutical companies (Boceprevir, Telaprevir, Imatinib, Ipilumimab) that were later acquired by the big boys.

So a small pharma company did the innovating, usually funded by a university or the product of particuarly profound insights by PhD students; turned into successful drugs; run through to the stage 3 trial stage and then, once all the development costs are done and dusted, acquired for a discount price of the predicted future revenue stream So tell me, where are all the drugs being developed by america? I would say the rest of the world is more than pulling it's weight.

In fact, given rough population parity between the European first world and the United states, it could in fact be argued that the United states is not pulling it's weight.


> So tell me, where are all the drugs being developed by america? I would say the rest of the world is more than pulling it's weight.

Going by where the companies are headquartered is meaningless, because these are all multinational conglomerates. The question is where they procure the funds for their R&D.

As it turns out, not only is 50% of the entire world's medical research actually conducted in the US, but even for research developed outside the US, the US market still serves as the primary driver for the funding, which is pretty easy to see if you bother to dig into their public financial disclosures.


From the 2016 ITA Pharmaceuticals Top Markets Report:

>"In addition to a favorable IP and regulatory environment, U.S. laws allowing direct-to-consumer advertising creates immense demand for specific patented drugs. More importantly, the United States is the world’s largest free-pricing market for pharmaceuticals. As a result, prices are comparatively high to make up for lower profits in other countries and to cover R&D costs.

The United States also has high per capita incomes, unmatched access to healthcare, a large elderly population, a culture of end-of-life prolongation, high rates of chronic diseases and drug consumption and a strong consumer preference for innovative drugs.

All of these factors contribute to it being, by far, the world’s largest pharmaceutical market with $333 billion in sales in 2015, about triple the size of its nearest rival, China.

The United States will remain the world’s most important market for the foreseeable future with healthy growth expected across all product sectors."

<trade.gov/topmarkets/pdf/Pharmaceuticals_Executive_Summary.pdf>


>'Would you rather live in a society where everyone has a right to medical care regardless of their social standing or financial wherewithal, but some people will die because of bureaucratic incompetence or because the person who could've saved them has no incentive to?'

That is delusional. As a doctor in a single payer country, I can categorically say that the quality of living of myself and my colleagues is excellent. In fact, for those not from privileged backgrounds (many, as we have relatively affordable tertiary education) not having a quarter to a half a million of debt" graduation actually means we are better off.

So there's that, then there's the fact that I aggregate, the level of care in Australia, or the uk, or Japan, or Germany, is actually substantially better than that I the US.

Inform yourself sir.


I support a single-payer approach, largely simply because the biggest risk pool spreads the risk most evenly, but I think we have to be very careful with the word "right". I agree that basic medical care can be considered a right, in the sense that a wealthy society, which we are, is morally obliged to provide it to its least fortunate. But there has to be a limit to what counts as "basic"; if we don't impose one, we're going to wind up with even worse cost inflation than we have now.

The rich will have better health care even in a single-payer system, and I'm fine with that.

The thing I really don't want is the pre-ACA system, where only people with good jobs can get access to health care.

BTW I saw a great Yonatan Zunger blog post on this a while back... ah, here it is: https://healthcareinamerica.us/how-to-ask-good-questions-abo...


You hit the nail on the head with what counts as "basic" - as long as politicians can win elections by giving a benefit to people that they don't have to pay for/or collectively can't afford, I'm not sure how you ever contain this problem...


> The former is (to a first approximation) what you get with European-style single payer

Aside from the fact that most European countries - even those with government-mandated healthcare - do not have single-payer insurance, this is a false dichotomy that ignores the global market dynamics.

Just as Medicare in the US could not operate in its current form without the existence of the private market to implicitly subsidize the public system, European countries would have a very different healthcare story in the absence of the US market.

Nobody likes to admit it, but there's a reason that the US is the source of over half of all direct biomedical and pharmaceutical research worldwide, including research conducted by European pharmaceutical companies. These companies use sales on the US market as the source of funds for the research that all countries benefit from, and in the absence of the US market, either those costs would be borne by Europe, or that research would simply not happen[0]. They also pull funding from the US market via other, less direct means.

Yes, the US system has massive problems, and yes, it could and should be cheaper. But you can't analyze these as binary options in isolation, because they're not binary[1], and they're not operating in isolation either.

[0] If you want to make the argument that Europe could come up with a system that pays for this research in the absence of the US market, fine, but then you have to explain both why that would not simply recreate the same expenses, and explain the fact that, so far, that system has not been created even by the European pharmaceutical and biomedical companies.

[1] The UK has four main payers; the Netherlands doesn't even have single-payer at all, and so forth.


I'd be okay with less innovation if it meant that everybody got decent medical care. Statistically speaking, most people don't die from exotic conditions but rather from mundane things that just need treatment.


So assume that the U.S. health system goes away and that no further medical research is ever conducted; we're left with whatever the state of knowledge is now, and it'll never get better. This is what I was somewhat obliquely referring to as "some people will die because the person who could've saved them has no incentive to".

The question still stands - would you rather live in the world where everyone has access to medical care but it isn't cutting-edge, or one where the very best in care and the very best in research techniques are available, but only for a price? I'm honestly curious about peoples' answers, because it is a dichotomy. Not necessarily a sharp one - you could imagine several intermediate systems in between - but there's a tradeoff between universal access vs. incentivizing further research and new techniques.


> So assume that the U.S. health system goes away and that no further medical research is ever conducted; we're left with whatever the state of knowledge is now, and it'll never get better. This is what I was somewhat obliquely referring to as "some people will die because the person who could've saved them has no incentive to".

Again, there is no "would you rather". You can't treat these as binary options, and you can't treat these as operating in isolation. They're an array of systems that mutually operate within a global context. There is no answer to that question, because the dichotomy assumes both a binary and isolation.

There is indeed a tradeoff between quality and access, and there's a worthwhile and necessary conversation to be had around that. But that's not the same as the difference between the US and the multitudinous systems within Europe (most of which are not single-payer). And it's not the same as the question you opened with.


Why would there be a dichotomy? Both space travel and the internet come to mind as government funded projects moved the United States into lucrative markets with cutting edge technology.

There is no dichotomy between universal coverage and cutting edge technology.


>> no incentive

If I see someone drowning, I have no financial incentive to go save them. But I will go save them. Financial incentives aren't the only incentives. They aren't even the best incentives.

Why might someone go into medicine and/or research if it didn't pay huge salaries? Maybe because it's meaningful work. Maybe because it brings prestige. Maybe because they enjoy it. Maybe because they care for people.

I contribute to open source software and have never been paid a dime, yet you can hardly say that open source software is inferior to proprietary/for-profit software.


The US payers don't subsidise medical research for the rest of the world; they pay for the vast amounts of advertising that the US companies do to doctors and consumers.


Neither. Why not dream bigger than that?

We have unprecedented means to distribute information for "free" (or at least cheaply enough that even homeless people can access insane amounts of information, unlike in the past when a lot of stuff was only accessible to the elite) and diet and lifestyle are cited over and over and over as contributing to deadly conditions. There is lots of room here to do good things for everyone, quite cheaply.

Though I am for the U.S. transitioning to universal basic health coverage for its citizens. The current situation is terribly broken.


The US isn't heading toward "miracle treatments for the rich", it's heading towards "over testing, over diagnosis, and over treatment for the rich", all of which are linked to harm.

And single payer systems mostly don't prevent private treatment - you don't need it because the single payer is good quality and the only benefit you get from private treatment is access to ineffective experimental very expensive treatments and nicer hospital rooms.


Put another way: "Oh no! I'm rich and so can pay for whatever infinite quality, resource wasting healthcare and so I'm scared I might have to endure poor people's healthcare".

Rest easy - you can still buy your way to better care.

Fwiw there is an "Intellectual Care Advantage" in that someone who is articulate and educated (aka well off) has a much better chance of getting good care, through their ability to navigate system, communicate with healthcare professionals, do their own research, be the squeaky wheel. But in my experience that advantage exists equally in both the US private system and in the European socialized system.


I'm European so maybe I'm just proving your point , but I think you're severely overestimating modern medicine.

Most ailments get 'treated' alright, but the actual help you get isnt statistically better than placebos would've been.

Often, you get better despite of the treatment, not because of it.

Even something as basic as a broken bone just boils down to 'force patient to keep still while nobody does anything for weeks'.

.. heck, the biggest impact on healthcare continues to be personal hygiene. Most of the life expectancy improvements within the last 200 years can be attributed to that.


This is demonstrably false on a huge number of conditions: type 1 diabetes, arthritis (knee and hip replacements), childhood vaccinations, antibiotics- you are being disingenuous to the advances over even the last 50 years here.


ah, I did not mean to imply that modern medicine is useless. I'm sorry if that sounded like that.

there are absolutely examples of its success, as you've correctly pointed out! It's still not nearly as amazing as the grand-grandparent made it sound. and my previous statement still stands: personal hygiene continues to save more people than any other treatment. this includes vaccinations and antibiotics (they're both wonderful discoveries that help save a lot of people).


I want everyone to have the same system, so that rich people are forced to expend their influence on trying to improve the system for everyone.

Give them the option, and they'll just make the best walled garden they can and fuck everyone else.


The solution is AI. Self-driving cars and AI healthcare has the potential to make the insurance industries associated with both. I only recently learnt about the horrific healthcare in the US, and am doubling down on developing AI for healthcare. If I replace one doctor's job with an AI, I've probably saved 10s of lives.


How do you intend to ensure the fruits of your research will be used to benefit people rather than the large organizations who will (at least initially) control healthcare AI?


Doctors per se are not the most critical problem in US healthcare. Premature optimization is the root of all evil. Find the real tentpoles and start there.


I think you're confusing "health insurance" which has a strong social redistribution component, with pure insurance, which is a business transaction to pay off on the chance something happens.

Pure insurance is when a consumer buys a Playstation for $300, and then pays $5 for an extended warranty, or when a company insures their office building against a fire. I don't think your arguments apply to that. In such a case, is there unacceptable social harm if a insurance company determines I'm really bad at taking care of my Playstation, and refuses to insure me? Is a company that badly off if they need to write down the cost of a building if it gets burned down?

Is all insurance a social right? I feel that health insurance has the strongest claim to this, because it's not a pure business transaction and it's about who we're letting die in society.


I think fair and transparent business contracts are a consumer right.

Insurance is statistical in nature, and contracts should be required to explicitly outline the scope of coverage. If I’m paying $5/m for coverage of manufacturing issues with my Playstation, I expect any manufacturing issues to be covered. I would also expect an extremely unlucky customer to receive multiple device replacements without any change of premium - because the contract and price should reflect the expected failure rate of the device (plus overhead + profit).

In that example, it should be illegal to boot an honest customer after the first failure… the only reason to do so would be because the insurance company set an artificially low rate that doesn’t reflect the ammortized rate of manufacturing issues. In other words: the business is breaching contract by charging me for a different service than I’m getting.

Although, given the clear scope of coverage, proof of malfeasance is justification to both refuse payout and ban the customer.

However, if I’m paying $5/m for unlimited coverage, I expect unlimited coverage. That rate is expected to cover idiots that keep their Playstation on a fireplace, and perfect people that never move the device from a cool location away from vibrations and interference. Again - if I get kicked after the first failure, that’s failse advertising. Of course there are people that will microwave their device for fun and demand a replacement - the rate should include those people, or the contract should not offer unlimited coverage.

Businesses are free to not offer unprofitable coverage, but consumers have an economic right to demand that businesses honor contracts. I’d argue that consumers also have a right to accurate advertising - if the “unlimited coverage” plan has fine text that says “manufacturing issues only”, well, that’s not really above-board.


Totally agree; the problem of insurance is one of contract law. Most people denied claims are denied legitimately based on the contract they signed. However, there is the perception that claims are denied unfairly because there is a disconnect between what you thought you signed with what you actually signed.

I saw this every day when I was a catastrophe claims adjuster with Farmers Insurance during Hurricane Ike that demolished a good part of the Texas/Louisiana coast. I actually had a customer threaten to shoot me because I couldn’t write a check for a water damaged wood floor despite writing a big check to replace the roof. The actual source of the water damage wasn’t the roof, it was the floodwater. So while the walls from the roof downward were covered because that damage was from the seepage from the damaged roof, the floor damage was entirely from the flood. (It was a two story house so the water from the roof seeped through the walls from the attic and leached downward into the drywall, while the floor downstairs was covered in a pool of water from the floor.

The point is the homeowner thought he was covered despite there being an extremely clear flood exclusion for that particular policy. I could have been really strict and only covered the walls down to the flood line, but since the walls were a total loss either way, I had the flexibility to cover the walls all the way to the floor.

I saw this misunderstanding again and again when it came to roofs. A 20 year roof that is 10 years old is only covered at a fraction of replacement cost because it only had 10 years of value remaining. Those were uncomfortable situations for me however, the homeowner, when buying them policy could have bought a replacement cost add-on, but they wanted to save money so they got burned when they needed the coverage.

Insurance agents are a HUGE part of the problem – is claims adjusters had to be the “bad guy” and break the news that their policy didn’t cover what they thought it did. I was the one getting harrassee when all I was doing was following the contract. I did my best to lean on the side of the homeowner, but all of my payouts had to be supported by detailed measurements, photographs and Xactimate estimates.

A nasty business that was. I barely lasted a year before I burned out.


Every time I have ever purchased any insurance policy, I have read it. All of it. Then I pick out sentences or paragraphs and ask my agent to explain what they mean. The agent never knows. Their boss never knows.

I'm a fairly educated person. I understand a lot of complicated things. I can read and comprehend legal statutes, building codes, lease agreements, historical documents, Shakespeare, transcripts of legal proceedings, and lots of hiphop. But I have never been given a policy statement from my insurance agent that was coherent. Or even complete.


I think it is these "pick and choose" exclusions that have no actual sense to them. Of course a homeowner's insurance policy should cover flood damage to a floor. The floor is part of the home, isn't it? But no, the company decides to pick and choose, and they never really call attention to it.

This is why the ACA came up with the "Essential Health Benefits" list. There were so many things that, common sense would tell you should be covered, but insurance companies would exclude for no viable reason (making more money or not having to pay out claims are not things I consider "viable reasons" in this context). You'd buy insurance, only to find out it wouldn't actually cover things that people would want to use it for.


As I understand it, in the US, flood damage is almost never covered by homeowner's insurance. It is covered by flood insurance from the US government.

The reason for this is because most human settlements are near water. It is not only essential to life, it is a good means of transportation and has been for a long time. So most human settlements are built in flood plains. Thus, sooner or later, most homes will be at risk of flood damage.

Insurance is about risk management. There is no risk to manage here in terms of taking a financial bet. It is all downside for the insurance company. The question is not IF the house will be in danger of flood so much as WHEN. Insurance companies try to avoid such bets, for the most part. (Not counting life insurance.)


If and when are the same from a risk management perspective... Have you heard of life insurance? 100% of customers will die, the bet is whether they die before the collected premiums exceed payout.


No, actually, a lot of term policies basically bet that you die after the policy expires.

Whole life policies make the bet you are describing. They are a lot more expensive than term policies and you can borrow against them because you are basically putting money into a fund in some sense.

The vast majority of life insurance is absolutely a bet. Many, many life insurance policies are only good if you die on this flight to New Zealand or if you die in a car wreck or if you die in the next five years while still quite young. People buy these things because they are cheap as all fuck because they are long shot bets. Most people won't die on their plane flight or in the next five years while in their 20s or 30s.

And the last line in the comment to which you are replying makes it crystal clear that I have, in fact, heard of life insurance.


Living on a floodplain is like smoking two packs of cigarettes a day. You'll be fine for a while, and then you won't be. If the house isn't on stilts, you'll have to fix the flood damage eventually. Insurance companies know this, so they'll charge enough for flood coverage to cover the inevitable losses.


Insurance doesn't generally cover flood damage for structures in flood zones, or does so at a much higher price.

The point of briandear's example was that wind had damaged the roof and walls, and wind storms were covered by the insurance; whereas flooding had damaged the floors, and flooding was not covered by the insurance.

When you get insurance, it doesn't necessarily cover everything. You might have insurance that will pay for your home if it catches fire and is destroyed accidentally, but will not pay if a person deliberately commits arson. Insurance might pay of your home is destroyed by a storm, but not by a landslide, and so on.

The main problem I heard with briandear's example is that people apparently didn't understand the coverage they had purchased. If I operated an insurance company, I would consider summarizing the policy that people were about to purchase with a simple form showing the most common hazards. Maybe even show them with simple glyphs depicting fire, floods, storms, etc., and indicating whether their plan covers that scenario or not. Ask them to sign or initial that form. It's not a legal form, but you'd present it to them and ask them to confirm they understand it along with the contract text version.

Then, when an event happens and they're asking for an insurance payment, you show them the form that they had initialized, and explain how things were covered or not covered.

I would also want to explain to people that multiple disasters can happen at once, and explain how the insurance company will reason about what's covered, based on the cause of each thing that was damaged or destroyed.


> The main problem I heard with briandear's example is that people apparently didn't understand the coverage they had purchased.

While that's true, a part of the reason is the complexity of policies, and exclusions for situations which people consider "common sense" to be covered. Situations which are medium risk, but part of people's everyday lives.

For example, my travel insurance does not cover accidents which are "a result of drug or alcohol influence". My laptop loss insurance does not cover theft if it is "left unattended in a room with public access".

It might make sense to exclude getting high on unknown drugs in Thailand and stabbing yourself, or leaving your laptop on a truck stop cafe table while going to the toilet.

But at the same time, having a few beers while on holiday, and leaving your laptop on your desk at a startup office are both things which reasonable, responsible people still often do. And would not expect to invalidate their insurance cover.

Unfortunately nobody could explain to me the precise details of these clauses - what counts as a "result of" or "public access".


I wonder how much extra insurance companies are able to charge consumers because it is so complex for most people. There is massive information asymmetry there in favor of the insurance company which almost certainly is reflected in higher margins than they'd otherwise have if they had an educated customer able to properly assess the offering.


> Of course there are people that will microwave their device for fun and demand a replacement

This is known as insurance fraud.


The example offered "unlimited coverage" - I hoped to point out that making unrealistic offers is also a problem on the business side.


> Is a company that badly off if they need to write down the cost of a building if it gets burned down?

That means a company has to always keep cash in reserve against the off-chance of its building burning down just because insurance can't be trusted. That's money that can't go into expanding the business and creating additional jobs. Imagine the overhead of this parked money across thousands of businesses. Not to mention a lot of startups or young businesses can't have that sort of cash position, which means it becomes another barrier to starting businesses. It would be a major impediment to the economy.


Even worse, if you have to account for that possibility, why buy insurance in the first place?


All insurance companies have the temptation to disqualify claims to improve profits. The nature of the problem is that when you buy insurance, you are disconnected in time from the point where you might need to make a claim against that policy. And it is only when you make the claim that you find out how nice or terrible that company is at actually delivering the product you've been buying.

There is a better way than just purchasing a policy and hoping. E.g. in CA, you can inform yourself about various home insurance companies before you buy. By looking at the data the CA Dept of Insurance publishes, you can see the ratio of claim complaints to policies.

In some lines of insurance like healthcare via employee benefits, you aren't the person deciding on the insurance company - and that definitely leads to problems...


The biggest reason for the social redistribution component is the pesky issue of age. Old people seem to consume a lot more health services. People when born also do but are taught to consume less. Somehow they forget when they get older...

The problem would not exist to this extent if there were lifelong contracts. Even in places where they are common the premiums are not reflecting the cost of the age cohort but have some actuary life insurance component to them. Eventually one has to pay in what one is statistically likely to consume and that is easier when younger. So even in a totally capitalistic system while earning one pays for ones future old age risk. The US system is an outlier as the old age risk is socialized.


The easiest way to see that health insurance is not pure insurance is to notice that if your auto insurance behaved like health your gas, oil and windshield wiper replacements would be reimbursed also.


> the moment a customer becomes more trouble than they are worth, they are dropped.

Insurance is a business. I don't think any business would want customers that are more trouble than they are worth.

> they are too protected by our legal system for them to not do it.

Solving the risk issue with patients who will never be able to afford their healthcare is not an insurance problem. These people are uninsurable. There's a known cost to pharmaceuticals associated with being a hemophiliac. There's a known cost to the outpatient care associated with kidney disease. There's no "risk" associated with those costs.

We need to re-frame the discussion around socialized healthcare, not health insurance. Health insurance, apart from high-deductible, low-cost plans, doesn't exist. The US already has socialized healthcare, the problem is that it is a split private/public model.


> Insurance is a business. I don't think any business would want customers that are more trouble than they are worth.

But insurance is precisely the business of taking money from everyone that's exposed to a potential loss (namely the expected value of that loss, plus some more to cover administration cost and profit), and then distributing it to those actually suffering the loss.

If the insurance then turns around and kicks those affected out, it is reneging not only on the spirit of the contract, but on its entire raison d'être.

Agreed, though, on your later point that in the health domain, certain risks, once they've occurred, are so massive that traditional (private market) insurance structures might not be really suited to them, which is why nearly the entire developed world has some sort of public health insurance, fortunately.


> If the insurance then turns around and kicks those affected out, it is reneging not only on the spirit of the contract, but on its entire raison d'être.

It's not reneging, assuming they make you whole on the loss.

If I wreck my car, and I have insurance, I will be reimbursed for my loss. There's no expectation at that point that I will necessarily keep my coverage, or keep it at the same premium, now that I have demonstrated that I am a higher risk.

For health insurance, it's a bit different because some diseases can't be cured, and it's harder to put a dollar amount on the "loss" incurred. For example, if I develop diabetes, that may be something that has to be managed for the rest of my life, and has various other side effects such as circulatory problems. But, we have data; there are lifetime averages for this sort of thing, and they can be computed into the actuarial risk profile. As long as you acquire the insurance before you incur the loss, the model works.

> nearly the entire developed world has some sort of public health insurance

We should not call it insurance when that's not what it is, though. If you have a disease (preexisting) the insurance model doesn't work, any more than it would work to sell homeowners insurance to people whose houses are currently on fire. The risk of loss to the insurer goes from "actuarial probability" to "100%"


The solution to preexisting conditions is usually mandated coverage. This way, since you always have insurance, you can't be blamed for only getting insurance when you need it.

This still doesn't allow people who get a condition to upgrade their insurance. Allowing this amounts to socialized health-care. An alternative is to make such coverage part of the mandatory package. This way, it is still insurance. This is only as socialist as insurance inherently is (i.e. the unlucky being covered by the lucky).

The big issue here is 'liberty', but if you hold that no-one should die because they cant access health care, and don't want to make healthcare free, mandated insurance is the only option.


Yep, but as long as they're for-profit and the people making decisions there are allowed to prioritize increasing shareholder value above minimizing human suffering, I don't think it'll change.


> which is why nearly the entire developed world has some sort of public health insurance, fortunately.

"That 'nearly' is a real killer" - Somebody from the "nearly"


Re: health – that's because what you really want is a single-payer health care system funded through taxes, not commercial health insurance, but your country's ideology does not allow for that.


I think you are making some big assumptions about what Socrates wants. There are other possibilities. I live in Australia where there is a dual system, I'm from Canada which has public health care.

Limiting your thoughts to make assumptions about the original poster is limiting your potential to see opportunities.


I am not making assumptions. I'm providing my own opinion that the problems he mentions are best addressed by funding healthcare with taxes instead of having an insurance system.


> is the inherent disproportionate power relationship between the company and their customer.

And the principle of "utmost good faith", which insurance companies abuse to remove cover after a claim, unfairly disadvantages many people.

https://en.wikipedia.org/wiki/Insurance_law#Utmost_good_fait...

https://en.wikipedia.org/wiki/Uberrima_fides


Given that insurers so far have been unsuccessful in legislating requirement for a customer to hand over any DNA test they have performed, it seems quite sensible solution that customer gets dropped, as otherwise they could exercise information asymmetry to their benefit, and great peril of insurance provider.

Of course this is sarcastic, but argument about information asymmetry, created by DNA testing, that supposedly threatens the existence of insurance business is quite real.


> "Essentially, the moment a customer becomes more trouble than they are worth, they are dropped [by the insurance company]."

In healthcare there are many different models, but one popular one is the concept of an ASO. This is the case where a healthcare insurance company (think Anthem) will provide administrative services only (ASO) and not (ultimately) be financially responsible for paying claims. The group responsible, in this ASO relationship, is generally an employer.

This is actually fairly common and in it the insurance company has no incentive to drop a "customer" (member), even if/when they legally could.

There is a lot of "bad" in the health insurance industry, but there is also a lot of "good" - people working from the inside who are trying to make things better for members/individuals. Things like improving quality of care, managing coordinated care models, identifying medical risk (eg. opioid abuse), etc.

I think first people need to better educate themselves on how the industry currently works, where the problems are (there are many), and where the more positive efforts are being made in the industry. Bottom-line - don't write it off, but get better informed and try to contribute.


What you are proposing,"get better informed and contribute", doesn't many any sense.

"get better informed" about what? How insurance companies take advantage of poor people? Even if I know all the laws and regulations and details of my policy, if I don't have the money (hire a lawyer) to fight it, then I am screwed.

And this has happened to me. I was in the right, but my insurance company ruled against me, I complained and they basically told me to hire a lawyer if I didn't like it.

And "contribute"? what is that? Contribute money?

You still don't have a solution for the problem, insurance companies having asymmetric power (via information and money and legal influence) in the customer relationship.

They collude with other insurance companies to create complicated policies that you can't negotiate or understand, but are forced to have legally.

It's billion dollar powerful and well connected corporations vs. one person. Not exactly a fair fight.


My point being that you can contribute by demanding your state or federal government officials write or support laws that change how health insurance companies are allow to operate - or - by joining the industry and fixing it from the inside.

Your argument is an emotional one, and that is fine, but it does not help to _realistically_ approach this problem.


I realize my argument is pessimistic, but it's much more realistic than calling "my" senator.

Our system is broken. Calling or contacting our representatives is essentially futile.

Honestly, the best way to change anything, would be to get rich and try to buy some influence. Which is exactly what got us here in the first place, rich people buying influence.


Before you go thinking about how this applies to healthcare... health insurance in the U.S. is different from other types of insurance and personally I think we'd all be better off it were not even called "insurance."

Health insurance is a mix of pre-paying for predictable and certain expenses with tax-free dollars, a transfer/entitlement system to ensure that more people can afford insurance (by design, your premium does not match your expected risk--either you are pooled with others at your employer, or your exchange account is subject to rating band requirements which means, for example, that in many states old people can only be charged 3X more than young people even though old people are likely to be much more than 3x more expensive to insure), and actual insurance. I'm not sure what percentage of your premium reflects the cost of actually insuring you against uncertain future health events, but it's far from 100%.

This is an interesting article, and some of it applies to healthcare in the U.S., but much of it does not.


"health insurance in the U.S. is different from other types of insurance and personally I think we'd all be better off it were not even called "insurance.""

Agreed. If regular, predictable events are covered, it is not insurance. Regular, predictable events are not insurable. Be cause math.

Wellness checkups and scheduled preventative care and yearly mammograms/prostate are all fantastic things ... but they're not insurable. If someone is selling "insurance" for those things, you can be certain that you're paying 100% of the cost somewhere.


>If regular, predictable events are covered, it is not insurance. Regular, predictable events are not insurable.

The problem in the U.S. is that we have this bizarre system where hospitals charge exorbitant prices and then insurers haggle them down to something halfway sane. So when you're paying for "insurance" you're (ideally) getting both catastrophic coverage (i.e. actual insurance) as well as access to a cartel that negotiates prices down from impossible heights on your behalf -- even for routine care.

Since most people who regularly access medical care do so through these cartels, care providers have no incentive to make care more affordable than what they can get away with -- and insurers have no incentive to allow the price to drop either, since people being able to afford care outside the cartels would ultimately undercut their profits.

This system is fundamentally unworkable. There's really no way to detangle the perverse incentives here in a way that will bring prices down to a level comparable with single payer healthcare.


The ultimate reason behind hospitals attempting to charge exorbitant prices is due to Medicare and Medicaid paying under cost for services. Hospitals need to make that difference up somewhere. Surprisingly, if you remove the profit hospitals make on ancillary services like the gift shop, parking fees and investment income, they are losing money.


Isn't the overly-litigious nature of the U.S.A also why costs are so high?

The malpractice insurance that docs and hospitals need to carry in order to defend themselves should they be sued is passed onto consumers in the form of higher medical costs.

Or at least that's how someone once explained it to me. Is that not also a contributing factor?


Anybody in the entire health care system can point their finger at someone else and claim that they're the ones who are gouging us. I suspect that they're all gouging us.

One thing I've read is that states with caps on malpractice claims do not have lower medical costs.


"overly-litigious" would need to be cited in my opinion. What is "overly"?


That can't be true. They are not required to accept Medicare or Medicaid. If it was a losing offer they just wouldn't accept it.


"Payment rates for Medicare and Medicaid, with the exception of managed care plans, are set by law rather than through a negotiation process, as with private insurers. These payment rates are currently set below the costs of providing care, resulting in underpayment. Payments made by managed care plans contracting with the Medicare and Medicaid programs are generally negotiated with the hospital.

Hospital participation in Medicare and Medicaid is voluntary. However, as a condition for receiving federal tax exemption for providing health care to the community, not-for-profit hospitals are required to care for Medicare and Medicaid beneficiaries. Also, Medicare and Medicaid account for more than 60 percent of all care provided by hospitals. Consequently, very few hospitals can elect not to participate in Medicare and Medicaid."

Source (American Hospital Association, December 2016): http://www.aha.org/content/16/medicaremedicaidunderpmt.pdf (Sorry it's a PDF)

Edit: updated from 2010 reference to 2016 reference


That quote is misleading because it implies that the cost of care is static, that it's not also heavily influenced by spending choices made by the hospital that don't affect patient outcomes. Or heavily influenced by the consequences of the broken healthcare system, like the overuse of emergency rooms by people who can't afford to see a doctor.

Hospitals could easily afford to provide care at Medicare/Medicaid rates — if they're willing to have less impressive lobbies, marketing materials, corporate facilities and shareholder profits. Citation: all other first world countries.


> shareholder profits

Do intelligent people ever go to for-profit hospitals? I'd group those with for-profit universities and for-profit prisons as "nope, not touching that, stay as far away as possible and hope they all disappear".


No matter your intelligence, if you're having a heart attack, you go to the nearest hospital, whatever its tax status may be.


Okay, but apart from emergencies, why would anyone go to a hospital whose goal is profit when all the best research hospitals are non-profit?


Your tax status doesn't necessarily indicate what your goals are. SpaceX and Tesla are for-profit and the Susan G Komen foundation is non-profit.


But do you have any actual counter-examples to "all the best research hospitals are non-profit"?


Do you have any price comparisons between for-profit and non-profit hospitals?


non-profit hospitals and non-profit universities have had exorbitant price increases in the last few decades so they aren't doing any better


Maybe, but for the same expense I'd rather go to (non-profit) Harvard than (for-profit) Trump University.

All the best universities are non-profit, for the obvious reason that it allows them to keep massive endowments, which are spent on better education instead of being paid out to investors.


It's because in addition to the reimbursement, hospitals are paid a bonus fee by US taxpayers called a DSH to subsidize the subsidies. This serves to incentivize providers not to drop Medicare/Medicaid patients and also covers up the losses incurred.

More info: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Paymen...

Good commentary about upcoming changes that endanger these programs: http://www.modernhealthcare.com/article/20170626/NEWS/170629...


The ultimate reason behind hospitals attempting to charge exorbitant prices is that you have no choice but to pay.


Hospitals charge high prices because they can. They are often local monopolies, and behave accordingly. And with an utter lack of price transparency, which makes the idea that patients could shop around a joke.


There is a simple reason for the "cartel": it's called moral hazard.

You have the monopsony that comes from collective buying power on the one hand. (An argument for SINGLE PAYER insurance.)

On the other you have the usual moral hazard which says, if the customer ain't paying, try to charge as much as possible.

So it's this game of bigger and bigger armies. Same as when countries can't make a peace deal where neighborhoods and individuals long ago could have. A single person can torpedo a deal. It's all or nothing.

It's also why some British bureaucrats in the NHS face the choice of dropping coverage for a drug because the company just won't play ball and charge a low enough price. When are you willing to walk away when you represent a lot of people??


There's some nuance here: It might be that a rational insurance provider encourages their clients to do regular checkups for conditions that can be caught early and treated at a much lower cost.

Now, the parent comment still is correct that that cost would have to be covered by premiums, but the premiums should still be equal or lower than they were if they didn't provide the checkups.

In effect, in such cases the insurer could market the regular checkup as a benefit, but rationally if they could they'd rather make the checkups a policy obligation to preserve their margins. This is what aligned incentives looks like :)


There's some nuance here: It might be that a rational insurance provider encourages their clients to do regular checkups for conditions that can be caught early and treated at a much lower cost.

I'm a member of Kaiser HMO, and they do just that -- they regularly notify me of screening tests I should be doing and they offer several ways to contact my doctor without actually seeing my doctor.

If I'm not sure I need to go in to see him for that lump on my toe, I can call a triage nurse for advice, set up a phone call appointment with my doctor, or do a video chat with him.

For my last annual checkup, my doctor emailed me, asked me to go in for some bloodwork, then a few days later, I went to visit the doctor and we talked over the results while he conducted the physical.

I know some people don't like Kaiser, but I've had only good experiences with the system, and I love their electronic records system - I can view test results online, and if I'm referred to another doctor, the other doctor has instant access to my records.


I'm not sure I agree. If my insurance is on the hook for prostate cancer treatment, then they may expect a prostate exam to save them money, in which case they would have an incentive to pay for it.


Precisely why healthcare insurance is different.

Preventative health saves more resources than reactive health (i.e. catching cancer early as opposed to when it display symptoms). One of the big problems of healthcare insurance in the U.S. is treating it like car insurance - a numbers game of reactions to accidents.

Some insurance policies cover 100% of annual checkups but it still trains people to avoid going to the hospital.


It's not that different, though. Preventative measures show up in many insurance contexts (although I guess usually as a premium discount, not as being paid for by the insurer): fire alarms, and training for motorcyclists and pilots, come to mind.


Except your other insurers do not pay for fire alarms, oil changes, etc., which usually don't cost hundreds to thousands of dollars each year.


Wouldn't insurance companies want people to get preventative care over reactive care, to lower their own operating costs? I know that Cigna is a big proponent of this, but I can't think of any others that do the same.


> Agreed. If regular, predictable events are covered, it is not insurance. Regular, predictable events are not insurable

Ignoring the US specific stuff, there's a reason that my private health insurance basically covers a regular medical screening - and it's not because the cost is in the premium. It's because that preventative strategy allowed them to reduce the size of claims from people who otherwise would find problems later and those would be more expensive.

Imagine, if you will, a car insurer who can't turn around and refuse to pay out on claims where the car hadn't been serviced in 5 years. The tyres are bald, the break pads worn, etc. Now imagine that they offer a yearly basic road-worthiness check for free each year. They'll sell more policies (because it's free stuff, and they care) and have fewer claims caused by poorly maintained cars.

The costs are being paid, clearly, but they come in part from changes in the claim profile that you would be paying for otherwise.


> If someone is selling "insurance" for those things, you can be certain that you're paying 100% of the cost somewhere.

Nope; probably more like 150%. Except I hear that in America, those insurers can get a deal for you for the routine stuff compared to someone un-"insured". Pretty f'ed up.


Payors are healthcare wholesalers. They can buy health services from physicians and facilities at about a third to a tenth of the cost you can because: 1) It's not life or death for them; and 2) They can buy in bulk


If your insurance covers pre-existing conditions, it's not insurance anymore.


The problem is that every condition becomes a "pre-existing condition" when you change insurer. And because insurance is tied to jobs, people are forced to change insurers frequently (whenever they change jobs, or whenever their employer changes providers).

So you're on insurance A with no pre-existing conditions and get cancer. Next year your employer switches to insurance B. Now you have a "pre-existing condition" - is it fair to suddenly refuse to treat you? If that's the case, what's the point of having "insurance" at all?


If this were an "insurance" market, when you get diagnosed with a problem (cancer, say), the old insurance A would have to pay for the cancer treatment, and keep paying even if you leave the insurer.

Any "new" conditions would be covered by your new insurer B (or not covered, if you didn't get new insurance), and insurer B would have the right to refuse to pay for pre-existing conditions because those would be covered by your old insurance A.

But that isn't to say that if we had "insurance" life would be altogether better. Insurers would increase the premiums of people who beat cancer, because cancer has a habit of coming back. Quite likely anybody who beat cancer would be unable to afford insurance in the future.


Pre-existing conditions includes disorders that makes you more susceptible to diseases while not guaranteeing you'll get them. That's still insurance.


Not necessarily. In my view, all insurance is a creature of regulation. Insurance needs regulatory oversight to manage substantial moral hazards and arbitrages, otherwise nobody would buy it. The enabling regulations for health insurance could include provisions for managing the care of people who have pre-existing conditions.


That's not true. Look at insurance clubs in third world countries (funeral insurance clubs in South Africa for example). It's completely unregulated, but people band together to help amortize the cost/risk of rare financially devastating events.


That's fair, but I suspect that the insurance industry as we know it would be reduced to a microscopic fraction of itself without enabling regulations. Likewise for business in general without liability limitation and other corporate regulations.


If you're talking about the pre-existing condition of broken leg, I agree with you. You should not be able to sign up for insurance after breaking your leg and get all the relevant care paid for.

If you're talking about the pre-existing condition of fat and family history of heart disease, then I disagree.


It wasn't meant as a political statement. Instead I was commenting on how the terminology doesn't make sense.

A single payer system would remove a lot of the perverse incentives we have with our current model that prioritizes profits over care.


Don't forget collective bargaining against hospitals. [1]

[1] https://en.wikipedia.org/wiki/Chargemaster


Isn't it still insurance though, as in insurance against tremendous healthcare costs without it? Maybe I'm misunderstanding, but I thought the definition of insurance was just protection from loss


Here's a great blog post on insurance and healthcare: https://healthcareinamerica.us/how-to-ask-good-questions-abo...

I think insurance is not an accurate word for the health care industry. I, like you, think of that word as coverage for risk, and in fact that is how the industry started in sixteenth century Netherlands (mentioned in that blog post).

But the business of insurance is about defining and measuring risk, and putting people into pools so that you can charge the riskier people more.

I don't think that maps well to health care, especially when you consider how good DNA testing will be in a matter of years. "Yup, your kid is in a high-risk pool for leukemia. You get to pay $50,000 a year for family insurance instead of the normal $19,000." [The first number is made up.]

Also, if you run an insurance business and someone with a pre-existing condition knocks on your door, their "market" rates will be their cost of treatment as their risk has become a certainty.

If you don't think charging people based on your best knowledge of the risk is fair, then it is a government program, a forced redistribution of risk across a larger pool; not insurance.


I see what you're saying, thanks.

Also, as far as I know health insurance companies can't charge different rates based on genetic testing. How would this be different, than, say, laws preventing car insurance companies from charging different premiums based on race?


I've always wondered about US health insurance -- why can't the physician give me quotes about my personal obligation for various treatment options? It's frustrating that as soon as it's time to come up with a bill, poof there it is but prior to the bill being generated all I get is shrugs?

Is it because the insurance coverage algorithms are too complicated? Because the different entities involved in a single treatment plan is too complicated to navigate? Because physicians feel that cost is orthogonal to medicine and they prefer not to be involved/prefer to recommend the ideal treatment based on a predicted outcome? All of the above?

It feels like if there were a particular hospital group / physician group that had this feature, they would attract a lot of attention. Just imagine, "Your initial differential diagnosis will not exceed $150 and we'll discuss treatment options or more conclusive diagnostic tests afterwards."

All I've heard so far are physicians who don't accept insurance but instead have a straightforward "menu" for common items, which is interesting but not what I think most people want.


Nobody can tell you because nobody knows. And nobody can know.

Here is a simple example that my sister (a nurse) gave me yesterday. Suppose that you go in for an operation at the hospital, spend a week recovering, and develop diarrhea on day 2 while you are there. That diarrhea is a "hospital acquired infection" and insurance won't pay a dime for your operation. Therefore until you've been through the hospital, nobody knows whether you'll get paid.

Oh right, and the possibility of this happening is a reason for the hospital to kick you out of the hospital as quickly as possible. Average patient outcomes may be better if you stay a week, but their odds of getting paid are better if you're kicked out within 48 hours.

This is just the tip of the iceberg. She went on about how broken health care is for an hour...


> Nobody can tell you because nobody knows. And nobody can know.

That's definitely not the case, because they have to know in order to bill you. To get us back on the same page, let's rescope and consider only elective procedures and primary care.

Your example is extraordinary and could be specifically excluded. Even if I got a treatment plan with equivocating language about "risk of procedures / changes / infections / etc" and all that noise at least I could make an informed decision about which treatment plan I think is appropriate.

The guff I was sold when we were shoved to high deductible plans a ~decade or so ago was that we could make decisions about our healthcare. They come up with BS estimates or treatment calculators that are from the insurer and not the provider.


That's definitely not the case, because they have to know in order to bill you.

They bill you after the fact, after they know what they did and what insurance paid for. At that point it is easy. But before the operation, nobody knows what they will find or what insurance will decide.

Your example is extraordinary and could be specifically excluded.

On what evidence do you conclude that it is extraordinary?

All evidence that I have, including my conversation last night with a retired head nurse, is that confusion and uncertainty about what will be covered by insurance and what negotiated limits there might be on what can be charged are more the rule than the exception. And if my impression is correct, then what you want is impossible. Because before the fact, nobody really knows.


But this weirdness still happens when you have a combined entity like Kaiser.

I went for a routine visit, and paid the $30 copay before the visit.

After the visit, I get a bill for Ridiculous_Number_X - Ridiculous_Number_Y = $30.

The "actual cost" of the visit and the "negotiated discount" are numbers that are obviously pulled out of someone's ass because they magically align so that I have to pay $30.

And since everything was handled by Kaiser, how the hell could they not know before my visit that they would want $30 extra and just charge me $60 beforehand and be done with it?


So the predictable checkups are predictably priced, and the unpredictable treatments are unpredictably priced.


Here's a great video that I think is related to this topic about the near-impossibility of finding out the cost of giving birth: https://www.youtube.com/watch?v=Tct38KwROdw

I'd imagine the reasons for the complexity are the same as an injury.

Edit: Just a thought...

What if enough consumers went line-by-line AFTER the fact and shared what the specific breakdown of every item cost? So then you'd be able to say, okay, at this hospital them giving us an Advil cost $X and them doing this procedure cost $Y.

Some way of making the master price list for how much individual items cost public and grouping together ones that generally appear together...


Me and a friend were talking that idea a few weeks ago. You'd need to further include what insurance plan that consumer was on as well, so know what the hospital would charge knowing that information.

Crowdsourcing it would make it significantly more transparent, but the problem (to me, at least) is more that submitting that information somewhere is more of a privacy/HIPAA thing than most consumers and companies are willing to handle.

I could definitely envision a government system, like medicare, would hire people to do this, and make the prices more transparent to consumers, but this is the same medicare whose part D cannot negotiate drug prices due to lobbying efforts.


Hey, the hospitals could even hire actuaries to statistically analyze costs and charge everybody the expected average.

We could call that...oh wait. Nevermind.


I assume you didn't watch the video and therefore didn't understand the point.


Insurance!


> Your example is extraordinary and could be specifically excluded.

Complications and hospital related infections are not extraordinary. For most of the history of healthcare they were the norm.


If you read the very next paragraph, you'll note that they meant that nobody can now know the total costs beforehand. I.e., the total costs often include events that they are unable to reliable predict in advance, so they are unable to give you a reliable or accurate estimate of costs until its all done (which is when billing occurs)


Nobody can know your restaurant bill beforehand, since who knows what you will order for dessert, right? The hospital should still be able to give estimates for individual items beforehand. If they are not flying completely blind, someone must already know these numbers, it would just be a matter of making them public.

To me, the actual problem seems to be that they would like to make up the price after the fact, when they have a better idea how much they can charge and get away with. This gives them the unfair advantage of setting their own prices unchecked by market forces, and is frankly a reprehensible business practice.


They could provide mean, median and min/max.


The problem is there is a bunch of hidden complexity in medical coding and billing. There's 5 Evaluation & Maintenance (E&M) codes that may apply to an office visit, another 5 for ER visits, 4 for tele-medicine consults - which one is used depends on multiple factors that you can only know after the fact, and which one is applicable to the visit determines the expense. This doesn't factor in other procedures such as labs, and whether such charges are required to be bundled into the E&M fee by a specific payer or not - plus differing allowables from each payer. Add in the fact that nearly nobody bothers doing pre-authorizations except surgery centers and other outpatient services that payers require prior authorization for anyway and the whole situation turns into a giant clusterfuck.

Is it POSSIBLE to do all of this and give you a proper quote before a visit? Sure, but it requires some fairly complex software to do so and manual input of tons of different data specific to your insurance contract that almost nobody wants to do it (ironically, the billing company I work for DOES this - but since we aren't involved in patient care it's only utilized to ensure we get paid properly by insurance companies).


>Sure, but it requires some fairly complex software to do so and manual input of tons of different data specific to your insurance contract that almost nobody wants to do it

Can someone quantify the value added by having this complexity baked into the system? Is there any advantage besides the "confusopoly" aspect?

https://en.wikipedia.org/wiki/Confusopoly

Who is the main benefactor (in $$$) behind the drive for complication of medical billing? Doctors? Medical Office Receptionists? Insurance companies? Other third parties that doctors hire to handle paperwork?

What are the benefits supposed to be over whatever we were using in 1975? If you were founding a clinic on Mars for the first colony, would anyone duplicate our current system of medical billing?


Can someone quantify the value added by having this complexity baked into the system?

The value added is relatively little, and past comparisons of the cost of healthcare between the US and Canada have identified paperwork as being most of the difference.

But the cost to the one insurer or hospital which DOESN'T participate in adding to the mess is very high. So everyone puts in a lot of energy to wind up in approximately the same place, only with more paperwork. After a few decades of this, well...


Sometimes when working with legacy software you just start wrapping legacy crap in added layers of complication, hoping to to create a sane interface to the underlying insanity. I think the same thing might be happening with auxiliary healthcare companies. I say this because I've worked at a couple such companies, and I see some mentioned on Hacker News from time to time.

A new company will look at healthcare in America and say, "I'll start a company, and we'll fix part of this." And to some extend they succeed, they deal with some of the underlying insanity, and stick a nice API in front of it. But ultimately what they really do is bring in a bunch of people to sap more money out of the healthcare industry. I used to be one of them when I worked for such companies as a developer. Ultimately a small part of your high medical bill ended up in my pocket. One of the companies I worked for had hundreds of employees and could have been entirely replaced with a 50 line Python script and a cron job if only the government would pick a standard CSV format and require states to use it. (There was no patient data we were dealing with.)

It seems to me, that to make healthcare affordable in America a lot of these auxiliary workers are going to have to lose their jobs. They system must be made much smaller.


Theres no main benefactor. It was Medicare/Medicaid that initiated code based payment and because they are the largest payor, everyone else was forced to go along.

What they get out of it now are public health statistics. Doctors dont get anything out of this.

Ultimately treating medical coding as the price determination mechanism is the cancer behind all our problems.


> What they get out of it now are public health statistics.

We actually don't really get those out of the medical billing situation either. ICD codes are what's used for public health statistics, whereas CPT codes are used for billing. I mean, we could use that data for public health statistics, but we don't really. And we could still have gotten it without the rest of the sacrifices that have come along with the code-based payment systems that have turned practices into offices for billing, with a marginal medical practice on the side.

Unfortunately, as you said, because Medicare is 40% of the payer market, once they switched to this model, it created the vicious cycle we're now in.


> ICD codes are what's used for public health statistics, whereas CPT codes are used for billing.

Very roughly (it's more complex, but not worth more detail here) ICD-10-CM diagnosis codes are used for billing, and ICD-10-PCS procedure codes are used for institutional billing, as well. HCPCS (which include CPT) procedure codes are used for professional services billing.


> Very roughly (it's more complex, but not worth more detail here) ICD-10-CM diagnosis codes are used for billing, and ICD-10-PCS procedure codes are used for institutional billing, as well. HCPCS (which include CPT) procedure codes are used for professional services billing.

Yeah, this is the rabbit hole I was hoping not to have to go down. :)

All I wanted to illustrate was that the desire for public health statistics could be satisfied without requiring a move to the flaws of the current billing model - they're different systems.

(And historically, the move to the current billing model came about primarily for reasons other than a desire for public health statistics).


The complexity in reimbursement policies is always in favor of the insurance companies, the complexity isn't necessarily in coding the charts - that's pretty straightforward, it's all in insurance contracts and the individually contracted rates.


However, most hospitals don't enforce any requirements of "codes" or there are bunch of inter-changeable codes.

If you get a bill from hospital, you can call billing department, ask them if they can try a different code to bill insurance company. And it is possible new code will lower your out of pocket cost. On few occasions I did this, I end up owing nothing out of pocket.


Even with a line item precoded estimate, it would require some negotiation between what the doctor/lab thinks it costs versus what the insurance thinks.

Doctors/Labs are often surprised after the fact by what the insurance company allows, thinks is miscoded, will pay, etc.


I think what's happening is that your doctor will attempt to get as much money from the insurance company as he/she can.

My wife has experience of the doctor's office asking insurance company for $X, and the insurance company comes back and say "no, max $Y". So then the final "cost" all of a sudden becomes $Y. Pay attention to the claims that your doctors send to insurance company and you might be able to see that.

So instead of telling you, yes, whatever procedure is definitely just going to cost $Y. They can't tell you how much things are. It depends on maneuvers with other players in the industry.

This is very different than say in Canada. If I want to get a teeth filling in Canada, my dentist straight up tells me how much before the procedure. If I want to price shop that, I can. In the US, nobody is willing to say how much, because "it depends".

It's not because intrinsically there can't be price transparency. It's because of all the messed up incentives that the industry has that causes US health care to be as such.


Actually, dental care is like that in the US - your dentist can tell you the price, and you can price shop it. If you happen to have dental insurance, they may not know how much of that bill will be covered, but you can absolutely get costs from them.

Other healthcare on the other hand is often a mess, although it is getting better. I've found recently (an MRI in this instance) that I was able to get costs beforehand, and even compare prices. I think the prevalence of HDHP (high deductible health plans) has steered people towards expecting to pay out-of-pocket for care, which has led to a positive change in this area.


Vets are like this too. Vets and Dental are very simple.

My root canal is $325? Cool. I can shop it around or go with it. Same with a pet procedure.

Medical is the crazy town.


Is this because dentists can tell patients who forgot their wallets to take a hike, hospitals can't, and for the most part hospitals don't do emergency dentistry? [0] That is, if dentists were more "ethical", we might see the same problems with cost and payment in dentistry that we see in health care in general?

[0] Sure, there are extreme exceptions, since most hospitals have a dentist they can call when an emergency patient is admitted because an abscessed tooth has destroyed their entire body... It takes commitment and/or great misfortune to get to that point.


Got it. I only used dental as an example in Canada because majority of everything else is already covered by universal health care, so I don't have experience dealing with pricing for other things in Canada.


To be fair to doctors offices, this is in part because some insurance plans (Medicare's the biggest offender, but then again Medicare's the biggest everything) pay doctors below cost for certain procedures. Doctors cope with this by systematically overcharging other patients' insurance companies when they're reasonably sure the patient has already hit their copay for the procedure.

Essentially, health insurance for the poor isn't formally subsidized well enough to make it actually workable, but doctors have professional ethics that disincentivize them from refusing care. So the system has evolved a clumsy, ad-hoc mechanism for wealthy patients to cross-subsidize poorer ones.

American health insurance sucks.


Below what cost?


Below the marginal costs of care.

In other words, if a practice can purchase a vaccine or supplies for a lab test at $100/unit wholesale, Medicare pays the doctor (in the aggregate) $93 for it. That doesn't take into account any overhead or costs of running a practice, of course, such as wages for nurses and administrative staff.

Providers typically make a loss on Medicare patients and then make up the difference by charging private insurers (who are, by law, required to pay more than Medicare does).

Medicare's rates are so notoriously low that for doctors who can't do this - doctors who treat a disproportionate number of Medicare patients - they actually have a separate stipend program to pay them enough to stay in business.


Does anyone know how to look up what Medicare/Medicaid pays for particular procedures, and how to look up codes in the first place?

Somehow I came across that G8709 was for prescribing antibiotics. I figure I should be able to plug that into something like:

https://www.cms.gov/apps/physician-fee-schedule/search/searc...

...but I apparently don't know the proper incantation to get that to work. It would also be interesting is someone had concrete side-by-side examples of what Medicare/Medicaid pay vs. what everyone else pays for several different "common" items.


> It would also be interesting is someone had concrete side-by-side examples of what Medicare/Medicaid pay vs. what everyone else pays for several different "common" items

No payer (including Medicare) pays a single price across the board - even Medicare pays different amounts to different providers in different regions, etc. So there is no one single price for each payer that we could compare, and it'd be hard to find true apples-to-apples comparisons between them, short of polling individual practices and asking them what they received last month (which is hardly rigorous).

Remember that these are often treated as closely guarded secrets - if they were truly public, the AMA couldn't charge for access to CPT codes, and it would be harder for Medicare and private payers to negotiate the minimum rate for each provider. It's the same reason you'd be hard-pressed to ask most companies to make all of their individual salary data public.

The reason we know that Medicare pays so little, though, is that (a) it's no secret - even Medicare doesn't really try to hide it, (b) Medicare has to publish aggregate data, and we know from the aggregate data that they reimburse 7% less than COGS on average, and (c) it's statutorily mandated.


By contrast, you can see the entire GOÄ (Gebuhrenordnung für Ärzte) for Germany online: http://www.e-bis.de/goae/defaultFrame.htm

The first column are the number of points a given service is assessed for, the second is what the publicly-mandated insurances that most Germans are covered by will pay, and the third is the private rate: private insurance or straight-up cash. Doctors and other providers can choose to charge higher than the usual 2.3 multiplier for private patients, and they can choose to only accept private patients, but most accept the public insurances, too.

I can confirm that these are the current prices - I'm privately insured with the highest legal annual deductible (1200 EUR) and pay those bills out of pocket.

Result: Visits to my Hausärztin (primary care doctor) are somewhere in the 30-70 EUR range, full price. Just about everything in healthcare is startlingly cheap in Germany compared to the US (dentistry is only somewhat less expensive than in the US). About 10 years ago, I paid less for the same procedure without participation from my insurer than a friend did in the US after her insurance paid its portion - and I had a night in the hospital, while she was an outpatient!


A small correction: The second column is not what public insurance pays (usually it's more). They use an entirely different table, the EBM.


Are you saying that Medicare/Medicaid reimbursement rates aren't public information?


> Are you saying that Medicare/Medicaid reimbursement rates aren't public information?

Private insurer rates are definitely not public information, for any definition of "public".

Medicare reimbursement rates are sort of public, but not at the level of granularity you want. And a portion of that is because the question is not easily defined. For a given CPT code, Medicare might pay one of many different rates, depending on factors such as the geographic region, whether the provider operates in a CAH, whether the provider qualifies as a DSH, etc. That level of granularity is not easily accessible, and without it, there's no way to give meaningful example individual comparisons without running the risk of cherry-picking non-representative examples simply due to availability bias.

(Also, Medicare and Medicaid can't be lumped together. Medicare is a single, federal program that is administrated in four parts. Medicaid is a set of 50 different programs run at the state level, each of which can be administrated in more ways than I can count. The one thing that they all have in common here is that, like Medicare, they pay abysmal rates to providers, but the relationships that they have are even more complex - even in a single state, like New York, there are literally hundreds of different ways that Medicaid services can be provided, depending on the type of plan chosen.

Source: founded a company that had to abstract all of this complexity for patients, who were disproportionately on Medicare or Medicaid)


Yes, I'm willing to give up on the comparison to private insurance/transactions. So now I'm just wondering how to get a hold of Medicare reimbursement rates. We know that they vary by location, and other factors. But it must boil down somewhere, to a lookup table or a formula or the guy processing the forms who rolls a dice and multiplies by the last 3 digits of the medical code to come up with the reimbursement, etc.. Or is it all based on trust, and Medicare just pays 70% of any invoice that gets submitted to them? (And they send auditors out every once in a while in order to keep up appearances)


I am familiar with NY medicaid. They do publish a way to calculate the Medicaid default rate. Insurers do not have to pay exactly this but it provides a decent base line. Here is a basic description of how inpatient pricing works.

Each year the state publishes the set of hospital rates and intensity weights for each DRG (Diagnosis-Related Group) and severity combo (currently using weights developed in 2014). So a DRG of 460 (Renal Failure) with a severity 2 has a weight of 0.7393. Now the actual cost will depend on which hospital you go to since each hospital has a different base rate. For example each Mount Sinai hospital has a base rate of $8,743.45 while Niagara Falls memorial hospital has a base rate of $5,558.99. Each hospital also has a per discharge rate. To calculate the default rate take the hospital base rate x DRG intensity weight + per discharge rate.

https://www.health.ny.gov/facilities/hospital/reimbursement/...

https://www.health.ny.gov/facilities/hospital/reimbursement/...


> Does anyone know how to look up what Medicare/Medicaid pays for particular procedures

Medicaid is separate state-run programs with different reimbursement policies in each state, and othe common federal rules governing the state programs include provider-specific (both cost and charges to the general public) limits, so, there is no simple “what rate Medicaid pays” for any service.

(And that's even before considering that in some states, a substantial portion of Medicaid is provided by private insurers who are paid capitated rates, not fee-for-sercice, by the states.)


Forgive me, but I'm deeply skeptical of unsourced claims about any government program on forums where there are a lot of IT folks. Do you have references or suggestions for specific things to search for to support these statements?


Below operating costs. Rent plus utilities plus relevant salaries plus amortized cost of equipment.

This is confounded a bit because a lot of medicine involves lots of expensive equipment and staff with huge student loans to pay down but low day-to-day operating costs, but for a lot of specialties there exists no set of insurance-independent prices that allow a normal clinic following industry standard practices to operate without losing money.


> Below operating costs. Rent plus utilities plus relevant salaries plus amortized cost of equipment.

It's worse than that - it's below COGS (direct materials). So even before you account for rent/utilities/salaries/amortized costs, they're still making a loss, unless they operate in a CAH.


That's actually a response to the insurance company performing a type of information arbitrage with multiple other parties.

You could have health insurance with transparency, but there is too much profit potential in forcing information asymmetry between all of the parties involved in the system.

Every time that you think...doctors...hospitals...nurses...are up to something, most of the time it can be tracked back to insurance companies and the sway that they hold over congress with their money. I'm not saying that there aren't doctors, nurses, hospitals trying to gouge people. I'm just saying that insurance companies are worse. (With some very rare and egregious exceptions.)


Even with that I still don't give doctors an excuse. There are a bunch messed up incentives there too. Such as doctors recommending more expensive drugs, or giving me coupons to buy said drug. I'm assuming there's money exchanging hands there too. Not sure if it's with doctors directly.

But the end result is that I simply cannot 100% trust any advice I'm given.


These days there's not going to be money - but there might be steak dinners. But there are lots and lots of doctors who's ethics say that steak dinners with drug reps are off limits.

But no steak dinners still doesn't mean you won't get this happening, because some docs look at your insurance and figure that for you, your out of pocket will be lower with a coupon than with a generic. Sure the insurance company might pay an arm and a leg - but by and large docs don't care about insurance company profits, and do care about the person in front of them. And thus waste.

Other docs think all generics all the time -- even if the cost to the patient is massively higher. On the opposite side sometimes the expensive drugs just are better (even if just marginally) and most docs don't think about costs at all - as it's very very complex and their lives are busy enough.

It's messed up for a thousand reasons, not for one reason.


>But there are lots and lots of doctors who's ethics say that steak dinners with drug reps are off limits.

There are a lot more that think it's not their job to care about those things. They think they are only responsible for curing the sick regardless of time or money constraints or conflicts of interest.

They say they don't do this, especially in regards to money, but talk to all sorts of docs about how much of their patients' time they waste every day and they get real defensive. They think they are owed anything and everything and fuck running an efficient practice, fuck your time because they're a doctor and they are over in a different room performing miracles.

The egos in medicine do WAY more harm than good.


I personally know a bunch of doctors and you are right, they are pretty arrogant. Each one of them is also brilliant. I'm actually pretty close to some of them so in one or two cases I'm biased.

They actually have a hard time being "efficient" in the sense that you use the word, because if they don't run every possible test when they miss something and get sued they will have to answer for it.

Why are there so many lawsuits? Because the first thing that insurance companies do is lawyer up.

I'm not saying that doctors aren't also bastards sometimes, but Americans also think that doctors should deliver healthcare like a retail service and that's just stupid.

Your whole "in a different room performing miracles" might actually be running late because they are double booked and behind schedule due to trying to be thorough with an old woman who has compounded issues related to multiple diseases. That woman is also a person, just like you and the doctor might be trying to spend some time trying to help them even though insurance and the shitty clinic they work in only want them to spend 10 minutes with any one patient. That may sound efficient until you need to spend 20 minutes to do something right. Then the schedule is effed the rest of the day and people will act like you are trying to do something to them by being late.

Its hard for me to say this, because generally I hate people, but not everything is intended as a slight against you.


Its not with doctors directly in almost all situations. Not saying that they aren't also cocks sometimes but there's a lot of the iceberg that you can't see. I'm telling you, the more you look the more you will see its middle men like insurance companies that are screwing every party in a multiparty transaction.

Never trust anyone 100%. This is America.


The bill shows they asked for $X, but the doctor already has a negotiated agreement with the insurance company that says they will accept $Y for the service.

Additionally, if you inform the office you are paying the bill yourself (without insurance) they usually give you a discounted price somewhere between $X and $Y.

In other words, almost nobody is paying the list price of $X. It's not really a meaningful number.

(And, as others have pointed out, the weak US dental insurance market means that actually dentists are pretty up-front about pricing in my experience.)


And in a number of situations, they'll give you a price significantly below $Y.


Dental insurance in the US is a bad example, because they generally pay for (in a year) 2 routine cleanings, silver fillings, and a percent of anything else, up to some ridiculously small maximum of $2k or something. You very much can get price quotes for dentistry.


And really, they should NOT be paying for 2 routine cleanings, because those costs are both modest and predictable and that's not the point of insurance.

The reason they do pay for the cleanings is that it's probably cheaper than paying for the increased fillings and root canals that they would incur if people skipped the routine cleanings. So they want to incentivize that, even though it's not really the sort of unexpected ruinous expense risk that insurance is really meant to assume.

They could achieve the same goal by providing a discounted premium with proof of routine cleanings, but that's probably more complicated for both them and their customers.


This is a great example of why most "health insurance" (or dental or vision "insurance") isn't really insurance.

It's a bundled prepayment model, similar to selling gift certificates/cards or the like. Basically making money on breakage / float.

Real casualty insurance wants to reduce the number/magnitude of casualty losses. So the theft insurer wants you to get good locks and an alarm, the fire insurer wants you to get sprinklers, and they all want nice orderly public services with good response times and suitable building codes. Win-win-win.

Nobody would ever be unhappy if they paid their whole life for fire insurance and their house never burned down.

But health "insurance" can't really reduce the amount they pay out (the "medical losses") because the customer is expecting to consume healthcare. It's also more complicated because one of the best ways to reduce medium term healthcare costs is to spend more on short term healthcare costs.

Can you imagine if the best way to prevent a house fire was to have a little house fire every year? (Well, that's not so crazy in terms of wildfires, perhaps.)

Then, there's the fact that in the very long term, everyone will die and many will get really sick just before that. And the private health "insurance" companies do their damnedest to avoid that group entirely, having effectively shunted them all off onto the commonwealth (Medicare).

Health insurance is not like other insurance and we need a new word for what it really is.


It's a bundled prepayment model, similar to selling gift certificates/cards or the like. Basically making money on breakage / float.

It's not just prepayment, but also a negotiated price that's lower than the average person can negotiate themselves.


> The reason they do pay for the cleanings is that it's probably cheaper than paying for the increased fillings and root canals that they would incur if people skipped the routine cleanings.

Actually, no, they reason they do is because they're usually subsidized by employers providing the plans. In other words, it'd be equivalent to the employer reimbursing a portion of your regular dental care that you pay for out-of-pocket. The expected reduction in cost for the insurer due to routine cleanings is negligible from their perspective.

If you purchase dental insurance individually, these treatments are very rarely covered, or if they are, the price under insurance is usually about the same as the price without insurance. Which makes sense from a risk model - when there is literally no risk at hand, the price under insurance should actually be higher than the uninsured price, by a tiny amount.


I agree, to me the second biggest industry acceptance that is counter intuitive is that insurers need to make money off of the float. Why can't an insurer come along who charges a fee for the service of ACTUALLY BEING ACCESSIBLE TO THE CUSTOMER. Intead of fax me this paper and wait two months. I am paying the insurer on the basis that they want to draw out any claim I have.

"All I've heard so far are physicians who don't accept insurance but instead have a straightforward "menu" for common items, which is interesting but not what I think most people want." - I think people want this but they are scared of going off of insurance in the event they need to see someone who doesn't offer this (chance occurance, expensive disease).


We are actually setting up an insurer in the UK which is doing exactly that by changing the business model to taking fees on settled insurance claims instead of betting on an underwriting/investment profit.

Have a look.

insureathing.com


For routine things, your responsibility is a flat amount, usually printed on your insurance card. So you know, for example, if you go to your general physician, you pay this much. Go to a specialist, pay this much. Go to emergency room, pay this much.

For more complex things, it's usually:

1. Not possible to know in advance everything that will need to be done. Many medical procedures are not things that just go identically every single time, and complications can occur during the procedure. Having to call it off, re-quote, re-schedule, etc. is not optimal.

2. The doctor likely doesn't actually know how the procedure will be billed. Medical billing is done using standardized codes to describe procedures, and the doctor will have someone who knows how to do that, but that person may not even work in the same building as the doctor. And the sets of allowed codes and how to use them can change quarterly, and that's without getting into the arms race of doctors trying to "up-code" (rather than the most obvious code for a procedure, find a way to bill it as multiple procedures or as a plausible but higher-paying code, since doctors and insurance companies are locked in an eternal battle of doctors trying to make as much money as they'd like and insurance companies trying to pay as little money as they'd like).


On your first point, even if they know exactly what will be done, they can't answer. I can't look for it at the moment, but there was a Vox video maybe last year about a man who wanted to find out the cost to deliver his and his wife's baby. He called a bunch of hospitals in the area, gave them his insurance information, and he asked them the cost assuming everything goes to plan, just the cost of delivery. I don't remember exactly how long it took, but he got a number after hours on the phone. Then the bill came, and it was still a different number. The whole thing couldn't be more opaque.


It's worth noting that this isn't always a "don't know". Often it may literally be a "can't say". The problem is that even if you call them up and say "sure, I know it could be more complex, I just want to know what it would be for a perfectly normal delivery", and then you go there and get a bigger bill due to complications, what happens? Do you have a case against them for misleading you into thinking it would be cheap? Do they have written evidence that you understood their quote was only for a no-complications scenario?

The safest thing is to refuse to give an answer.

To elaborate on this, I work for a company that offers health insurance. One of the nice features of our plans is that although it's PPO with a network of contracted providers, the co-pay for someone on the plan is the same whether a doctor is in- or out-of-network. But how do you advertise that? Saying "see any doctor you want" is a non-starter, because someone might take it to mean "doctors are required to see you even if they don't want to" and then claim we misled them with the "any doctor" line. It ended up taking quite a while to work out a way to advertise that benefit without tripping over anything that might be claimed to confuse or mislead.


A lot of good answers here. A few straightforward ones:

- Because healthcare providers negotiate different rates with providers, so the "list price" differs by your provider and plan.

- Because your personal cost is unknown to the doctor, as it would depend on factors between you and your insurance company (like deductible met), coverage types, etc.

Now, these are both solvable problems. And I agree with the sentiment of other posters here that it's predatory that medicine is one of the few fields where you simply don't know how much something will cost until you get the invoice.


> - Because your personal cost is unknown to the doctor, as it would depend on factors between you and your insurance company (like deductible met), coverage types, etc.

This one CAN be known to the doctor, the full details of your coverage, current deductible met, copay amounts, etc are an X12 270 transaction away. Almost nobody does this though, unless you are planning on billing an expensive claim (outpatient surgery, post-acute care, etc) where non-payment can mean a significant monetary loss the time and money doing these checks isn't worth it for the provider. This is further exacerbated by most (all?) clearinghouse's charging to run these transactions, and a really slow adoption of CORE Phase II connectivity standards by payers (which would bypass the clearinghouses completely and allow providers to directly submit eligibility requests to payers over a standard interface).


Oh 100%. There's no technical excuse not to have that. As others have pointed out, there's a pessimistic line of reasoning as to why doctors and insurance companies don't want you to know what things are going to cost. The sad part is that we've allowed that to become an acceptable way of doing business.

But imagine if your mechanic did that. "Hi, thanks for bringing your car in. We investigated that noise, ran a bunch of tests, and everything looks fine to us. That will be $5,000."

(Fun story: many years ago, Jiffy Lube topped up my dad's transmission fluid without telling him there was an associated cost. When they tried to charge him the $25 or whatever it was, he told them to suck it back out.)


Because it's sort of like hotels. There's a "rack rate" which is a high price that nobody pays, and a price floor is whatever Medicare pays. (With Hotels, GSA is the "normal" price floor, and cheaper rates are usually wholesale) If you price cheaper than Medicare, you get sued for fraud unless you charge that low cost to Medicare.

Everyone else has a bewildering discount scheme. The doctor literally has no idea what you pay.

In other cases you have HMOs, where primary care doctors get a monthly nut to take care of you and don't get a fee for service in most cases.


> Because it's sort of like hotels.

Great example. Ever checkout without an idea of what your hotel bill is going to be?

> The doctor literally has no idea what you pay.

But if it matters to me, then it should matter to my physician. Most of them will come up with a reasonable response if I tell them "doc, I checked at the pharmacist but I couldn't afford those drugs you prescribed, what else can we do?" Most of them empathize with their patients and come up with an alternate treatment plan if one exists.

I don't think it's good enough to say "well gee discounts and providers and algorithms -- math is hard let's surprise you" because somehow they can figure it out at bill-generation time. At the very least, hospitals/physician's offices could produce a "given your insurance + the nature of your chief complaint, this visit will cost $x, these common diagnostics cost $y/z/w."


Health insurance is a very different business than P&C and one that I've spent a lot less time researching. Each customer interaction at least 3 participating actors (patient, provider, payer), each of which have different incentives, rules, and understanding of those rules.

I think there are great companies being built in the space (take a look at what Clover Health is doing https://www.cloverhealth.com/en/), but it's not an area I'm focusing on.


It's funny that I can take my car to a mechanic and get a free and pretty accurate diagnosis. But you go to a hospital, and you need pay for the diagnosis and it may not be accurate.

Even for a checkup, after the procedures are done, the office can't tell me the bill.

...yet we we call mechanics "wrench monkey" in a demeaning manor.

BTW, this is probably why services like Minute Clinic are getting popular...go in, get something done, pay a flat/low fee.


Well the diagnoses for your vehicle come from a 200 page Haynes manual, your body doesn't exactly have a Haynes manual for your make/model/year.


How does the complexity of the human body come into play after they've done their procedure and still can't tell me how much I will be paying?

Do you take your car to the mechanic, get some work done, only to get a bill 3 months later?


i think the many books on human anatomy disagree with you by their very existence...


You might consider looking into Direct Primary Care. It is growing in popularity in the US. Here is a quick and dirty overview:

http://micheleincalifornia.blogspot.com/2017/01/direct-prima...


Mostly due to all of the variables that go into pricing a claim. And that logic on lives in the insurer's claim processing system.

Pieces that can impact the price. Your insurer and what product you have. These will affect who is considered in-network and the fee schedule to use. Different insures will have different arrangements. Depending on the product if you have a narrow network product they may or may not be in-network. It could also depend on the location. A provider can be in-network in one location but not in another.

Also the procedure that is actually performed may be slightly different from what was planned due to unforeseen circumstances.

This is assuming the provider is aware of what the actual costs are. In many cases they don't even know the ballpark price since that is not the portion that they deal with.


Of course. We know it can be done since it happens with alacrity at bill time. Why not do it in advance? It could could save the insurers money as well as the patient if the patient chooses the less expensive option.


You might be interested in something like the Surgery Center of Oklahoma which has an upfront pricing page for their surgery procedures: https://surgerycenterok.com/pricing/

Even though the ycombinator blog post is discussing innovation etc with regard to insurance, I like the idea of innovation on the side of service providers. And it is somewhat sad that a list of prices is innovative.


Having it all in a list like that leads to some interesting comparisons.


I have Kaiser insurance which is an HMO with straightforward pricing for most things. One fixed copay for doctor visit, one for specialist visit, one for outpatient care, etc. The problem is you are stuck using only Kaiser facilities and doctors.


There are benefits to continuity of facilities, though.

Anecdotally, my wife went to her regular doctor for a nominal fee at her yearly checkup. They drew blood, then asked her what hospital she wanted a follow-up diagnostic procedure to be scheduled at. She gave the one closest to us. She showed up, did the procedure, then almost a month later, we get 2 bills. One is for the blood ($1800) which, surprise, didn't go to an in-network lab despite all of our previous years' work being covered. The other bill was for the procedure ($800 if I remember correctly). If you go to the insurance website, enter her plan, enter the hospital and the procedure, it will tell you it costs something like $40. The whole system is broken, but at least these issues wouldn't have happened in a system like Kaiser.

Also anecdotally, my sister is on Kaiser in Colorado, and she has a chronic disease along with her pregnancy. They are taking very good care of her, and nothing seems to be dropped despite her having 3 physicians whom she sees regularly. I have almost no faith that if my wife gets pregnant, we'd have the same continuity in our current setup.


If an HMO got stupid amounts of marketshare it would probably fix the system naturally. It would also improve stuff like allowing HMOs to be able to better take advantage of medical data and provide better care through understanding the patient. The problem is there is too many HMOs, which makes HMOs in general less convenient.


Even ignoring insurance, it can be impossible to get an accurate cash price depending upon the physician. And if they can't figure out the cash price, there is no way in hell they will figure out the insured price.

We recently went to a physician who works in an area that regularly isn't covered by insurance. For all procedures, the cash pricing was upfront and understandable.

In comparison, we tried to deal with another physician for a different procedure we knew our insurance didn't cover. Literally days worth of time was spent on the phone to try to figure it out and the day of the procedure we were told the prices were wrong and didn't account for some stuff.


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