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Insurance copays are higher than the cost of the drug about 25% of the time (pbs.org)
488 points by jabo 6 months ago | hide | past | web | favorite | 291 comments



Health pricing is a weird fixed pricing with all sides in insurance companies, medical suppliers and doctors holding the cards to get the highest prices within the gamed rules with the consumer left out in the cold and each bill a random output that is rarely known beforehand.

Part of the problem is healthcare provided through work that skews pricing for large companies over individuals/small/medium businesses and entrepreneurs.

If we can't get healthcare removed from employers and have both a private and public option based on Medicare for all. We AT LEAST need legislation to bring in CLEAR pricing for insurance cost and non-insurance rates, similar to the CFPB mortgage Loan Estimate and Closing Disclosure that show all pricing clearly in one sheet of paper both the estimate and the final mortgage.

What other product do we buy that the price is not known until after the product/service is rendered? At least some idea of an estimate is even hard to get as each part of the medical pricing matrix scam (insurance companies, medical services/suppliers, doctors, pharmaceuticals) try to keep pricing shrouded to stick it to people wherever they can.

The consumer healthcare experience is horrible in the US healthcare system and employers being the insurance companies main customers is a major part of this problem but pricing can be helped with clear regulations and needs to be now.


I don’t disagree with your sentiment, but a major problem is that the US healthcare system’s function (or lack thereof) is based on price discrimination e.g. the list price for a doctor visit might be $150, the doctor gets reimbursed $15 for a Medicaid patient, $60 for a Medicare patient, $90 for privately insured patient, and a $135 for a cash pay patient.

It’s a lot like college tuition - there is a sticker price - but very few student’s actually “pay” the sticker amount, or the same price for that matter

At the end of the day the core problem is that price transparency and price discrimination are at odds with each other...people don’t like being told they have to pay more for something because of “who they are”


> I don’t disagree with your sentiment, but a major problem is that the US healthcare system’s function (or lack thereof) is based on price discrimination e.g. the list price for a doctor visit might be $150, the doctor gets reimbursed $15 for a Medicaid patient, $60 for a Medicare patient, $90 for privately insured patient, and a $135 for a cash pay patient.

But all of this price discrimination is bad -- it's hurting everybody. Medicaid and Medicare patients paying less causes more doctors to not accept them. Privately insured and uninsured patients paying more imposes costs on working people and small businesses who have to subsidize a government program, not through taxes in proportion to their revenue or wealth, but through higher insurance premiums in proportion to their number of employees regardless of how much the employees make.

Eliminating that sort of price discrimination would solve a significant portion of the problem by itself, by eliminating that cross-subsidy and requiring government benefits to be funded overly and by the people who can afford to pay rather than covertly through higher private insurance premiums on people who can't.


I think the reason meds are expensive are completely different why doctors or hospitals are expensive in the states. While all of those things happen because the system has no desire to be cheap and free market forces do not happen they are all different and need to be fixed individually.


In my view, understanding the flow of money in the health care system will be impossible until the system is wholly owned by the government. This may be the primary reason why health care in most civilized countries costs half of what it does here. Until then, everybody who's gouging us accuses everybody else of being the ones who are gouging us.


As far as prescription drug cost, even the part of the health care system that is government control - Medicare - prescription drug prices are whatever the company sets. When Bush signed the law making prescription drug coverage part of Medicare, part of the law was that the government could not negotiate prices.


I.e. Bush gimped any controls on drug costs.


You should consider the possibility that you have the direction of causality reversed there.


Trying to parse your suggested reversal. Do you mean "health care in most civilized countries costs half of what it does here system is the reason it is government-owned in those places"?

Leaving aside from the fact that very few countries have wholly-government owned health care - this formulation doesn't make sense.

Or is it the line about gouging you are referring to?

Can you explain a bit more clearly what your point is? I haven't woken up enough yet to decipher your comment.


Certainly, and I apologize if my brief wording wasn't clear.

> This may be the primary reason why health care in most civilized countries costs half of what it does here.

There is a common conception that simply adopting one of the many different systems used in these other countries would immediately solve the cost problems in US healthcare by way of single payer price negotiating, but the problem that addresses doesn't tell the whole story of high healthcare cost in the US.

It's not just US healthcare costs that are abnormally high but healthcare consumption - due in part somewhat to the defensive posture of medicine towards a tort heavy society, but also because healthcare consumers in the US simply demand more healthcare than consumers in other countries; (call it the Super Size Me effect?)

So it's not necessarily the case that any kind of single payer system is going to change that culture of consumption. The systems used in other countries are largely possible due to different levels and modes of consumption.

Mind you, I generally support some kind of single payer system for the US (preferably modeled after some combination of elements from Canada, France and Australia). But I'm bothered by these panacea arguments when it doesn't seem at all clear that such statements of causality can be convincingly made.


Considering ... done. Comparison with other countries says: Not reversed.


> until the system is wholly owned by the government

The thing is that single payer healthcare systems in Canada and Europe aren't necessarily owned by the government. In Canada, each province's healthcare is run as a government owned insurance company, with the requirement that everyone have health insurance. Some provinces bill this out to each insured person on a sliding scale of income, with a cut off for the low income.


> This may be the primary reason why health care in most civilized countries costs half of what it does here.

It's not, because other countries with mixed public/private systems don't have notably higher costs than the full- or primarily-public ones.


The most frustrating issue with the Bernie Sanders single payer campaign is that they flat out lie saying that the reason why healthcare is expensive is because it is private.

Healthcare hasnt been so expensive forever, it was actually very cheap decades ago, when it was still private. The efficiency issues are not public vs private. Its mostly regulatory burdens.


Yes regulatory burdens like actually being forced to cover people with pre-existing conditions, not being able to drop people once they use thier insurance and not being able to exclude certain conditions....


More like burdens like limiting the amount of doctors available, not allowing the importation of foreign drugs, tying healthcare to the employer, etc.

You can manage the problem of pre-existing conditions in an insurance system with a subsidy, instead of a mandate that forces a 20 year old minimum wage person to work part time, because the employer cannot afford to pay healthcare for him.


More like burdens like limiting the amount of doctors available,

There has never been a law in the US limiting the number of doctors available.

tying healthcare to the employer, etc.

There was never a law tying healthcare to the employer. Before the ACA, if you had a preexisting condition, that was the only way that you could get insurance - by being part of a covered group. The insurance company wouldn’t cover you.

You can manage the problem of pre-existing conditions in an insurance system with a subsidy, instead of a mandate that forces a 20 year old minimum wage person to work part time, because the employer cannot afford to pay healthcare for him.

So we need universal coverage like the rest of the civilized world....


> There has never been a law in the US limiting the number of doctors available.

My understanding is that the supply of doctors is limited by the amount of residency slots and that is limited somehow by whatever professional association licenses doctors.


> There has never been a law in the US limiting the number of doctors available.

There is at least one such limits to about 1/4 of 65.000. And even within that limit they have an irrational amount of extra requirements.

> There was never a law tying healthcare to the employer.

Sorry but in the US, health insurance is provided by the employer because it is a tax-exempt expenditure. Tax it and see wages diminish considerably once employers pass the cost to the employees.

> So we need universal coverage like the rest of the civilized world....

The uncivilized world also has universal coverage. That should be a red flag, shouldn't it?


Sorry but in the US, health insurance is provided by the employer because it is a tax-exempt expenditure. Tax it and see wages diminish considerably once employers pass the cost to the employees.

Employers already pass the cost to employees through lower wages.

The uncivilized world also has universal coverage. That should be a red flag, shouldn't it? reply

Yes, that in this regard the US is worst than a third world country...


They don’t pass to the employee the marginal tax rate pf the health benefit, which by the way is a very regressive policy.

And you would be very wrong to believe healthcare in the us is worse than in third world socialized medicine countries. You will find horror stories galore as well as all other kinds of trade offs you wouldn’t accept.


I'd be very curious as to what country you live in. I wasn't aware of any country with more rules around the provision of healthcare than the US has.


Most other countries have government run healthcare. By definition, they all have more government involvement.


Ok, that's our miscommunication. I'd say that government ownership is certainly government involvement but it's not at all the same as government regulation. Even when the government has an agency running all the hospitals you can still have a more or less regulated healthcare system depending on how many rules parliament has passed about where you can build hospitals, how you can hire or fire doctors, etc. In the US hospitals are private but possibly because of that we have a ton of rules about who can become a doctor, how medicines are made, how close you can build one hospital to another, etc that are in excess of what you see in other countries.

Also, while most countries have healthcare that is payed for by the government having the government run healthcare is also fairly uncommon. I know Canada, the UK, and Singapore have public provision but most countries have public payment and private provision.


Thats not how you measure the effect of regulatory burden on price. If the us government turned into single-payer, the doctors are still private, but the government is the insurance.


Almost all doctors in the UK work for the NHS. Most countries with single payer also negotiate drug prices and reimbursement rates. So how would you have the government setting prices and reimbursement rates and not have a higher "regulatory burden"?

How could that possibly be a free market system/.


> Most countries with single payer also negotiate drug prices and reimbursement rates

The government itself barred Medicare from negotiating drug prices. If it is incapable of overturning such a policy, why should it be entrusted with 10x more patients?

> So how would you have the government setting prices and reimbursement rates and not have a higher "regulatory burden"?

You could have the government give a health-stipend for insurance for all americans, so its government funded, kind of like school vouchers. Today medicare instituted fee-for-service, which means you have to document every procedure you do and you get reimbursed based on that, which I believe is the core reason why there is so much red-tape in Healthcare.

This would allow all patients to choose which insurance fits best, and unleash major competitive forces on price.


> The government itself barred Medicare from negotiating drug prices. If it is incapable of overturning such a policy, why should it be entrusted with 10x more patients?

The political faction which opposed and supports the policy you point to does so for precisely the same reason it is opposed to the faction proposing single payer; people voting for the faction that supports single payer would also vote out the faction supporting that policy. So, you are literally conflating two opposing things as the same thing.

> You could have the government give a health-stipend for insurance for all americans, so its government funded, kind of like school vouchers

Yes, and if you also have the government provide a default fully-public-funded option just like with school vouchers, you will have almost exactly recreated what Medicare already does for it's covered population (Medicare Parts A & B are the public option, Medicare Advantage plans are the private options to which public “voucher” subsidies can be applied in place of the default public option.)


> The political faction which opposed and supports the policy you point to does so for precisely the same reason it is opposed to the faction proposing single payer; people voting for the faction that supports single payer would also vote out the faction supporting that policy. So, you are literally conflating two opposing things as the same thing.

I disagree, but regardless of that appreciation the problem exists today when its smaller, if you had single-payer it will be a harder problem to fix.

> Yes, and if you also have the government provide a default fully-public-funded option just like with school vouchers, you will have almost exactly recreated what Medicare already does for it's covered population

It was an example to show how high government participation can lead to low regulatory burden, not an actual intended recipe for the US and its current or proposed system.


That's an excellent example of how even government provision of healthcare can be more or less regulated. The law doesn't allow the agency running Medicare to not buy certain drugs which is the other side of the coin in terms of them not negotiating. By contrast the NIH is legally allowed not to buy a drug and uses that fact to negotiate lower prices.


[flagged]


Please don't do this here.


I apologize, it was out of line in hindsight.


Appreciated!


As someone who lives in a country where the regulatory burdens are higher and healthcare is cheaper, you are very wrong.


Share your country and I will be very much able to show you why the burden of regulation is worse in the us, at least in terms of price. And lets add one more thing: we can compare the US to itself, to 50 years ago, and show that 50 years ago healthcare was super cheap, and still private.


"The efficiency issues are not public vs private. Its mostly regulatory burdens."

The phrase 'doubling down' comes to mind here.


I agree: going single-payer is absolutely doubling down. Medicare itself, today, has more patients than most national health programs like Canada, and it is also more expensive than them. We already know medicare is not cheaper than other countries health systems. And do you believe that expanding medicare 10x will make it more or less efficient? Because I believe it will do worse, a lot worse.


This is demonstrably untrue in pretty much any other developed western democracy.


Please make the demonstration


Rhetoric that is mostly correct.


>> In my view, understanding the flow of money in the health care system will be impossible until the system is wholly owned by the government.

To judge the correctness of your statement, just look at what has happened to other industries that the US Federal Government controls: costs rise, service times increase, quality suffers, accountability disappears, etc.


If Americans really believed in the superiority and effectiveness of the private system, they'd use it for their military. Troops should have a choice of Medevac service providers!


Another hypocrisy is the insurance congress critters grant themselves while denying anything comparable to the hoi polloi.


You might want to compare the cost and service from VA to the private medical system. It’s not pretty for the private sector.


I don't think it's so much the goverment but the industry that tells the government what to do. You don't bite the hand that feed you.


Agreed. I would have no problem with the Canadian government owning US healthcare since they already own and operate Canadian heath-care and do an ok job at it. Everything the US government owns seems to eventually slide toward being a lot like the DMV.


This seems to be because people in the US don't want to actually give their government control of anything. And thus anything that is government run seems to have clauses that allow private industries control things. The worst of both worlds!


I had this experience with imaging (MRI), cost 10% more with insurance than without.

I asked a friend in the healthcare industry about this - they said that since insurance companies negotiate all the services at once - the insurance company is trying to lower the total cost for the whole insured pool, this often means that they will marginally overpay for high margin services in order to get big discounts for the really costly things. The hospital makes more gross margin, and the insurance company lowers it’s total spend. The offshoot is that individual people may bear the brunt of this grand bargain...

No idea if it’s true, but had a ring of truth to it...


I had the same situation with multiple services:

1. ultrasound cost around $300 with insurance...$150 without

2. ER visit cost $4K with insurance....$900 without

3. specialist visit with insurance cost around $200...$150 without

And don't get me started on labs.

It's really a rip off to use insurance for anything other than:

1. general doctor visit (cheap co-pay, pretty expensive cash option)

2. really expensive shit (c-section w/o insurance runs $25-$30K -- cost me around $5K with insurance)

Anything in between seems to be cheaper when you pay individually.

As a disclaimer this is "gold-level" insurance coverage which costs around $1200-$1300/month for a family of 4.


One thing to keep in mind when paying individually is that many insurance providers won't count the payments toward your deductible or maximum out of pocket expenses, since it wasn't processed through your insurance.

If you're nowhere near hitting your deductible for the year, and don't anticipate hitting it, then looking for cash-only discounts make sense. But if you anticipate hitting your deductible anyway, sometimes it makes sense to pay the inflated price on that individual item, since you'll make up for it later when you hit your deductible and switch to only paying your coinsurance amount (or hitting your max OOP).


Wow. I used to live in the US but thank you for the reminder. I am very glad i now work a government job in a country with public health care. I went to the dentist last week. Walking out without paying anything, not a single form, feels like stealing. I cannot understand how anyone in the US can pay such costs. Simply staying alive seems a constant battle.


What dental services were performed? In the U.S. I frequently pay nothing nor fill out any forms for dental work.


Xrays, replaced a filling and got a night guard thing made. Took a couple hours.


Yeah, I've paid nothing for x-rays and fillings. Haven't needed a night guard yet.

I suspect that the chicanery in the U.S. is more severe in the non-dental sectors of healthcare as there's more volume/value there (from a provider/stakeholder POV).


My wife missed a checkup (perhaps two) due to pregnancy. When she went back she needed a root canal. I happened to need a filling for the first time in 12 years. Before any of my work we had hit our insurance max for the year and had to pay cash for the excess--about $1000. This all happened in the same month or two so we didn't know until after.


Ironically for all that everyone talks about healthcare in the UK being free, dentistry and optician services aren't - although there is a subsidised base service tier, all the service providers are independent private businesses.

https://www.nhs.uk/using-the-nhs/nhs-services/dentists/under...


> c-section w/o insurance runs $25-$30K -- cost me around $5K with insurance

$30K without insurance is insane! I live in another developed country, where childbirth isn't covered by insurance (since it's elective, right?), but the whole C-section procedure + 12 days in a private room in hospital cost a bit over $5K. Almost $4K of that were then paid by the city government (nationwide program to help cover birth costs).


Except that essentially no one is paying $30k in any of the cases despite the “price tag”


The simple/fast solution is healthcare providers have to 1) publish costs and 2) have fixed prices regardless of purchasers.

And while I support universal healthcare, this is an easy solution that falls well into capitalism (no 'socialism' here for the far right) as governments role is to create open and level playing fields for both consumer and business to promote a free market.

The fact no legislator has brought forward, let alone voted through, such a simple and effective improvement shows how deep the healthcare industry is in the corridors of power.

Edit: spelling


Both of your proposed solutions are appealing - but Medicaid and Medicare create a large problem, as both programs pay way below listed rates (~10% and ~40%. Respectively) so your proposal while eloquent would create massive upheaval (perhaps well deserved) making the proposal much more radical than it seems on the surface


Not an expert in this space so my comment comes with a shovel full of ignorance...

So your comment implies that medicare/medicaid prices would go up? Is that true? Could the 'listed rate' drop 40%? I always hear listed rates are grossly inflated for those that dont have insurance and land in emergency etc

When you see some of the inflated prices a >40% drop seems distinctly possible if a truly competitive market is created. Would that be fair?


It’s actually worse - a healthcare provider is typically paid 10%-40% of the cash pay rate for a Medicaid or Medicare patient so 60%-90% below the listed rate!

I’m far from an expert as well, but my point is that a transparent everyone pays the same system is in direct conflict with the current system where certain patients pay multiples of the other patients for the exact same care/service etc.


Where do you work?


> I had this experience with imaging (MRI), cost 10% more with insurance than without.

Depending on where you went it could have been much more than 10%. Non-emergency imaging is definitely one of those things you ask about other locations and if they have cash pricing. When I needed an MRI if I was to use my insurance it was going to be ~$1000 because of high deductible plan. A different place took payment at the time and it was $350. According to the doctor who wanted me to get the MRI, hospitals are far and away the most expensive places to get one.


In such case, could someone just deny the service, ask for a referral, then go someplace else and say they don't have insurance?


Absolutely - but they might still ask themselves why they are paying an insurance company to negotiate a rate above what they can obtain on their own.

In vs out of network, deductibles, and co-insurance can also complicate the calculus


This gets to the core of Milton Friedmans criticism of the healthcare system. PAtients might ask themselves that but they get healthcare services through the employer, so they show little to no elasticity between insurance companies and their premiums.

If you untied healthcare from employers, then you would unleash a massive competitive force, where if one insurance outperforms another one, patients will react as you say. But today, changing insurance companies would mean changing jobs.


Healthcare insurance is different. What you would see is that insurance companies would compete for the healthiest demographic and offer them the best rates but no one would cover people outside of that demographic or they would charge ridiculous rates.


Yes!

And this is because healthcare is not an insurance! It should be instead thought of as a societal contribution (via a tax) for the benefit of universal healthcare.

Framing healthcare under the microscope of insurance causes the boxed-in solutions currently in existence.


That would actually be a good force. It is insanity that a 20 year old pays the same that a 50 year old, or that someone that exercises, does his check-up, etc pays the same as someone that never goes to the doctor, doesnt take care of himself etc etc. Even car insurance does this.

The point of insurance is to manage risk, not to reward it.


And then there is the whole pre-existing condition thing. How dare someone be born with handicap, get cancer, etc. Would you be okay if your insurance tripled or was completely denied if you were diagnosed with cancer? And why should a woman have to pay into an insurance pool that pays out for prostate exams?

Car insurance is mostly based on things you can control -- at fault car accidents, tickets, etc.


You pay your insurance against cancer before you get it.

A more complicated pre-existing condition would be maybe for kids, young adults whose parents didnt give coverage for , etc. But you could use subsidies to manage those cases and it would be a blip in the budget. If someone deliberately avoided insurance and the catches an expensive disease, he should be toast, because thats the gamble he made and the result of it.

Please also keep in mind that in a state run system, if a treatment is very expensive the state will not give it and thats it. Thats one of the reasons why public healthcare is often cheaper, because it says no to many treatments, which is not something easy to accept for americans.


You pay your insurance against cancer before you get it.

That’s not how things worked pre ACA. The insurance company could drop you after a certain point even if you had paid for coverage.

Also, before the ACA, if your cancer was in remission and then five years later, even if you had continuing coverage, and you tried to get insurance on your own, you couldn’t get it.

A more complicated pre-existing condition would be maybe for kids, young adults whose parents didnt give coverage for , etc.

That’s also not how things worked pre ACA. If you had insurance that you bought yourself and not through your employer and you had a kid who was born with a birth defect, the insurance company wouldn’t cover you.


> Milton Friedmans

That guys a quack and everything he's done has been debunked.

The definitive work on this was Kenneth Arrows work in the early 60's.

See Uncertainty and the Welfare Economics of Medical Care.

http://www.who.int/bulletin/volumes/82/2/PHCBP.pdf

tl;dr: Markets don't work for healthcare. Full stop.


Why can't they just say that they'd like to pay without insurance? Is it some kind of crime to not use insurance even though you have it?


No but they may try to make you think it is. I’ve seen this first hand at an urgent care center.


Sounds like price fixing; a crime


Price fixing is a crime only when coordinated among multiple suppliers.


A crime is only what legislature declares is a crime...

One would consider why it is the law for a mechanic to give you a written estimate for work to your vehicle, and be required to call you before exceeding by a notional amount- yet, a hospital can legally withhold all cost information from you and yet you’re responsible for the bill in full after the service.


My refrain. If a mechanic conducted business like a hospital they'd have their business license pulled and the owner would go to jail.


Healthcare and profit don't go together. This is just exhibit n° 31415926535897932384626433.

What happens in the software world when you see twentyseven useless levels of abstraction? Exactly the same. You smell a rat.

In my ideal world:

* Healthcare research funding to come from the public sector and donations only.[0]

* Healthcare products can only be sold once the production process is verifiably fully publicly documented. This means independent reproduction by multiple reputable non-profits.

* Market based generics manufacturers handle production. Competitors (for profit or non-profit) jump in if pricing gets out of hand.

* Healthcare education free to students.

* Only non-profit healthcare services allowed.

* Compensation for people providing healthcare services is linked to median income.

[0] This is not such a big difference as one would think, as more than half of the basic research in the field is actually publicly funded already.


>Healthcare research funding to come from the public sector and donations only.

And I suppose the public will indirectly vote on where research goes and where it does not? I don't trust any party in power to have a monopoly on healthcare research without a private sector counterbalance. But I'm open to reconsidering the current allocation.


I was watching some NASA scientists ask the federal government for money on C-SPAN and the NASA people said that they decide what research to fund by surveying the scientific community. I forget what they call the system exactly.

EDIT: I found it. They use something called a "decadal survey"

https://science.nasa.gov/earth-science/decadal-surveys


I would trust the group of folks NASA is surveying MUCH more than the general public, even when it came to healthcare.


The freedom to research would stay! If anything, researchers should have more freedom to research. An example.

Imagine a researcher invents cheap medication that obviates the need for some kind of eye surgery.

What would happen now? Surgeons don't like it, insurance companies don't like it. It might never catch on. The silly researcher certainly wouldn't get rewarded for his idiotic idea.

What would happen in an ideal scenario? Better health with less side effects for the patients. Cheaper for the community.


Exactly. Institute proper nutrition at school lunch programs and easy access to clean water throughout the day, and watch what happens to healthcare costs, dental costs, test scores, etc. It costs more, but society currently pays the cost later times ten.

Same with sunlight to prevent the onset of myopia, etc. These are things we already know about and can have huge impact, but it's politically infeasible to solve these problems correctly.


> Only non-profit healthcare services allowed

Honestly, this isn't necessary, as long as you have single payer (or close to it). When the government is the one paying for 99% of healthcare, they have huge clout enforcing razor-thin margins and high efficiency on the provider side. Just look at how the massive supermarket chains are able to keep the margins of the upstream supply chain at a minimum.


> Honestly, this isn't necessary, as long as you have single payer (or close to it). When the government is the one paying for 99% of healthcare, they have huge clout enforcing razor-thin margins and high efficiency on the provider side. Just look at how the massive supermarket chains are able to keep the margins of the upstream supply chain at a minimum.

The problem is that governments don't work that way. When a purchasing officer at a business negotiates a lower price he gets a large bonus. What does a Congressman get when he negotiates a lower price, compared to what he gets (from the people he's negotiating with) if he "negotiates" a higher price? What about the government bureaucrat who will be working in that industry soon? That is the problem.

Meanwhile who is more knowledgeable about produce if you have a question, the staff at Walmart or the farmers at the local farmer's market? It's easy to order cost cutting from the top of the tower, but if you don't know what's happening on the ground, you don't know what you're actually cutting.

What you need is for people -- the people who are actually consuming services and can choose to go somewhere else if the price is wrong -- to be able to choose based on published price information. The argument people sometimes make about this is that you don't get to choose which hospital an ambulance takes you to when you're unconscious, but the majority of healthcare spending isn't that, and that doesn't explain why we have no price transparency for non-emergency surgical procedures or diabetes or cancer treatment.


> The problem is that governments don't work that way

Well, they can... Just look at France. Amazing healthcare, a lot of it private, relatively cheap

> What does a Congressman get

Nothing, they don't negotiate

> What about the government bureaucrat

A performance bonus, a raise, a promotion? Just like any other organisation?

> What you need is for people to be able to choose based on published price information

OK, go and buy a pound of ground meat. Or an LCD screen. Are you seriously telling me you can get a better deal than McDonalds or Apple?


> What you need is for people to be able to choose based on published price information

What they're saying is that a large amount of healthcare spending is driven by patients and providers, but paid for by insurance companies. Neither patients nor doctors have an immediate, short-term incentive to make sure they utilize insurance company resources judiciously. On the contrary, the both have an incentive to consume as many insurance company resources as possible (the patient wants to make sure they get every possible treatment, even if that means consuming 10x resources to prevent a 1/10th as likely outcome, and the provider wants to bill as much as possible to increase revenue).

I can tell you, as somebody whose family has catastrophic coverage only, that we think long and hard before we blow $200 so that a doctor can tell us to take some ibuprofen and drink plenty of fluids. And we also ask lots of questions about how much various recommended treatments will cost vs. what they will do for us.


> Well, they can... Just look at France. Amazing healthcare, a lot of it private, relatively cheap

In a place with a different political system, population, demographics, culture, economy, etc... and France has a price transparency law.

> Nothing, they don't negotiate

They pass laws dictating how others can negotiate (or not).

> A performance bonus, a raise, a promotion? Just like any other organisation?

But not like any other organization, because if you gave a government employee a million dollar bonus for doing their job there would be a riot. Meanwhile they can get million dollar private sector employment for not doing their job.

> OK, go and buy a pound of ground meat. Or an LCD screen. Are you seriously telling me you can get a better deal than McDonalds or Apple?

I'm telling you I can get a better deal than the Department of Defense.


Doesn’t the French government have some leverage via pharmaceutical intellectual property rights? I’m no expert, but I don’t think it’s as simple as “everyone should just buy in bulk like we do.”


> What does a Congressman get when he negotiates a lower price, compared to what he gets (from the people he's negotiating with) if he "negotiates" a higher price? What about the government bureaucrat who will be working in that industry soon?

Ideally there would be some sort of accountability for elected officials, where they would have to answer to their electorate, and where conflicts of interest would be against the law (and prosecuted), but who am I kidding?


> Ideally there would be some sort of accountability for elected officials, where they would have to answer to their electorate, and where conflicts of interest would be against the law (and prosecuted), but who am I kidding?

Right, exactly. It's like the claim that Communism would work great once automation eliminates the need for all human labor. It's a nice theory, might even be true, but until we can satisfy the precondition what practical relevance does it have? Go work on the precondition and come back after you accomplish that. In the meantime we need something else.


If the us tried to become your ideal world, you would lose a huge chunk of the doctors you have, and the amount of medical services you would provide will be lower than it is today.


"Only non-profit healthcare services allowed."

Not sure if this is required - the UK manages to have a socialist health care system (the NHS) for the vast majority and a relatively small private healthcare system for those who want treatments not covered by the NHS, or a nicer room etc.

I'm not sure I'd be happy with completely banning access to private healthcare - although I'd prefer it if the NHS was resourced to a level where there really wasn't much need to to go private (which certainly used to be the case).


I wouldn't hold the NHS up as a paragon of virtue. I got sick on a recent trip to London and tried to get in to see a GP under the NHS and it was impossible.

The clinics near my hotel only accepted same day bookings. I tried calling just after opening hours and the phone was engaged. I managed to get through 15 minutes after the clinic opened and the clinic was booked out for the day and I would have to call back the next day. I tried a number of clinics and they were all booked out. I was lucky that I wasn't that sick and got better. Otherwise, I was looking at an exorbitant fee to see a private doctor.

I was shocked, as I always assumed that the NHS was better than the system we have in Australia. I think that there are lots of perverse incentives involved in Medicine and Healthcare. Government intervention is required to balance out these incentives from profit takers and consumers (i.e. smokers, obesity, etc). I'm not sure that any model in the world right now gets the balance right.


Note my comment about "I'd prefer it if the NHS was resourced to a level"....

The issue with not getting GP appointments quickly seems to have been a relatively recent thing - due to lack of resources and mismanagement rather than fundamental problems with the approach.


That's not entirely true. If you're actually emergent and require a same day apptmnt then they've got held appointments for you. However this has led to an extremely strange system where often GP receptionists are essentially gatekeeping services (as a pre requisite to accessing the GPs who gatekeep the other services...)


> I'd prefer it if the NHS was resourced to a level

You know what a great system for allocating resources in an incredibly complex system is?

Prices.


> a relatively small private healthcare system for those who want treatments not covered by the NHS, or a nicer room etc.

From what I've heard about the Charlie Gard [0] and Alfie Evans [1] cases, that isn't always allowed, and even being an Italian citizen or an offer from the Pope can't sway the decision [3].

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

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

[3] https://www.telegraph.co.uk/news/2018/04/23/protesters-storm...


??? Alfie Evans had nothing to do with the NHS not wanting to cover the treatment. From the first paragraph of the wikipedia article you linked to:

> Alder Hey Children's NHS Foundation Trust sought a declaration that continued ventilatory support was "unkind and inhumane", and not in Evans' best interests


Some people liken that to a "death panel", in that it was not unanimously agreed with by other medical professionals, including those that thought there may be other forms of treatment for the same affliction that were not being covered by the NHS.


Yes, doctors here (as, indeed, in most countries) can take cases to court when they believe the best interests of their patients are not being looked after by the legal guardians. And these are not mediocre doctors, nor was this being done lightly.

The treatments not covered were not even approved for use in the UK privately afaik - it was entirely unrelated to the NHS budgets.


The NHS is a partnership with the private sector any way, because GPs are greedy.

All GP practices in the UK are privately run.


>31415926535897932384626433

This should be 31415926535897932384626434.


This all assumes that healthcare is a human right, which I am not so sure about. Why should health education be free but not engineering education? I'd hazard an argument that not everyone deserves healthcare, so it would be difficult to make it a Right.


Something is very wrong with the whole medical insurance system in the US. Having recently been exposed to it, I keep discovering new surprises and being shocked regularly.

What I found most bizarre is that Americans who are "temporarily" in the US (e.g. expats, visiting) can get health insurance with better terms and at about 1/10th the price of what residents are offered.

Someone is being had, I'd say.


That could be because for the really expensive stuff they'll pay for you to be transported back to your home country, where your primary insurance will treat you.


No, that is not the type of insurance I was writing about. To take an example, take a look at Patriot America Plus from https://www.visitorscoverage.com/visitor-health-insurance/pl...

It does include the acute onset of pre-existing conditions, $250 total yearly deductible, 100% percent in-network coverage. But it is not available to US residents, only for short term (up to two years) stays.


> The Patriot America Plus Plan is available for any non-US Resident , visiting the USA for a short period of time

> Pre-existing conditions are not covered by Patriot America Plus Plan

It requires you to already have insurance somewhere else, and they expect you to go home for anything chronic (expensive). It sounds exactly the same as any travel insurance you can get in your home country (and is included in many fancy credit cards)

You said "expats" before, but ex-pat implies residency in the US. Tourists/business travelers are a whole other ballgame. They're just protecting against not getting hit by a car when they're at their week-long conference. They're all limited in scope of their costs by their visitor's visa duration (typically 90 days)


Maximum coverage limits are low on these plans. This is definitely a contributing factor. Since the affordable Care Act passed, there are no maximum coverage limits. This has increased the cost of health care dramatically.


From Patriot on that page, "Cannot accept an address in Maryland (MD)."


I am a foreigner in the US, and I am not eligible to health insurance at home anymore, there is a residence condition.


Consider that the average healthcare consumer pays an insurance company a premium and a co-pay so that the insurance company can reimburse a doctor whose rates are higher to offset the cost of administrative salaries for assistants to deal with the insurance companies. If you think about it, it's basically a form of racketeering which happens to be legal because the doctors and the insurance companies aren't formally colluding to needlessly increase the administrative complexity of the system, and because there is no legal response, the insurance companies are incentivized to raise administrative complexity and cost over time (since inelastic demand has no effect on preventing revenues from rising from pure cost increases).


If you're an expat, you really need one of those insurance polices in addition to regular US insurance, as you'll discover when you try to claim.

My colleague spent weeks on the phone arguing with the insurance company while debt collectors from the hospital hounded him after a simple ER visit. In the end someone at the insurance company paid his bill with their corporate credit card because they couldn't figure out a way to get it paid through the system. This despite the fact that the insurance company claimed to have a 'network'-type relationship with the hospital (which the hospital denied any knowledge of). They stopped offering coverage for the US altogether after that because it was too expensive.

My parents are still trying to get their travel insurance to reimburse them after an ER visit while on holiday.

Basically everyone is being had.


Accident vs. long term sickness, maybe? If you’re a visitor to the US and are diagnosed with cancer you’re not going to stick around and rack up a 250k in medical fees (and I expect it’s not covered anyway).


Heathcard insurance premiums are using community rates - priced on the overall risk / claim rate of the population of people covered under a certain policy.

My guess is that expats and visitors from other countries are a healthy and lower risk group (because they’re also wealthier) than the general population.


Does the insurance cover pre-existing conditions?


Nothing makes sense how billing in the US medical system works. It's a total ripoff.


Under the NHS most patients pay a "prescription charge" which is intended to encourage patients not to seek prescription meds when they needn't do anything. (Several big categories like pregnant women are exempt from charges, and if you use lots of medicine you can "prepay" a fixed fee of about £100 each year to stop getting charged regardless)

The charge is more than some cheap OTC medicine you might get prescribed, e.g. hay fever tablets are pennies per box and the charge is almost £10. But pharmacists are required to tell you if you could just buy it yourself for less - they collect the charge so they have the opportunity to point this out whereas your doctor needn't know if you pay or not.

Logically the charge must also be bigger than the price for some of the cheapest prescription-only medicine and there's no way to avoid paying extra in the UK as far as I know in this case.


Over 90% of prescriptions are free, because they're prescribed to exempt groups (children, the elderly, people on benefits). It's a slightly peculiar system that doesn't make a huge amount of sense.

https://www.pharmaceutical-journal.com/news-and-analysis/pre...


The alternative conclusion is that it’s fulfilling its purpose as a deterrent against abusing prescription medication


Another exempt group is the chronically ill - if have diabetes or thyroid disease or anything else that requires regular medication you don't pay. It's clear that most prescriptions are written for this group.


In Austria it's harder to get exempt. If you rack up 2% of your net income in those charges you can apply for exemption. 80% of Austrians never have been exempt, only 4% sometimes hit the cap and about 12% get an exemption due to specific illnesses which are costly.

I have seen the system here and some of the effects that come out of it are interesting. Because if the cost of a drug falls below the "recipe fee" it bypasses the insurance and is directly charged there is a mysterious amount of drugs close or below the recipe fee.


Perhaps they could go with a Humble Bundle style "pay what you want" model :) I would happily pay more.


The charge is more than some cheap OTC medicine you might get prescribed

I've had both similar, and opposite, experience in the U.S.

My wife has a prescription for an OTS drug. Getting the prescription filled with insurance costs $35. But buying it OTC costs $22-25, depending on the store.

I have a prescription for an OTC drug. Getting the prescription filled with insurance costs $3.55. But buying it OTC costs $10-$12.

It's like they always say in health care — ask questions, keep records.


Just thought I would mention in Scotland with NHS Scotland we pay no prescriptions charges.


Also Wales.


Defend your public services and safety nets at all costs; vultures await an apathetic electorate.


I think we're 15 years too late to recognise this. We've been pushing healthcare budgets down and into private hands (PFI, tendered provision contracts) for at least that long. And while it's demonstrably failed, we keep pushing that way.

We have too many politicians with too many fingers in too many pies telling too many lies about the "dream" that is American healthcare.


I was blown away at the intensity of the propaganda blitz when the Obama administration was working on healthcare - I haven’t seen so much manipulation outside an election cycle. The ‘American healthcare is the best in the world!’ line that was oft repeated stands out to me, since by most objective standards it is far from the best.


The more I read about it the more convinced I am that there is no way to know who is right, both sides are so invested in their arguments and both sides have so many incentives to skew the numbers are play with the outcomes that it's become impossible to get any sort of definitive answer on this.

You say that the US is objectively worse, but I can bring you to 10 people who will argue convincingly that it's objectively better, and then turn you around to 10 people who will convince you of the opposite again. All with real numbers and facts that don't contradict each other.


Objectively worse? To what end? What really matters?

Do you care more that your healthcare is 10% more effective at its peak, or that 30% of the population is uninsured, without access to good preventative care? From there you have to extrapolate because nobody can predict the cost of these societal schisms, or that of the cost to heal them.

There is no objectivity to be had here; just morality, hope and fear.


I was sick for years as a growingly impoverished self employed person with no non-emergency healthcare access. This situation is, as far as I know, unique to the US as other countries don’t tie health benefits to private employment.


Then bring this argument. Or don't.

Insisting that "10 people will argue convincingly that four is prime" isn't a convincing argument that four is or even might be prime.


Politicians that can’t be reasoned with can be replaced.

Run for office. Failing that, support candidates that support your views. Democracy exists as a function of effort.


Political will isn't enough. The NHS needs tens of billions to backpeddle years of decline, to re-in-house services and surge-hire staff where they're need with appropriate incentives.

Doing that in a climate of contracting economical growth and leaving the EU (where 40% of our nurses come from) makes this impossible without politically suicidal borrowing.


Raising taxes on vacant real estate owned by non-residents/non-citizens is one option to raise revenue. Russian and Chinese nationals who are using vacant, valuable UK real estate as an asset store don't vote.

We can’t argue the money doesn’t exist. It exists. You just need a majority of people to decide that efficient healthcare is worth paying for.


You're preaching to the choir. I'm not saying it's impossible, just that wanting to do this stuff isn't enough.

Case in point, current opposition leadership would do all this in a heartbeat but between center-leaning members and a very Conservative press, they'll always be portrayed as Nazi-sympathising Communists.

Brexit hasn't helped this either.


And if a modest use charge makes the spending more efficient and results in the delivery of more care?

(efficient in terms of medical benefit delivered per unit of spending)


That’s a rather large and unproven if.

If nothing else more complex transactions have higher costs due to the complexity. So, the benifit would need to be rather large and easy to measure to offset this. Until that data shows up it’s rather pointless to argue about.

PS: Also, the effort/tine investment to collect prescriptions is already a modest fee.


[removed by poster]


My mistake, I thought the thread was about the prescription charges mentioned in the top level comment.


No mistake at all. Subthread went off the beaten path, your argument is still sound. Apologies!


There's also a focus amongst GPs to not prescribe cheaply available drugs, with safeguarding allowances. The NHS pays flat processing fees on classes of drugs. A 10p box of paracetamol ends up costing the CCG £4 to dispense via a high street pharmacy.

This crackdown is at least partially due to the perennial social media posts doing the rounds telling people how to get "free" Calpol for their kids.


Don't forget that prescriptions are free in Wales and Scotland.


I am on the same exact medication. I live in Italy. My 90-day supply is 15 euro (5 euro per box), but the government covers most of it through the healthcare system, so I end up paying 3 euro (1 euro per box).


And you could probably get it even cheaper if you ordered them from a pharmacy in India.


Except they'd probably get stopped by customs.


and might be counterfeit


Anyone who thinks the FDA should be abolished should read the Warning Letter of the Week and reconsider: http://chemjobber.blogspot.com/search/label/warning%20letter...


Our investigator documented that you have an employee food preparation area within your drug manufacturing area with no separation between open manufacturing equipment, cooking utensils, and personal-use items. The practices observed at your facility, which was observed open to the outdoors, increase the likelihood of your drug products becoming contaminated.


Eating in the lab is poor form, it goes against all the social norms a manufacturing chemist has imbibed during their training. Such poor discipline usually points to further trouble, and indeed there are deeper problems:

You provided no evidence that you have performed chemical and microbial testing on each batch you manufactured before making a batch disposition decision.


And read the history of the Thalidomide disaster avoided in the USA by a FDA scientist Frances Oldham Kelsey


Aren't most people advocating for the removal of the DEA not the entire FDA?


Lets make it a middle ground, let the fda run its tests, but let people consume the meds they want. FDA charges patients for the benefit of their regulatory overwatch, while those that choose to risk it will find cheaper meds. Everyone happy!


I have a doctor friend who's made it a habit to recommend that patients use GoodRx anytime they go to pick up prescriptions. Doctors can only be so involved in the pharmacy side of the transaction and a lot of pharmacists aren't able to intervene.

It's sad that it requires a 3rd party app to help people not get screwed over by the current US medical system.


You don't need a third-party app to use GoodRx. I use it regularly, and you can just have em email or text you the discount info. When you go to the pharmacist, you hand em the printout or phone, and they type it in. I'd definitely suggest people at least compare prices with em before going to pick up their medicine.

Another suggestion, at least for California: always ask for paper prescriptions! Fuck digital prescriptions. With a paper prescription you can go to any pharmacy you want and have it filled (i.e. shop around and find the cheapest)! But with a digital prescription you can't have it transferred to another pharmacy without calling up the doctor, which is completely fucked up. It's especially frustrating when your regular pharmacy is out of your prescription and your refill day happens to land on the weekend. Now you have to wait 2 days for your refill. One situation I've had happen occasionally is that I'll miss my regular pharmacy's closing hours because I was busy, so I'll just drive to my nearest 24-hour pharmacy to have my prescription filled; you can't do that with digital prescriptions!

I've literally saved hundreds of dollars, just by shopping around a bit. And heck, it's not as if driving an extra half a mile is such a big deal, especially when it can end up saving you a few hundred dollars. I'll also note that sometimes even within the same franchise prices can vary greatly, so it's often worth going a little bit further.

I think pharmacists are allowed to point out services like GoodRx, but it might be frowned upon, I'm not sure. At least in my case, I found out about their services thanks to a pharmacist: I was refilling a prescription, and the pharmacist walked out of their sealed off area, pulled me to the side and told me to look up this "GoodRx" thing.


GoodRx /is/ the third party app. The point is that US consumers shouldn't need to worry that their medical insurance is duping them.


I think he was just nitpicking that GoodRX is available through more than a binary you have to install. I've used it through its website quite a bit. Its a wonderful service.


My mother who is a doctor had their business card in her office, you could you the info on it for any prescription. No need to go to a website or download an app.


Not very good advice. Pharmacies can deny paper prescriptions at their discretion. And most people know where they’re picking up scripts ahead if time.

For example, the pharmacist at a CVS decided not to refill my Vyvanse (amphetamine) paper script because I was paying in cash (+ using paper script). Treated me like a criminal. Digital scripts avoid this unpleasant scenario.

The pharmacy system itself needs reform. It’s idiotic that your doctor can write you a prescription that gets denied by someone who puts pills into a bottle. An anti-abuse system that treats everyone like criminals needs a better solution.


It's a little different in my state.

A pharmacist is required to fill any prescription, paper or digital, except if the pharmacist has a religious objection (birth control, morning after pill, etc...). This came out in a recent court case.

It's the state that decides if prescriptions for controlled substances (like your Vyvanse) get rejected through a centralized database that works off of your driver's license/state ID scan* to prevent abuse.

There was much chaos a few months ago when the state imposed tighter restrictions on the number of opioid pain pills that could be dispensed at one time. You might have a prescription from your doctor for a 90-day supply, but you could only pick up five at a time. (Not an exact number, as I'm not on opioids.) For months, the lines at the pharmacy were backed up for hours as thousands of people ran into the new rules and took them out on the pharmacists.

* Amusingly, one of America's largest supermarket chains, Albertson's, isn't using the computerized driver's license scan. It keeps records in paper binders where the pharmacist writes down your DL# and you sign next to it. They don't even record what it is that you filled, or how much. Good job, Albertson's!


Many states are screwing up Albertson's strategy with mandatory centralized database reporting. The "opioid epidemic" is terrific justification for growing government power and enforcement arms.


It’s worse. Pseudoephedrine is available without prescription but you are limited to 30 day supply in total per month and there is a mandatory state database. All that seems reasonable, until you can’t both buy pills fit yourself and your child without going over.


Oh man, great point. The pseudoephedrine thing is a nightmare. I have several kids so I have to make a note to purchase some every month, because once a sickness ravages the house I won't be able to buy enough. It's insane.


I believe in my state it's not available at all any more.


Could I ask what state you're in? I've been taking amphetamines for a pretty long time now, and the only times I've been turned down was when I went to take my refill in before its due date, and they still let me drop it off, they just wouldn't hand me the medicine until the due date. It's a bit annoying if you have a lot of errands to run on the next day, or if you're going on a trip, but I can sorta understand where they're coming from. Especially since it has such a high potential of abuse.


There are lots of Pharmacies. I always use paper and cash.

I always use smaller, non chain pharmacists too. Msny will compound, they know me and mine, and that relationship is worth a lot.

The cheapest is not too important most of the time. Things being right, and an active pharmacist helping with cost, special programs, and accuracy matters more.


They don’t just put pills in a bottle. They’ve been tasked, by the government, with making sure the correct drugs are dispenses to avoid abuse and other damage.

Obviously if certain behaviors correlate strongly with people who abuse, then it’s their job to use their discretion to demand more proof, or deny.


Odd. Can't they verify the prescription with the prescribing doctor, and verify your state issued ID? I personally haven't had this issue with Walgreens (but I get a lot of medicines through them, and only controlled substances I've filled were small dosage Norco post-surgery)


That's interesting. I'm in Illinois and can only use paper scripts for controlled substances. It is quite annoying to have to physically go into the doctor's office to get my Adderrall prescription because they aren't allowed to use a digital script.


My mother (a doctor) will only give eScripts because of the abuse, it sucks, but sometimes the bad actors ruin it for the rest of us.


In my state most doctors don't have the technology to send digital eScript for controlled substances


Out of curiosity, what state are you in?

Even in Alaska, not generally a very technically advanced state, I never met a doctors that didn't have the ability to send eScripts. I never visited a doc in a remote village however, might be a different story out there.


California, you'd think the handful of doctors I've busted could send an eScript to a national chain (CVS), but I'm denied and made to carry 3 months worth of wonky triplicate paper prescriptions that are prone to being misplaced.


I'm in Illinois and have to get a paper script for my controlled substance prescriptions (Adderall)


My doctor brought in his laptop and showed me this site. I was completely floored that these are cheaper then my co-pay. I now recommend this to everyone. My neighbor who is low income retired senior, was paying more with all these government subsidized prices, then Safeway. He was absolutely livid he could get a $15 that cost him $280. At this point I realized that the entire insurance scheme is a scam. The co-pay is above what the prices you can find on GoodRx. You end up paying MORE with the insurance co-pay then you would if you were to just shop around. This should be felony fraud! From speaking with my friends, nobody knew about GoodRx so I bet a majority of medicine is overpaid with "insurance" -- this should be headlines everywhere.


GoodRx is a pharmacy benefit manager, most insurance companies use a pharmacy benefit manager. What they do is negotiate prices for some certain set of drugs. So 2 insurance companies might have 2 different prices than GoodRx and each of the 3 will offer a slightly different set of drugs.

When you use insurance and pay the co-pay, that counts against your out of pocket maximum on the plan. Prescriptions bought with GoodRx don't.

The insurance isn't doing a great job when they charge a co-pay that is larger than the price GoodRx has negotiated, but it isn't evidence of a scam.


GoodRx is not a Pharmacy Benefit Manager (PBM) actually. A PBM negotiates prices with pharmacies to include them in their network, GoodRx does not do that to my knowledge. Instead, GoodRx offers a service that allows users to compare different coupon and membership prices so that people can chose the best available price/pharmacy combination.


They do it by taking up the role of a PBM. This is for some other discounter, but you get the idea, they process the prescription using GoodRx's system:

https://www.discountdrugnetwork.com/what-rx-bin-and-group-nu...


> Doctors can only be so involved in the pharmacy side of the transaction and a lot of pharmacists aren't able to intervene.

Pharmacists can intervene a lot more than your doctor friend lets on. A good pharmacist will tell the patient there is a generic version of the drug when the doctor wrote a script for a brand name.

A good pharmacist will also tell you not to use your copay when its more than the out of pocket cost.

A bad pharmacist will do neither of those, but they are 2 simple questions anyone can ask when they go to get their prescriptions filled.

Is there a generic? Is it cheaper than my copay?

I learned the hard way after coming home with an Rx that was more expensive than I remembered. Wife found out they gave my brand name "well thats what the doctor wrote!" and chewed her out.

That said, if you are OK with privacy concerns or don't have the time to call yourself, GoodRx is nice to find the lowest cost as they definitely aren't standard and some places even have certain drugs for free.

Source: wife & mother pharmacists :)


Truth.

Source: awesome family pharmacist.


Are you aware of any privacy issues with GoodRx? I’ve avoided it because I assume they are making money selling my prescription information.


I can't say if GoodRx is doing it, but Walgreen's seems to be selling information.

I was with a friend picking up his meds and I bleeped my rewards card to collect the points, since he didn't have one. Now I get offers in the mail to treat his condition.


So this has been a roller coaster. My initial thought was that this was a big HIPAA violation but then I decided to actually look to see if my assumption held up. According to the Department of Health & Human Services page on HIPAA and marketing [0], Walgreens can use personal health information (PHI) in marketing without violating HIPAA, as long as they have permission to do so.

So with that in mind, I went and looked at Walgreen's notice of privacy practices [1] and they say that they will get a written disclosure before using PHI (and that is restated in their Balance Reward ToS.

Bottom line is, if they are selling information then hopefully you're friend has signed a form authorizing use of the PHI otherwise Walgreens is violating HIPAA.

[0] https://www.hhs.gov/hipaa/for-professionals/privacy/guidance...

[1] https://www.walgreens.com/topic/help/general/noticeprivacypr...


GoodRx is strictly against selling personal medical data. Reference. https://support.goodrx.com/hc/en-us/articles/115005228506-Pr...

"GoodRx does not sell information regarding your drug prescriptions and medical conditions that are linked to your name, contact information and other personal data you provide us."


This could just mean pseudoanonymization. I.e. they staple you medical information to your IP, a cookie, or an advertising ID. A buyer can deanonymize that kind of data in many cases.


Would also like an answer to this. This is worrying, just started using them...


I would say this is an argument for free markets.


What's funny is I imagine "Amazon Prescription Drugs", would look like dark-net market websites.

Both sell prescriptions, both use USPS or whomever to ship. Besides I bet it would be easier to track illicit use if it was regulated. Not to mention cheaper, faster and digital. Less prejudice.

Too bad the general consensus is that these jobs are necessary when they aren't.


I do wonder if insurance paying for everything under the sun is part of the issue. I remember hearing talk of medicine for some chronic conditions being available over the counter (migraines, diabetes, asthma, etc.). The way I see it, my car insurance only covers a limited number of issues. Unfortunately, health insurance has historically come on the wrong side of things (e.g.: pre-existing conditions BS)


Health insurance in the US isn’t insurance. It’s a scheme to try and spread around the costs of providing healthcare to everyone, and everyone tries to pass the buck to those with the least power in the system. Large employers with young, healthy office workers win, and poorer taxpayers who don’t have health insurance or independent contractors who have very little power lose. The people who have nothing get medical care, but it’s not ideal, but they don’t have anything to pay with either.

So try not to be in the middle - the ones with enough assets to take, but not enough to defend against having them taken (e.g. not being part of a group that can negotiate out of it).

God forbid we actually come out and say we, as a country, want to support each other. A large portion of our fellow citizens would rather play this game of hot potato, but don’t have the balls to turn poor people away from the emergency room and tell them to die.


Health insurance in the US isn’t insurance. It’s a scheme to try and spread around the costs of providing healthcare to everyone

That by definition is insurance.... https://www.investopedia.com/terms/i/insurance.asp


The key difference is that the recipients are also others who pay for insurance, whereas in US health insurance, it’s a game of see which provider can collect more from which payer (government, insurance, individual) to make up for the losses on those that can’t pay.

Also, chronic and old age health issues don’t even seem like insurable risks, like getting 20 year term life insurance for a 90 year old. You would basically just be paying for someone else to manage your premium money and take a cut before giving it back to you since the insured risk is inevitable and has to be priced accordingly.


The key difference is that the recipients are also others who pay for insurance, whereas in US health insurance, it’s a game of see which provider can collect more from which payer (government, insurance, individual) to make up for the losses on those that can’t pay.

Health costs between what you pay as an individual and what you pay as part of a group is just like anything else. You couldn’t buy the same parts for a computer at the same price as Dell. Dell can get bulk discounts you can’t.

A health care provider is willing to charge less for care per person for a group of people through an insurance carrier than you individually.

If you have ever signed up for term life insurance, you usually get a fixed premium up to a certain age, and then premiums skyrocket as you get older. You theoretically can price life insurance for a 90 year old based on actuarial data. The cost will be prohibitively expensive.


An individual isn't paying increased costs for parts for computer because the merchant was forced to sell parts to someone for free. A merchant might be making less on the marginal profit to a large vendor (or accept slight loss to benefit from the marketing of having a large customer), but I don't see it quite as bad for the little guy as it is in US healthcare.

Edit: I understand the analogy of a bigger buyer means better prices, but it's a little different too because the merchant of the computer parts can't bill the losses to the government who then pays via increased taxes. The pricing differences are astronomical too between what prices are given to people who want to pay cash versus via insurance or Medicare or Medicaid, it makes no sense.

I see the US healthcare market as the middle and lower middle class spending a larger portion of their wealth subsidizing the poor class while the upper middle and upper class spend a smaller portion of their wealth subsidizing the poor class because they can negotiate out of it, and they probably get better care too.

And this is all exacerbated because employers get to deduct health insurance premiums from taxes, while independent contractors buying insurance independently don't.


Health insurance is deductible as an independent consultant.

https://turbotax.intuit.com/tax-tips/home-ownership/deductin...


Is that a recent change? I was under the impression that people who buy their own insurance can’t deduct it, or at least I haven’t ready any 1040 instructions that say you can. What if you’re employer doesn’t offer health insurance and you buy it? Then you’re not an independent contractor, but you still don’t get it from employer.


It’s part of your standard business expenses as an independent contractor. It’s been that way at least since 2012 when I was a consultant.


Interesting, thanks for the correct info. I can't seem to find anything about people employed by small business that aren't required to offer health insurance, so I think they still have to purchase health insurance themselves with post tax income, so I guess my point only stands for them.

But still, it's all needlessly complicated and unreasonable to expect people to be able to optimize in our current system.


If you are employee and receive a W2, you can only deduct healthcare expenses that are more than 10% of you income.

I would say that any company, no matter how small has no excuse not to offer health insurance to thier employees. The cost in administration is minimal and can be outsourced. I have a relative who runs a law firm with just herself and one or two assistants and even she offers unsubsiduzed health insurance. I’m not saying they should subsidize the cost. Just by offering it through the company, it’s cheaper for the employee because the company can offer it pretax.

As an employee, I would never be an employee of a company that didn’t offer insurance if I needed it. If they won’t offer (unsubsidized) insurance, and I want to work for the company, I would insist on working as an independent contractor at a rate that would make up for not getting paid time off, self employment taxes, and future unemployment benefits.


>God forbid we actually come out and say we, as a country, want to support each other. A large portion of our fellow citizens would rather play this game of hot potato, but don’t have the balls to turn poor people away from the emergency room and tell them to die.

This.

If we can't actually commit to taking care of our own, just who are we as a nation?


What would happen if we suddenly made opaque pricing illegal? If anyone sells anything to anyone, they'd be required to publicly disclose the price.

Having thought about it for all of thirty seconds, I can't see any downsides. Can anyone convince me otherwise?


Not necessarily a downside, but in some industries I think most people don't care that much if different customers get different prices.

Like B2B, often the sales people feel out and negotiate a customer to see how high they can sell a product/service for. And that can actually be nice for small companies. They are probably getting subsidized by larger companies to some extent. I know the company I work for has negotiated very aggressively on some of our infrastructure pieces (metrics, config-management, db etc), where there was no way we could afford the sticker price.

EDIT: OTOH making opaque prices illegal, wouldn't bar negotiation.


Do pharmacists have to take the Hippocratic Oath? How is not telling your customers that the insurance copay is higher than cash not harmful?


There are articles such as this: https://www.pharmacytimes.com/contributor/douglas-jennings-p... , suggesting that some contracts forbid pharmacies from mentioning a cash option to patients. Which should be illegal.


They have gag clauses that prevent them from doing so

Why Your Pharmacist Can’t Tell You That $20 Prescription Could Cost Only $8: https://www.nytimes.com/2018/02/24/us/politics/pharmacy-bene...


Even doctors don't have an obligation to serve the patient's financial interest. I used to work for a Chicago-based company, and they offered Blue Cross / Blue Shield of Illinois. In California, where I live, these are two separate insurers. The doctor's office got to choose which run to my treatments through.

After finding that they were doing it in a way that was advantageous to them and disadvantageous to me, I asked a friend who works in medical ethics and billing whether doctors have a duty to serve the client's best financial interest. I was surprised the answer was no because lawyers (my former career) certainly are required to do so.


The pharmacists are beholden to the large companies that control their paychecks.


depends on the deal. Copay might be higher in one case but it will discount other cases. So overall it might be higher for this patient for but for everyone in total its cheaper.


Another example of how distorted prices are in this market. Price discovery is nearly impossible. Some places can't even tell you how much a drug cost without insurance because they don't even know!


Price transparency would dramatically reduce the cost of healthcare in the US. It is an essential step that we must take before 'fixing' healthcare.


Anecdata warning . Took paper Rx to a very large chain that has a one word name beginning with a W and was told they wouldn't quote the cost of the prescription without scanning the Rx. And destroying it so I couldn't take it anywhere else.


Often times they take the script and put their sticker on it before even checking if it's in stock. I have had this happen numerous times. I then go to another pharmacy because the first was out of stock (and my time is worth nothing, so of course I can drive all over town and stand in line for 20 to 40 minutes at each place) and get interrogated by the pharmacy tech, "did you take this somewhere else to fill!!???" Because apparently only a criminal would fill a controlled substance. And with the DEA artificially limiting production, it's very normal for the first three pharmacies to be completely out of stock.


That right there should be an anti-trust case. I am big on the free market, but that whole concept hinges on transparency in pricing.


Yes, price discovery is impossible. The core way to solve it would be to detach healthcare from employers. This way insurance companies would have to compete to provide measurable price benefits to their patients. Even Bernie sanders with his single-payer platform includes separating healthcare from employer, its the most clear-cut change to do, but also a hugely disruptive one.


I am skeptical of claims that the US heathcare system could be fixed solely by better consumer medical information. But this is one area where consumers can often save money - just by asking their pharmicist when they go to fill a prescription to run the cost both under insurance vs cash pay.

One wonders what value health system administrators are providing when such a high percentage of negotiated drug plans result in higher prices than cash prices.


>One wonders what value health insurance administrators are providing

Good question. This was also discussed last week on HN[1].

Since 1970, the number of doctors is up 150%, in line with pop. growth, while healthcare administrators up by 3200%.

1-https://news.ycombinator.com/item?id=17756845


Can someone explin to me how the US prescription process works? As someone in the UK it seems quite alien.


It's always seemed weird to me as well. Let's say you go to the doctor for something like strep throat. You get a prescription for an antibiotic. Doctors offices don't carry drugs, so you take this prescription to a pharmacy to fill it. The pharmacy is a third party that isn't affiliated with the doctor's office. Only doctors can write prescriptions, and as far as I'm aware only pharmacists can fill them. Pharmacists aren't allowed to write prescriptions, even if it's something trivial.

On the insurance side, it's a nightmare. The doctor probably charges your insurance $200 for the office visit. Your insurance has a negotiated rate with the doctor's office for $150. You have a coinsurance of 50% if you've met your deductible, so assuming you haven't hit your max out of pocket for the year you pay $75. If you haven't met your deductible (some arbitrary amount you have to pay on top of paying for insurance) you pay $150. If you have hit this max out of pocket number, you'd pay 0. The $50 goes into the void. My employers insurance is something like a $1000 deductible / $5000 max out of pocket / 75% coinsurance.

When you get the prescription filled, well, I have no idea how this insane process works. Last time I needed antibiotics the receipt had a "before insurance" amount of $50 with an actual cost to me of $4. I have no idea where the $46 went or what my insurance actually paid.


In the UK, I go to a doctor, get the prescription. Some doctors in rural areas have pharmacies joined on but I think the majority don't. I go to the pharmacy, hand in my prescription and pay £8.80 per item (so two boxes of the same drug is £8.80). I pay upfront, so it costs me £104 a year for anything prescribed by an NHS doctor.

I see US folks talk about getting half their prescription filled, or seemingly using the same prescription multiple times. We can submit repeat prescriptions (such as I do for BP etc). but the actual prescription 'document' is a one time deal.

It's very, very odd to me the way it's set up over there. Especially so that some people fight so hard against change.


For chronic medications it is common to have a single prescription include multiple refills. So one paper document might get you 4 months worth of medication, but only filled 1 month at a time.

Mail order pharmacies often fill 90 days at a time, possibly with multiple refills. 90 days dispensed at once is uncommon at retail pharmacies, but is possible in at least some cases. (Not sure if it is laws or contracts that normally prevent this).

It is also possible that a pharmacy may not have enough to fill the script all at once, so they dispense only part, and you come back for the rest later. (I've never experienced this so I'm unclear on the details.)


Not from the US. But how in God sake does this make any possible sense? I mean if the insurance doesn't want to insure a certain medication, then you just pay it for yourself (provided they explain why; or that your contract said so).

But how could it be possible that you pay more?


you just pay it for yourself

That used to be the way it worked. You'd go to the doctor and he'd charge you, say, $35 for a basic exam, and you'd pay in cash.

Since health insurance became widespread, now doctors charge crazy amounts. My doctor charges something like $210 for a basic exam, or $185 for the "negotiated rate" to the insurance company.

I saw on television once that the reason we're in this mess has to do with WWII. With so many working-age people fighting overseas, finding workers was hard for companies, so they started raising wages. The government was afraid of war + inflation, so it put limits on pay raises. So, instead, big companies started offering health care benefits. And thus, an industry was born.

At least that's what I remember from the TV. I can't cite the show or channel, but I do watch a lot of PBS and virtually zero YouTube.


It’s also tax exempt income for some stupid reason, so $1 extra in wages is less than $1 extra in healthcare resulting from health insurance benefits.


Since health insurance became widespread, now doctors charge crazy amounts. My doctor charges something like $210 for a basic exam, or $185 for the "negotiated rate" to the insurance company.

The price a doctor charges per hour doesn’t go directly in his pocket. That hourly cost has to cover support staff, the facilities, liability insurance, his accountant, etc.


So did the $35.


But how in God sake does this make any possible sense?

The US health care system doesn't make sense.

Health insurance began as a perk to attract more qualified people and became the expected norm at some point and typically covered the entire family. When that no longer made sense for employers, benefits began eroding and it became more common for benefits to only cover the employee. Employees had to pay extra to cover family. Then the ACA decided the way we fix this mess is we require everyone to purchase insurance.

It's crazy enough that I would seriously consider leaving the country if I thought there was any way for me to pull that off. But I don't see that as at all feasible currently.


It's easier and more affordable to leave than you'd think.


The costs are not made clear to the consumer. Usually how it works in the US is you give your insurance information to the pharmacy, then then the pharmacy tells you how much you have to pay. You may be told what portion the insurance paid, but that’s a portion of a cost the insurance company negotiated. You aren’t told what it would have cost if the insurance was never involved.


It’s explained in the article. PBMs are responsible for the raised prices.

Which, by the way, is absurd to me as an American. I think at this point most Americans agree there are major flaws in our system, it’s just a disagreement about how to fix it.


> Not from the US. But how in God sake does this make any possible sense?

It isn't designed to make sense, it's designed to obfuscate.


I think the telmisartan story is cherry picked to tell the story the author wanted to tell.

I’m on that drug, and have a good health plan that charges the lesser of copay or actual cost for drugs.

That drug was going generic two years ago, and it took the generic manufactures awhile to ramp up. The generic drug cost more than the name brand version for a few months and was constrained — the pharmacies my my area had difficulty doing a 90 day fill.

It ultimately didn’t drop to super cheap status until they were approved to sell it in a normal pill bottle — previously it was sold in blister pack form.


Watch "drug Short" on the "Dirty Money" series on Netflix. It pretty enraging, and you are likely already familiar with the story, Valeant Pharma and Martin Skrelli....

https://www.netflix.com/watch/80149535?trackId=14170289&tctx...


I wonder what % of people now believe the US medical system is the scam that it is. Utterly dishonest pricing.


I live in Dubai. I used to get glasses made for AED 100 - AED 200 (USD 27 to USD 54) when I was young, based on what I remember from visits to the opticians with my dad. No insurance.

Sometime after that insurance was introduced. Now, as an adult I pay AED 100 - AED 200 (USD 27 - USD 54) [basically the same amount] as 20% co-insurance when getting glasses.

Note 1: USD and AED are pegged.

Note 2: There has been inflation, but not that much. Tea increased from AED 1 to AED 1.5. Taxi increased from AED 10 to AED 20. Clothes increased 50% perhaps.


Slightly off topic, but you can order glasses (frames and lenses) for under $10 on zennioptical.com

Ive ordered my last 3 pairs there, and will never pay $200 for glasses again


Not sure how widely known or common this is for medications but I take PrEP (Truvada) and the maker has a free "co-pay" card on their website that basically covers $4800/year in copayments (well above the $50/month I would ever pay).

I'm sure there's some shady big pharma economics behind why these exist in the first place, but at the very least I'm getting a very expensive drug for free.


They are taking advantage of misaligned interests. You get to choose what drug to get (in consultation with your doctor), and you and your insurance pay for it together.

The drug company sets a super high price, gives you a rebate to cover your share, and then charges your insurance company an arm and a leg. By doing this, they can net more money than if they had a lower price and got money from both you and your insurance company.

This practice also happens in auto repairs, where shops will "waive your deductible" and then charge your insurance company an inflated price. See discussion toward the end of this article: https://www.4autoinsurancequote.com/blog/when-is-deductible-...


Just had this discussion with a co-worker that is taking brand-name Humira - and AbbVie does exactly this, they coupon his out of pocket to his deductible limit and then he pays nothing. The rest of us in the risk pool of course then carry the ~$4K/month cost and nobody in the food chain pushes back, because they are incented to do the opposite. The result is 2017 sales for Humira of $18.43 billion dollars, 2/3rds of which was US. This is just one drug that the US healthcare insurance participant is carrying pharmaceutical profits for.


> I'm sure there's some shady big pharma economics behind why these exist in the first place

The co-pay is designed to make you share in the pain of the sky-high costs the drug manufacturer charges the insurance company. This has two benefits—1) you are only going to get it if you really need it 2) maybe you’ll lobby your congressperson to rein in monopolist pricing.

By giving you a coupon there’s no pain sharing and those benefits are lost. Sure you’ll pay higher premiums, either directly or in reduced wage gains, but that’s defuse and indirect, so far less likely to drive behavior.


Biologic drugs are grown, not manufactured. Mine should be around 4k / dose; insurance won't cover it, so the drug company only charges me I think a $25 copay.

Fwiw, the insurance would have covered older alternatives, but the potential side effects on those are worse than the cure.


Should be in what sense? Is that the marginal cost to manufacturer a dose?


Should be in the sense that I don't recall the specific number, only that it was around $4k. Given the decreased consistency in the process (living things vs. mixing chemicals), I imagine a fairly good chunk of that 4k is also marginal cost to the manufacturer. Everything from research, to scaling up production, to storage and shipping (spoils at room temp) becomes more expensive.


Makes sense


We're about to get Truvada free on the NHS here in the UK and I'm interested on going on it. Have you had any side effects?


No side effects, no.


Not sure how widely known or common this is for medications but I take PrEP (Truvada) and the maker has a free "co-pay" card on their website that basically covers $4800/year in copayments (well above the $50/month I would ever pay).

I see drug commercials all the time that say something like "Visit our web site, or call this number to find out how you can get ___ for little or no money." Perhaps this is the same thing.


Interestingly the cash price is around $1800/30 day supply. Absolute insanity.

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