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Insured, but Still Owing $109K for a Heart Attack (khn.org)
316 points by tim_sw 7 months ago | hide | past | web | favorite | 364 comments



> UPDATE: Monday, shortly after publication and broadcast of this story by Kaiser Health News and NPR, St. David’s said it was now willing to accept $782.29 to resolve the $108,951 balance because Drew Calver qualifies for its “financial assistance discount.”

Sounds all fine and dandy until you realize that these charges will just be made up for by people that aren't able to get NPR to publish a story about them.


When you realize that the hospital was charging $19,000 for a stent that cost $1,500, you realize that painting Calver as someone who is going to cost us all money is misdirected anger.

And, to be clear, they charged $19,000 for the stent, not "stent plus theater time to place it plus surgeon, anesthesiology, OR nurses", of course not. Those are all absolutely billed separately.


I believe there should be legal consequences for getting things this wrong. Wondering how they came up with the $19,000 number.

Also, in speaking with a vascular surgeon I know, their hourly rate is between 200-350/hr. The middlemen and hospitals have figured out how to milk this cow and they're feasting.


Absolutely, and it is this sort of practice that all Americans could get behind legislation that made it illegal. Unfortunately we can't seem to have a civil discussion on health care to find the issues we have in common.


Our total bill for a normal delivery was 25k. 25k for a doctor and nurse to pull a baby out of the vag!

It took 2 months for the bill to arrive.

Healthcare in US is like legal extortion. You could literally bill for breathing hospital air and people would have to pay.


>You could literally bill for breathing hospital air and people would have to pay.

Don't be ridiculous. You'd be billed for air and hospital odor separately!

Though I should note that a delivery is usually more complex than simply waiting there for the little one to fall out, there is some after care and such that is being performed plus the doctor is usually not that cheap either. (They have a lot of student debt to pay off after all)


Their liability insurance has to cover the costs of lifetime care for any babies that are injured during delivery (juries have made this clear enough). It's not strange that they pass this cost on to mothers.


Medical billing is a nightmare. I have HMO insurance (which means the process should be really streamlined - everything is in-house) and I once tried to figure out why certain rather simple bill item was billed certain cost. It took about three weeks, multiple calls and emails, and speaking to several people, to get to the stage where they said "this is probably because if it was classified as code X, though we can not give you rules why it is code X and not code Y, and there's no way to know upfront which it would be, we'll just send you the bill later and you pay whatever we say" and even then they couldn't answer why sometimes they billed certain percentage upfront and sometimes another, so that you end up getting different pre-payments and different bills for the same thing. This whole thing is an ungodly mess.


Hospitals should be required to publicly post prices, just like fast food restaurants are now required (in some places) to publicly post the calories for each dish.


This isn't just restricted to US. It has become very common even in a country like India for doctors and hospital owners to invite their doctor buddies for 'second opinions' and looking at non-issues and then billing the patients 'consulting fees'.

There is also a huge industry built along the lines of phony testing.

The term used for that think is called 'basin test', basically samples are flushed down the basin and made up numbers are put in reports. You can put in what you like as the doctors know the patient is healthy.


Hospitals should be legally mandated to accept replacement of materials in lieu of payment.

If I can source the same stents for cheaper than the hospital bills me, they should be required to erase them from the bill and accept them as material replacement.

It's not as if medical supplies are unavailable to the end consumer.

https://www.esutures.com/product/0-in-date/41-boston-scienti... Here are the stents available for under $1000.

When I had a broken finger and was uninsured, I was charged ~$40 for a finger splint that costs $7 at Walgreens (yeah, the very basic one made out of aluminum and blue foam).

Also, a word of advice - never ever pay what you were sent from the hospital right away. I personally throw most medical bills in the trash and wait until they call me, then negotiate it down to a fraction of what was billed, offering to pay in cash.


> Hospitals should be legally mandated to accept replacement of materials in lieu of payment.

> If I can source the same stents for cheaper than the hospital bills me, they should be required to erase them from the bill and accept them as material replacement.

Meh. The only reason they inflate supply costs is because that's where insurance negotiations let them. Mandating supplies must be available at-cost to consumers is just a stupid cost-shifting game. Consumers shouldn't care in particular about the cost of supplies — overall cost is what matters.

Price-fixing in general does not really work. The difference is made up somewhere. Things that would actually reduce pricing stupidity and surprise bills are obvious things like: increased pricing transparency, consumer stake in reducing costs (HDHPs are a stab in this direction), and single payer.


Health care is not a regular market. You can't shop around for emergency care when your leg is severed or you are unconscious in a car accident.

Healthcare can and should be heavily regulated, its not like buying a hammer.


Emergency care is not a great market to be a buyer in, but that does not change that market economics apply. And it is beside the point. The vast majority of healthcare is boring, predictable, non-emergency expenses that can be shopped around.

I agree that regulation makes sense, just not with the extremely specific proposal that medical devices be sold at cost (or whatever slightly higher unit cost is available to consumers).


Trivially disproven by UK's health care system, which consistently ranks #1 in the world by outcomes and employs price caps for health care suppliers.

https://www.commonwealthfund.org/press-release/2017/new-11-c...

> Mandating supplies must be available at-cost to consumers is just a stupid cost-shifting game.

That's not what I suggested in my post at all.

Also, if it reduces costs for the end consumer, what's the harm? Why should consumers subsidize hospitals with cutthroat billing departments who make up numbers out of thin air?


> Trivially disproven by UK's health care system

Not trivially? [1]

[1] https://www.theguardian.com/society/2017/jul/18/uk-cancer-su...


NHS is a single-payer system, which is one of the solutions I proposed.

Yes, mandating supplies be sold at-cost is exactly what you proposed:

> Hospitals should be legally mandated to accept replacement of materials in lieu of payment.

> If I can source the same stents for cheaper than the hospital bills me, they should be required to erase them from the bill and accept them as material replacement.

And to address:

> Also, if it reduces costs for the end consumer, what's the harm?

The problem is in the condition. At the end of the day, ineffective regulation increases costs for the consumer.


Are you suggesting that a sick person, recovering from an operation, be responsible for researching prices on the parts that were used in surgery? Most do not have the time or expertise for that, nor would anyone want to do it.


Have your spouse/relative shop around for replacement while you recover. Or be destitute for 10 years after being bankrupted by medical bills. I know which one I'd prefer.

> Most do not have the time or expertise for that, nor would anyone want to do it.

Is that a joke? You can find most of those things with a 30 second Google search. I thought this was a forum with technically apt people?


> Also, if it reduces costs for the end consumer, what's the harm?

Less profit for the company.


Is anyone working on an app that can do this? There were those parking ticket negotiating apps for a bit. I wonder if there is a way to systemize the negotiation process here. I bet you could charge people up to 10% of the money you save them.


> never ever pay what you were sent from the hospital right away

This is actually good advice. It shocked me when I realised it. But it’s good advice.


People are surprised when I tell them I simply refused the 3k dollar (after insurance) couple hour hospital bill for having the flu. They couldn't tell me why two tylenols, a saline drip, and a prescription cost that much. (I was vomiting blood which is why I was taken in).

They ended up dropping the bill altogether as insurance had already paid them.


> They couldn't tell me why two tylenols, a saline drip, and a prescription cost that much

I know the US system is different to what I grew up with (UK NHS), but I have had similar "treatment" when ill as a tourist in 3rd world countries: couple of pills / drip.

I understand that the difference of systems in regards to extensive care, but a couple of pills and a drip - why on earth is such basic care just not free to all?


Have you been following the quality of people running our government?

I mean, I know this seems like just a snarky political comment. But it's just the honest answer. Our federal government is simply completely dysfunctional right now, incapable of solving anything.

For what it's worth, "Medicare for All" has been polling increasingly higher recently, due to more Americans being basically ready to give up on the current private system entirely.


> dysfunctional right now

Just now? It’s seemed dysfunctional to me since I was capable of understanding government, circa 15 years ago. My parents felt the same way 30 years ago, and their parents felt the same way 50 years ago.


It's dysfunctionaler.


Nope. No way. Have we learned nothing from "fulfilled by Amazon" counterfeits?

The supply chain has to be verifiable as genuine goods from the factory to the hospital floor. Trying to verify the authenticity of patient-supplied replacements would be a nightmare.


Then force hospitals to price match or force them to show YOU, the customer, how much the item actually cost when it was delivered to them for storage.

I wasn't actually seriously suggesting that patients be required to source the item physically, then physically deliver it to the hospital in person.


Yes. It would be expensive, and that cost would be pushed onto consumers in some other way.


Honest question - does this really work? I have tried it once or twice without success. Are there particular 'magic phrases' you need to use, or is it jut a question of persistence? Does it impact your credit?


> Are there particular 'magic phrases' you need to use, or is it jut a question of persistence?

My situations varied, but when I had no insurance and was living off of savings, I found a generic "hardship" form and explained my situation to them - they waived 80% of the fee without much resistance. This is compared to the laughable discount of 2% they offered me on the spot if I paid in cash (at the moment of the visit)

In other situations, I'd imagine it's more a question of persistence, but I'd venture to say you can knock off at least 50% on _any_ hospital bill.

I recently bought a house, and my credit was 800+, so I don't think it does in any appreciable way.

That wasn't the gist of my post though. I was advocating more to resist the bullshit and to legislate something that allows the customer to replace materials instead of paying a hugely marked up item.

Same concept would be applicable, for example, for a car mechanic shop. Just because they billed me $600 for brake pads doesn't mean that they've actually provided me with a 10x markup of value on having bought brake pads myself for $60 - at some point this needs to be treated as "usury" (I don't know if there's a word for exorbitant markup on a regular good).

Another thing I would add - don't put your social security number on medical forms. I've never seen it enforced and there's no medical reason for them to have it.


Hospitals generally operate on <5% margins. If you force them to provide supplies at cost then they'll have to get that revenue from somewhere else.

Also, people like you who force hospitals to chase you down to pay a bill are part of the reason why it's so expensive in the first place.


The hospital in OP article is part of HCA, that has perpetuated $billions in fraud profits. https://en.m.wikipedia.org/wiki/Hospital_Corporation_of_Amer...


Paying 300-500/mo for decades, as a chronic heart patient here. I've had multiple open heart surgeries and nothing sweeter than paying 6k for the recovery room and 0 for the surgery (along with sweet receipts for 1mil in aggregate surgery costs). The separate billing is a pointless red herring, in context of the article.

$10,920 for room charges is absolutely ludicrous.


In the UK and paying a monthly National Insurance tax:

About 5 years ago, I had 6 weeks in hospital, a total of 3 angiograms, one MRI scan...and then 5 stents (should have been 4, but they tore something and had to put in a covered one!).

The wait was mainly down to an unfortunate series of events: One stent was needed in a 'tricky' place and so I was timetabled to be operated on by a specialist surgeon elsewhere, but his father fell seriously ill so he went on leave. My first op was rebooked for another hospital...and they had a 'flu outbreak so ops were postponed. Eventually I was booked in elsewhere had a one hour ambulance transport ride for 'third time lucky'.

The stents were fitted in two separate operations about two weeks apart. The most notable expense I incurred was for data top-ups on my cellphone because hospital wifi was still being setup and hadn't quite made it to my ward.

The NHS gets a lot of flak, and it's by no means perfect, but it's generally there for you when you really need it.

PS: I'm on a slew of meds for my heart condition and T2 diabetes - all free at the point of collection.


I'm curious - do you think the figures for room and board is generally high? Or do you just think it is high for the city?

I'm asking because a friend was in the hospital in the bay area for 7 days and his room and board was approximately $21,000


I had my surgeries in the middle of Los Angeles (Kaiser - 4867 W Sunset Blvd, Los Angeles, CA 90027). My insurance covered 7 days, but I paid for additional recovery time at about 2k a day.

In regard to your friend ... his 7 x 2 = $14k. That's a LOT for basically a bed, blood draws daily, limited TV and cafeteria food, but in the center of Los Angeles, that's what you get.


There is a whole industry of "medical billing advocates" you can pay to find what is likely thousands if not tens of thousands of dollars of completely made up charges on any given US hospital bill and "negotiate" them away. You don't necessarily need press coverage though it obviously helps.

Hell one time I got a $15k bill for something insurance should have covered. Called the hospital, turns out insurance had covered it and I didn't actually owe any money at all. How many people get this kind of stuff and just pay it anyway?


Relevant blog post: https://meaningness.com/metablog/post-apocalyptic-health-car...

> Hiring someone became imperative for me when coordinating my mother’s care got to be a way-more-than-full-time job. (In retrospect, I wish I had done that months earlier.)

> It could also be worthwhile in less critical cases, if no one in the family can take enough time off from work, or in which you’d simply rather pay someone else to clean up after a hospital’s paperwork pollution.

> This role has developed only recently, as systems have broken down. There’s not yet a standardized term; “health care advocate” is one among several.

> Mine specializes in gerontology and dementia. Others specialize in other disease areas; or in other aspects of the administrative nightmare, such as sorting out bogus hospital bills, which frequently include fraudulent additions.

> They are not inexpensive (mine charges $150/hour), so not an option for everyone.

> There are good and not-so-good advocates. I spoke with several before hiring one. Some were clearly clueless; the one I hired last month has seemed consistently competent.

> Since they recommend particular providers, there is an inherent principal-agent problem. Ask if they get any compensation from services they recommend. Take their recommendations with a grain of salt in any case.


Billing "mistakes" seem to be standard practice.

I went through surgery at the Stanford Hospital, using Stanford's insurance. Prior to the surgery, they charged me $2000, the out of pocket maximum. Then, a couple of weeks post-surgery. I got another $250 bill. I had to spend the whole day on the phone first with the hospital, then the insurance, and then the hospital.

Turns out, that all I had to pay was $250, that the hospital had made a mistake in billing me $2000 at the door. I got my money back a month later.

I would normally attribute this to ineptitude. But the frequency and scale with which this happens, reeks of widespread scams.


Yea, but to hire a medical billing advocate, you need: 1) knowledge/information that they exist and that hospital bills are BS, and 2) money to pay the advocate AND the reduced bill. If the final bill is $800 and the advocate gets a cut of the savings, how many people in dire straights are likely to be able to afford that? Keep in mind, most Americans don't have 1k in savings, living pay check to pay check because they have no choice. Facing a 100k bill, people are more likely to wait for the collector to show up and then declare bankruptcy, facing damage to their already poor credit, garnishment of already subsistence wages, etc..

I'm much less worried about the folks who pay it anyway than I am about the folks whose lives are destroyed by an industry predating on people in the worst of circumstances.


sounds like an opportunity....


For what? Lay out a business plan in this area for me that doesn't take money from the worst off.


If you make money off them but save them more money than you costs, it is still towards their benefit. The only problem occurs when you start working with the hospital to create even more arcane bills that you get into immoral territory.


That's exactly the circumstance I outlined previously. This plan has you taking the debts of somebody who cannot afford to pay, reducing them to something above the actual cost, then asking them to pay the higher amount. You are making money from the least able to pay and profiting from a system driving people into bankruptcy. I cannot imagine starting such a company without serious empathy issues.


I don't have all the answers, but here's where i'd start:

https://gist.github.com/ndarville/4295324

I'd start with a mentally forced mashup for each to get a few that might work. e.g. "If i've got to make money by lead generation with a medical bill review service/app, how could i do it?"

Then i'd focus on how we'd drive value to the consumers.

Then think about driving value to others parties who may be willing to pay for something similar.

ie would pharmaceutical and medical device companies be willing to communicate directly with these consumers?

note i'm not saying its easy by any means, but i do think its a real problem that could take off if an elegant and worthwhile solution came about.


I had a hernia surgery shortly after a plan change. The hospital believed insurance wouldn't cover, so they discussed cash pricing with me of around 7k. The insurance ended up covering their portion with me paying about 2k out of pocket.

But then I almost had a hard attack when the statement arrived. The first number I saw was 24k, WTF!! Well, reading on there was a very large "discount" applied and the final bill to the insurance company was about right. I could only imagine though, that under some circumstance, the hospital would have tried to stick me with that totally bogus 24k bill had the insurance not covered it or the pricing not been negotiated in advance..


A key element here is do not pay immediately. Once you pay, they stop working on the problem entirely.

I'm not saying, "ignore it and it goes away." Just that the billing side of things has no interest in working when they already have your money.


Millions of people no doubt.


Not always. My mom had a quadruple bypass about 6 years ago during a gap year where she stopped working but didn't have Medicare yet. Unlucky. I think she was billed for around $180k.

She told them "I'm on Social Security for $1000/mo, I'll pay you $50/mo". It was basically that or sending it to collections and never getting a dime from a retiree. So they accepted and told her a "non-profit" paid for the doctor's portion of the bill, which was all but about $40k.

She'll probably be around another 10 years max, which means she'll end up paying about $10k of that balance.

Medical debt is the least concerning type of debt for most lenders. If you ever fall into this hole, don't sweat it. [Unsolicited advice.] Just let it go to collections. You'll get harassed for a little over a year. Debt older than a year is almost never pursued by collections agencies. After things quiet down start sending letters to the credits agencies saying the collections debt has been settled. The collections agency will usually slip up and not respond at some point and it'll be gone from your credit history.


I worked with somebody who at 23 was bitten by a cat and it got infected. She didn't want to seek medical treatment even though her hand swelled up like crazy--"I don't have insurance, I will get better". I basically forced her to go to the hospital and she ended up spending a couple of days in the ICU. They told her if she waited another day, she might not have made it.

Total cost, something around $23,000 I think. This is somebody who was making maybe $10/hr. They took a payment plan of around $15/month, so she will be paying it back for the next 128 years.


Another anecdote about my mom. A few months ago she was rushed to the hospital for symptoms of a pulmonary embolism. She spent 36 hours in the critical care unit. They couldn't determine what caused her episode; no clots, etc. They charged her $25k for that. That's how fucked up the situation is. A single night in a hospital that may save your life ends up costing almost what your kid/grandkid is paying for a year of college.

Recently she got a bill for $250 for the ambulance, which she paid, and another letter saying her bill for the hospital stay was settled. She told me she would have offered $15/mo had they held her to the $25k or told them to screw off if they didn't accept. They're not even bothering anymore.


> Medical debt is the least concerning type of debt for most lenders.

Just another data point, a large property management company I used to work for specifically exempted bankruptcies due to medical debt when calculating applicant credit scores.


I have a friend who sells debtor data for a living. He literally sells Excel spreadsheets of debtor data (name, address, SSN, amount owed, etc) to collections agencies for $5k-$25k a pop. He makes mid-six figures doing it. The quality of the data is what commands the price. He said the least desirable debt are debts older than a year and medical debt. He can't even give that crap away.

Also, if you're ever called by a collections agency, you should ask them to provide proof that they actually hold the debt you're obligated to pay. In some cases they've just bought the data, usually from another collections agency who couldn't collect, and they're trying to shake you down. Once you use the magic phrase "provide proof" they give up and stop hassling you, because they have no proof.


I used to worked at Wells Fargo and my friend in sales said the mortgage underwriters typically didn't blink at medical debt.

I wonder what would happen if it was widespread knowledge that the smart money was in never paying it.


I'm not sure I believe that debt over a year old is not pursued. Anecdotal, but...

I've had 4 different cell phone numbers in my lifetime. All of them were still getting debt collection calls or still are up to 15 years later. I've had my current number for over 15 years. I'd love to meet Tanya who ran up the bills for my current number.

Also, I had my appendix rupture right after getting laid off and going on COBRA. I am still getting occasional calls about that even though the insurance eventually paid off. That was over 10 years ago.

COBRA is another scam. $1650 per month that my employer was paying ~$600 for.

Scumbaggery is rife in the insurance industry. The Rainmaker should be required watching...


> COBRA is another scam. $1650 per month that my employer was paying ~$600 for.

COBRA is whatever the employer was paying + 2% administration fee.


Sorry, you're wrong, unless my former employer is lying to the gov't. I believed a similar story


If you tell them to stop calling you they are legally required to stop or you can sue them for statutot damages


The debt keeps getting resold. I'd have to be able to predict the future...


> Just let it go to collections. You'll get harassed for a little over a year. Debt older than a year is almost never pursued by collections agencies.

I don't understand. Is there no penalty to not paying other than a hit on your credit score? Can't you end up with wage garnishments or liens or something like that?


It'll definitely show up on your credit report. The key is a lot of lenders supposedly will just look past it. Ultimately it's up to them if you get a loan or not, not just based on the number alone.


One caveat, you definitely want to contest the debt in writing regularly. If it goes away because the collector failed to respond you are fine. If it goes away because they "forgive" the debt, its seen as income by the IRS and you will pay taxes on it. So imagine the tax bill if 200K of "income" is added to your taxes one year.


Where I live (Arizona) there's a statute of limitations on consumer debt, think it's 2 years for random bills and 3 years for recurring payments...or something similar.


That sounds like legalized theft. Why pay any non recurring bills ever?


Nope. Wage garnishments and liens only happen with debts to the government such as unpaid taxes, child support, or fines.


Ok but can't the hospital (or the collections agency) take you to court? Let's say you have 100k bill from the hospital that you just ignore. They sell it to a collections agency for 60k. You refuse to pay the collections agency. Now what happens?


Did some more research on this...

Yes, the hospital or collections agency can sue you to try to garnish your wages. If they win, you're boned.

If they lose, or they never sue for garnishment, it's unclear what happens if you refuse to pay. From what I can tell, the debt disappears from your credit report after seven years, but the debt is still valid and they can still try to recover the money from you, but they won't be able to use the courts to do it.

However, there's always the option of declaring bankruptcy. Even if they garnish wages, declaring bankruptcy will wipe it away. Obviously, that's the nuclear option and will destroy your credit rating for seven years.


> Sounds all fine and dandy until you realize that these charges will just be made up for by people that aren't able to get NPR to publish a story about them.

No, St. David's has already fully recouped their costs and then some. They were simply trying to extract as much money as the stone could bleed.


I was going to respond saying that most hospitals are nonprofits and aren't actually making a great profit margin off this sort of overcharging. But then I looked it up and St. David's, despite having a religious nonprofit-sounding name, is actually owned by HCA Healthcare, which is a for-profit that has almost 4x'd its stock price over the past five years while acquiring more hospitals to grow. So, yeah, this one is about corporations squeezing money out of people because they can.

sources:

https://www.beckershospitalreview.com/hospital-transactions-...

https://www.google.com/search?q=NYSE:HCA


> despite having a religious nonprofit-sounding name

They came by the name honestly, but it is indeed a shame the way it has gone since the St. David's Foundation partnered with HCA.

The hospital(s) were originally founded and run by St. David's Episcopal and were one of the first and foremost hospitals in Austin, with very high quality care and good service to the community.

After operating them for nearly 75 years, and growing to an enormous enterprise, it became clear that a church congregation simply couldn't and shouldn't be operating them any further and they were spun out. Some of the profits are still sent back to the foundation for community health care grants.

This particular wealth extraction strategy would never have occurred under church leadership.

(disclaimer: I was a member of the church during this period and hold it in very high regard)


My ex worked for HCA and she insisted that she could tell you the exact cost of a procedure before undergoing it.

Well at some point she needed surgery (at HCA), and about five months later after dealing with 10 < x < 20 bills including one we'd never heard about until collections came knocking she just looked at me and said "Nobody knows what this is going to cost." It really bums me out that a human being working in healthcare here isn't able to even remotely predict the cost of a procedure at the hospital at which they work.


For hospitals which really are non-profit a) the non-profit status doesn't prevent price gouging b) even if acting as a traditional non-proft, they may do so to balance revenue against people with no insurance and no ability to pay. (a burden we load onto hospitals that we should actually be sharing much more explictly and universally across our nation).



HCA is owned by Bill Frist's family. Dirty stuff.


Maybe they could change their name to "Hospital of the Temple Moneychangers"


> squeezing money out of insurance companies because they can

FTFY.

But seriously, how can it possibly be the hospital's fault for doing exactly what the law and market incentives give them every reason to do? There's almost no downward pressure on prices: little competition, no transparent pricing, huge barriers to market entry, and third party payers.


"But seriously, how can it possibly be the hospital's fault for doing exactly what the law and market incentives give them every reason to do? "

Because they're the ones actually doing it? Because they're run by adults who are fully capable of taking responsibility for their actions?


The US (and others, but the US especially) has a long-standing practice of divesting corporations from the responsibility for their actions.

Worse, it's frequently the same people who argue that corporations are "people" arguing that corporations as a whole shouldn't be held responsible for their actions.


A profit-making corporation exists to make a profit, which isn't illegal or immoral, so I fail to see what 'responsibility' they have other than continuing to do what their shareholders have literally given them money to do. Your problem is with the system, not with my grandma whose pension fund is invested in the hospital.


For what it's worth, I'm not interested in blaming the corporation for trying to raise profits. I just think that clearly the system is not ideal, and the right way to fix the system is probably different depending on whether the diagnosis is 1/ inefficiently-operating nonprofits or 2/ non-consumer-happiness-optimizing corporations.


Right, I definitely agree with you. My only point was that it's easy to point to villains but real solutions are structural.


Nobody's denying the facts you gave...lack of competition, lack of transparent pricing, etc.

But to use people's lives as leverage to extract absurd amounts of money goes well beyond being immoral, it's just downright evil.


If making money from using people's lives as leverage is evil, then let's go ahead and condemn doctors, nurses, ambulance drivers, insulin injector manufacturers, and lifeguards while we're at it.


I'm almost rendered speechless at the absurdity of your suggestion.

Of course they deserve to be paid. And paid quite nicely, too, considering the education levels needed to work such jobs (Lifeguards, obviously requiring significantly less than doctors)!

But they can be paid nicely while charging reasonable prices. The $164k the hospital charged that man for his heart attack is beyond unreasonable.


But who gets to decide what is 'reasonable?' The point of the parent post is that there are no forces keeping prices down besides this vague standard of 'reasonableness', which obviously isn't very useful. Shame doesn't bring down prices; competition and structural reforms do.


The point is that the bill won't just go away for other people, regardless of how much profit is made and whether costs are already covered by the hospital.


What's strange is that many hospitals seem to legitimately be in financial trouble. You often hear about smaller hospitals not being able to make it financially, and being gobbled up by larger health networks. How can I be paying them $600 for an asprin, and other fake charges, and they still can't make any money?


Well, you'll notice on this bill in the article they've taken to charging "near retail" pricing for aspirin, and generic pricing for common drugs many of us will know the price of (still relatively outrageous, but $1/pill for aspirin, $10/pill for metoprolol).

Why? Not out of the kindness of their hearts. They know that their name showing up with a bill for $500 for ASA is bad PR, so better to make those common things realistic, and pad their numbers elsewhere (like charging $19,500 for a $1,500 stent)...


Like in Education the glut of "Administrators" is certainly not helping.


Yes, but OPs point is they will still do this to people who can't get media attention. It continues to be a systemic issue that must be fixed.

Disclaimer: Universal healthcare advocate


The hospital already got 50k from the insurance company. The article also the treatment should have cost ~25k.


The power of companies. They write words and numbers on a stamped letter and now it's god spell.

I once played dumb to an importer abusing fees, after monthes of bouncing mails to different people babbling the same thing over and over, then dealing with a 'lawyer firm' who behaved the same (basically nobody knew precisely what they were talking about). They suddenly accepted to give me a rebate of NN%. So I received a new bill with 100$ - '80$ promotional deal' = 20$ (normal fee). A very partial grin ensued.


I don't think anyone is treating the company's word as law. Just about everything is open to negotiation just about all of the time.

I'm assuming you mean "gospel" and not the 1971 Broadway musical.


People have and will pay the minute they receive an official looking letter.


Yeah, more like he qualifies for the "got some sympathetic media coverage" discount. That's not something most people can count on.


>Sounds all fine and dandy until you realize that these charges will just be made up for by people that aren't able to get NPR to publish a story about them.

Sounds a bit like getting support from Google.


Later in that correction paragraph, it says:

> In a statement, the hospital said this offer was contingent on Calver submitting his application for a discount based on his household finances. Calver disputed that he owes any additional money to St. David’s and said this situation should have been resolved long before now.

I might be misreading, but is this saying that Calver isn't going to accept even the $700 charge, just to make a statement? I obviously side with him but this seems like a crazy stand to take on principle alone.


He shouldn't have to submit for a "discount" based on his "household finances" anyway! What if he doesn't qualify after all? Does he owe $100k if he makes more than $70k/year? Actually what level of income should be the low threshold for having to pay $100k after insurance for your life-critical health event?


I'm not saying he's wrong on the principle. I'm saying I wouldn't have the guts to risk $108,300 just for a chance to maybe win a moral victory over $700.


Sounds like the usual billing practice of "send him a bill for everything he'll ever have and then graciously negotiate it down merely everything he's got now".


Can you stop blaming individuals and start blaming the people who set up and keep the current system?


I think this is pretty common. If you get a hospital bill and the insurance already paid a lot, call up the hospital and complain, and it will often be lowered. This happened to me once, a $15k bill was reduced to $3k. The insurance had already paid $50k or so. Hospitals don't really seem to care about the extra portion the patient is supposed to pay. The try to get it, but don't make much fuss when you challenge it, since they already got what they really wanted, the insurance company's money.


Any unmet costs would likely be made up by other patients, but the charges have nothing to do with the costs, so who knows what impact this has.


No, it just means they will make a little less profit.


> St. David’s HealthCare defended its handling of Calver’s bill and sought to blame the school district and Aetna for offering such a narrow network.

So while dying of a heart attack he should have been negotiating with the ambulance driver, the paramedics, the nurses, each intern and doctor to make sure they are "in-network".

> St. David’s said it was now willing to accept $782.29 to resolve the $108,951 balance because Drew Calver qualifies for its “financial assistance discount.” I

You can pay $100k or just $700, whatever is cool with us. I guess, go to the media and try to shame everyone involved is your best hope? I can see if they did this to people buying luxury suites or yachts. Doing this to people who are dying of a heart attack is particularly disgusting. And it's not like anyone involved is going to be punished for this practice or learn a lesson. They'll turn around and do the same thing to the next patient.


> So while dying of a heart attack he should have been negotiating with the ambulance driver, the paramedics, the nurses, each intern and doctor to make sure they are "in-network".

Absolutely! </s> I work in EMS. Thankfully, our Medic One system is funded entirely by property taxes and we simply do not bill (at all) for any treatment or transport.

However, a few years ago United got a lot of grief over denying airlift transport claims from things like MVAs, or traumas in remote locations, stating that the "transport had not been pre-approved through the insurer".

Apparently in their mind, us paramedics (or maybe the chopper pilot) should have been calling in between stabilizing our patient...

"This is John, I'm a paramedic working on one of your patients who was hit by a truck. We would like to fly him to the hospital due to his extensive multisystem trauma but we need your approval. His name? Hang on, let me find his wallet. No, that's Smythe, S-M-Y-T-H-E, sorry, it's a bit loud with the jaws of life in the background... Yes, I can hold for a nurse consult..."


So, when will the rich and powerful start hiring teams units straight from cyberpunk novels? (their own helicopters included)

At these rate differences it starts seeming prudent to medical airlift to the right hospital...


Hey! Cyberpunk 2077 had a sequence like this in the new game-play trailer, NSFW: https://youtu.be/MfW1WcuEI8Y?t=37m48s


I wouldn't pay them a single cent more. The 782.29 is just as bogus as the initial charges. There is pretty solid pricing data suggesting the insurance company already over paid.


I once got cut by a skate playing hockey. Showed up at the hospital pulsing blood from my leg. My first question to them, “Do you take X insurance?” Only after they assured me that my insurance would be accepted did I drag my bloody leg into the care room.

Turns out the doctor that the hospital assigned to me did _not_ take my insurance.

I got billed the full amount, yelled very loudly at lots of people, and when I “resubmitted” the claim ended up paying like $50 out of pocket. I’m pretty sure that every item in the hospital is purchased by a separate company and that the Venn diagram of approved insurance companies never intersects.

My dad is a nurse and I grew up hearing how insurance was destroying health care. As a free market libertarian, I have no idea what to do about it. But next time I need stitches I think I’ll just opt for the super glue in my workshop...


It's not a free market if you (literally) can't walk away from the transaction. Trying to apply free market principles to non-free markets is what got us into this mess in the first place.


Medical emergencies are sadly not a free market.

You have a need that the customer (patient) needs to fill with a product (medical care).

The problem is, if the customer doesn't get the need fullfilled within the next 10 minutes they die of cardiac arrest. Or worse, the customer is already in cardiac arrest and requires resuscitation.

An unconsicous customer can't make market decisions.

So now we get to the next stage, a hospital revives/saves the patient but they are unconscious for a few days in the ICU.

The patient can hardly walk away while being non-responsive or later when drugged up on painkillers so they don't scream all the time.

By the time a patient can leave a hospital without dying the hospital has likely already spent 90% of the money that would be spent if the patient stayed for a few days more to recover.

But is it free market to bill the patient for actions taken while they were non-responsive or not even consented too (because they were non-responsive and/or dying)?

IMO the answer is simple; free markets don't exist. They are an ideal construct similar to how a bouncy ball should mathematically bounce forever but doesn't. And especially in healthcare there are too many interfering patterns for a free market to actually exist. In other markets, you could make a free market because people could pick and choose and compare and consent (ie, buying logs of wood for your fireplace). But dying people can't participate in the market to not die freely.

I also advice against superglue for wounds, the stuff can be toxic and/or nasty and will likely lead to an infection. There are some natural glues that your body produces to stitch wounds and you can obtain them in your supermarket, though they aren't clean enough that I would consider them fit for that use either.


> As a free market libertarian, I have no idea what to do about it.

As someone who used to be a free market libertarian: take is as a data point, and make appropriate conclusions. Such as: free market doesn't solve every problem. It doesn't mean that we should ditch it - it's still the least invasive way to allocate resources, so it's a reasonable default. But we shouldn't elevate it to dogma. When it works, great! When it doesn't, regulate it. And thus, we can have the best of both worlds.


”But next time I need stitches I think I’ll just opt for the super glue in my workshop...”

Super glue aka “Dermabond” https://emedicine.medscape.com/article/874047-overview


A good start would have them providing a price list, up front, so you can intelligently request transport to a hospital that doesn’t have a 1000% markup on parts, and reasonable charges on labor.


My father had a heart attack 4 months ago, and he’s been in and out of the ICU for 3 of those months. Everyone likes to think “oh, I’m insured. I’ll be fine.” But let me tell you, you won’t be fine. 3 months of ICU at Robert Wood Johnson was billed for $4Mn. BCBS-NJ only paid out $750k. The headache begins there- from a personal financial standpoint, and Tri-party incentive standpoint. Ignoring the difference of $3.25Mn “owed” to the hospital (technically, this $4Mn is an exaggerated number by RWJ to recoup as much as they can), the insurance company is essentially denying basic/reasonable services. The doctors have been fighting with insurance to get him to an LTACH, but the most they’ll pay for is a nursing home.

Insurance is a business. They aren’t looking out for you, or your loved ones. I hate to sound cynical, but boy, these past 4 months have shown me the deepest, ugliest side of commerce that inevitably results from aligning incentives with profits.


Health insurance companies' profit margins are restricted by law, whereas Robert Wood Johnson and its executives and doctors profit margins are not restricted. If anyone is on the patient's side from a cost perspective, it's insurance, and the ones benefiting from higher pricing and unnecessary procedures are the providers.


I've suddenly started seeing this take all over the place and I have no idea where it comes from because it doesn't make sense. That the insurance companies profit margins are restricted means rather little because executive pay isn't capped: if they earn too much money, they can simply pay bonuses to raise their expenses. Or cut shareholders a check. Or. Or. Or. Tangentially, this is why "non-profit" doesn't mean what people think it means.

And despite what caps exist (can you point me to resources on this topic?), the industry is enjoying record profits right now. That's not to say hospitals aren't as well, but I'm puzzled that so many people seem to want to point the fingers at doctors. Doctors and nurses actually provide the care. If there's anyone I'm less worried about making a little more, it's the people actually doing the work. The administrators and the corporations that set and negotiate prices with the insurance companies though... I'm with you there.

Lastly, the incentives of insurance companies do not align with the patients unless you ignore most of how the industry works. Insurance companies make money when they're able to deny you coverage or require you to pay more out of pocket (in vs out of network). That doesn't align with patients at all.

There should not be a profit incentive in health insurance.


> I've suddenly started seeing this take all over the place and I have no idea where it comes from because it doesn't make sense. That the insurance companies profit margins are restricted means rather little because executive pay isn't capped: if they earn too much money, they can simply pay bonuses to raise their expenses. Or cut shareholders a check. Or. Or. Or. Tangentially, this is why "non-profit" doesn't mean what people think it means.

This is not correct, as I understand it. Under the ACA (Obamacare), health plan providers had to ensure that at least 80% of premiums were paid out for patient services. That leaves 20% for overheard, including profit and compensation.

The "trick" here is that service providers (doctors, hospitals, MRI facilities, labs, etc.) are not limited in this way (except by "usual and customary" terms where applicable), and there are LOTS of layers of providers. So in the end you can get many multiples of actual costs by simply washing the underlying treatment or service through 5 or so layers of providers.


> This is not correct, as I understand it. Under the ACA (Obamacare), health plan providers had to ensure that at least 80% of premiums were paid out for patient services. That leaves 20% for overheard, including profit and compensation.

Doesn't this imply that it's in the interest of health plan providers for patient services in general to be as expensive as possible? That means premiums will have to be correspondingly high, and the 20% available for profit and compensation will be larger.


Right, they have less incentive to negotiate for lower rates, because higher rates mean higher premiums, and higher premiums mean higher executive compensation.


Yup. The ACA failed to address the core problem that the hospitals are charging exorbitant prices.

Trying to make health insurance affordable is a fool's errand as long as hospitals can charge whatever the hell they want.


That's been one of the biggest complaints about Obamacare, yes. Other than the "I shouldn't have to pay for my neighbor's wellbeing" complaint


How is an 20% cap worse than no cap? Obviously if this scam works it would also work with less regulation.


If they pay bonuses to themselves, then their premiums will be higher than other insurance companies so they would lose customers, the same that stops any other business from doing the same.

And since taxpayer funded healthcare is off the table in the US, we have to work with what we can. The biggest problem with health insurance right now is everyone is not forced to use healthcare.gov so the risk pools don't have the correct distribution of healthy and unhealthy people.


> If they pay bonuses to themselves, then their premiums will be higher than other insurance companies so they would lose customers, the same that stops any other business from doing the same.

This might stand up in a highly competitive market, but even there you have network effects, and asymmetric power/information issues, that keep it from ever being completely true. In a market like health insurance where large fractions of people get their coverage from their employers who make choices for their employees, it's not really credible to say that high premiums will drive an insurance company out of the market. Moreover, the data bears out that premiums, profits, and executive compensation are all increasing while the overall cost of our healthcare as a nation spirals out of control.

> And since taxpayer funded healthcare is off the table in the US, we have to work with what we can.

If you expect elected officials to fix it by writing them letters and angry comments on the internet, well, yes. But campaigning and petitioning are not the only routes to accomplishing political goals. The teachers' union/wildcat strikes across states with unified Republican control of the government that successfully forced wage and funding increases, despite timid unions that wanted to push for less, should be an indication of what actually works. We don't have to accept the system as it is.

> The biggest problem with health insurance right now is everyone is not forced to use healthcare.gov so the risk pools don't have the correct distribution of healthy and unhealthy people.

That's a problem in that will cause premiums to spiral faster and eventually shutter those insurance pools. But that's a slow death. The largest problem in health insurance right now are the actual, living people being forced across the country to either suffer or die from solvable medical problems, people who are rationing medication because they cannot afford to buy more, people who are being forced into bankruptcy by a broken system. When lives are already being destroyed today, a patch that prevents the rate of lives from being destroyed from increasing quite so quickly is nice, but it quite clearly misses the forest for the trees.


That’s why three party systems, such as this, is a headache. Everyone involved has vastly different goals, and incentives.

Insurance companies are mandated to strict profit margins, yes. But they aren’t mandated to align with what the other parties say a patient needs. This creates a situation where insurance companies can discriminantly choose which services, and level of care to agree to pay for.

I see it happening right now: Long story short, to put it into everyday terminology, our family and the mechanic is urging for a new engine. Insurance is saying “all you need is air in your tires. That’s all we’ll approve.”


US voters don't want taxpayer funded healthcare, like other developed countries. US voters also aren't able to negotiate with medical providers directly, due to lack of knowledge and ability to negotiate while dying. The health insurance setup with capped profit margins seems like a decent option, considering no others have worked. There are a few problems, like allowing employers to offer it and tax exempt premium payments. If everyone was dumped on healthcare.gov, a healthy market for health insurance might emerge.


I don't think this follows. Insurance profit margins are restricted, but they're a percentage of overall payments to hospitals. If the total charge goes up, their total profit also increases.


Insurance companies are required to pay out 80%/85% of the collected premiums on medical care. Which means the remaining 20%/15% has to cover all the insurance company costs and any profit they can manage. If premiums are raised then their portion also will increase as a percentage. But if the medical costs increase without a corresponding premium increase, the insurance company won't see any profits.


"But if the medical costs increase without a corresponding premium increase, the insurance company won't see any profits."

That almost never happens.


Ideally, this is solved by a different health insurance company offering lower premiums, same as vehicle insurance. Obviously, there are some nuances in the health insurance market that make this difficult, but other than taxpayer funded healthcare, no one has come up with a better option.


> Health insurance companies' profit margins are restricted by law, whereas Robert Wood Johnson and its executives and doctors profit margins are not restricted. If anyone is on the patient's side from a cost perspective, it's insurance, and the ones benefiting from higher pricing and unnecessary procedures are the providers.

Untrue, because health insurers profits are limited by law, sure, but to a specified fraction of the costs they pay; if their payouts are too small, they have to refund the excess profits to the people paying premiums.


How does that make it untrue? Health insurance companies are supposed to compete with each other based on their premium prices, and the insurance companies with lower premiums (and hence lower costs) will win more customers.


> Health insurance companies are supposed to compete with each other based on their premium prices

It's not a market with particularly robust competition, due to small number of players, and barriers to entry, both natural (two-sided network effects, practical capital requirements) and regulatory.


Except the insurance market doesn't work like that. You get a job, that job determines your insurance. There's no shopping around for the best rates.


That's because the government allowed tax exempt employer funded health insurance to stick around. If everyone was forced onto healthcare.gov then it could be possible. Employers would have one less thing to deal with that has nothing to do with their product and taxpayers wouldn't have to worry about being tied to their employers, and can more accurately compare differences in pay and whatnot.


I strongly agree with everything you said except forcing everyone to healthcare.gov. A free market for insurance can and should exist without the need for a government run website/market


A free market also requires knowledgeable purchasers to make informed decisions. In the case of health insurance, it's so complicated that it makes sense to simplify it to protect consumers and offer easy to compare options (bronze/silver/gold). I guess it doesn't have to be government run, but it's already built and does a pretty good job.


> Except the insurance market doesn't work like that. You get a job, that job determines your insurance.

That's not really the source of the lack of competition, as employers are motivated to minimize rates for what they ger, whether they are seeking to fulfill a government minimum-coverage mandate or provide a competitive benefit to attract/retain staff.

(It is a source of some other problems, just not the one at issue.)


Instead of insurance companies competing for millions of individual customers, they are vying for maybe thousands of business customers. Except that the insurance companies don't seem to care at all about giving small businesses a good deal, so subtract them from the pool of potential customers that insurance companies care about. Really big businesses don't buy insurance, they just self insure, so insurance companies aren't competing for those customers either.

Employer provided insurance absolutely reduces competitive forces (among other problems it causes, as you point out).


RWJ is a non-profit.


What's your point? Nothing says a nonprofit can't overcharge. If the hospital wants a few doctors and a new MRI, it's looking at many megadollars. Nothing says a nonprofit hospital would bill less aggressively than a for-profit one.


After a reporter made inquiries, St. David’s said collection efforts were put on hold, and a hospital representative called Calver, offering to help him apply for a discount based on his income.

I refuse to believe that the US medical system is run by humans, and not trolls we pulled from under a nearby bridge.


No, it's run by people like George Shultz, who himself pays for an on-call boutique physician, while the plebs can get their medical testing for cheap from Theranos. When the grandson, who was a Theranos intern, becomes concerned because Theranos' numbers are not better than throwing darts on a board the grandfather becomes enraged, arguing that his investment and his reputation are being threatened.


How is a regular person who has other things to do than to read and understated all the details and traps of his health insurance supposed to navigate this insane system?

From what I read going to a hospital is pretty much a gamble that has a certain probability to bankrupt you and there is pretty much nothing you can do about it.

There should be bipartisan agreement that these practices are just not acceptable and that there must be a way for a patient to get binding information upfront.


Yes, I demand full and final information about what the heart attack I am currently suffering is going to cost me to be treated at this hospital.

If I think you are trying to extort me, I am just going to go to another hospital.


I'm actually not sure if you are being serious. If the information on costs for emergency services were clear and available up front people could shop around ahead of time and basically write up a living will saying, if I have a heart attack, take me here.

Insurance companies are the reason the costs are not clear and up front.


Are you serious? You think every American should be required to write a living will for them and their children listing every conceivable illness and injury by individually researching all the medical options in their area? And what, update it weekly as they follow the markets? Should they keep up with the latest medical research so they know what the newest drugs and treatments will cost? What about vacation, do you need to do a week of research to prepare for a weekend trip to NYC?


"listing every conceivable illness and injury"

No. Just the ones that are true emergencies where you won't have time to do any shopping around ahead of time. Why is this such a hard concept? Think of all the times you've seen a doctor in your life. How many of those were super time critical? Big accidents and heart attacks are. Having a cold or flu isn't. Heck, even cancer isn't super time critical, you could take a few days to shop around treatment centers. Shopping around for most medical care shouldn't be that weird of a concept.

Another option would be to only have insurance for those critical time sensitive events, then you don't have to be super price sensitive for those, and the free market could drive down prices of all the other medical care we get.


Ok, here's one list, I'm sure it isn't comprehensive: http://ourmed.org/wiki/List_of_medical_emergencies

So for each item on this list you'll need to find out every possible treatment and drug and what they cost at every hospital within ~50 miles. Make sure you look up allergies and any side effects when combined with medication you regularly take, you don't want to be in a situation where you listed Hospital X for meningitis, but their cheap drug can't be combined with your asthma medication, or whatever.

And again, how often do you update this will? And what about travel?

Is there anything else in your life that you shop around for in case of emergency?


Your google skills are strong. How many things on that list need treatment within minutes?

"Is there anything else in your life that you shop around for in case of emergency?"

Have you never heard of Preppers? But seriously, yes, I shopped around a little for a fire extinguisher in my home, I shopped around a bit for a good first aid class so I'd have some skills. I have spare batteries around the house in case the power goes out and shopped around for a flashlight. I have practiced changing a tire for my car just in case. I have a little food stored up in my house.

Why is preparing ahead of time completely off the table for people when it comes to medical care?


>How many things on that list need treatment within minutes?

Let's go down the list for things that don't need treatment in minutes:

- Malaria

- Rabies

- Salmonella

- Lyme disease

- Malnutrition and starvation (though you'd rather have this taken care of fast if possible, in severe cases minutes would count)

- Attempted suicide, non fatal (though only if you aren't up for anything else as a result of said attempted suicide, you'll be fine if you don't get immediate treatment)

- Psychotic episode (under supervision)

- Suicidal ideation (if you're under supervision)

- Smoke inhalation (in very very minor cases)

- HELPP syndrome (doesn't seem to be very dangerous in the minute range though you'll want treatment either way)

- Priapism (although it is very painful)

- Sexual assault (before you downvote consider that sexual assault is generally not fatal itself and you don't need urgent medical attention, though urgent psychological attention is, in general you'll survive if you need more than a few minutes to the hospital)

Most of these come with a few ifs, notably that no other medical emergency coincides and some depend on severity, the rest of the list is to my knowledge pretty deadly if you don't get it taken care of as quickly as possible and for half the list it is likely you'd be either in extremely severe pain, unconscious, non-responsive, dying or a combination of the previous in any order.


> How many things on that list need treatment within minutes?

I don't know, I think most? I am not a medical expert, and as such am not qualified to answer that question. I think that means I'm also unqualified to draw up a living will detailing what to do if I exhibit symptoms of any of these.

> I shopped around a little for a fire extinguisher

And then bought it immediately, right? You're not gonna wait for a fire to buy one. Same with the first aid class, the batteries, the flashlight, and the food. You cannot buy medical care ahead of time, or take a class to train you to treat yourself.

In case you missed it in my other comments, how often would you update your living will in this world? How would you prepare for travel within the US?


"You cannot buy medical care ahead of time"

Actually, that's pretty much what our current "insurance" system tries to look like, so maybe you do have a point there :-)


"Sorry, sir. Your spouse's living will restricted emergency care provider vendors such that she was unable to receive care in time. With our CareWatch(tm) package, we can give you geo-fence alerts with response times that would be outside your living will provider preference range. Press one to be connected with a sales associate."


Not sure if you are trying to be funny but you aren't.

"The next day, doctors implanted stents in his clogged “widow-maker” artery."

By that time they could have clarified the insurance situation. In any case I don't think it's acceptable that any kind of emergency can bankrupt you if you have the bad luck to end up at the wrong hospital or wrong doctor.


Looking at the bill, here is some ridiculous: NaCl (basically salted water) costing around $300/liter.

That's outrageous. These guys are protected by your politicians and make use of mercenary tactics. Villains in doctors clothing.

I'm for free markets but we are kinda going over the limit here. Maybe have fixed rates for emergency where you can't get the approval of the patient. Maybe give the patient the possibility to pay for these ridiculously priced items after.

I mean if I get you 1l of NaCl we'd be cool. And fix the rates for emergency.


What about this market seems free? The entry barriers for competition are so high, the only players are the well established, and much more importantly, well connected. And they can freely abuse the system with almost zero market or political repercussions. On a side note there is no industry more heavily regulated than the medical industry. Coincidence?


Exactly. Price has become divorced from end user value basically anywhere you look in the medical field.


So... When you're in the ambulance dying of a heart attack, you're supposed to be negotiating over your saline drip or on the phone with another ambulance company looking for a better deal?


Maybe if you had picked an example of some medical supply that is used only in emergencies your sentiment would make sense. The price of saline, and nearly all medical supplies, absolutely could be subjected to market pressures in the majority of medical situations, which would drive the price down for everyone, even for heart attack victims.


The price of saline is $1/L (subject to market pressure). It's being billed at $300/L which isn't subject to market pressure.


Retail cost for Lactated Ringer's solution, injectable (basic saline fluid for IV) was over $40/liter in qty 12 liters about 3 years ago. I can imagine it has gone up since then.

The use of the health care system to extract every single excess dollar from the middle class extends to many, many layers of the supply and service chain. It may be that the saline was "merely" marked up by a factor of 2x.


Seems like the problem is broadly in the medical sector (including pharmacological). There is 0 reasons why it would cost over $1. Maybe $2. $40 is still way ridiculous. I mean in a competitive market.


The problem is there will never be a truly competitive market in most health care products and services. Necessary regulation creates too many barriers to entry and competition, and the ultimate consumer has very little demand flexibility or even choice of provider.

What is needed is a monopsony buyer who can negotiate in this arena on a more even footing. In other words, single-payer.


The US is proof that a free-market system for healthcare does not work. This is also illustrated by all the stories here.

For free-market to work, a consumer needs to be able clearly understand what he is buying and how much it will cost before he consumes whatever he buys. This allows him to shop around, and find the best seller and price.

The current system just drives prices up instead of down, as the seller, who is in it for the profit, can set his prices after the goods have been bought. Ofcourse prices will go up, there's no competition anymore, as the buyer has already consumed the goods.

Trying to make this transparent before an operation would not work. It would just turn healthcare into another IT project, where seller will offer you the lowest prices, and then come up with extra-work that also needs to be done. Image being operated on, and the surgeon informs you they've discovered some required extra work, asking you if you will agree with the additional cost...

It's clear to me that healthcare and free-market are an incompatible combination, it needs to be heavily regulated, and probably single-payer.


"Calver asked whether his health insurance would cover all of this... The hospital told him not to worry and that they would accept his insurance."

From my experience, it is completely legal for any medical practitioner to say they accept an insurance even though they really do not.


From my experience, no human at the hospital has any idea whether they will accept your insurance or not. The doctors certainly don't. They just report things into the bill-processing system which occasionally delivers patients a crazy $100,000 bill.


They have no idea if the insurance company will pay. I know this from personal experience where the hospital explicitly called insurance co to ask if a procedure would be covered, received confirmation that it would be, AND the hospital recorded the call. But coverage was subsequently denied.


Yep, this happened to my wife - she needed a fairly intensive and costly surgery and was told she was in-network and covered. It turned out the person on the phone was wrong and she ended up having to cash out her entire 401k to pay the 20k+ bill. We learned a lesson about the US healthcare system with that one...


"we accept it" is nowhere near the same thing as "the insurance company will pay for it". Of course they'll "accept" it, it just may not make a difference as to what you owe. they'll put it in their system.

the words used here have vastly different meanings to each party.


"accept an insurance" doesn't mean what you think it means.

It just means they will exchange paperwork with said insurance company. Whether or not your policy/company covers treatment is a completely different issue.


That's just nuts. As patient you go in blind and can just hope for the best.


Mere acceptance of insurance doesn't mean there won't be an exorbitant copay, anyway.


Yeah, but if they say that, then they should be responsible if they are wrong.


I feel like whenever I hear crazy stories like this about healthcare it usually involves these weird in or out of network issues. I'm certainly not an expert on healthcare, but is there no way to attack the problem from this angle?

If you have a hospital with a certain list price for a particular procedure, why is it legal for them to charge one insurance company 5% of that price and charge another insurance company or someone without insurance full price? It seems like exactly the kind of scenario that price discrimination laws are meant to prevent.

Similarly for the insurance plans themselves, why can you sell basically the same plan to employees of a large company for much cheaper than you sell it to employees of a small company? (This one might need to be a new law specific to insurance companies, because clearly there are many other products that give group discounts when selling to large companies, but I think health insurance should be treated differently).

I'm sure I'm missing what some of the downsides might be, but it seems like making these kinds of backroom network-based deals illegal in health insurance would go a long way in making prices more understandable/predictable, and that might allow for more fair competition on price to emerge.


> I feel like whenever I hear crazy stories like this about healthcare it usually involves these weird in or out of network issues. I'm certainly not an expert on healthcare, but is there no way to attack the problem from this angle?

Because hospitals, and physicians, have decided that, for the most part, it is better for each of them for physicians to be "independent contractors", so the situation of "your hospital is in network, but your physician was not".

Or for me, most recently, going to my doctor for a checkup on my hypertension at an Urgent Care/Family Practice hybrid. Facility? In network? Physician/Assistant? In network? Lab in the same building (to be clear, it wasn't a multi-tenant complex, this was a medical practice) that they sent me for CBC draws? Out of network. Boom, hundreds of dollars in lab bills.


Prices, more and more, are negotiated between very few providers and customers. It's like there are 3 fruit stands and 3 buyers of fruit, and those three buyers of fruit are willing to buy huge quantities of fruit (provide a hospital business with lots of patients) as long as the fruit stand meets their price demands. The fruit stand can take it our leave it. If they leave it, they lose out on 1/3 of their potential sales. They go through this kind of negotiation with each of the three fruit sellers every so often.

This is far from an ideal free market.


All this is a bit surreal (Canadian here), but it prompts the question: why won't people sue in a class action to refund money they gave to the insurance in the first place?

I realize it's a complex subject, but at the end of the day, the insurance companies advertise and sell: insurance.


Any insurance policy will have clearly stated the difference between out of network and in network benefits.


But you can't always pick your providers. Example: You go to emergency room that is in-network. A month later you get the bill for the doctors that treated you - who aren't in-network.

"A new study that looked at more than 2 million emergency department visits found that more than 1 in 5 patients who went to ERs within their health-insurance networks ended up being treated by an "out-of-network" doctor — and thus exposed to additional charges not covered by their insurance plan." https://www.cnbc.com/2016/11/16/many-get-hit-with-surprise-o...


You think someone who is staring at bankruptcy is going to say to themselves "I know what I'll do, I'll spend thousands of dollars I don't have on a lawyer to solve this problem for other people in 5 years"?


You're right, that's unrealistic. In fact this sort of thing is why government was invented.


You need a government that is responsible to its citizens. We don't have that - we have a government that is responsible to its biggest donors. The more some company or some industry can abuse the market to extract insane profits, the more they can lobby the legislatures to cover their ass and secure their business model.

And it's not just health insurance. Case in point: we have companies writing tax accounting software lobbying against simplification of tax code. And it works!

https://www.vox.com/2016/3/29/11320386/turbotax-boycott-lobb...


I know, at least at federal level the US isn't a democracy anymore, it's been taken over by corruption entirely. Until that is changed the problems for normal people like the one described in the post will only get worse.


But muh freedom


Because that lawsuit would get thrown out.


Hahahahahaha. No. The American legal system is so stacked in favor of insurance companies it's ridiculous.


This isn’t true at all. Insurance is heavily regulated. If you can’t resolve an issue with your insurance, most states have arbitration committee that will smack down insurance companies pretty quickly.


Crucially, that's only true if you have the money and time to fight. For the people hurt worst by the system, they lack some or all of: knowledge that they can fight it, money with which to fight it (or again, knowledge that a lawyer will take it pro bono), and the time with which to fight it and not work one or more jobs. I know people on this forum are relatively well off, but everyone reading this should try to put themselves in the shoes of someone working multiple jobs, trying to take care of a sick family member, and facing predatory companies trying to bilk them for all they're worth.

That the government will protect you, in theory, is not the same thing as in practice.


Lolwat the entire purpose of Arbitration is to give a massive advantage to corporations.


This is a govt arbitration headed up by a state committee that regulates insurance in the state.

It’s not forced arbitration at all. You can still sue them.


Here's the deal. Insurance is a simple concept. Take house fires. They are fairly rare, but they do happen. We could all just save up enough money to cover a house fire ourselves, or, since we know that house fires are rare, we can pool our money together as friends and neighbors and when one of us in that pool gets unlucky and has their house burn down, it can be covered by insurance. A lot of us pay a little money for peace of mind that if a rare catastrophic event does hit us, we'll be OK.

This same concept applies to some medical issues, but there are a lot of medical issues it does not apply to. Getting a routine infection and needing antibiotics? Everyone is going to need that. It makes no sense to pool our money and pay out for the rare person that needs money for that. How many other medical expenses are like that? Even things that are rare for a group of 20-year olds like heart attacks are actually a lot less rare (more common than house fires, probably) for an older age group. So while it might make sense for a group of 20-year olds to pool money together to pay for the rare heart attack amongst that group, it might not make any sense for an over-50 group of people to do that same. It definitely doesn't make sense for a 20-year old to join that group. Yet this is exactly what we do. We all pool our money together and use it to pay for every medical expense that comes up. Minor infection? Use insurance! Need a couple stitches? Use insurance. Routine screening? Wow, didn't see that coming, good thing I have insurance.

This is insane, and this is the root of all our problems.


I completely disagree. The reason insurance pays for the small things is to encourage people to seek treatment early because it’s cheaper in the long run. Almost nobody would pay hundreds for a cancer screening like mammogram or colonoscopy that they don’t believe they need, but catching these things early is orders of magnitude better both for health and financial outcomes.

Insurance covering a minor infection prevents needing to handle a major infection. Your system assumes humans are rational and a good judge of risk, something that has proven to be untrue countless times.


Yes, humans are shortsighted and stupid. That's why we need state-sponsored medical care. Run by humans.


Not sure if you're joking, but that's a pretty lazy fallacy of composition there.

Ex: Human memory sucks, but you can generally trust the immutability of books, despite them being written and copied and bound and distributed and sold by humans.

It's all about using strengths in the right direction and order to sidestep weaknesses.


Fallacy of composition says I look at a few stupid humans and decide that all humans are stupid. That's what the person who I was replying to was doing in reply to my original post. I was trying to point out that if their supposition is true then we are all screwed no matter what.

Fortunately their supposition is false. Humans are not generally shortsighted and stupid, if you give them a chance.


> Fallacy of composition says I look at a few stupid humans and decide that all humans are stupid.

No, a fallacy of composition would be "the organization is stupid because its employees are stupid", or "metal boats are impossible because metal sinks in water." It involves something which is composed of the smaller pieces.

What you're describing is more like a hasty generalization, where individual-qualities within a sample lead to a conclusion about individual-qualities shared by the entire population.

> I was trying to point out that if their supposition is true then we are all screwed no matter what.

And -- even if their supposition is true -- I disagree!

Metal boats can float on water, even though individual metal pieces sink. Institutions can solve problems, even ones that individuals humans suck at.


Does this mean the average American is shortsighted and stupid then?

“But the average American has less than $4,000 in savings, while 57% of U.S. adults have less than $1,000 to their names.”

https://www.usatoday.com/story/money/personalfinance/budget-...


One reason they do it that way is that if you don't pay for screenings and small problems, people tend to skip going to the doctor for them, and you end up paying for more big, expensive problems.


Yes, and is that line of reasoning working? Are we as a society saving money doing it that way?

It seems what people really need is just a savings account and some incentive to actually save money for future expenses (because knowing that someday you are going to get an illness that 100% of people get apparently isn't enough motivation).


HSA’s are available and most people don’t effectively use them, part of the problem is most people don’t/can’t save anyway. You’re not all wrong, but you’re talking about changing behavior which is much harder than just making the system work for how people actually behave.


HSA's are horrible. Way to much government nonsense with limits on contributions and providers and tying them to particular insurance plans. Completely ineffective. When you see that you could save some money for future medical expenses, but you don't qualify for any tax breaks because the amount you want to save is too much or your health insurance doesn't allow it, it's very demotivating for saving at all.

The thought I have is we should all definitely carry catastrophic health insurance, but then people should be on their own for the rest. I'm sure that payment plans and medical care clubs would spring up to fit the needs of those who absolutely need a way to force themselves to save ahead. Those things should not be called insurance, they should not be sold as insurance, nor should they encroach at all into the territory of true insurance that is meant for rare and catastrophic events.


Only having catastrophic coverage for most people over 35 does not work, maybe younger too. We’ve already seen this.

You are basically guaranteed to receive care in the United States, doesn’t mean it’s affordable. The people that can’t afford the ~$300 screening or basic healthcare end up waiting until it’s major then we’re back to catastrophic level. People who can’t or don’t pay their medical bills still cost everyone using the health system money, it’s just hidden in fees, higher costs, tax write-offs, etc.


I'd like to think HSA's are a good idea, but many HSA's have a "use it or lose it" policy that any money contributed that doesn't get used by the end of the year just disappears into the pockets of the HSA provider. It's almost a scam. It might be nice for someone that has some sort of ailment that needs frequent care, such as diabetes or cancer, but it's worthless for someone that wants to have money kept aside in case of an emergency.


You are absolutely right, but we should probably just stop calling it "insurance", since it is nothing like what you are talking about. It's more like a pre-paid health plan. You pay a certain amount per month, and the plan pays for your health care. It's more like a co-op.


Read the article.

The man had insurance, it didn't pay out. Or more accurately, the hospital intentionally overwhelmed the insurance company's willingness to pay.

I can't think of the right analogy for house fire insurance. Because you can take your payout after the fire, and either rebuild or use it to buy another house. There's never a situation where you have house fire insurance, and end up paying MORE when your house burns down.


> Industry analysts and consumer advocates say St. David’s has a reputation for exorbitant billing and for trying to collect big payouts as an out-of-network provider.

Sounds just like St. David’s Medical Center in Austin, TX is run by crooks. I like the take-home message that "Faced with a surprise bill or a balance-billing situation, don’t rush to pay any medical bills you receive."


More specifically, it is run by HCA Healthcare, a for-profit company listed on the NYSE.


If you owe a 6-figure amount of money because of a health issue, you don't actually have health insurance.


You do, it just doesn't cover you at all medical providers in all 50 states.


If you send me a bill for anything over $100,000, you might as well send me a bill for $10 trillion. It doesn't matter, I can't pay. I'm bankrupt now. Great, you get my house and my retirement savings.

The point of insurance is to prevent that from happening. I pay a small amount so that if I get unlucky, I'm not ruined. I don't care if "oh the bill was actually much higher before" because the number never mattered- me being ruined is what mattered. If I still am, then the insurance did not do what I wanted it to do.


So you have a lottery ticket, which may or may not pay out when you receive health care services, decided by essentially random factors.


Or Health Insurance means some of your bills will be paid, not "full coverage" as most people assume.


It should be though: people do not understand healthcare, the insurance they are getting, what is included and what is not, and, very important, at times of illness you really do not have the time or bandwidth to think about it. To me it always sounds rather inhumane what happens over there. But then again, I only get my info from comments and articles like this.


The insurance company is basically saying, you should still choose the in-network provider even if you are unconscious or don't have a choice or we'll fuck you financially. I've had this happen to me, appealed, and after many months, actually won. In my case I was unconscious and the ambulance and hospital were out of network. I was lucky the hospital was willing to wait over a year and not send it to collections. It was hell. Why the fuck isn't there a law against this kind of shit? Do we expect people who are unconscious or having a heart attack to say, "oh no, take me to an in-network provider so I don't go bankrupt?" Fucking absurd the healthcare in this country and the lack of proper regulation. How long are we going to allow these insurance companies to get rich while people die and go bankrupt?


> The insurance company is basically saying, you should still choose the in-network provider even if you are unconscious or don't have a choice or we'll fuck you financially.

Actually, they are saying if you choose to cut premium costs by selecting a narrow provider network, well, there's a reason why the premium costs are low.

> Why the fuck isn't there a law against this kind of shit?

Because Republicans actively oppose any attempt at health security, and Democrats keep ignoring the majority support for single-payer that polls have shown for close to 30 years in favor of Rube Goldberg solutions that keep private insurers and this type of network-based limitation as central features, despite the fact that hey have less public support and are thus more subject to being politically sabotaged before passage (Clinton) and after (Obama).

Though there's signs of potential for that to change on the Democratic side in the near future...


Your first point is simply not true. There is no plan that covers every ER and every hospital. Even on the top plans, there are in-network and out of network providers. So once again, we're back to making decisions while incapacitated or unconscious. No matter how carefully you chose your plan and how much you pay, you're still fucked. Not to mention that almost everyone is stuck with the plans their employers choose. Even the platinum level ACA plans, however, are like this. That's what I'm talking about above, BTW, as well as equivalent plans provided by corporations. It's simply impossible to get a plan that covers everything and therefore prevents you from going bankrupt in all situations.


> Your first point is simply not true.

My first point is what the insurance company is saying. It's absolutely true that they are saying that. (It's also a true claim; your argument that all provider networks are limited such that the risk of similar problems exists at some level in all insurance plans is perhaps pedantically true, but not necessarily relevant—e.g., it may be that the only reason the care from the profile provider in this particular case was out of network was that the district's individually negotiated narrow network plan excluded providers that would have been included in standard plans this insurer offered in the area.)

> Not to mention that almost everyone is stuck with the plans their employers choose.

That's factually false; only 49% of Americans are covered by insurance provided by an employer (either their own or as a dependent) health insurance, and not all of them have no other practical option than that plan, so, no “almost everyone” is not stuck with their employer's plan choices.

But, in any case, the employer's plan choice is exactly what the insurance company is highlighting as the issue in this case.


> Why the fuck isn't there a law against this kind of shit?

There's a pretty clear answer to this question almost every single time it's asked... the people who benefit are wealthy and the people hurt are poor. The latter structurally lack the ability to fight it or lobby their congresspeople to change the law to help them. Until a mass movement steps forward to say "no, we will not tolerate this", nothing can possibly change. We have no recourse but each other and collective action.


Based on voting demographics, the poorest are the ones who are voting for politicians who hate the government and are opposed to any kind of subsidized healthcare.


How true is that? Poor people just don't vote, period. They're overworked, politicians don't listen to them, and in many states there are institutional barriers to casting a ballot even if one wanted to.

And it's not necessarily true among those who do vote either:

https://krugman.blogs.nytimes.com/2007/09/24/bubba-isnt-who-...

It's an old article and I don't doubt that 2016 has messed with the numbers, but the narrative of poor rednecks screwing themselves over every election is largely unfounded and smacks of classism.


Mostly because they believe and have been encouraged to believe that any protections/benefits would go to people who "don't deserve it" (also known as: whichever racial/ethnic demographic those voters have been raised to hate the most). They're very much in favor of discriminatory special-treatment programs that help them and only them, but very much against broad safety nets because they've been told such programs would only benefit the bad other people.


There's a lot to unpack here. First, neither party has the trust of the working class, whatever the rhetoric. Second, the candidate that talked about fixing the system, including healthcare, won -- that he was actually talking about breaking it further gets lost in the discourse around both candidates. There's a longer discussion to be had about how to build trust and what can be done about broken political systems, but it's not the parties that can act on that at this moment.

It will take something like the union/wildcat teachers' strikes, that forced Republican majorities with unified control of state governments to raise wages and increase funding, to do anything about healthcare or the many other structural challenges we face as a nation.


>Why...isn't there a law against this.. ?

Because the laws are made by people bought and paid for by the people perpetrating this fraud?


Do you expect one organization to have a pricing agreement with every single medical provider in the USA?


You mean, like Medicare? OK, it's not with every provider, just anyone who wants to be a provider.


I should have written one health insurance company instead of one organization. Obviously it doesn't make sense to compare a health insurance company that has to abide by 50 different state insurance regulators to the US government.


Then they shouldn't be allowed to conduct business. Of course I expect them to cover all emergencies period. How they do that, I don't really care. If it were up to me, I'd ban these monstrous leeches from society altogether and only allow them to offer supplemental plans. They clearly can't do their own job so they should be replaced by a program like Medicare or Medicaid that can do the job. Would you accept a car insurance policy that only covers some accidents? That's beyond ridiculous.


From outside of the US, it baffles me ( and I'm sure others ) why the US doesn't embrace governement based healthcare. We pay the same kinds of tax rates etc and don't have to pay for health insurance on top of that(though you can get extra health insurance for pretty cheap if you want). It's kind of like governement education which the US does pay for up to a certain point. Not only is it worth educating your population, it's worth looking after their health as well.

The amount of misery and unpayable debt it seems to cause people who live in the US seems really unecessary. Not to mention nearly everyone in good heealth has a certain level of anxiety about whether their insurance is good enough and will cover them.

Mind you guns also seem unecessary yet the general response to that seems to be, It's ok, we will live with our fear and everyone should be carrying guns and make it so everyone needs to be prepared to kill other people in gun fights. If you get wounded of course, then prepare for living the rest of your life in medical debt.. :I


> From outside of the US, it baffles me ( and I'm sure others ) why the US doesn't embrace governement based healthcare.

The US has had majority public support for fully-public healthcare for at least ~30 years.

What it has lacked—even among politicians championing “healthcare reform” like Bill Clinton and Barack Obama—is politicians willing to challenge the insurance industry even with the backing of majority public support.


There is a rising groundswell of support for government based healthcare recently:

https://www.cnbc.com/2018/08/28/most-americans-now-support-m...


There are midterms coming up. Vote for change and don’t vote for anyone who took one cent from the insurers.


And here's a handy list of all representatives and how much they took from healthcare lobbyists.

https://www.opensecrets.org/industries/summary.php?ind=H&cyc...


At least there's one thing with overwhelming, bipartisan support in Congress.


whats amazing to me is how little money it takes to sway a politicians vote. yes there are big numbers in the list but most of them are 10s of thousands. its just amazing that they are willing to put their conscience aside and condemn people to bankruptcy or worse for that little. for the worshipers of free market they sure are selling themselves off cheap.


I'm amazed by just how high the donations can go. What the hell did senator Sherrod Brown do to get $1.4M from the healthcare industry? A quick Google search doesn't reveal anything out of the ordinary, except for maybe the most ironic tweet of all time:

https://twitter.com/sensherrodbrown/status/89082321753065062...


The problem isn't that they're bought with $10k. They're approached and told "Take this money or we'll give your competitor $5 million to campaign and take your place". And they know they follow through with the threats, so they take the $10k.


but even that should ultimately bid-up the bribes after all its a 'free market'!


That probably rules out every state and federal politician. Either way, this was on the hospital. Insurance paid $50k for an operation that costs $25k, and still the hospital charged him $109k.

>UPDATE: Monday, shortly after publication and broadcast of this story by Kaiser Health News and NPR, St. David’s said it was now willing to accept $782.29 to resolve the $108,951 balance because Drew Calver qualifies for its “financial assistance discount.”


> That probably rules out every state and federal politician.

That sounds absolutely dystopian. A politician running on a platform to reform healthcare can’t possibly be bribed by the companies that would die in the process.


Who said anything about bribes? A politician runs on a reform agenda. Some hospitals put together an advertisement where concerned doctors say that the plan is "Not right for America". People trust doctors more than politicians so the reformer loses the election. Politicians know this so they don't try any reform that will reduce profits too much.


Seriously? Find me the politicians who haven't accepted campaign donations(bribes) from insurance or healthcare companies. Good Luck.


These guys don't take corporate money. https://now.justicedemocrats.com/candidates


I feel like the issue here is caused more by greedy Health Care company like HCA than the insurance industry.


The insurance industry is the enabler. Is there any other industry where you the individual do not know the cost until some third party that has agreed to pay the cost, negotiates said cost, and then even after negotiation may just give up and say, nevermind, pay it yourself?


This is why I plan on moving to Texas: creditor protection.

At any point in time I could require medical services and have medical service providers simply decide that I owe them a truly massive amount of money. The only route I have to mitigate that risk is through creditor protection laws.

In Texas, wage garnishment is limited to child support, unpaid taxes, and some other limited categories that medical billing doesn't have access to. Creditors can sue you, but they can only seize bank accounts, brokerage accounts, and the like - your primary residence is completely exempt, as are employer-sponsored retirement plans and IRAs.

So my emergency medical debt plan is to liquidate all taxable investments and close out bank accounts, send the cash from that to pay down a mortgage, and tell them to pound sand. The only real consequence is having to head to Walmart each month to cash paychecks and mail out money orders to pay bills.


You might be better moving to a country with a nationalised health system and avoiding this mess entirely.


It's significantly easier to move between US states than it is to emigrate.


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