IMO, it is incredibly unethical and dishonest for these medical corporations to charge different fees depending on who you are. Prices should be transparent, and should be the same for everyone.
Some may argue that an organization representing a large pool of people should be able to achieve economy of scale and a better price. This seems false to me, as in reality there is only one pool of people and care provider provide care to that one pool. Its time to kick the middlemen out.
And I got an adjusted bill.
I get the negotiation side of things. I get that the leverage insurance companies have is the culprit. But at the end of the day, hospitals just upcharge so they have the upper hand in negotiation. There’s no reason that individuals who choose not to go the insurance route are artificially charge X times what insurance companies are. There’s no excuse.
Charge them the cost of the procedures with whatever markup is reasonable for the hospital to stay in business. It shouldn’t be any other way.
If the middlemen have something of value to offer they have little to fear - just someone to buy gasoline by the tanker for instance keeps gas station middle-men safe because they provide both a workable connection between logistics of the very large production and consumer scale amounts - in addition to the distribution.
I'm sure there's a lot of varying billing policy, hospital to hospital. And varying ability to financially write off care.
As a gut guess, I'd expect rural hospitals to be the worst about this and suburban the best.
Hospital: "Call your insurance company and ask for a break"
Insurance Company: "Call the hospital and ask for a break"
Also, 2/4 of these hospitals had outsourced their billing which means they can't even make decisions on behalf of the hospital (and have a disincentive to write anything off). Seems like a structural way of avoiding writedowns.
And wow, does that search bring up a lot of astroturf: https://www.google.com/search?q=list+of+medical+billing+comp...
Basically, in the U.S. the healthcare system is not exactly a free market as pricing signals are unclear, and most consumers have no idea how or inclination to price shop as they have been trained for decades to not bother. The problem is now not just a matter of how insurance is structured, but cultural.
When a patient asks about prices she quotes them her standard price for the necessary services and calls their insurance company to confirm that the patient is covered and check what kind of copay the patient needs to pay. Assuming the patient is satisfied with the results of that call she provides the services, bills the patient for their copay, and files a claim with their insurance company.
Several months later (and no real way to predict when), the insurance company will provide an "offer" for probably somewhere around 60% of the quoted price (though this varies dramatically as well). She can accept the offer, in which case she's inevitably required by the terms to eat the difference instead of attempting to collect the balance from the patient. Or she can reject it and attempt to collect from the patient, in which case they will likely be very confused and angry as to why their insurance isn't being accepted, despite her explicitly confirming that it would be covered before they purchased her services.
To be clear, none of this is negotiated or agreed upon in any meaningful sense. She doesn't have any special relationship with any insurance provider. Instead, the providers use their massive power differential to dictate terms. She wouldn't be able to stay in business if she didn't accept at least some insurance, but they'd be quite happy to never write her another check.
She knows what her price schedule for everything is, but it doesn't end up mattering that much since she doesn't know when or how much she'll ultimately be reimbursed except in an extremely broad aggregate sense. The worst part is that she has to dramatically overprice her services so that she can ultimately get adequately reimbursed to keep the lights on, which just ends up hurting the patients who don't have insurance.
The only downside is I don't see how it would fly politically...which is a big downside.
You cant have your cake and eat it too. If you want prices to go down you have to say there are things you wont do anymore.
It was the only bright spot in a prolonged battle with the insurance company and the hospital.
That is very nice of you. I hope others like you in positions of power do the same!
True, but it did make a difference to those people you helped! so yeah, kudos to you.
After the patient I was with was stabilized, the nurse confirmed with us verbally what the rough cost should be for the rest of what the doctor prescribed, and asked if we wished to proceed. We could have said no and gone elsewhere if we wanted, since the patient at least was relatively stable and we knew what was wrong.
I want this experience to be the norm in the USA.
The idea that your access to healthcare should be linked to your own or your parents financial is crazy.
In the end I agree that a basic safety net is necessary and serves a greater good - providing things like normal checkups, preventative services, and acute trauma care is reasonable. However $200k for a second heart surgery for someone who hasn't taken heed of earlier exercise or diet advice by a practitioner should not be supported.
Do you think that someone who follows all but one of those rules still deserves healthcare? All but two? What's the moral difference between someone who smokes and someone who hasn't taken heed of diet/exercise advice after getting heart surgery? Where do you draw the line?
It's easy to say, "I don't want to pay for the healthcare of some hypothetical 'slob'". But make it real, consider what this actually means, and I think it's not something most of us want.
None of us is perfect. I'm sure that even olympic athletes occasionally eat bacon. Let he who is without sin cast the first stone, right?
Moral difference no idea, but neither one should expect to have society foot the entire bill for their bad habits.
> Where do you draw the line?
Probably around morbid obesity that's unrelated to genetic/chronic issues.
> Let he who is without sin cast the first stone, right?
By setting an unreasonable standard and saying no one under it has the ability to cast judgment is extremely anti-intellectual. If 2 people were telling you about health habits and one of them was an olympic athlete (who occasionally ate bacon), and the other was a random overweight person from the street, whose advice would you give more weight to?
The jury is still very much out on how common this is, isn't it? Who is going to make the decision of whether I am "at fault" for my obesity?
Also how many people actually choose to be morbidly obese? Like, suppose I am genetically predisposed to like "unhealthy foods" (scare quotes because we don't really know what that means). Does that excuse my obesity as genetically caused? How are you going to tell the difference between someone who "selfishly likes" unhealthy foods and someone who can't help themselves? More to the point, is there a difference?
> By setting an unreasonable standard and saying no one under it has the ability to cast judgment is extremely anti-intellectual. If 2 people were telling you about health habits and one of them was an olympic athlete (who occasionally ate bacon), and the other was a random overweight person from the street, whose advice would you give more weight to?
In the face of this claim that my argument is anti-intellectual, I think I get to be pedantic and say that this counter-argument is a straw-person and equivocates.
I am saying that I don't think an Olympic athelete should pass moral judgement on other people. But of course an expert can pass intellectual judgment on ideas (e.g. "candy is healthy").
I can't believe I'm here as an athiest defending Jesus, but there you go. :)
I'm sorry but this is insane. Are we just abolishing any notion of personal responsibility whatsoever? I can't and won't argue from that first principle so we're going to have to disagree here fundamentally.
What if I can't help myself but grope women? What if I'm genetically predisposed to violence? Or kleptomania? Those things also impose a heavy cost on society, but if I just can't help myself, am I really at fault?
> How are you going to tell the difference between someone who "selfishly likes" unhealthy foods and someone who can't help themselves? More to the point, is there a difference?
Of course there's a difference. If your willpower is not sufficient to correct your obesity, then you should take other, more radical steps that do. And if you don't, then you're just selfishly externalizing your problems to society.
> But of course an expert can pass intellectual judgment on ideas (e.g. "candy is healthy")
Good, at least we can agree on something. So to answer the first part of your post, you should ask an expert on obesity. I'm not one, so if their judgment differs from mine, I'll stand corrected. But until then, I'll be of the opinion that most obesity cases are not genetic.
You're saying you have no expertise in this, haven't spent any time reading the literature or consulting with experts, but you nonetheless are going to continue having a strong opinion on this question? What is the basis for this opinion on a question of fact? Hopefully it's not than the fact that fat people are icky and so must be morally at fault for their failings?
Why do you presume people are completely hopeless at controlling what they put in their stomach?
How many experts did you consult with to form your opinion?
We don't know that obesity is caused mostly by over-eating.
Many basic questions about diet are unsolved, including the reason(s) that some people gain weight while others don't and the reasons that the vast majority of people can't lose weight. We just do not know to what extent do genetics, gut flora, lifestyle, and diet affect weight. We also don't know what makes for a "good" diet, or whether the same diet is good for everyone.
This is not obscure knowledge. Literally if you google "what causes obesity?" you'll get pages like this: https://stanfordhealthcare.org/medical-conditions/healthy-li...
> How many experts did you consult with to form your opinion?
I spend a lot of social time around doctors, and I read a fair amount of medical literature (for someone who isn't in the medical sciences, anyway).
I am not claiming to be an expert, but I am claiming to be somewhat informed, yes.
I am also claiming, more strongly, that before we as a society punish someone for causing something we'd better be pretty damn sure that the person actually did cause the thing, with mens rea and so on. I am claiming that the scientific evidence is not there for obesity.
No, that part is obvious and we do know that more calories results in more weight. There's no debate. The only debate is in what causes over-eating.
> Many basic questions about diet are unsolved, including the reason(s) that some people gain weight while others don't and the reasons that the vast majority of people can't lose weight. We just do not know to what extent do genetics, gut flora, lifestyle, and diet affect weight. We also don't know what makes for a "good" diet, or whether the same diet is good for everyone.
Also flat out not true. You're creating some ridiculous standard for "knowledge" when in reality, you only have to have "good enough" knowledge in order to be healthy and not obese. Most people can easily adhere to, but for whatever reason, don't.
> This is not obscure knowledge. Literally if you google "what causes obesity?" you'll get pages like this: https://stanfordhealthcare.org/medical-conditions/healthy-li....
Yes, and? The answers are not equally weighted. Just because there are 3 answers, doesn't mean each answer is equally responsible in the cause of obesity.
> I am not claiming to be an expert, but I am claiming to be somewhat informed, yes.
I am claiming the same. My parents are biomolecular scientists and for them it is not contentious that overeating causes obesity. If we're giving weight to anecdotal evidence, I'm entitled to at least give my own evidence the same weight as you do yours.
> I am claiming that the scientific evidence is not there for obesity.
And there are people claiming that anthropogenic global warming is a myth, despite scientific evidence otherwise. However, I'll take claims that are true (overeating causes obesity - replicated many times), over claims that may or may not be true.
Please realize that you're in the minority on this, but the science is already settled. It's ok to admit that you're wrong.
OK, this is a concrete claim that we can test: "most people can easily adhere to a 'good enough' diet/lifestyle to avoid being obese".
If this were true, then there would exist a protocol that "easily" results in lasting weight loss for most people, right?
Does such a protocol exist?
If you have a link to one of his papers, I'll gladly peruse it.
Might be worth your time at 2x speed. Or not, I dunno.
It is essentially a bill of rights thing - either you support universal rights for everyone or you support them being taken away whenever convenient a.k.a. no rights at all for anyone.
Just go back as shallowly historically speaking as AIDS in the 80s. "Only gays and drug users get AIDS so why should we pay to help those degenerates?" sounds downright satirically stupid but that was essentially a real viewpoint and sadly still is really. Judging the 'guilt' of patients is a very dangerous thing for a society to do and doesn't help the underlying health problem at all.
However, I think if we gather a pool of public funds there needs to be a priority system or some feedback loop or liability included (back to finite resources being at stake).
Those things like sugar may come with a tax so that respective procedures are funded by it. Likewise for driving, insurance is required. For diet and exercise, maybe you can get an income tax credit for following certain things.
Not perfect, but I think we can get better then a simple pool that's support for everything and anything.
I disagree that failing to adhere to a certain diet should be punishable by death.
Then the problem is you have no pricing mechanism for determining how much the provider should actually be paid. If you offer less than what people value the service at, you'll get shortages (or, in this context, waiting lists and less life-saving medical R&D). If you offer too much, you're overpaying (see also US government contractors).
Governments in Europe apparently solve the "paying too much" problem by systematically underpaying, but that doesn't work if everybody does it. The US can't subsidize your medical R&D if they're doing the same thing.
> The idea that your access to healthcare should be linked to your own or your parents financial is crazy.
I've never understood why people have this idea about healthcare but not even more immediate necessities like food and housing. It's not as if the solution you're proposing is even analogous to the solutions we use for the poor there (i.e. free clinics akin to homeless shelters and soup kitchens). If the problem is that free clinics are poorly funded, why isn't the solution to fund them better rather than nationalizing the entire healthcare system?
Hmm but I have the same view for food and housing. Where I live if your mother doesn't have allow money to buy proper food the government will contribute (both for food and housing).
So what do you mean?
Its easier to eat up cost if its a lot lower and has caps. The US has no apetite for those level of restrictions.
Anyone can go to a doctor to get an appropriate level of treatment. If you want more than that, to the degree that you want to waste your own money, then of course you can do that by paying for it out of your own pocket.
It's funny that we are having this discussion. This is a solved problem in large parts or the world and the only reason it's an issue in the US is due to people being crazy.
When the rich people in europe get sick, they go to the U.S..
I would never again want to have medical treatment in the USA.
Next question, if the patient did go elsewhere, would they get to keep all the test results/would the hospital share the test results with the new facility? Or would the new place have to rerun all those tests?
Huh, is that a thing in the US? I understand the old hospital might not automatically giving them to you or the new one rerunning them anyway for practical reasons. But if you've payed for the tests, I'd expect you to own the results...
First line in Wikipedia (https://en.wikipedia.org/wiki/Healthcare_in_Switzerland)
There are no free state-provided health services, but private health insurance is compulsory for all persons residing in Switzerland (within three months of taking up residence or being born in the country).
The difference being their version of the individual mandate was not struck down or watered down to becoming a 'penalty'. Instead it was like what we do with auto insurance.
Most "free" healthcare systems have either (1) horrible quality of service or (2) impossibly long waits unless your life is in danger or close to it. The latter is a systemic issue I've noticed in that healthcare, regardless of pricing or structure, does not aim to foster optimal health, but merely to prevent mortality - so if you go with a 'minor' issue such as recurring headaches or chronic fatigue, it will be dismissed entirely.
I don't have the right answer here and am all for people having affordable options from 'free, wait 3 months' to '20K, full service now', but once again, personally speaking, I'm not rich enough for 'free' things. I'd rather pay and know exactly what (and in this case, much more importantly, when) I'm getting. And from what I've noticed, my personal beliefs that people should strive for optimal health rather than mere preservation of life, is a popular opinion deemed 'unrealistic' by experts.
So I'm not sure what constitutes "most free healthcare systems" but Canada is apparently different from "most"
We generally call this the 'Iron Triangle' in healthcare policy/management. You basically get a pick at most two out of (1) access, (2) quality, (3) cost.
As to your general sentiment healthcare is a bit 'one size fits all' when in terms of insurance/reimbursement solutions. Note that the needs of the aforementioned triangle are weighted differently based on acuity of care. More generalized simple/low acuity care we are happy to get low cost and ready access as our best solutions (e.g. minute clinics, online/virtual care/telemedicine for getting a vaccine or pinkeye/localized infection without complication).
Meanwhile ER representing the other spectrum we instead have greater need for higher quality and access. You must get to an ER ASAP and get stabilized.
Chronic care quality solutions with long term cost-effectiveness are what are needed. Access to a specialist for longer term condition management (or episode or care like a cancer diagnosis).
Similarly more procedures are becoming outpatient, or recovery at home, or at dialysis centers, or at skilled nursing facilities ... you get the point.
I argue the problem is that the insurers have not adequately fragmented the insurance market/reimbursement model. Healthcare is changing in how it is delivered and insurers are not keeping up with it when it comes to modeling their payouts. For example why does being in-network matter for low cost care at outpatient facilities? The added 'negotiation' of being in a specific network doesn't add much value. One size fits all doesn't work with the modern spectrum of care.
You mentioned the grading of schools leading to higher quality. Do we know if any metric suffered as a result? One guess I have is that teachers started teaching for the test rather than for the foundation.
Take that same question and apply it back to the issue of hospital cost. If there's more transparency, the obvious conclusion is that there will be increased competition and an overall lowering of costs for patients. Does that come at the cost of quality of care? My gut says no, but my brain says that hospital administrators are incredibly talented at cutting costs. Maybe we have other safeguards such as HCAHPS to prevent the worsening of quality.
And as my own comment on this situation - how does this move fit into the insurance realm? My understanding is that hospitals will display the overinflated prices, but not the individual insurance negotiated prices. So how does this increased 'transparency' help?
We don't know. Something might have suffered but if you're not measuring a metric, you can't really know anything about it. That was the reality of the educational system--very little measurement of anything--and hence the baseline of agreement (not just in Florida but in many states) was simply: let's start measuring.
> One guess I have is that teachers started teaching for the test rather than for the foundation.
This is a good guess, and some teachers and parents definitely agree with you. But the reality is that (again) unless you are carefully measuring a metric, you don't know what is really happening. Collecting a few anecdotes and opinions does not necessarily result in good data.
It's also possible that in the absence of performance metrics, some teachers managed their work to maximize throughput and minimize complaints--by passing students through to the next grade whether or not they were ready. This is also supported by anecdotes, like colleges and employers reporting a decline in student readiness.
...and Florida still is a bad place to get a public education.
Every single month I call and they give me the run-around. After 6 months of this, I have yet to pay the full bill until they mail me an itemized list and without fail it's wrong. I contact them, they remove two or three charges, I ask them to mail me the updated one. They do, then next month I receive a bill for those proceedures they removed the last time.
Its to the point every month my bill now goes from $0 to ~$800, then back to $0 by the end of the month. Unfortunately, they now called and threaten the ~$800 "over due bill" to collection's. Luckily, I've recorded and documented everything, so I got it removed (again).
However, I'm just waiting for this to go to collection's at some point, even though I owe zero at the end of every month. I'm 90% sure this is a bug in their system, but I can't seem to get around it.
Having worked for a medical billing office, I hate to say it, but this is the norm. The billing office is often not officially the hospital or medical practice. Although we got all the records, we never really interacted and it was just files on a computer. I used to do write-offs, which was basically taking $10m a day and just clicking "don't need to pay". Usually it was dead people, poor, etc. At least that part of the job seemed somewhat nice.
The other bill apparently came from the Dr who read the MRI. The fun part was we were never contacted by that Dr about the results. She eventually left the hospital and she canceled our follow up appointment.
/now I pay a few dollars (no matter if I owe something or if they owe me) near the end of the 90 days those two companies have to figure out how much I owe so I don't have to deal with collections.
When you give agency to someone so they can "fix the problem" you inevitably create a means for wealthy special interests to grasp control.
The problem, as some other comments point out, is that they're way too complicated. The link I posted, for example, is just the provider charges. A hospital visit typically has a facility claim and at least one provider claim. Depending on the type of service received and the agreement between insurance and facility, the facility fees can be billed a variety of ways (diagnosis related groups, ambulatory payment classifications, or HCPCS). Each provider that sees you or performs labs, x-rays, etc can bill separately, and each could have a separate or no contract with your insurance. The latter is how surprise 'out of network' bills happen.
It's a total mess and hopelessly complex for the average consumer.
Naturally the doctor assigned to me did not take my insurance...
I got out of the out-of-network billing after hours of phone calls and lots of unkind words. But man was it just a terrible experience. And with insurance coming from work, it’s not like I could change providers. And with one hospital close to my house I didn’t have lots of options in an emergency. Nor would I expect any other hospital to treat me differently.
My dad is a nurse and I grew up wandering hospitals. He complained as far back as the 80s that insurance was killing medicine. I didn’t understand it as a kid, but I see more what he was getting at as an adult.
I haven't either, and have generally gone by your route of asking the hospital whether it will be insured, but I'd imagine calling insurance (if a feasible option?) would provide a lower rate of error.
But this is actually the one that provides the service. You dont call the music band to ask about the prices ticketek charges.
You should and can ask about the price without insurance and you might get an answer (though you wont like it).
What makes the expectation unreasonable is when you don't know what you will need. Surgery is a great example of that: what if there is a complication? What if a specialist is required, etc etc.
But think what happens when you have a patient with insurance, bleeding right in front of you: would you turn them away because of this lack of assurance? its an unreasonable ask of a human being.
Insurance copmanies are the Ticketek of the health industry: they take the bad rep for the ones reaping the benefits.
It's a common business mindset, unfortunately.
Sounds like something the people on this forum can help improve.
A lot of the problems average consumers face are political/social and not technical (technical problems associated with these issues were solved decades ago). For example, it takes 10 days for my bank to send funds from U.S to my home country. Why 10 days? I have no idea. What I do know is 10 days is extremely unreasonable at the end of 2018.
I filled a form and put "none" for "any visible marks like scars, tattoo etc?" question, because I honestly have none. The form got rejected, now I have to "creatively" answer this question.
When my dad was in the hospital, I got so many bills - I had a lot of trouble looking through those and locating errors (we were charged extra and the only way to find those was to painstakingly go through the bills line by line). I had no energy or interest to do it (when my dad was in the ICU) - every single thing was complex, needlessly so, and was frustrating to the point of tears.
And then comes insurance - ever tried post processing a claim? Wouldn't wish it on my enemy.
There are hundreds and hundreds of examples like these - hospitals, courts/police, banks (even the private ones), airports, any government office in general ... it seems as if they relish in wasting average person's time and money. No amount of software/ML/AI etc can fix these, until the mindset is changed for good.
A large group of people owe their careers and salaries to these inefficiencies, they won't give it up without a serious fight. For example, filing taxes in US - there is no way H&R block, turbo tax etc will go down without a fight, it is just not in their interest to have a simpler tax code.
I guess there is political pressure to make the process as annoying as possible, and not just from tax services corporations.
Maybe you could have "fighting hospital billing as a service", but that's definitely going to need a chunk of human labour on top of whatever AI assistance you apply.
While it might be nice in the short term to see some technological approaches to address the mess, the solution is ALSO political, NOT technological.
Making the information public, however obfuscated, will enable journalists and activists to systematically expose this problem for what it is and that's the first step towards fixing it.
The next thing that will happen is that many more people will be able to win massive lawsuits which is the only recourse the healthcare/insurance industrial complex understands.
I guess there is not enough incentive ($$) to solve this problem.
See https://www.vox.com/health-care/2018/12/18/18134825/emergenc... to start digging into the mess
Sure, the average cost is $1000. But yours might be $5000.
But not for insurance companies; it's in their interest to compare hospitals and get the best care for the lowest price.
I for one hope this will trigger competition. On the other hand, it'll probably end up shafting the personnel instead of the ridiculous profit margins.
The benefit that competition provides to incentivize lower prices and better services is a consumer's ability to easily deny someone their business and go elsewhere.
What would this look like here?
Would one be in the back of an ambulance doing price shopping on a tablet as they are fighting some terrible injury?
Perhaps tie in different billing departments in a conference call as they bid over who will do the critically urgent surgery as the patient slides in and out of consciousness?
Maybe decide to have a heart attack during a winter sale special or reach into their dresser to get a coupon out as they collapse to the floor?
Or would someone be placed on a transportable life support system as they get ferried across a city deal hunting by having different procedures at different institutions, expecting them to talk to each other and string together piecemeal lab results for a coherent diagnosis?
Maybe someone would do the work beforehand, search all the popular ailments and their procedures and then do price shopping in good health and prepare an execution plan if they fall ill?
Maybe there's a non-absurd example, but I honestly can't think of it. The competition mechanism seems to be a completely unrealistic application.
But even with emergency procedures I think you could still have effective competition based on outcomes and price. Here's an article suggesting that in some cases a poor quality hospital will triple your chance of death compared to a good hospital . With more data, I could imagine a study that says, "Hospital B is so much worse for treating heart attacks than Hospital A that it is equivalent to delaying treatment by 20-25 minutes". Paramedics treating a heart attack victim would therefore have a fairly simple calculation: What is the difference between estimated time taken to reach Hospital A and estimated time taken to reach Hospital B? If more than 25 minutes you choose hospital B, if less than 20 minutes you choose Hospital A, and if between 20 and 25 minutes you choose whichever hospital historically charges the least for heart attack treatment.
What is the best answer to the "emergency care competition" that you've found?
And what proportion of medical spending is on emergency vs. not?
It's not a good model to structure the allocation in this particular instance, too many conditions are nearly impossible to satisfy. It's not a sensible way to design this market.
Dentistry is a good example of competitive service, eye care is as well. And negotiation is normal.
You're moving the goal posts in the right direction, but to the edge.
Grocery stores, sandwich shops, coffee houses, clothing stores, coin laundromats, circuit design, postal carriers, kitchen utensils and serving equipment, rental cars, housekeeping things like brooms and dustpans, bouquets and flowers, nuts bolts and fasteners, airlines...
Essentially anything where the brands are fairly indistinguishable and you have a hard time separating them. That's competition working.
Eyeglasses are probably one of the closest in medical. Common medicines like lactase, dextromethorphan and acetaminophen also score high.
The internet disrupts consumer by consumer and product by product, not industry by industry.
Going to a brick and mortar certainly appears cost prohibitive once you get used to paying $10 for stylish fitted pairs of prescription glasses.
Definitely a situation where any partial progress toward clarity and openness is a big step in the right direction. The potential for cascading changes in business practices and further reveals of all the private deals and hidden costs makes it an even better value in the future.
Pay what the insurance or medicare pays, plus a capped xx% because they got a volume discount. By law hospitals have to stabilize you, can't let you die, money or no money. (I know they have been cases of trying to dump patients but...)
So you saved me, but how did you come up with the $455,000 bill? We entered into a contract without prices, so the prices should be customary. 5-10X what insurance pays isn't fair.
Is there a current good answer to a consumer having the ability to competitively (without too much work) receive emergency care?
But then, I can imagine them charging, say, $3800 to stabilize you with whatever surgery (there goes the urgency) and start billing you normally for the rest of the care. They'll make it back and then some.
One interesting idea (not well thought out at all) would say that all prices need to be +\- 50% of what Medicare pays.
Medicare pays $20,000 for stent placement? Great! You can charge whatever you want up to $30,000.
A lot of effort goes into setting Medicare rates (and they are based on self reported costs across the country), so forcing providers to be in the ballpark of those might help.
It wouldn’t solve the issue, but it would eliminate those ridiculous “why do you charge $10,000 for an MRI when the clinic down the street charges $1,000?”.
This is actually close to what happens with private insurers- they negotiate with a hospital to pay n-times what Medicare pays for some set of treatments.
So why does Medicare pay the least? Because they have the most patients covered of any insurance network in the US. That's a hell of a bargaining factor. More patients = cheaper prices.
The logical conclusion is to then have Medicare for all. That'll regulate all prices to be exactly what Medicare pays!
Doctors bill $10k to your insurance, the insurance decides its too much, lawyers are on-hire to negotiate and take a 30% cut of the outcome, and finally 2k is paid out; the absurd bill naturally accounts for the absurd process, and I don't think anyone except the consumer ever expects 10k to really be 10k. And ofc, the insured consumer only ever pays $500 of it from his deductible.
This was basically Shkreli's defense as well -- the insured patient doesn't pay anything close to the bill given; and I'm pretty sure, neither does the insurance. If you want to raise the price be $10, you add $1000 to the bill.
What’s ironic (?) is that by mismanaging a scheme to get everyone on private insurance they’re really working towards socialized insurance. Which good or bad, there is no going away from once you have it.
Just go all cash with an HSA.
What doctors do you know? My friends who are just getting out of residency and such are making a few hundred thousand a year. My college roommate’s father was an anesthesiologist making $800k/year.
Just because they don’t draw attention to themselves with ostentatious vehicles doesn’t mean they couldn’t afford to (the anesthesiologist only had a Porsche for each of his kids).
So between $200k-400k depending on seniority and speciality. It's not really outrageous compared to other, highly educated professions.
This page gives $4246: https://www.healthsystemtracker.org/chart-collection/health-...
Here's a nice run through of the numbers.
Even if I turn up at a private hospital here in Norway, I pay nowhere near what you would pay in the US. Which tells me that either hospitals are run extremely inefficiently in the US (orders of magnitude worse than here) or there are layers of pretty substantial profit margins.
I may be a bit peculiar, but I think a healthcare sector that is set up to mainly benefit execs and shareholders is a bit immoral.
If all insurance lowered to Medicare reimbursements, you will reduce supply.
That said, every branch of healthcare works different and could be upside down from this where they make a ton on Medicare but not commercial
Its more like how airlines work: they make money on first class, and coach is something that fills the plane to cover some costs. If planes were made mandatory to only have coach, they would go bankrupt.
Which suggests to me that prices do not reflect actual cost, but rather inflated profit margins.
There are lots of healthcare companies that are public. Healthcare insurance companies are amongst the lowest earnings of any insurance, contrary to the argumentational of Bernie Sanders.
Also, one of the biggest health insurance companies, blue cross, is a non-profit.
Furthermore, 60% of hospitals are non-profit. And hospitals are 30% of the national healthcare spending.
If we are theorizing at random on what changes could impact the cost-effectiveness of healthcare, it is the increase of profits, not the decrease, that would be a more significant change.
- a very low doc/population count, due to the artificial constraints of medical licensing and immigration law.
- a draconian FDA process for drugs and an unreasonable patent application to drugs.
- An incredibly distortive public service implementation (Medicare) that provokes cost-shifting (by paying below cost), that creates heavy admin burden (fee-for-service), and that overpays specialties and punishes primary care (fix reimbursement fees in multiples for specialties, giving a very low primary care doc count)
- An incredibly distortive tax credit for the wealthier to spend on healthcare (the richer you are, the more tax effective it is to get better insurance through your employer)
- A free-market abolishing regulation requirement: tying healthcare provider to employer.
Example (Sweden): I pay a full public insurance through taxes, and I have a private insurance via my employer that lets me cut some waiting times for certain procedures from 90 to 14 days. It’s an expensive way for my employer to make sure I’d be back to work quicker than I would otherwise be. Obviously, this is a luxury few use or need so the number of hospitals that provide this care is extremely limited (a few percent).
The “paying twice for the same thing” is a feature, not a bug. Most people wouldn’t do that of course, meaning they would simply get rid of their private insurance.
But when the public hospital is 10 miles away, and the private hospital is 1 mile away, paying twice effectively lowers the access of care to the people that can't afford to pay twice.
And then, proximity to public hospitals would be so valuable, that housing prices would icnrease close to the best public hospitals, and the richer will again take profit of it, just like it happens with zone-dependent schools.
> paying twice effectively lowers the access of care to the people that can't afford to pay twice
My private insurance that kicks in if I e.g. need a knee surgery with 14 days wait instead of 90, will often require me to fly to a different city, likely even a different country, to get the procedure performed at a specialist private clinic. This care is something completely different to the regular care I need day-to-day for a child delivery, cancer treatment, appendectomy or whatever. As there is so very little overlap I'm also not paying twice. There isn't a private insurer that will offer me cancer treatment, child delivery etc.
They don't exist because who would want to pay twice for that?
Not really, because all the insurers typically insure all hospitals. By having multiple insurance companies, hospitals get bargaining power and lower what insurance can ask from them. If you had only one insurance, like the state, you have 3 possible solutions: its the same, it pays more than the competing system (overly generous and thus worse for the tax payer), it pays less (uses monopoly market power and reduces hospital size/supply)
Hospitals and insurance companies are in a bargaining fight constantly, and if you look at the numbers, hospitals have won. However, hospitals are 60%+ non-profit (60% non profit, 20% public, 20% profit hospitals), so its not so clear you want hospitals to lose. Its really messy.
> My private insurance that kicks in if I e.g. need a knee surgery with 14 days wait instead of 90, will often require me to fly to a different city, likely even a different country, to get the procedure performed at a specialist private clinic. This care is something completely different to the regular care I need day-to-day for a child delivery, cancer treatment, appendectomy or whatever. As there is so very little overlap I'm also not paying twice. There isn't a private insurer that will offer me cancer treatment, child delivery etc.
The main benefit of having a single insurance company, or single payer system, is that you dont have to spend so much moeny on administrative costs. If you start getting into the rabbit hole of what will be public or private, at what cost and quality, i suspect the gains from the administrative relief will fade. Economically, maybe the best thing about having a public/private system would be that the public system is dirt cheap and effective, while the private one is simply more expensive. Thus there is some component of redistribution, but also some market forces. I think hybrid beats full state owned (I accept my own ideological bias and maybe hybrid beats fully private, though I believe it wouldnt).
> They don't exist because who would want to pay twice for that?
As an example of this, I can speak of Argentina. Argentina has had a diminishing public expenditure of public funds to public health. It has a very decaying public health system, and a thriving private one. The private one does have price controls, but not too much in effective terms: they biggest cost threat is probably that patients could choose to not have private insurance and just go to a public hospital. The reality is however crude: some public health services are of terrible quality. But its a trade-off: poor people dont pay and receive quite the tax benefit as a whole. Private is thriving and has very good quality metrics at reasonable prices.
So yes, you can have a system with "double paying" that is definitely stable.
And no, Medicare doesn’t have the lowest rates (Medicaid does). The rates aren’t low due to negotiation (hah!), it’s the gov’t basically saying “here is what we pay, take it or leave it”.
I think scaling the average costs from other countries accounting for GDP would be a good way to set the rates.
In all OECD countries, unfortunately, healthcare spending doesn't seem to be especially correlated with increased lifespace.
Besides, you have to factor in living costs.
I've looked into living cost a few times when considering working in the Bay Area and I realized that while my income would easily double, my living costs would increase a more than just a factor of two. I would have to accept a lower standard of living than I enjoy now.
I think the only way to really deal with healthcare cost is to look at whether or not we think it is a good idea that there is a huge profit margin. For patient outcomes and for society as a whole.
Because healthcare is an ever expanding, ever innovating industry with infinite scope. For countries with universal healthcare this is painfully obvious. What once was a service in the 1950s to perform what now would be considered very rudimentary procedures and proscribe < 1% of contemporary drugs, now do space age procedures as if routine and treatment plans that took decades of international cooperation to develop.
> In all OECD countries, unfortunately, healthcare spending doesn't seem to be especially correlated with increased lifespace.
Diseases of plenty now represent greater harm in most of the developed world than do ailments of scarcity.
Median actually does a better job of including the poor than does mean. The reason is that median counts the number of affected people, whereas mean counts the amount of spending. Clearly the latter skews more towards the rich, for whom spending may approach infinity.
Second, just where is this extra income supposed to come from? More likely households bear almost all of the incidence of this spending, meaning each dollar spent on health means approximately one dollar less available to households to use elsewhere. This is certainly what the literature on employer health insurance benefits tends to suggest.
Third, the timing of this is all wrong. It’s clear the arrow of causation goes overwhelmingly from income to health spending because changes in health spending clearly follow changes in income. Over the past few decades it takes an average of about 2-3 years for changes income to be fully reflected in changes in health spending due to the large role played by 3rd party payers, employers, etc (the current year elasticity is about 0.2 whereas the long-term elasticity is north of 1.6).
Adjusted for GDP, US spending on inpatient procedures is somewhat inline. However, spending for outpatient procedures is way higher. Americans just have a lot more outpatient stuff done than other countries.
 McKinsey analysis of US healthcare spending; search my history for actual link or google it!
Inventing a fancy index is not a replacement for "price fixing". And price fixing does not work. You reduce supply.
Am I going to get a quad bypass just because it is cheaper?
People seek care because they need it. The kind of care that people use more because it is cheaper/available is maintenance care (which reduces overall costs because things are often treated before they become critical).
The first time I heard “I am feeling sick / cut my hand / need stitches but I cannot afford to go to the doctor” was in the US, and it left me dumbfounded - I have lived in a few places, and that’s a US only thing.
Also, I could understand some of George Carlin’s jokes (e.g. “dirty doctor” one) until I had lived in the US.
E.g., in the netherlands (and IIRC also in Germany), it is considered rude to come to work when you are sick - you expose everyone else to risk, for a work day that's likely less-than-effective (because, you are sick) -- whereas in the US, you're expected to just pop an advil and show up (and .. if you are visibly suffering, you'd be considered a hero).
In argentina I remember calling a doctor home to check up on a cold. This would be unreasonably expensive in the US for very little healthservice in exchange.
IIRC, it made zero measurable difference on the number of visits, but the bureaucracy involved with charging this was costing more than than the money collected, so it was eventually scrapped.
(I might be mistaken, an Israeli versed in how the system works / worked is welcome to correct me)
In fact, the US could improve a lot of basic services if it looked at what other developed countries (OECD) are delivering, and for how much, and made those targets for the next lets say ~10 years.
After those 10 years of bringing the US more into line with the best countries in the world, it should strive to do even better.
Or, alternatively, the US can keep falling further behind.
It amazes me how the US is still arguing how archaic districting laws should work, how to have elections with integrity or manage without paper checks or fax machines.
I realize there are politicsl/historical and cultural differences but there is a combination of exceptionalism (“the US is so special we can’t just look at France and imitate”) and resignation (“yeah we want that but we cant have that because it would never work because X”) surrounding each of these discussions. The US is pushing boundaries in so many areas but when it comes to evolving society in a way that requires broad agreements, there isn’t much to report on
I can tell from first hand experience. Healthcare companies, set prices by market. Specifically, by what price that market will sustain. It just so happens that the US can sustain the highest prices. You know being unregulated and rich af and all.
This is how all industries/companies set prices btw. What you’re saying, It’s kind of like saying, I want New York City to base real estate prices off median home prices in the Midwest because as a buyer I like those prices better.
In fact, it sounds like a great way to make things worse!
“Tweaking” the system is how the US system got so messed up in the first place. Anyone who suggests “just one simple tweak should fix things” is an idiot.
In some cases, maybe the US has better care. But the cost of that is just way too damn high.
Yes, medical research in the US is superior, but that shouldn’t be at the cost of peoples’ lives.
Reducing investment in medical research will absolutely come at the cost of people’s lives. More people’s infact, as anybody will die from a terminal illness that doesn’t have a treatment. As an example the US market constitutes something life 70% of _global_ pharmaceutical profits.
But as we see above, plenty are willing to carry the water of the poor, downtrodden drug companies.
The incremental cost of selling drugs you’ve already developed is quite low, so of course they can still profit from them in less profitable markets. But it’s the US that’s paying for them to be developed. This isn’t even up for debate, R&D in the US dwarfs everywhere else.
In the private sector, far larger amounts of funding are spent on marketing than research. The basic maths shows: investment in research can be maintained or even increased while providing greater access to the fruits of that research.
The money is there. What we lack is the proper incentivisation.
So they focus on illnesses of the rich gerontocracy while diseases of the developing world have to be addressed by public funding. Additionally, there's no real incentive to work on cost reduction.
The US was rather a shock for me. Costs were mind-boggling, and most physicians struck me as jerks. At least, the male ones did, and they predominated. Nurses, on the other hand, generally seemed OK.
Somehow the US healthcare system seems to attract jerks for physicians, and they seem to be mostly in it for the money. Not all of them, obviously. But enough to set the standard.
I have no clue how that happened. Or how to reverse it.
Edit: Some might ask why being "in it for the money" is bad. I mean, that's what "free enterprise" is about, isn't it? But think about it. Is it OK for priests/minster/rabbis to be "in it for the money"? Or politicians? I hope not. And then, why physicians?
One of the problems with care in the US are clinics that treat Drs (and NPs and PAs) essentially as billing machines, and don't allow them any time to build any rapport or relationship with patients. Depending on your insurance coverage, your location, and your needs, your experience will vary wildly.
For what it's worth, my experience teaching premeds was also not so great :) That's also anecdotal. But colleagues had similar complaints.
> And we fail to recognize that what we really have is a distribution problem. Parts of this country have lots of doctors, perhaps too many. ... A result is that many rural areas, and less popular cities, experience more of a doctor shortage than others.
> The other distribution issue is in specialization. When it comes to generalists, we ranked 24th of 28 countries in doctors per 1,000 people. Specialists are a different story. There, we were 11th. This is an important fact about the American health care system. We sometimes hear that we have too many specialists and too few generalists. That’s not necessarily the case. We have an average number of specialists compared with other advanced countries, and even shortages in some specialties. It’s the ratio of specialists to generalists that’s the problem. When you compare the percentage of physicians who are generalists with those who are specialists, the United States beats only Greece among developed economies.
> Here, financial drivers play a role. Doctors who choose to specialize can make much more money, millions more dollars over a career, than primary care physicians.
Also see https://www.politico.com/agenda/story/2017/10/25/doctors-sal...
If the quality of care is so amazing I'd expect Americans to have longer life expectancy, and they don't.
This is manifestly untrue in so many domains, including medicine. Most research is heavily government funded, particularly pure research, and most academics are not interested in profit. The only orgs motivated by profit (drug companies, insurance companies) are the ones who push this misconception, because they profit from it. As one example, the UK runs large trials comstantly to improve care, without a profit motive.
Nobody has to postulate that price fixing (as you call it), or single payer healthcare without insurers works better, because the rest of the developed world outside the US uses that system and delivers very similar outcomes for radically lower cost. The facts are clear.
If you refer to the professionals’ compensations that’s correct, but not that useful as it applies to all of the adult working population.
If you’re referring to the capital accumulation of investments in healthcare companies, you’re off the mark, as there are several examples that falsify your statement, even in the US
It’s no different in Canada - small towns don’t offer as good of care particularly when it’s something that’s not common.
Anyway, I found a reference to support your claim:
Also consistent with the conclusions of Torrey1 and Saha et al,2 our analyses shown in table 3 found a strong tendency for prevalence to increase with latitude.
Vitamin D deficiency from what I've read is common everywhere. It does make sense that longer winters would impact a person such as staying inside more. Yet I doubt any evidence can confirm lack of Vitamin D is associated with the illness schizophrenia.
And there's probably at least quite a few things that aren't mental illness that benefit from mental healthcare.
The evidence is constantly against US healthcare except for experimental or rare treatments. The doctors aren't any worse, surely.
I 100% agree: experience is key ... but so is a clinic's/hospital's internal investment in any given speciality. And if it's a teaching/research hospital, so then is publishing by its clinical experts.
They dont work, simply because if you limit payment then hospitals will stop doing the procedure, will fight against doing them, and will engage in high cost cutting to provide them. Please remember that about 60%+ plus of hospitals are non-profits: they only bask in the profits for their own salaries, but don't have the profit-based mentality usually accussed of.
You might want them to do that, but I doubt the market will agree with you on that one.
There will be a heavy pushback from industry about how that’s socialism, delivered via Fox News and other conservative outlets.
EDIT: and if anyone can explain why forcing doctors and hospitals to provide their services at a loss, is not socialism, then feel free to reply; as that will be assuredly more enlightening than a simple downvote.
> Well that is socialism
As indeed is provision of roads, fire trucks, police, military and so on. For some reason, people rarely call those out
> Being a form of price control, it also happens to not work very well
I think there's a strong strong case that it works very well in every rich country, because they're all doing it to some degree?
> forcing doctors and hospitals to provide their services at a loss
This assume they're not currently making super-normal profit, which I'm far from convinced by.
Personally I would call out. But hey, so what if I did? As you rightly pointed out most people are convinced that they need the govt in their _many_ aspects of their lives. I'm outnumbered by people who think, that they can decide what is good for me as an individual.