I spent 45 minutes at the hospital where I was to get a lab test done, trying to get a quote for said test.
Prescribing doctor didn't know the cost. Lab tech didn't know. Billing department told me I needed a procedure code. Lab tech who was ready to draw blood couldn't tell me the needed code even after spending five minutes at a computer looking for it. Prescribing doctor gave me the code. Called back billing. They will call me back in 2 to 5 days with a quote. Weeks later, I've yet to hear from anyone.
This was at The Ohio State University Wexner Medical Center.
I was in Japan two years ago; got pneumonia and needed antibiotics.
Went to a hospital with no insurance and no appointment. I was being seen by a doctor within 30 minutes. Doctor wanted to do some additional labs just to rule other things out, but he was worried that it would be expensive for me given the lack of insurance. He called up billing with me still in the room and had a price within a couple minutes: ~$70 USD.
Ultimately I left the hospital after being seen, getting chest xrays, the additional labs, and antibiotics in hand. No insurance and I paid less than ~$160 USD.
Exactly the way it works in a SE Asian country I grew up. The private and public hospitals have price quotes on different procedures and it's for everyone to see. The comments above using Boglehead's quote as a justification of why medical pricing has a lot of variance is mostly a lie. My wife, who is a doctor trained in our home (SE Asian) country and is doing her residency in the US, and I were just laughing at the fact that it's much, much more expensive to get an X-ray here in the US than it is in our country (which costs ~$4 at most). Here, there's no price list for procedure as simple as taking an X-ray.
Hospitals, doctors, insurance companies and pharma companies are all scamming the US population. Every evening, my wife and I watch TV (WNBC to be exact) and we see many commercials from hospital networks, insurance companies and drug companies. This reminds us everyday that medicine and healthcare is commercialized to the max in this country and the only way from here is downhill. We both don't hope to retire in the US; when we grow old, we will go back to our home country and live there in the hope of getting much more affordable (and yet, of more or less similar quality) medical treatments.
This is also a side effect of how much medical education costs in the US, though. Education is so expensive that medical professionals have to have eye-watering salaries to have any hope of paying it off.
Of course, this is partially the fault of the AMA restricting medical school slots, but also is part of the general trend of tertiary education in the US being ridiculously expensive.
Indeed! As she was applying for residency programs, my wife briefly entertained the thought of becoming a radiologist because boy, they made a load of money for 8am-2pm work! We both are 100% self-aware that healthcare industry has a lot of bad actors including doctors, pharma companies, hospital admins, lawyers and pretty much everyone involved.
If residents cry about 60+ hours/week of work during the first year residency, I don't pity them much. First of all, the hours aren't really that bad even for a hospital in metro NY area (speaking from my wife's residency experience so far). In our home country, residents have it worse; my wife had night float EVERY THREE DAYS over there. In the US, it's at most four times a month! Second of all, the "grueling hours" are for the first year of residency (in fact, during those hours, there's not much happening especially in night floats, so you can get decent sleep) and after that, things got much, much better. Sacrificing just one year and paying exorbitant exam/school fees--in the region of ~$250K total--to make $250K as starting salary is TOTALLY WORTH it. If any of the doctors complain that they are debt-laden, they are either fiscally irresponsible or are simply exaggerating. They can repay $250K debt + interest in less than 5 years if they really want to. Of course, it's much easier to use these (debt and hours/years sacrificed) as excuses to justify their pay.
If the doctors are true and honest, they should be advocating AMA to relax the residency and medical school requirements. No more than five years total (no undergrad necessary) is needed to treat garden variety problems. Then each specialty/fellowship can take however long it needs to take. But AMA and its leechers (KAPLAN, ECFMG, USMLE, FSMB, etc.) won't allow that because they make loads of money from exam and preparation fees. Everything about healthcare is business now and whether it is good or bad depends on one's moral compass (and how strongly one feels about capitalism).
> that medicine and healthcare is commercialized to the max
There are commercial problems but it isn't totally fair to call a system where nobody can tell you a price 'commercialised to the max'.
The problem isn't the commerce, the problem is that someone has set up a regulatory framework where people don't pay for services.
A perspective that could be important when it comes to American healthcare: insurance doesn't on average pay out more than people pay in. My understanding is traditionally insurance actually pays out exactly what people pay in and profits off the float. 'Having insurance' doesn't make anything more affordable for anyone, it is more like hiring someone else to track the savings for you and a few conveniences massaging risk through time.
Japan's system is interesting. Perhaps one of the most successful in the world.
Their life expectancy has gone up which obviously means the amount of care to be provided goes up. Costs haven't followed suit and the other side of the equation - outcomes, has also gotten better (comparing against 1990 since that's the first result set i can see attributed to the MHLW in JP) The challenges of their economy are well known yet they've pulled off what other countries probably would not be able to.
Yet they spend approximately half what America does - and for better outcomes.
> Their life expectancy has gone up which obviously means the amount of care to be provided goes up. Costs haven't followed suit
While their healthcare costs are much lower than eg the US, Japan is currently in the middle of a healthcare cost crisis in fact:
"annual health-care expenditure grew at a pace 40 times faster than the economy from 2000 to 2016." [2]
Their healthcare expenditures have more than doubled in the last ~27 years, while their economy hasn't expanded and their population hasn't expanded. While I don't consider a 100% increase over 27 years to be extremely alarming, especially in the healthcare field, it's a substantial increase given the context that Japan is dealing with (budget buried in debt costs, declining standard of living due to debasing of the Yen due to debt, aging population, zero population growth, net negative economic expansion over 25-30 years).
While the US has the ability to cut a lot of unnecessary fat in healthcare to bring down costs, I don't see how Japan is going to be able to do that without harming care (as their system is already well run). The US also has had dramatic economic growth during the time in which Japan has had none, including adding an economy the size of Japan to itself in just the last six years.
Nippon.com, Oct 2019: "Growing Medical Woes: Japan’s Healthcare Expenditures Rise to Record ¥42.6 Trillion"
Bloomberg, May 2018: "Japan Seeks Private Sector's Help With Blowout Health Costs"
"Faced with an aging crisis that’s projected to push up heath-care spending by more than 50 percent in the decade through 2025, the economy ministry is leading efforts for local governments to draw on the expertise of private companies."
I had to go into emergency for a bronchitis, after all tests and getting everything the spot, the bill was around 40eur. The doctor asked me if I wanted the additional forms and paperwork to claim it on my US insurance.
Can you cite that number? Even pulling numbers out of thin air for receptions, call center, it, hospitality, food, nursing, etc I find it hard to get thathigh.
This study puts the billing staff to doctors ratio at 0.67.
Its from a book, Code Blue: Inside Americas Medical Industrial Complex, by Mike Magee. The author is a Doctor and distinguished medical academic and past hospital executive.
The book contains many references, but it's dense. I thought admin overhead tended to go to 15% because of ACA provisions of 85% spending requirement on direct care? I would likely have to do a fair bit of digging to compare how the scope is defined exactly vs an ACA definition. Makes for something of a perverse incentive if the companies want/need to route additional absolute dollars into their service depts - but I don't know how much it actually gets bent in that direction.
I was in Philadelphia last year and had a bad fall and had to get about 10 staples in my head. I went to a local urgent care center and the total cost was $150 without any insurance.
From a Bogleheads topic titled “How to Minimize Your Emergency Care Expenses”:
> Fifth, nobody you interact with at the hospital at the time of your visit has any idea how much anything costs. Part of that is the whole price transparency thing. Those who know the price don't want the front line workers to know it. Part of it is the fact that there are so many moving parts. Medicine gets inappropriately compared to aviation a lot, but it really isn't a fair comparison. Every one getting on a flight is basically getting the same thing. Medicine is like an airline flight where every row has its own flight attendant, every one on the plane is going somewhere different, and they all get a different movie and meal hand delivered to them. Imagine how much that flight would cost? Finally, despite the fact that there are hundreds of different products and services being sold, everybody pays a different price for them. This is due to dozens of different insurance plans each of which has negotiated a different price for every product and service, co-insurance plans, government plans, and various different levels of deductibles and co-insurance and different amounts of previously consumed care already in the year.
So few people self pay that hospitals just aren't set up to make the experience make sense. All of their resources are devoted to dealing with insurers and the government.
Many, many people pay a deductible, though. Many people pay a copayment. For these, you can still quote the cash price, I would thing, or give a range for what the entire thing costs, explaining the range is because of insurance discounts. In the age of modern tech, this shouldn't be a big deal.
I had an appointment that was billed at $400, if I recall correctly, while one insurance allowed $140 and another $70. That's the total cost, none of which was paid by insurance due to a large deductible. LabCorp I think has been similarly marked down from hundreds to tens, although I don't remember numbers. I don't think it's uncommon to have the official price be multiples of what's reasonable just in case someone might pay it.
A long time ago, I was told that a local hospital automatically gave half off if you paid cash. But that could well be gouging relative to insurance or Medicare.
Couldn’t you have called Labcorp and got the test from a lab? My doctor doesn’t do any lab testing. It goes to the lab in my county that’s connected to the hospital or to lab corp.
My father has been monitoring his calcium levels and uses Labcorp directly. It is great that you can cut out the middleman. They draw blood right there and you can view your results very quickly online.
This process is a hidden gem in our bloated system.
Go directly to the lab.
Now obviously this is just for health maintenance and dietary checkups.
Not to many people are aware that you can go right to the lab directly.
What? Who doesn't go "directly" to Labcorp? They have obviously cut costs to the bone, but that makes me nervous. They have basically one person per location who does everything, and I worry that they are too stressed/tired/burned out/disgruntled to do their job right.
I heard something years ago about a medical lab that was just throwing out all their samples and using a simple statistical model to return results. That's what you can get if you are just rewarding efficiency.
That is not the simplest scenario for the people you were asking for information. Their process isn't optimized for that because almost no one does it.
> Medicine is like an airline flight where every row has its own flight attendant, every one on the plane is going somewhere different, and they all get a different movie and meal hand delivered to them.
In the bloodwork example isn't it like me walking into a parts store and talking to the guy to buy an auto part?
Sure, this is the reason why you can't get an answer but it's not a justification.
There are 2 parts to it. The first, which is reasonable, is that a lot of treatments are bespoke. Fine. That's a justification for their being costly not for your having to imagine the cost because no one can tell you.
Even for flights, the truth is I can get a bespoke flight if I can afford it. And if I want to know how much it is then I ring them up. The idea that you can't know what something costs, until after the event, because it's expensive is perverse.
But the second part, that everyone pays a different price, is solely a function of the lack of transparency and has no justification beyond perpetuating the scam.
Even in that socialist utopia that is the UK, we have private health care. If I wish to use it without insurance, then they'll tell me the cost upfront. If I use it with insurance then they'll tell me the same cost but I'll only pay the excess. At each stage in the process you get the cost information upfront because TBH it's insane to think that you wouldn't.
Honestly, this is a solved problem. The only real reason it's not solved in the US is because a lot of interested parties are very determined that it doesn't get solved.
Interesting comparison, because airline pricing is notoriously complicated, resulting in things like hidden-city fares[1] and such considerations as "do we expect to be able to be to sell that seat to some business traveler at the last minute whose only choice is us?"
Furthermore, there are all kinds of unknowns that can happen on the flight.[2]
And yet they still have no problem quoting you a price.
[1] where a flight from A to B costs more than a flight from A to C with a stop in B.
> The first, which is reasonable, is that a lot of treatments are bespoke. Fine. That's a justification for their being costly not for your having to imagine the cost because no one can tell you.
Treatments are billed using billing codes so they are definitely not bespoke.
Those billing codes are CRAZY complex tho. One example: when you see a doctor you may generate multiple billing events. For instance they may draw blood, take an X-Ray, and perform a specific type of test.
In a sane world you would generate three billing codes, sum them, and you'd have your price. But that's not how it really works. Instead certain billing codes can be combined to form new billing codes which makes things stupid crazy hard to reason about.
Those rolled up billing codes can then even roll up to different billing codes when combined with other procedures or other grouped billing codes.
When billing is this complex the treatments do begin to look relatively bespoke.
Basically we're inefficient from basically every direction in the USA. Because every player in the system negotiates with basically everyone else individually you end up with a nightmare of complexity and all of the associated insanity. Hospitals love it because it means that they can take advantage of the complexity to bill for all sorts of things that they otherwise couldn't simply because no one can audit this stuff effectively.
Don't forget each piece of equipment involved in drawing blood. Had to try three times because you're dehydrated? Different-sized needles because you're a person of smaller stature? Gotta bill you for each piece consumed, and the premium for being outside the range for 'average.'
"Basically we're inefficient from basically every direction in the USA"
This, and so much this. And I don't always understand this. To use the example here, billing codes: I'd think this is something that could be standardized - and being such, pricing would need to be standardized. I truly don't understand why this isn't coded into law.
The negotiation gets me as well - it means that no one can tell you a price. In a more perfect world, there would just be a price, and you could simply get the price from the hospital and it would be illegal for the hospitals to charge one price for cash patients and another for those with insurance.
CPT codes are ... complex. They also aren't the only thing billed for (just the simplest to do). Also what you bill and what you get paid are not the same thing. And they payers do not pay the same thing for the same bill.
If a business performs a service for me and won't tell me ahead of time how much it costs, can it afterward decide I must pay whatever it wants? One trillion dollars? For those without insurance, is there some contract agreed to with the hospital?
For those with insurance, in which contract do I end up bound to pay an amount that isn't told me until after I've already made the decision to purchase the service? Are there limits to these amounts in that contract or somewhere else?
Check this out. I had decent and expensive insurance when my wife had surgery. We hit the max Out-of-pocket, which according to my employee docs was about $6500.
However, when I get the information from my insurance company it has totally different copy information with a OOP of $7300.
I talked to my employer several times and eventually filed a Dept. of Labor complaint because everyone is telling me it's ultimately my employers problem to fix.
Fast forward 3 months and after multiple go arounds and hours of phone calls they finally fix it. So what does my insurer do? They claw back fully paid payments for stuff that was done after my OOP was met. I have to call multiple doctors and argue with the insurance company for every bill.
Going a bit off topic, but this is one difference many are perhaps not aware: personal bankruptcy isn't a thing in many European countries. In my home country you don't have a mechanism for simply shedding your debt. Generally any debt is garnishable. Your best hope is debt restructuring with part of the debt forgiven (in perhaps 10 years).
On one hand this probably makes financing considerably cheaper as the risk for the bank is quite a bit lower. On the other hand you do not want to have personal liabilities anywhere near a risky venture.
Hospital networks usually have you sign a waiver agreeing to pay for all costs before treatment begins. It's a bit strange to be waiting in the ER and a have a billing handler ask you to sign a form on a clipboard before you can get service.
Yes. It is nearly impossible to determine the cost of treatment up front when the health cause is still unknown.
You could be there for a common cold or for phase 4 lung cancer, with costs ranging widely even just for the diagnostic procedures. You're agreeing up front to pay for the service involved to determine and eventually treat your symptoms.
I think people that sit in the offices that directly face customers are told not to discuss price. I think they prohibit any verbal pricing because they want that to go through the insurance system, so they can maximize profits.
If they told you the real price in person, especially before you finished the procedure - they would fear you cancelling before the work is done.
I just want a way to sue the fuck out of all medical professionals that told me something would be covered by my insurance
Getting evidence of these statements is a challenge but a civil court would easily put them on the hook for the cost they said I wouldn't incur and 3x it with punitive damages
and then double whammy with a review of their license
They'll go ahead and try to argue what "covered" meant, and everyone will laugh them back to med school because of the shared experience of this bullshit
I just want all of my medical needs covered no matter where I go or who I see. The burden of in- or out- network should not be on me especially when ins providers can change each year because the U.S. still thinks you should have to have a job to have insurance that you can afford.
Lab tests are particularly complicated to price because usually they are being processed by someone else. Usually labs won't even try to get an authorization from insurance until they get your sample and start working on it as it affects their turnaround time which is one of their main differentiators, and each insurer will have different rules about what they will pay for under what conditions (insurers also have separate deals with each individual hospital and potentially individual doctors or groups of doctors). The short answer is they can't tell you because they don't know.
None of this has anything to do with lab tests, which are an absurdly routine procedure. It's entirely divorced from the subject matter. It's not "complicated" out of necessity, but for profit.
Frequency and complexity are not mutually exclusive. The pricing structure reflects the diverse system of payers (insurance companies) and has time-based complexity (i.e. bundling) that prevents payment cost structure from being calculated up front.
> The short answer is they can't tell you because they don't know.
Bingo. My partner works in revenue cycle management (arguing with insurance companies to pay their bills) for a large hospital chain, and even she can't get accurate prices for procedures. She can walk down the hall to the finance department, and ask them, but even they can't figure it out.
I found this out after asking her why they don't prioritize cases with the largest bills, and she said it's because the billed price of the procedure has no relation to the actual priced paid. They could review a $800,000 cancer case and only recover $750.
> Bingo. My partner works in revenue cycle management (arguing with insurance companies to pay their bills) for a large hospital chain, and even she can't get accurate prices for procedures. She can walk down the hall to the finance department, and ask them, but even they can't figure it out.
That's because they are not properly incentivized. It is very simple to solve this problem: charge them with fraud. Same way as a doctor who overbills Medicare would be charged with fraud.
We had this kind of things before Enron - CEOs pretended that they cannot possibly know if the numbers in the accounting documents were correct because it was oh so complicated. Now, however begrudgingly, they do sign off on the books and since they are personally responsible they have all the needed incentives.
This is one of the reasons that medical pricing is out of control. If nobody knows the pricing for anything, how can anybody (not just patients, but anybody else involved with the system) make rational decisions?
I worked in lab EHR software and can say this is the correct answer. Lab pricing is particularly complex and is not like buying a hammer or a pedicure.
There was a separate billing module that calculated pricing for individual procedures based on a number of factors, such as insurance provider, diagnosis codes, performing lab, urgency, etc. along with a whole set of separate rules for medicare/medicaid patients. Even the timing of drawing blood (relative to other procedures) was factored in for insurers.
Transparency isn't going to help much here when the problem is the complexity created by multiple payers.
I think it’s to prevent people from shopping around. There’s no reason they can’t tell you what codes they will bill for a physical and routine blood draw or ultrasound so that you can ask your insurance company how much it will cost.
Is it illegal to write “we will bill your insurance for procedure codes x y z for your visit”?
They don’t need to tell you the cost, but they know what they’re going to charge you beforehand. They should be able to tell you the codes so you can give it t your insurance company to find out how much it will cost.
The reason healthcare providers don’t give out codes for known predictable procedures is it would enable customers to shop around. Instead, they want you to sign a paper saying you’re liable for whatever they claim you’re liable for.
The procedure codes involved in your visit explicitly call out what your treatment was, since information about your state of health and ongoing medical information is considered private information we have HIPAA to protect that privacy. Information about what procedures you've had done are relatively important to keep private so that knowledge of such procedures isn't used to influence your employment - while getting blood drawn like resulted in a pretty innocuous procedure code, there are other procedure codes that are far more sensitive to disclose - including pregnancy detection (to avoid being let go for a company to dodge maternity requirements) and more social privacy concerns like being treated for an STD.
Unless the patient is prescribed a controlled substance. Then docs force patients to sign a waiver that enables the police and just any other state agency to take a peek for any reason. Of course, the patient always can refuse to sign the waiver and seek out non-traditional/conventional sources of treatment.
As a lawyer it is shocking to see how far the medical profession has fallen w.r.t. patient privacy.
Can you elaborate a little? Where/when is this waiver signed? If I get a small pain killer for post surgery pain, like Vicodin, am I asked to sign this waiver by my doc? Or is it at the pharmacy counter?
Usually, it is the healthcare provider, they require drug testing (urinalysis) and require patients to waive patient privacy. The details may vary by state or among providers. And, I believe some healthcare providers require patient privacy waivers that are broader than specifically required by the locality. This might be an effort to avoid having to update the patient waivers as local law change.
For example, a healthcare provider in Seattle, WA (UW Physicians') uses a controlled substance privacy waiver that can be read to allow any state or local agency access to a patient's medical record for any reason.
Then they can print out a quote for me before the appointment listing the codes that will be billed so I can obtain the cost from the insurance company. My point is that they don't want to provide them before the appointment to prevent shopping around.
Yes, it is illegal to send that information to your email account or your mailbox. These days most providers have services that enable them to communicate with patients electronically, but it's a totally separate system that you have to login to. Your private health information will never show up in your email inbox.
This is generally incorrect, sending PHI over email is not inherently a HIPAA violation, it all depends on factors that really need to be reviewed by a compliance officer.
They won't reply via online accounts either. I will send them messages via the portal, and I always get generic responses. And doctors will never respond, it's always second hand from nurses, but they will just ask to call the office.
Not secure in the sense that it's encrypted, though that's part of it. Secure in the sense that you know you're communicating with the patient and only the patient, not their spouse, or their grandson, or Google's servers.
If that's actually a requirement, then why are most providers happy to accept that it's me over the phone/at the pharmacy if I simply say I'm Silas and maybe give the right date of birth?
Because it's not actually about meeting the stated goal. It's about checking all the boxes on some asinine bureaucratic form that assumes if all the boxes are checked, then the goal is met. This is how stupid people do things when you give them authority.
Yes, that is possible, and some do that. In practice, HIPAA is pretty complicated and email is more of a dark gray area than a hard no. For that reason most providers avoid it and prefer to use dedicated secure messaging systems that have things like consent and auditing built in.
HIPAA compliance is a very complicated thing. Sending PHI over a non-encrypted channel would probably be acceptable in response to a patient request - while sending PHI over a heavily encrypted channel in an unsolicited manner would likely be a violation.
HIPAA is complicated and a lot of the things it is concerned with are far less technical than they may appear on the tin.
Also, IANAL - nothing in this post should be considered sound advice for any reason in any context.
I'm being offered $550 by my insurance in "gift cards" if I use certain facilities for any MRIs or other diagnostics. I think that shows just how wildly variable different locations charge, and how much they get away with.
I'd love to see a published price list for standard procedures, because I think hospitals have become too used to being cash cows for administrators and CEOs. This isn't to say I think nurses or doctors are overpaid or underworked, or don't deliver good care. I just wish that people in the USA could get good healthcare without having to claim bankruptcy.
I really miss the NHS and Bupa private insurance in the UK. NHS was great for so much stuff, but when I needed multiple surgeries on my leg metalwork, I chose to use private health insurance. This let me have the same consultant as the NHS hospital, same surgeons, but in a smaller "fancier" hospital that took really good care of me. What's funny to me is that extra private insurance was just a few pounds a month, and nothing at all like the thousands we spend here in the USA.
> This isn't to say I think nurses or doctors are overpaid
The probably are. Clearly hospital executives and administrators are raking in most of the money, but we can't sit here and pretend that caregivers don't directly benefit from such an arrangement as well.
There's a reason urgent care centers and small clinics pay their doctors less than most of us make, or skip employing doctors at all in favor of nurse practitioners, and their nursing staff makes ~1/3 what they would be earning in a hospital setting. Labor is expensive; specialized labor is even more so.
> skip employing doctors at all in favor of nurse practitioners
Hold up. I hope you're not being negative on hiring NPs. As someone who is in favor of NPs (and knows many NPs), they provide excellent primary care and hiring them can help bring down the overall cost of healthcare. I say we should teach and hire MORE NPs to provide cheaper primary and preventative care, not blame clinics for hiring them.
This, and exactly this. NP's are great for the run-of-the-mill sicknesses and minor injuries that most adults and children get. In conjunction with a PCP, they provide excellent primary care even for more complicated patients.
In addition, specialist nurses are a great addition to a specialist's team. I don't see a neurologist all that often, but I have checkups with one of the team of wonderful nurses at the office, some of which specialize in the disease I have. It works out wonderfully and allows the specialist to take care of more patients and still provide pretty wonderful service.
I am not, I'm just stating the fact that they are replacing physicians, mainly due to costs. I'm struggling to see how you read into that statement a negative tone on the matter.
FWIW, my partner was an NP before leaving direct patient care.
> The probably are. Clearly hospital executives and administrators are raking in most of the money, but we can't sit here and pretend that caregivers don't directly benefit from such an arrangement as well.
I agree with you but I think at least the nurses, doctors, NPs/PAs, bring more value than what I've seen within my own department at a hospital. A manager hits $100-150k pretty easy and the middle and upper middle ranks are stacked. We have someone that's a director of a three person team, and seven new middle management roles (being filled w/ no internal hires).
The previous administration had a similar effort that failed. I hope that this effort is successful.
>"For instance, it could allow one provider to follow and match the prices of the other provider (like two gas stations across the street from one another who face no other competition)," Garmon said.
I understand this argument, but I think they underrate how much people are willing to shop around when they actually have prices to use as a metric. I would be willing to travel to get a cheaper hip replacement if I actually know what the local price is, rather than being surprised by it every time.
>I understand this argument, but I think they underrate how much people are willing to shop around when they actually have prices to use as a metric.
If prices are transparent enough, eventually bored programmers will create websites & other tools that make it super simple to find the lowest cost provider in any non-emergency situation, and probably even emergency situations if you are looking ahead of time
Hell a good program could tell me how much time I have to address said emergency and then give me prices and time to locations for said emergency. I bet people would even be willing to take a bit of risk and drive an extra 10 minutes to save 50% with an increased risk of long term damage of say 10%. In fact, let's start A/B testing that!
I'd pay more for quality. If I knew hospital X is better at hip replacement I'd pay extra to go there. Of course how much extra I'm not sure, and I'm also not sure how you compare hip replacement quality like that.
It is only emergency rooms where I don't get a choice - if you need an emergency room close is important.
> It is only emergency rooms where I don't get a choice - if you need an emergency room close is important.
i feel like the folks on here peddling this line have not ever spent any time watching who comes through an ER.
most of the people who go into an ER aren't dying, or screaming in pain. they've just got a problem that can't wait until urgent care opens up again in the morning. or they need something done that urgent cares aren't equipped to do (fancier diagnostic equipment; whatever). they've got plenty of time to consult with a hypothetical "find a cheap/good ER near me" app.
I think lots of people say "ER" for "ED" Emergency Department became the most common term about a decade ago and Emergency Room faded from building guides and hospital documents.
Either way most don’t have trauma centers, in SF I think only SF General is the only level 1 trauma center although some of the people also rotate through UCSF’s ED.
If you're concerned about hip replacement quality, you should care more about the surgeon than the hospital. Check out the ProPublica Surgeon Scorecard: https://projects.propublica.org/surgeons/
Unfortunately, under the current system, price and quality of care are relatively uncorrelated. Which makes sense as we learn how arbitrary pricing is.
But as I understand how medical billing actually works, if only a single patient uses an MRI machine in a year, they would pass on the entirety of the cost to the single patient. But a hospital that uses the MRI constantly spreads the cost across all patients. In the latter hospital, they would also have better outcomes since they have more experience and specialization in the procedure.
This is also the opposite of how it would work in a market-based industry. In an auto-shop, I know how much I can charge for any service, and before buying equipment and personnel to expand my services, I determine if it is worthwhile to invest the capital.
You compare hip replacement quality by asking what the center's/surgeons complication rate is. How many are they having to go back and redo, a revision as they call it. It would be nice if these rates were publicly accessible in a easy to search database. As it stands now, hospitals market themselves on size, volume, and fancy buildings all of which don't mean much compared to complication rates.
> I'd pay more for quality. If I knew hospital X is better at hip replacement I'd pay extra to go there.
Recently, HSAs and transparent prices were proposed by a Marketwatch article on HN.
But, assuming you have a average America "Max Out Of Pocket", price transparency over this amount doesn't have the intended effect or perhaps, as you point out, the opposite effect.
There are lots of ways to measure outcomes. First, you can look at institutional metrics like nosocomial infection rates. Second, you can look at metrics for that procedure like rate of surgery revision. Many of these kinds of metrics exist, but are never exposed to the public.
Of course doctors and hospitals don't want price transparency. That would create pricing competition, which would drive down consumer prices, lower profit margins, and force them to become more efficient. Price transparency is one of the key elements of the highly successful Singapore healthcare system. Add in universal tax-free (or tax-deferred) Health Savings Accounts, and we could not only improve the US healthcare system but also help more Americans save for retirement and build wealth. There's no excuse not to try simple regulatory solutions before committing to a massive government takeover. I hope we get bipartisan support for price transparency.
In Singapore, the government forces you to deposit a percentage of your income into an HSA, and then they tell you what you can and cannot spend that money on. You're only allowed to use that money to buy government-approved drugs, for example, and it's not like the FDA where they're just testing for effectiveness and safety. Also, most hospitals are owned by the government, most doctors are government employees, and most hospital visits are mostly paid for by the government.
Price transparency is a relatively minor part of what makes the Singapore health system work.
I'm not aware of a single advanced-economy state (I usually shorthand this "OECD" but Singapore's not a member, AFAIK) that doesn't use price controls, explicitly or de facto (monopsony), in their health care system.
Price controls, non-profit status requirement for insurers, and a non-ruinously-expensive "public option" seem to be common factors in the most "free market" (relatively speaking) systems of our peer states. Despite Obamacare we've achieved zero of those, nor have we opted to go further "left" to mimic any other proven-to-control-costs-and-deliver-care system.
> doctors and hospitals don't want price transparency
Well, I do want price transparency - IF it works the way they promise. It’s hard for me, as a programmer, not to draw parallels to every employer’s expectation that I should be able to listen to them describe a software problem and quote them a timeframe on the spot (which, of course, they’ll then try to “negotiate” down). On the one hand, as a non-medical-professional outsider looking in, it seems to me that _of course_ they should be able to say ahead of time how much a cataract removal surgery should cost, they’ve done it hundreds of times (I hope). On the other hand, I know how much variability occurs in software projects and how little of that is trivially predictable.
On the other other hand, I can’t for the life of me imagine any possible reason why they can’t say EXACTLY how much an MRI will cost before they do it.
Yeah but come on. It's one thing to program something with nebulous requirements.
The cost of the X-ray machine is known. The cost of collecting X-rays can be calculated deterministically.
The only thing similar to programming is trying to diagnose a rare disease or tricky condition. But for run-of-the-mill deterministic procedures, the cost should absolutely be known.
Well, I think so too, but - just to play devil’s advocate - many of my former bosses would almost certainly say something like, “the cost of the web server is known. The cost of collecting the web traffic can be calculated deterministically. We’re just talking about a website here, the cost should absolutely be known.”
The prices don't change in a supermarket if you edit your shopping list, eh?
A hospital can't predict everything a patient will need (their shopping list), but they should be able to account for the cost of each procedure/drug/test/bandage/etc... eh?
Well are you asking me to setup infrastructure or to design you a website? The first is deterministic and I can certainly give you a fixed price/timeframe to set up your web servers/DNS/etc.
Designing a website on the other hand, isn't deterministic. That mandates lots of requirements gathering and suffering through iterations where the peanut gallery criticizes every CSS choice and demands minor CSS tweaks until some arbitrary "feel" is achieved.
> parallels to every employer’s expectation that I should be able to listen to them describe a software problem and quote them a timeframe on the spot
I don't agree with that parallel. It would be like a patient asking, "How much to cure my cancer?" Total cost will of course differ for each patient, but the doctor should be able to tell me the exact cost for a 20 minute office visit or a single session chemotherapy. I think that's all anyone could expect.
Agreed. Procedures are like products. From a hospital administrator's perspective, you should have a good idea of your cost of goods sold for standard procedures. Lipid panel costs $X in materials (needles, vials, bandages), $Y in cost of the siemens equipment that does the test, $Z in labor cost to draw the blood, etc.
If the administrator knows the COGS for each procedure, test, minute per consult per professional, etc. then quoting and billing should be much simpler than any type of hourly based quote work.
The only time there would be a parallel would be if some doctor deliberated on a diagnosis for a long time. Most of the time though it's a quick collection of symptoms and then diagnosis or trial and error based on those symptoms. Maybe in some surgeries that have more complications than usual I could see a parallel to hourly work.
Indiana funds the HSA deductible on their plans and saw a good deal of savings. Combine this with price transparency and health care costs could and should fall and do so rapidly.
however the biggest obstacle to health care reform and cost reduction are the federal and state governments. in particular CON (Certificate of Need), thirty plus states still have these which are used to block new hospitals and other care facilities. the ACA banned new Doctor owned hospitals in a further move to protect the big hospitals; the CON law at Federal level was done away with in 87.
People need to have skin in the game. This means that prices must be revealed as well as handing control over to patients where how the money is spent. So HSA with paid deductibles can save states a large amount of money and help people make better decisions. with preventative treatments normally being free and people seeing hsa money rolls over and its theirs it really changes how people behave.
the US should have great health care but the government is stuck in VA for all mode and that is the charge being led by current candidates. Look at it this way, the VA system has been a wreck for decades and if Congress cannot or will not fix that why should you trust them to take over what we have now?
Went to a quick care the other day because of a flu that would not go away, was seen and diagnosed with bronchitis in less than 5 minutes. The quick care billed my insurance $1,840, which they talked down to $300, and had me pay $115. What?
This kind of stuff is even more ridiculous with higher cost procedures: course of radiation therapy to treat cancer - in network hospital sends bill for more than $1m, insurance pays about $3k, bills nothing to patient.
From the UK. Health care cost stories in the US seem incredibly dreadful. Hard to grasp how a huge power like the US can't get itself around decently-priced healthcare.
It is incentives. Most people get their heath care from insurance, which is subsidized by their job. I can legally buy my own insurance, but it will cost a lot more than what I pay through work so of course I don't. My boss wants me to keep working, and so high medical costs keep me from quiting to start my on competitive business. I can live for a couple years on cheap food and little else, but I need at least emergency health coverage as a just in case.
Lack of transparent prices is one tool the system has to ensure I don't have any other option.
> I can legally buy my own insurance, but it will cost a lot more than what I pay through work so of course I don't.
Which is entirely frustrating too. This only happens because employers only subsidize specific health plans, instead of letting the employee spend that money on the health plan that they deem best for themselves. Isn't that ridiculous? Why would my employer care what health insurance I get anyways, they don't know my health situation. I should be able to use the money they spend on my health insurance however I want!
> Why would my employer care what health insurance I get anyways,
Two reasons.
One is that it gives people pause before leaving for another job, as they might have to figure out new healthcare providers.
Second is that it gives larger employers the benefit of paying less for insurance, especially if their employee group consists of younger healthier white collar workers. It also helps them because businesses can pay for health insurance with pre tax dollars, which helps compete against small businesses that can’t afford to pay for health insurance for employees, whose employees have to pay for their own health insurance with after tax money.
>Hard to grasp how a huge power like the US can't get itself around decently-priced healthcare.
To be honest, it's not that hard to figure out.
The US gov't largely believes itself is ineffective and needs to be privatized and ran like a business. Private businesses are held up as beacons of innovation and efficiency without the "red tape" the gov't has due to purposefully created checks, balances and regulations.
Hence why we elected a CEO, albeit a massive failure of one, but a CEO regardless.
> The US gov't largely believes itself is ineffective and needs to be privatized and ran like a business. Private businesses are held up as beacons of innovation and efficiency without the "red tape" the gov't has due to purposefully created checks, balances and regulations.
The medical system is really not private. It is a hybrid of a state-controlled system and a capitalistic system. Here are some ways of how the system is state-controlled:
1. Hospitals cannot be freely constructed. One must apply for a "certificate of need" to gain permission from the government to build a hospital. This is not a free market.
2. Credentialism is BAD in our medical system. There is only one group of people approved by the government to do prescribe most medications and perform most surgeries - doctors. This is not a free market and greatly increase costs. Doctors earn a median of 300k/year and are the highest paid profession in every state. This is not a free market.
3. Hospitals are legally forced to treat anyone who shows up at their door - even if they can't afford the treatment. This is not a free market.
4. Medicare/Medicaid are forced to nearly buy any drug, regardless of cost, if it could save a live. Even if a drug is 500k/year, the system is forced to buy it. This is not a free market and greatly increases costs.
> 4. Medicare/Medicaid are forced to nearly buy any drug, regardless of cost, if it could save a live. Even if a drug is 500k/year, the system is forced to buy it. This is not a free market and greatly increases costs.
No, they aren't. Medicare Part D plans are not required to cover any particular drugs, though what they choose to cover is subject to approval by CMS.
Maybe, but those (perhaps except the first one) are
absolute requirements for a functioning system.
If a market based solution can't work with these restrictions, then the obvious conclusion is that you have to give up on market-based healthcare, not that you have to allow anyone to prescribe medicine, or have hospitals which won't treat dying people because they can't pay.
The Econtalk podcast latest episode is about a surgery clinic in Oklahoma that has full price-transparency policy. I am outsider to US healthcare system, but after listening to it, it seems hardly controversial what would be the right thing to do here:
Texas Free Market Surgery offers a near identical business model based out of Austin.
Green Imaging (who I used to work for) offers cash-pay imaging services for all modalities across Texas, and are in the process of expanding nationally. Because they contract with existing imaging facilities, they don't post prices publicly to avoid poaching patients, but if you call in or message them through the website, they'll give you an up-front price for any service they offer.
For family practice/general medicine, there's a business model called "Direct Primary Care" that offers you unlimited primary care services, usually for a cost of $50-80/month, and most big cities will have a few providers following this model.
A lot of progress is being made in terms of transparent/affordable outpatient and day surgery services, but it's hard to get spread the word because the current healthcare model is so entrenched.
Americans already have co-pays, deductibles, coinsurance and whatever other terms the insurance industry has cooked up, with no visible effects on costs. In addition to your other changes the following would also help:
- Allow competition. Don't give hospitals the power to veto new hospitals in their area.
- Disallow regional consolidation of hospital systems and medical practices. Regional monopolies are bad.
- Increase resident slots and supply of doctors. Make foreign degrees easier to transfer to the US.
- Outright ban pharmaceutical advertising. Nothing whatsoever of importance would be lost and all the pharma companies would save millions every year.
So a quick way to check reality is by looking at behavior, so say you wanted the "best" care for something no matter the costs. Most people would fly to the U.S from wherever. That is telling you something.
I agree the "general" care like broken bones etc its probably all the same, but healthcare innovation is done in the U.S. So it is kind of moot to say "its good here"... yes after the innovation trickles its way over to your country.
Lastly, one of my best friends is studying to become a doctor, in fact is a resident now. He is getting paid the princely salary of $55k after 15 years of studying and he has many years to go before he's able to really realize any gains.
To make the profession a civil servant's position is insanity.
I have never heard of anybody fly from Austria to the US because the medical care here wasn't good enough, or because some procedure was not available.
I've only heard of people travel to get dental work done cheaper (not to the US).
The only complaint I've heard is that some procedures (eg. joint replacements) have a waiting list, so if a doctor decides that you don't need it urgently, you may have to wait a few months. I don't know what the situation for these procedures is like in the US.
Just because it's publicly funded doesn't mean it's bad quality. It just means there's no incentive to charge ridiculous amounts for procedures.
Also, Doctors still earn a decent salary here. Maybe not comparable to US salaries in absolute numbers, but it's enough to live a very comfortable life, and they don't have any students loans to pay back...
First of all, the idea of a “wait list” is terrible in and of itself. That’s called rationing. And it’s only “okay” for now assuming the public finances don’t deteriorate. Anecdotally you’re not the first person from a rationed system to mention long wait lines.
Second, I believe Austria has great care and smart surgeons etc. But again there’s a vast difference between “good” and “outstanding/ first in class”. I’m not cheerleading the current US system, I think it’s terrible that it’s a monstrosity that leans more socialist than free market and everyone gets the worst of both worlds.
But seriously, let’s not argue where most medical innovation and drug breakthroughs come from. Before everyone goes into a rage, I’m not saying all innovation, but most. Kinda like there are tech hubs around the world but right now the center of gravitas is mostly SF.
> First of all, the idea of a “wait list” is terrible in and of itself. That’s called rationing.
What do you want to do? There are only so many operating theaters, and only so many surgical teams, and demand is greater. So you have two options:
- offer the procedure to whoever pays the most / has the best insurance / has good connections
- prioritise patients based on how urgently they need the procedure
I prefer the latter -- grandma had to wait a few months, but she got her new knee joint. She gets the same medical treatment as the president. You could pay extra to get a nicer room in the hospital, but you can't pay to get better medical care (At least in theory -- we have some amount of corruption just like everywhere else)
Of course, it would be even nicer if nobody had to wait! I don't know what the situation in the US is like. Do hospitals in the US not need to "ration" certain procedures? Do they have enough capacity to treat everyone who needs a joint replacement without any waiting time?
I've read that a lot of people in the US don't have good health insurance and can't afford the care they need. To me that sounds like rationing care based on who has the most money.
Your other point, that most medical innovation originates from the US, sounds implausible to me. People from the US only hear about US achievements, so they think nobody else achieves anything.
For example, take the wikipedia article on fetal surgery: It lists 3 hospitals in the US that perform fetal surgery, and 1 in Canada. So clearly the US is the world leader in fetal surgery!
But then you look at the German wikipedia page, we see a list of 5 hospitals in Germany and 2 in the US. Obviously Germany is the world leader in fetal surgery!
(Neither article bothers mentioning Austrian hospitals that perform fetal surgery)
Super late reply (not sure if you'll see this), but no, there is no rationing like that in the US. If you need a procedure, it gets done in the next few days/week (depends on the urgency)
> Most people would fly to the U.S from wherever. That is telling you something.
> but healthcare innovation is done in the U.S
These are assertions without much evidence. Don't forget that the US does well on relatively meaningless measures (5 year survival rates for cancer) but poorly on all cause mortality. Why do US citizens die younger than people of other countries if the US healthcare system is so innovative?
There's an argument to be made with respect to advertising to physicians, but not the general public. Doctors have limited time and they ought to know what meds are available somehow..
I thought that was called pharma marketing, not advertising. That too has had corruption and perverse incentives in the past. However, I did mean banning advertising to the general public.
Doctors have the knowledge and expertise to critically evaluate statements presented to them by marketing materials (whether they do so or not is a different story). The general public, modulo the odd autodidactic genius, largely does not. If someone from the general public wants this information, they are free to find it on the Internet. In fact maybe we could make it mandatory that any materials presented to doctors are also posted on the company's website for anyone to see.
If pharmaceutical reps were "advertising to physicians" in that they provide medical information on how a drug works, why a doctor should prescribe it, potential risks, etc. then I might agree. However, it seems like more often than not pharma reps buy doctors a fancy steak dinner and a lap dance in exchange for pushing legal heroin on every person that walks through the door. I would rather pharmaceutical marketing be made illegal, and instead require doctors to do some kind of continued education on advancements in medication and other relevant info.
> all the pharma companies would save millions every year.
Their savings would never be passed on to the customer. And it's hard to believe there would be any savings overall, because the advertising must be bringing in more money than it costs or they wouldn't be doing it.
I'm not disputing pharma advertising is profitable for individual products. I'm skeptical if it's profitable in aggregate. Drug demand is a function of the occurrence of disease. Advertising can increase profits by:
1. Taking market share away from a competitors. Profitable for that product, zero-sum for the industry. Competitors respond by increasing their ad spend, equilibrium returns (unless one drug is genuinely superior to another)
2. Increasing demand for unnecessary medicines. Profitable for the market, bad for society.
Advertising is an arms race. Even if I don't want to advertise, I have to because my competitors do. If it's banned, everyone saves the expense of advertising.
Unless pharma companies are engaging in cartel-like price-fixing some of that money will definitely go to lower prices (some will also go to R&D, dividends/buybacks, and exec pay). It only takes one company to do it and the rest have to follow.
There are two niches in which your analysis is incomplete.
First, There are underdiagnosed diseases for which patients don't seek care, sometimes because they do not believe there to be a treatment. The lack of treatment means that it isn't as vital for physicians or patients to pursue diagnosis. Those patients might see an ad and return to a physician to ask if that treatment is a fit.
Second, not all physicians are as on top of new treatment options as we expect. It might have slipped their notice or be in a field with which they aren't the most familiar, and those patients might benefit from revisiting whether a new treatment is a good fit.
I don't really think these two cases make up for all of the advertising, but they might be missed if advertising is cut or abolished.
It might have some fairly large drawbacks, but I think it would be good for pharma and biotech companies to put some amount of money into a fund based on the disease and have awareness campaigns around the diseases. For example, companies with diabetes treatments could form a group that puts out diabetes ads urging patients to talk to their physicians. It gets dicey for first-in-market treatments, but I think it would be an overall improvement from the current system.
Disclaimer: I work in big pharma biology research; pricing and advertising are done in a fancier building with more marble floors, so I've thought about this a bit, but it isn't my department.
> not all physicians are as on top of new treatment options as we expect.
I thought this was called pharma marketing. I don't think this should be abolished - I only meant direct-to-consumer advertising. Although I've seen someone else argue that doctors should be required to undergo continuing education instead.
I'd like to see numbers on how often an ad is how the patient learns they have a disease. I imagine that anyone with really annoying or debilitating symptoms would research them online from time to time.
My point about marketing to patients is that patients see the ad, think "that might be something I need", and go ask their physicians. Then the physician can look into it more thoroughly.
With regard to patients searching their symptoms regularly, it is my understanding from the physicians and clinical trial folks that you would be in the incredibly small minority, but it's a good idea.
Americans are allowed to chose whether they get certain tests or not; and whether they get treatment or not for stuff found by those tests.
America has a problem with over-testing, over-diagnosis, and over-treatment. It seems that merely giving people a choice, telling them the cost, and getting them to pay a contribution isn't enough to prevent this.
Let's say it's 1990, and I'm in the market for a car. A Yugo costs a lot less than some other cars. But I'm getting a lot less for it, too - it's less reliable, won't last as long, and is less comfortable. But, as a car buyer, I can kind of tell that. It doesn't feel like it's as solid a car as some of the other options.
Now say I'm trying to have a hip replacement. Here's a place that costs 20% less than the other place. Sounds great, but... what are their rates of complications. How about if you go out 20 years? Without that kind of information, I can't compare on price, because I don't know whether I'm buying equivalent things.
What you say is correct, but you also have to admit there are plenty of shitty doctors today. The shitty doctor problem isn't going away no matter what they are paid.
Here in Canada, there is no price transparency whatsoever. Just when people are facing the stress and uncertainty of fighting a crisis like Cancer, they are given absolutely no inkling what their treatment will cost.
When a physician makes an appointment for you with a plastic surgeon to discuss reconstructive surgery... No transparency about the cost.
When they prescribe chemotherapy... No transparency about what the doses cost.*
When they schedule surgery... You don't have any idea if they'll pull in another nurse or surgeon during the procedure, and again... No transparency about cost.
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I feel icky making jokes about this. But seriously, price transparency is a perfect example of the "XY Problem."
America asks, "How do we make paying for health care an efficient and transparent marketplace," but the correct answer is, "If what you want is a functioning, civilized country, stop trying to make healthcare a marketplace."
* Prescription drugs are still a quagmire in Canada. Basic chemotherapy is somewhat covered by various provincial drug plans, but if you're employed you usually rely on your employment benefits for prescription drugs much as Americans do.
Many of the things covered by employment plans are more convenient than those covered by the public plans. For example, the public plan may require a dose a day, while the product that only requires a dose a week is only covered by an employment plan.
But the bottom line is that if you aren't employed and can't afford chemotherapy, you will get treated.
There are shades of bad. The US health care system with price transparency is better than the US health care system without it.
The same procedure can cost 1,000x more if you go across town. It's been long reported that Hospitals mostly pull prices out of their asses. The health care problem in the US is not just a health insurance problem, it is also a health care provider problem. Even if you had a single payer system, pricing like this is insane.
What you say is true, but does not negate or discount what I said in any way.
Again, with the XY problem...
If someone asks for X, but really needs Y and there is a better way to get Y than to help them with X... Of course X is better than no X and no Y.
But that doesn't change the fact that Y is much, much better than X. And in the case of health care, it is not even close. Price transparency may lead to each person paying a little less, or at least being less stressed, but it still won't fix the fact that America has the most expensive system, with the worst outcomes, in the developed world.
So yeah, X is better than --X, and ++X even better than X, but that doesn't change the fact that Y is still the correct solution when you focus on the problem you really want to solve rather than making the incorrect solution slightly less incorrect.
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Also, IANAE, but I do not believe that in Canada, hospitals are permitted to have a 1000x variance in pricing. I think that for those things we socialize, the government sets the price.
I think you're right (profit motive and health care don't mix) but then how do you cut the Gordian Knot? I'm cautiously hopeful that price transparency might be a start.
Like the education system, the health care system's retail price is basically ludicrous.
This is to extract maximum situational revenue, basically get as much from the patient as they can afford.
Colleges charge 100k, but will adapt spending (as little as possible) to get students to be able to pay. They even preferentially let in richer students.
It's the ideal way for a business to make money if they can charge based on how much each individual can pay (and bankruptcy is someone-else's-problem in both healthcare and tuition)
"Healthcare in Switzerland is universal and is regulated by the Swiss Federal Law on Health Insurance. There are no free state-provided health services, but private health insurance is compulsory for all persons residing in Switzerland"
I also read:
"Swiss are required to purchase basic health insurance, which covers a range of treatments detailed in the Swiss Federal Law on Health Insurance. It is therefore the same throughout the country and avoids double standards in healthcare. Insurers are required to offer this basic insurance to everyone, regardless of age or medical condition. They are not allowed to make a profit off this basic insurance, but can on supplemental plans."
"The insured person pays the insurance premium for the basic plan up to 8% of their personal income. If a premium is higher than this, the government gives the insured person a cash subsidy to pay for any additional premium."
Now let's not quibble. The core question her is, "Should basic healthcare be a marketplace?"
If basic healthcare is a marketplace, providers can charge what they like, and it's "caveat emptor" when it comes to purchasing healthcare, whether it's directly purchasing treatment, or purchasing insurance.
Here in Canada there are lots of non-basic kinds of healthcare that are a marketplace. How much does it cost to get a cortisone shot so that I can cycle? I don't know until I shop around. Same for physiotherapy, chiropractic care (is that heath care or phrenology?), dental care, orthodontics, and lots of things involving mental health.
But basic health care--for some definition of "basic"--is not a marketplace, and it is not optional whether you are covered.
I guess that’s the difference between Wikipedia and using it :)
How the French government finances insurance is orthogonal to how consumers purchase outpatient care.
The capsule summary is that patients go to the doctor. The pay 100% of the visit cost. The insurance company reimbursement is 80% of “reasonable and customary “ value that is widely known. Et voila, functioning price discovery without a dystopian society.
(There are some caveats. If you’re indigent, the government gives you a special card that allows the provider to bill the insurance directly. You can buy private insurance that covers your 20% and doesn’t require as much reimbursement hassle at the cost of constraining your provider choice. And naturally none of this applies to inpatient hospital admissions)
I brought it up and got a wonderful discussion in a previous HN about this topic, https://news.ycombinator.com/item?id=20275097, that my experience with this will be: "All transparency will do is put a number in front of my single choice." Months later I'm convinced this is just a talking point to avoid talking about reforming US healthcare.
There are lots of sick people who want to know how much their treatment options cost. Not just Americans, but Canadians as well (I know some).
When you have a poorly understood illness that is killing you you have two choices: pay out of pocket or die. It doesn't matter if your country has universal health care or not because treatments will not be covered until they go through a lengthy (decades) approval process. If your illness is controversial then it will be even longer.
It doesn't harm anyone to publish real healthcare prices. Please do not fight something that will harm no one. This will benefit some of the most neglected people in society.
I have empathy for where you're coming from, but to me it feel like the following:
Imagine that in America, husbands are allowed to beat their wives, and the government proposes a law that they may not use a stick with a girth bigger than their thumb.
Alice says, "This is insane. Husbands are not allowed to beat their wives in Canada, that is the correct solution."
And then Bob says, "Well, that's just unrealistic here, so please do not undermine our efforts to make things better for wives by limiting how hard they can be beaten."
Did you read my entire post? Universal health care does not solve the problem. Canadians that have my illness have just as much difficulty as I do. I swear you kinds of healthy people do not even read/listen to the words that I and other crippled people say.
Your analogy is not even remotely appropriate.
And how is open pricing incompatible with universal health care? Is your ideology so important to you that you will fight such an innocuous change?
I just wanted to say that your original post made plenty sense, and that I agree. And I found parent's wife-beating analogy quite confusing and unrelated.
Here in Ontario, prices for basic health care are regulated. So the hospital doesn't get to charge $3,000 for that bag unless this is a procedure not covered by basic health care, or if the government has already approved that pricing, and it is the same in every hospital.
On the other hand, the private room you're in is not covered by basic health care, so if they feel like charging you $3,000 a night just for the room, or $1,000 for television, or $500 for WiFi, that's allowed.
If a nurse comes into your hospital room with a bag of saline you're going to check the price tag and argue with him about whether it's the right brand?
My uncle wrecked his motorcycle once. He ended up in a ditch unconscious.
Someone called 911. For what ever reason a life flight helicopter was then called and picked him up and took him to a local county hospital. He woke up there a few hours later. After they had already ran all kinds of tests. They had a large list of all the problems from busted spleen, broken bones, head concussion, etc.
After a day of rest in the bed, the only thing wrong was a sore ankle and some deep scratches on his face. He checked himself out and we went and drove him home. They sent a bill of $16,000 the next month to him. He asked why it was so high since the only thing they did was give him a helicopter ride and a bed to sleep in (none of which he consented to but of course hard to consent when you are unconscious).
He sent them a check for $16 which was the minimum amount required. He fully expected to pay $16 per month for the rest of his life, but they never sent another bill and he never asked... That was 15 years ago.
> Transparency is not going to work where there is no competition, Emily Gee, a health economist at the left-leaning Center for American Progress, told Healthcare Dive.
That's bs. I will drive to a further away hospital if it saves me $75 an hour of time spent...
(edit: clearly I'm talking about non-emergency here)
We've seen massive consolidation of health groups over the last 20 years. I believe that's the point Ms. Gee is making. There used to be competition 10 or 20 minutes away. Now it's entirely plausible you'll be driving for hours to find a different medical group with similar services available.
In my area (250k people, Iowa) there are 2 health groups.
I actively tried finding a PCP who wasn't part of the two health groups but accepted insurance - as mega health groups greatly increase the total cost of care. I gave up after looking up about 20 from the hundred or so names insurance sent me. Basically everyone
Unity Point recently announced it wouldn't be merging with Sanford health group. That would have expanded Sanford's strong footing in northwest Iowa, gaining 5 hospitals in Des Moines and at least one hospital in most locally large cities across the east half of state.
It's hard enough to make the math work for hospitals in rural areas. The merger would have made it more difficult for the entire region to find competition.
That "further away hospital" is literally "competition."
Also, 1 hour away is not much in terms of time or distance, considering that many metropolitan residents have a daily commute in excess of 1 hour, and many rural residents live several hours from the closest hospital.
But it won't. Your insurance will pay for it either way, so you are spending an hour of your time to save your insurance $75 - which won't even be given back to you in form of lower premium.
This is an assumption based on a very good insurance package. Most have out of pocket co-pays . So yes, we have to gross it up by the co-pay percent and discount it by the Annual deductible limitt, but generally the point stands. If I can save enough money I might travel away from the monopoly. Until that data is transparently available I can't optimize that scenario w/ my own choices.
> which won't even be given back to you in form of lower premium
Systemically it will eventually if insurance companies are competing with eachother for your business
Sort of; in my experience, even with a high deductible health insurance plan, the insurance company's negotiated rates are still in effect. In other words, if a visit would be billed to an uninsured person at $200, but my insurance caps it at $100, then $100 is the price accepted by the doctor's office no matter if I'm paying because I haven't reached my high deductible or insurance is paying because I have a regular, not high deductible plan.
The problem is you can't inspect -> quote -> customer decision with someone who's having a heart attack. Even if the person is lucid, they are unlikely to say no to any price if they're at death's door. No amount of competition changes the simple fact that health care is not a fungible service. CPR at facility A can't be exchanged for CPR at facility B if B is even a few minutes away.
Combined with the emotional state most patients are in (something other industries, like mortuaries, prey on as well) and you have a recipe for gouging even under ideal competitive regulations.
I don't see a problem with ambulance coming in -> charge them to the moon because if we don't do what we're going to do, they are going to die.
There's a problem with applying that logic to - hey I have a pain in my hand because I was rowing a boat today without warming up. Take this 800mg Ibuprofen. 3 months later $800. (So that's a true experience with my wife and rowing a boat)
While publishing the negotiated prices for each procedure code would be interesting, I don't see how it would change much since it wouldn't necessarily be the price they would actually charge me, and it wouldn't help me know beforehand what sort of add-on procedure codes/bills were going to be part of my care.
The policy I would like to see is that patients should only be legally liable for costs that they sign off on up front (at least for most elective care). It never ceases to bother me that every time I go to the doctor I have no option but to give the hospital a blank check and have to cross fingers that they will not hit me a month later with ridiculous charges.
Eventually the published price will be close to the amount you are being charged. I would expect health care providers to stick with their promise to post the highest possible cost but as people being to use these prices to shop around (both these numbers are exorbitant, but this one is less so, etc.), I am confident they will abandon this gambit.
IMHO, it's kind of nuts they are even starting out with this argument.
This is why we need single payer and to abolish/greatly diminish private insurance. Hospitals and insurance companies continuously demonstrate the failed state of the healthcare market. Market-based healthcare will always be unworkable due to impossible to reconcile conflicting incentives.
An interesting interview this week on Econtalk about price transparency. The interview happened before Trump's price transparency plan was announced but the podcast just made it up this week.
Some guy has been running a non-insurance based surgery center for years, the surgeons make more and patients pay less or so he claims. All prices are listed on their website. They claimed they don't change prices. If a doctor misses something and needs to do extra work their policy is that's the doctors fault for not doing enough due diligence beforehand.
He also claimed there are some perverse incentives like he claimed a hospital might bill an $100k but only receive $13k. But, they can claim a $87k loss which the government will partly reimburse. He further claimed that insurance companies often have contracts with employers where the employer is supposed to pay a percentage of the amount the insurance company saved for them. In other words, the insurance company will say "we managed to save you $87k on your $100k bill, pay us 20% of the savings" so they have an incentive to ask the hospital to charge more.
Note: I have no idea how backed up this is. Just passing on the podcast, hoping to see more knowledgeable feedback.
The most salient issue is insurance providers being able to proclaim arbitrary hospitals as "in-network" and "out-of-network". My significant other claims that hospitals are now hiring contractors, who are always by definition "out-of-network". This hurts the career prospects of the contractor and lowers the level of care received.
And for nothing! Insurance should not be certifying which doctors you can and cannot see. That's for the medical boards to decide.
Yeah, if I go to an in-network facility, then they have an out-of-network provider walk into my room, how am I supposed to know? The same is true of labs. My wife had her blood drawn and sent to a lab every couple of years without issue until one year they sent it to a different lab unbeknownst to her. It was out-of-network and cost $800.
It's been way too long now, but thanks for the tip. We called insurance and the doctor's office several times each to no avail. Insurance's answer was that we should sit in the exam room with an insurance representative on the phone to ask where each vial of blood is going and what for, then relay that to the insurance representative to give a verdict.
There should be a basic law of health care: no person is liable for a debt they incurred before they were presented with the price and had an opportunity to refuse. I'd give some amount of leeway for unconscious patients, but aside from that every single penny of expense should be agreed to up front. The absence of this policy explains a lot about how things have become so perversely broken.
It's an interesting question.
Health care is a human right. Therefore it must be free.
A prompt and fair trial is also a human right. Therefore legal help must be free.
Moving around, staying warm and basic hygiene - a lot of stuff sound like basic human rights, but very few argue that transportation, heating and sewer draining services should be free.
I think most people around don't mind paying for the service. They just want the prices to be reasonable and predictable.
Oh, you're preaching to the choir, but I'm not optimistic about our country's chances of doing the right thing. If we're not going to follow the successful examples we've been presented with (because it's socialism! /s), and we're going to have capitalism, then we should have capitalism and engage in transactions where both parties have complete knowledge.
Let's say they make prices transparent. You ask them about the cost of getting an X-ray done and they quote you $Number. You go and get an x-ray done and you're billed for $number plus a few extra thousand for any number of unknown costs.
Hospital billing is a lot like getting billed for internet/phone/cable etc. They'll throw all kinds of bullshit charges, ding you for not using certain things and more. Then you have to waste energy calling them up to talk with someone whose job is to get you off the line.
That's assuming you can even shop for your needs. If it's an emergency then you're screwed either way. The only change this would cause is that insurers and hospitals would adapt and figure out other ways to sneak in charges.
If you want to fix this problem at the core, then trying to make it more of a free market won't work. You need stronger oversight and control to keep things in check.
I think the bigger scam is how they break apart the hospital/doctors offices into separate companies. Now I'm not complaining how I go from one building to get blood drawn and a different building for the emergency department.
I'm complaining how I walk across the hallway in my doctors walled garden inside the building but when I enter that room, in his area, and get an x-ray that is a completely different company that bills me separately and I have to pay a different co-pay to.
> Instead of helping patients know their out-of-pocket costs, this rule will introduce widespread confusion, accelerate anticompetitive behavior among health insurers, and stymie innovations in value-based care.
So people are too dumb to understand prices, and unlike any other economic system to ever succeed, knowing the value of a thing will DECREASE pricing competition.
I was waiting for the good argument on why this is a bad idea. Instead we got _that_.
Additional anecdata: Enjoyed an extended honeymoon through Thailand, Singapore, and Malaysia in 2016 and my wife was bitten by a stray dog in rural Thailand early on -> 7 medical interactions involving post-exposure prophylaxis and rabies shots in all 3 countries over that next month. (She's fine BTW!). Price transparency was really amazing in all these places and I think it might be a single reform that's broadly ameliorative of the max-friction / painful experience of US healthcare. In each country, we basically called around, asked "do you have this shot and how much is it" and got a more or less straight answer, despite having some language issues everywhere but Singapore. Whole experience cost ~ $1k, including some visits for 2nd opinions to high-end private clinic in Singapore and we just gave up bothering with it on our US insurance b/c of deductibles and hassle.
Doctors' wages have grown minimally ocer the last 20 years. Increased costs go to big pharma, 'not for profit' hospitals, and insurance companies, the "cartel". Meanwhile, the expense and number of years of training for high end docs increases. I am 57 and still did 4 years undergrad, 4 years med school, and 5 years postgrad. I did not do the 1 or 2 year fellowship now required for many radiology positions. Read the Proscan law suit about what happens when undertrained folks read imaging exams. It is not the shortcut needed to save healthcare. We can pay docs fairly if we get 80 percent of care away from hospitals where it costs 3 times more than it does elsewhere. Because hospitals employ or subsidize 70 percent of docs, most care happens there. That is really a huge part of the problem.
I'm surprised there is no startup that sells you membership in offshore healthcare. If you want to do anything, you just jump on a short hop flight to a man made island in international waters and get healthcare. Or, coupled with a trip to Thailand. It would be disruptive and cheaper.
My wife is a doctor and last night she tried to renew her credentials at a major hospital network here. She could not, despite clear instructions, open the PDF locally to add her signature. I inspected the web view in chrome tools and see it is an awful Microsoft product behind the scenes.
This is the reason this attempt by Trump will never happen (I'm supportive even though I despise Trump). My wife's incentives and the hospital incentives are aligned, even though no one will admit it. Even if hospitals are forced to give price transparency, they will just go and buy a shitty solution from Microsoft (I'm using Microsoft as a placeholder, but it can be any large tech company who wants in on the action), who will be happy to certify it for the law. It won't work and the hospitals can blame Microsoft. Microsoft will lobby politicians to water down the law so they won't pay anything but a pittance if things don't work. Consumers will get continually screwed. The doctors and the hospitals will continue to make great money because they will still not have to admit pricing this way, with zero transparency, is the golden goose of healthcare and why costs are insane in the US.
Right now healthcare in the U.S. is the worst of capitalism (basic health is tied to income/employment, perverse profit-incentives) and the worst of anti-capitalism (anti-competitive monopolies/cartels) at the same time. I don't think improving its ability to function as a free market will ever be a real solution, but it certainly can't hurt.
The problem with transparency at the hospital level is the CPT coding system, for which all medical entities including the govt pay the AMA millions of dollars to use, which splits up exams and procedures into components. So even though the knee MRI might cost $1600 (ridiculous but typical), that does not include the radiologist's interp, billed separately by the rad group, or the $300 orbit xray to screen for metal. Also anesthesia is paid based on time, cannot predict that. It is all a sham. And, they can get out of it for a $300 a day fine....well worth it to most of them.
My dad, who is in his late 60s, has about $200k to live off of in his retirement. Provided I outlive him, I have a sneaking suspicion that his savings will not only be siphoned out by whatever hospital system inevitably treats him, but that _I_ will have to cough up the remainder! Granted, this isn't a discussion he and I have had. Just goes to show that if you have some terminal condition in this broken country, it's better to just be hit by a bus or drown, than be "treated" comfortably in a hospital bed for $5k+ a night.
(EXPLETIVE DELETED! I try to avoid low-content comments, i do, but goddmnit it pisses me off to hear them say, "Oh the poor patients will be so confused!")
This is purely anecdotal, but I had a 15 minute (literally) ultrasound. Hospital "facility use" fee: $800. 15 minutes of technician's time: $250. Bill came down to $650 after adjustments.
This is messed up.
I imagine people with serious health problems just kill themselves or ruin their lives forever.
I got 1 stitch at the ER (before I was aware that Urgent Care was a a thing). First hospital visit in my adult life. Some saline solution, an alcohol wipe, a shot of Novocaine, and 1 stitch. $3,200. I now avoid the hospital like the plague (ironically).
It's amazing what tiny tidbits of knowledge like the urgent care thing can save you.
Recently when picking up the tab for a relative who went to an out of network hospital I discovered another one. The first was an enormous discount for paying same day (so if you're well off but have bad insurance they just pretend you have mediocre insurance). Combined with the power of saying "Really??? Isn't there anything you can do?" to as many people as possible, $1,600 became $360.
So the lesson is on one of the worst days of your life focus on what really matters: haggling, being an informed consumer, and obscure policies.
I hit my head a while back and had to get about 10 staples. Total cost was only $150 without insurance. This was at Penn Urgent Care in Philadelphia. Our combined anecdotes reveal how useful it would be for customers to be able to shop around.
Unfortunately, central planning stifles innovation. We have the best cutting-edge medical technology in the world for the few who would like it and can afford it. But by eliminating pricing transparency we've also eliminated the incentive to make those technologies cheaper and more accessible to the common man.
You don't need innovation for the usual complaints that you see a primary care physician for - broken arm, throat infection &c. That stuff lends itself to standardization and following of protocols.
Except when your broken arm needs to be reduced or you have an open fracture and you require moderate sedation to have a physician perform those procedures. Not so standardized and not to protocolized.
I don't know about suicide or ruining their lives per-se, but people often go bankrupt from medical bullshit. Also it is quite common for people suffering from all sorts of things to wait until their minor discomforts become intolerable suffering before seeing a doctor, which is how I operate. Too many physician visits where a doctor filled out some Epic form bullshit while ignoring me and then pushing me out of their office as quickly as possible because I wasn't currently dying.
>I don't know about suicide or ruining their lives per-se, but people often go bankrupt from medical bullshit.
One study found that only 4% of US bankruptcies are because of medical bills https://www.washingtonpost.com/blogs/post-partisan/wp/2018/0... . A tipoff that [insert large percentage here] of bankruptcies aren't actually because of medical costs is that only 6% of bankruptcies by those without health insurance are because of that cause. The biggest cause of bankruptcies is lack of income, which health insurance doesn't affect.
As a comparison: For ultrasound, the price range in Germany is 100-200€ - but our hospitals don't have to inflate prices to account for non-paying patients and the salaries/other overhead costs are lower too...
If the US wants to get rid of horribly high sticker prices it needs a reform of how stuff is paid for, especially homeless/unemployed/undocumented patients. In Germany, the state covers insurance premiums for the first two categories and undocumented/asylum seeking patients only get life-saving treatments (truly inhumane if you ask me).
Non-paying patients are, while frequently trotted out, not the reason for why prices are 3-4x higher in the US.
Outside of the ER, if you don't have insurance, and can't pay, you'll get shown the door. The overwhelming majority of medical procedures that take place across the country are not done in the ER.
So many medical clinics and outpatient facilities don't have to deal with costs supporting those groups and they still have outrageous pricing. The homeless/unemployed/etc groups only really affect emergency care. If they aren't about to die from lack of care, the hospitals aren't required to treat them.
My wife got one of those “fun scans” 3D color ultrasound when she was pregnant. $75 a full 45 minutes with technician on a brand new $$$ ultrasound machine.
A regular, 5 minute diagnostic scan on archaic machine is over $1k.
Prescribing doctor didn't know the cost. Lab tech didn't know. Billing department told me I needed a procedure code. Lab tech who was ready to draw blood couldn't tell me the needed code even after spending five minutes at a computer looking for it. Prescribing doctor gave me the code. Called back billing. They will call me back in 2 to 5 days with a quote. Weeks later, I've yet to hear from anyone.
This was at The Ohio State University Wexner Medical Center.