> If the doctor sees you and sends you home, that's one price (tied to Medicare outpatient prospective payment system or OPPS). Depending on how severe your issue is, the triaging care, such as pain relievers, may or may not be included in the "evaluation and management" procedure coding level you're assigned.
Wait, hold on sec though. I've dealt with navigating inpatient vs outpatient coverage with my insurance compacts. It impacts what they will pay and it impacts what their coverage is, but that's a very different thing than telling the hospital what its prices need to be.
A hospital knows what it wants to charge for an aspirin tablet. Separately, some of that cost is going to be covered by insurance (maybe 100%, maybe 80%, whatever). Maybe there's going to be have to be separate negotiation afterwards to figure out what the insurance is willing to pay. Maybe the hospital won't get to charge what it wants, because the insurance company will whittle them down or move the entire procedure into a separate coding level.
But being able to predict the outcomes of that is more than I was asking. I am fine with a situation where a nurse goes to hand me an aspirin and says, "just so you know, this will be $5, though of course your insurance may end up covering it or negotiating you into a different code where you pay something lower." Because, again, other industries have figured out how to do this. A psychiatrist will not be able to tell you before the visit how much your insurance is going to pay, or even what the final price that they negotiate with your insurance will be. But you'll still know the general price of a session beforehand, the base amount that they want to charge.
Is there a reason why a hospital can't even tell me even just what the maximum amount is that the aspirin they're about to place into my hand would cost inside of their walls?
> That doesn't even touch the administrative burden of documenting and collecting on all of that care. If your care wasn't meticulously documented by providers making hundreds an hour to type longform notes, it's essentially free, because no provider will risk billing for care they can't support with documentation. Once insurance pays (or not, they might deny the claim), they will often say "yeah we agreed to pay you x but the patient has 20% coinsurance so here's 80%, you need to talk to him about the rest". The hospital and especially caregivers are not aware of how much of your annual out of pocket max you've spent (thereotically they could check with the insurer, but not realistically in an ER), so maybe you have 20% coinsurance or maybe you don't, only you and the insurance company can realistically know that before the hospital sends the bill.
This still feels like a lot of words to essentially agree with what I was originally saying -- that the entire process is not used to price transparency, and that this is not the result of an inherent complication in healthcare itself, it's the result of a system that at every level has gotten used to the idea that consumers shouldn't get to know what they pay, and that prices should be determined behind closed doors, not through an open market process.
If from the beginning, nobody tolerated getting mystery bills days or weeks after a hospital visit, would insurance companies have felt this comfortable demanding that hospitals follow a specific payment structure? Would hospitals have been as willing to accept supply contracts where the prices fluctuated so much?
After all of this conversation, we're still kind of back to the original point, which is that it's really good to put pressure on this system, that transparent pricing showcases the various issues with the system in a very public way, and that shining light on those issues and making them obvious to consumers may lead to improvements across the board. If the problem starts with insurance companies, then great. Attempts at transparent pricing open the door for public conversations where the public and regulatory boards ask "why is the insurance company refusing to pay the transparent prices that the hospital is offering?"
I mean, you bring up the (very common) scenario of insurance companies and hospitals disagreeing about what a procedure should cost and only agreeing to pay part of it. That's something that happens because there isn't a market rate for any of these procedures, and there's honestly no way to determine whether the insurer or the hospital is being reasonable. Price transparency helps with that, it gives us a more accurate picture of what the normal variation in prices are for a procedure across the entire industry.
I think that it might be coming across that I blame hospitals entirely for this, and I really don't, I'm focusing in on hospitals to make the point that the pricing outcomes are worse in hospitals than in most other industries. I understand that insurance makes this more complicated, I understand that suppliers make this more complicated, I understand that hospitals are trying to figure out how to bill as much as possible within the scope of regulations that dictate some price limits depending on context. What I'm saying is that price transparency regulation puts pressure on those systems to get better, and that it's good to put pressure on those systems to get better, and (most importantly) that there's nothing about medical care that inherently means those systems need to be this way. We have other examples of parts of the industry that have proven that this kind of complexity for the end consumer could be lower. We could have a medical system with transparent billing, the complications you're bringing up are regulatory, administrative, and contractual; they're not laws of nature. They're complications that were invented by human beings (not necessarily by hospitals specifically) and spread across the entire industry, because there was no incentive not to invent them.
Yes, insurance companies also need transparent pricing for hospitals. That doesn't mean that hospitals don't need transparent pricing for consumers.
Wait, hold on sec though. I've dealt with navigating inpatient vs outpatient coverage with my insurance compacts. It impacts what they will pay and it impacts what their coverage is, but that's a very different thing than telling the hospital what its prices need to be.
A hospital knows what it wants to charge for an aspirin tablet. Separately, some of that cost is going to be covered by insurance (maybe 100%, maybe 80%, whatever). Maybe there's going to be have to be separate negotiation afterwards to figure out what the insurance is willing to pay. Maybe the hospital won't get to charge what it wants, because the insurance company will whittle them down or move the entire procedure into a separate coding level.
But being able to predict the outcomes of that is more than I was asking. I am fine with a situation where a nurse goes to hand me an aspirin and says, "just so you know, this will be $5, though of course your insurance may end up covering it or negotiating you into a different code where you pay something lower." Because, again, other industries have figured out how to do this. A psychiatrist will not be able to tell you before the visit how much your insurance is going to pay, or even what the final price that they negotiate with your insurance will be. But you'll still know the general price of a session beforehand, the base amount that they want to charge.
Is there a reason why a hospital can't even tell me even just what the maximum amount is that the aspirin they're about to place into my hand would cost inside of their walls?
> That doesn't even touch the administrative burden of documenting and collecting on all of that care. If your care wasn't meticulously documented by providers making hundreds an hour to type longform notes, it's essentially free, because no provider will risk billing for care they can't support with documentation. Once insurance pays (or not, they might deny the claim), they will often say "yeah we agreed to pay you x but the patient has 20% coinsurance so here's 80%, you need to talk to him about the rest". The hospital and especially caregivers are not aware of how much of your annual out of pocket max you've spent (thereotically they could check with the insurer, but not realistically in an ER), so maybe you have 20% coinsurance or maybe you don't, only you and the insurance company can realistically know that before the hospital sends the bill.
This still feels like a lot of words to essentially agree with what I was originally saying -- that the entire process is not used to price transparency, and that this is not the result of an inherent complication in healthcare itself, it's the result of a system that at every level has gotten used to the idea that consumers shouldn't get to know what they pay, and that prices should be determined behind closed doors, not through an open market process.
If from the beginning, nobody tolerated getting mystery bills days or weeks after a hospital visit, would insurance companies have felt this comfortable demanding that hospitals follow a specific payment structure? Would hospitals have been as willing to accept supply contracts where the prices fluctuated so much?
After all of this conversation, we're still kind of back to the original point, which is that it's really good to put pressure on this system, that transparent pricing showcases the various issues with the system in a very public way, and that shining light on those issues and making them obvious to consumers may lead to improvements across the board. If the problem starts with insurance companies, then great. Attempts at transparent pricing open the door for public conversations where the public and regulatory boards ask "why is the insurance company refusing to pay the transparent prices that the hospital is offering?"
I mean, you bring up the (very common) scenario of insurance companies and hospitals disagreeing about what a procedure should cost and only agreeing to pay part of it. That's something that happens because there isn't a market rate for any of these procedures, and there's honestly no way to determine whether the insurer or the hospital is being reasonable. Price transparency helps with that, it gives us a more accurate picture of what the normal variation in prices are for a procedure across the entire industry.
I think that it might be coming across that I blame hospitals entirely for this, and I really don't, I'm focusing in on hospitals to make the point that the pricing outcomes are worse in hospitals than in most other industries. I understand that insurance makes this more complicated, I understand that suppliers make this more complicated, I understand that hospitals are trying to figure out how to bill as much as possible within the scope of regulations that dictate some price limits depending on context. What I'm saying is that price transparency regulation puts pressure on those systems to get better, and that it's good to put pressure on those systems to get better, and (most importantly) that there's nothing about medical care that inherently means those systems need to be this way. We have other examples of parts of the industry that have proven that this kind of complexity for the end consumer could be lower. We could have a medical system with transparent billing, the complications you're bringing up are regulatory, administrative, and contractual; they're not laws of nature. They're complications that were invented by human beings (not necessarily by hospitals specifically) and spread across the entire industry, because there was no incentive not to invent them.
Yes, insurance companies also need transparent pricing for hospitals. That doesn't mean that hospitals don't need transparent pricing for consumers.