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Open-source hospital price transparency (dolthub.com)
649 points by sl-dolt 9 months ago | hide | past | favorite | 275 comments

I wrote Hacking Healthcare for O'Reilly and I've spent the bulk of my career as a CEO and senior executive operating large health systems. It is a meaningful step forward to have most of this data in the public sphere but I think it is still early and that a lot of work has to continue to shape and analyze this information in a way that is more meaningful and practical for patients.

Appreciate the complexity of billing codes, these are not created by hospitals but by by the American Medical Association, Center for Medicaid/Medicare and a soup of other organizations. There are tens of thousands of procedure and drug codes (things that are done or given) and tens of thousands of diagnostic codes (reasons justifying the procedure), creating a space well into the quadrillions of possible routine combinations. That's a large restaurant menu.

There are a number of other comments comparing hospital pricing to retail type interactions. It is also important to consider that hospital interactions involve unexpected and unknown things that aren't easily captured in a pricing context before you get there.

From an instution standpoint there are some bad apples but a lot of organizations that are not complying are not complying because they are facing technology and operational issues that are stopping them from complying. From the trenches in my consulting practice one example is an institution whose has a core element of their billing system, that is largely a black box even to them, using technologies that are decades old. Why would someone continue to rely on that? Because it has direct integration with critical partners and counterparties that was set up decades ago and that continues to work.

Replacing it is underway but is costing 8 figures and taking years. The potential fines are small relative to that and there isn't much they can do to comply in the immediate term anyway.

For context understand that Medicare billing routinely involved actual physical dial-up modems somewhere in the chain (even if it was invisible to you) until late 2018.

While it's great that you've been working in the space for a while, this comment does smell of "hand wringing" of the problem as "too complex to solve".

At the end of the day, people just want a "good enough" estimate of what a hospital visit will cost in the typical case for their reason for visiting the hospital. In the event there's variability, that's fine. Just surface that. Knowing several doctors who have seen what has actually been charged for their patients... the vast majority of procedures aren't going to have wild variability for most patients.

Let's look at one common issue that people face: they get charged $400 for a pill of ibuprofen or $2k for a bag of saline with no meds. Even exposing consumable prices is a step in the right direction.

> At the end of the day, people just want a "good enough" estimate of what a hospital visit will cost in the typical case for their reason for visiting the hospital.

I had some really bad intestinal pain and tons of vomiting a few months ago, bad enough I ended going to an ER because I was passing out.

Do you really expect they'd be able to tell me within a minute or two evaluation of me what everything they'd need to do, based solely on that knowledge?

Maybe all they'll end up doing is giving me some good anti-nausea meds and a saline drip. Maybe I'll need surgery in a half hour. How could they possibly give me a realistic up front estimate they could stick to?

Healthcare isn't a free market. When my family member was puking blood I wasn't shopping around, we just called 911.

My first child, I got an estimate for the cost. An extra day of labor past expectations and half a week under Billie lights in the NICU blew that estimate not just out of the water but out of this galaxy. Imagine if fixing a dented bumper took an estimate from $200 to $60k, and yet that's not uncommon in healthcare.

If it's urgent you usually don't ask for the price, you just want to be saved. Otherwise, you do what every civilized country does. You get the price of the initial consultation, then the doctor tells you whatver tests he has in mind that might be the source of the problem. You compare the price of each procedure,then do them, go back with the results to doc, and repeat.

Relying on the patient to gauge what is fair pricing & what is gouging, then haggle when they get the bill seems like trying to solve the problem from the wrong end. Free marketeers will say a fair price is what someone is willing to pay. Trying to make price decisions when your health is in the balance seems like it will lead to either poor decisions on price or on health.

These attempts at pricing transparency seem like another way to put blame on the patient for making "poor choices" when really the system needs to be less complex for the patient. Let auditors & regulators handle pricing and gouging, ideally within a single-payer/public option system.

> Free marketeers will say a fair price is what someone is willing to pay.

Which is exactly why the system is broken. How much are you willing to spend to not die? Healthcare is one of those things that markets just aren't good at setting prices for. The demand curve is a wreck. I think the US has proved conclusively that a market based approach is a mistake.

The price for non-lifesaving healthcare is ridiculously high as well, so there must be something more to the story than this

> How much are you willing to spend to not die?

Of course most health care is not an immediate life or death situation. Most of it is for chronic issues or routine "well care" where you would have ample time to compare prices at different providers, if there were a straightforward way to do that.

For non life or death things, it's still kind of, idk, what's a good economic word to describe "something you basically have to / will inevitably buy?"

Your arm is broken and was put in a splint. To get the splint removed properly you gotta go back to the hospital for them to saw it off (and xray to determine it's a good time to saw the thing off). You're gonna... shop around and compare prices for this routine? I mean, you HAVE to get the splint off or your arm will rot off, plus, your quality of life is reduced with it on. "The Market" is armed with the knowledge that you've gotta get the thing off. Even with a couple hospital "options," the hospitals and insurance companies can collude (implicitly or otherwise) to charge basically whatever they want for the operation. The question isn't, what's a fair price, the question is, how much of this person's income can we extract before they'll risk cutting the thing off themselves.

It seems irrational to try to justify this environment when considering the needs of the citizenry. All signs point to methods of organizing healthcare that take as much power as possible from "the market" (which just means whoever can form oligopoly), be that by having a single payer system or by simply nationalizing healthcare.

I don't really think the make or break is from a $100 spread on wellness visits. It's going to be the acute illnesses and injury that you do not have time to plan for that are the killer. Also chronic illness often can be difficult to manage, with acute flare-ups requiring unexpected hospitalizations. If you're on immuno/biologic therapy, more of the cost is in your drugs than in the doctor or facility.

As GP pointed out there are a myriad of medical/diagnostic codes, and variety of scenarios that could turn something like a baby delivery from a $5,000 affair into a $500,000 affair. Do we really expect that patient to accurately compare all the medical/diagnostic codes between providers to determine if they're getting gouged or not? Would it even be ethical to take a baby out of a NICU to try to save $50,000? We need to stop acting like healthcare is like buying a car or buying Fruity Pebbles from the store.

People aren't going bankrupt because they spent an extra $100 on a wellness visit. They're going bankrupt because of needed care that was very expensive, and even cutting the price in half or by 2/3rds would've still resulted in them going bankrupt. I guess with pricing transparency they can more confidently find out they can't afford it anywhere.

Ugh. I feel like defeatism like this comment is what causes the paralysis against fixing all of our medical cost issues.

> Do we really expect that patient to accurately compare all the medical/diagnostic codes between providers

Forest for the trees. The end user doesn't need to micromanage medical codes when deciding which provider to use. They need a cost "grade" for each provider (maybe based on averages or select common procedures). Apps like Google Maps would be able to help us decide the cost versus distance equation.

Price transparency bends the cost curve down. It doesn't matter whether it is wellness or Urgent Care. So long as you are conscious, you should have information+tools to help you decide where to go. Obviously if you are arguing single-payer, that would be a different situation but since most Americans don't have that, we need to address the issues that apply to us.

Facilities mark up the drugs they provide. Pharmacies have mark-up. Price transparency helps those transactions as well.

> acute illnesses and injury that you do not have time to plan for that are the killer

Perhaps, but not for everyone. Kidney dialysis is an example of a predictable, frequent, necessary for 500,000 Americans) and expensive ($3k - $15k per month) and represents about 6% of all American healthcare spending.[1] Working price transparency for a few of the large cost drivers like dialysis would increase competition on price and reduce the total paid by patients and insurers (and thus, all insured).

> even cutting the price in half or by 2/3rds would've still resulted in them going bankrupt.

Price transparency won't fix all of the price distortions. Nobody is saying it will. But it's a necessary component of bringing prices down, along with like 80 other changes.

[1] https://healthpolicy.usc.edu/brookings-schaeffer/congress-sh...

I think it's realist, not defeatist. More information can be good, but this doesn't mean it brings with it lower costs. It will require significant investment in aggregating & analyzing the data to make it useful. I think it is useful, but for professionals who understand the system. Alternatively it will put even more burden on the patient to coordinate their care, which is already a challenge. I assure you that you can still be incapacitated by pain or discomfort while conscious, and going line by line through medical bills to haggle over price is just not patient friendly.

Even if you get an idea of the price ahead of time, the price when you arrive might end up different because of your unique circumstances or maybe even just shady behavior. Yes, maybe the pricing transparency gives the patient more ammo to haggle with, but relying on sick patients to become market watchdogs just seems like the wrong horse to hitch our wagon too.

We have grocery stores with 200% markup on some goods, yet they're still in business. Price being posted doesn't mean it's affordable. Then you add in sales, coupons, rebates, discount clubs, "add to cart" pricing, SKU variations, "convenience" fees, etc... And the price listed is now no longer "the price listed". It gets even more complicated with medical systems.

> but this doesn't mean it brings with it lower costs

It's not a certainty, but the odds are far higher than having 0 chance of shopping by phone/website, which is the way the US medical industry currently exists.

> grocery stores

Have accurate prices on every item. They calculate most of the variables at the display and all of the variables at the time of the transaction. They are a great example of somewhat complex pricing being transparent.

Grocery profit margins are tiny (usually in the 1-3% range). Sure, the occasional store and the occasional item right before a special event may bring in a larger margin, but grocery stores are an example of effective price transparency working.

Like you, I'm not hopeful that price transparency would fix much, but at least it would distinguish the "Shop-n-Save" medical center from the "Lunardi's" (premium grocers in affluent Silicon Valley suburbs) of medical centers. Right now we can't even distinguish those classes of prices across medical providers.

Time is an important component, but is not enough. Tere is no utility price - for example if all tv producers conspire and set TV prices at $10,000 for entry level tv i will go without one. So will all consumers. Thats your price limit.

However that does not apply to medicine, see epipen scandal. prices can be inceeased infinitely.

Also Many medicines enjoy patent protection and thus have no competition,

While what you say is mostly true, it's not the whole story.

Price transparency doesn't fix price fixing, broken intellectual property laws, etc. But it does increase competition in a space where opacity is currently a feature.

Americans are paying so much that medical visits to other countries are affordable. Trips to Mexico or Canada to purchase medicines. Trips to Europe to get a hip replacement.

The fact that "Medical tourism" even has a term means that Americans are searching for ways to reduce cost. Price transparency is a tool, even if it's debatable about how big the lever is.

Yeah. I know Americans tire of hearing about the rest of the world on this issue, but truly the only sane way for this to be is where you go to the hospital and literally never see a bill.

This is how it is in Canada. Our politicians are currently busy fighting over dental, optical, and prescription drugs [1], and truthfully that's just as baffling— why should going to the dentist be any different than going to the hospital? Is getting eyeglasses somehow "elective"?

[1]: https://www.ndp.ca/better-care?focus=13934141

Japan has an interesting approach - you have health insurance that makes everything dirt cheap, but even without insurance they don't charge ridiculous American-style prices. While on holiday I saw a doctor for 3000yen ($20) and a dentist for 4500yen ($32 incl. x-ray and meds) without any local insurance.

It's actually much better than the UK for dentists at least.

Even if I put my capitalism hat on I don't understand why one would argue against socialized healthcare. You want productive workers, with the cost amortized across the entire population, don't you? You like that your workers have roads to drive on to get to work, right? You like that there's infrastructure you can leverage for them to make sales phone calls, surely? The entire value of your business is basically leveraged on the fact that there's a national and global supply chain infrastructure amortized by taxpayers, socialized, and nationalized programs, right?

Exactly, yeah. It really is baffling how both the argument against socialized medicine and the argument for socialized road infrastructure both somehow became about freedom— one is the freedom to choose where and when and whether to get care, and the other is the freedom to go wherever you want in your personal vehicle at no cost. Or maybe it's about what you didn't pay for? Freedom is not having to have your taxes pay for someone else's surgery, but roads are a good deal as long as you drive as much as possible on them?

Anyway, as a four season bike commuter and mass transit fan, it seems to me that being a slave to automobile manufacturers and oil companies and urban sprawl is the opposite of freedom, but I don't have a century of concerted propaganda on my side for that position, so most people look at me like I have three heads.

> Even if I put my capitalism hat on I don't understand why one would argue against socialized healthcare.

Honest answer: because currently my family and I have access to above-average care at below-average wait times due to having money. This will go away necessarily due to math. So asking people who are lucky enough to be in this position to support socialized healthcare is tantamount to asking them to value the lives of randoms more than those of their family.

But if you're an American, it's more likely that you actually have average healthcare at higher than average wait times at much higher than average prices, which, unless you're extraordinarily rich, means your quality of life is diminished in other ways (lower quality of housing, maybe, or, idk, you have to retire later, whatever. Less vacations. Idk). And if you're extraordinarily rich the conversation is moot: you can always fly to wherever in the world for whatever private healthcare needs you have.

> This will go away necessarily due to math

Above misconception of the reality of the quality of American healthcare, but also, will it though? If your government cut your military budget by 80% and spent it all on universal healthcare, what has changed about your situation? More people at the doctor so longer lines? I guess you don't think the healthcare system would be expanded to meet needs? Well I suppose that's possible, but it seems very short sighted.

I get this perspective, and it's no judgment on you specifically for holding it, but from my point of view as another upper middle class person, my quality of life is also improved when my neighbours have the care they need.

I don't want to have to live in a gated community so that I can shut out the lepers, and that extends to things like schools too— I want a public school system that gives every kid a decent chance of succeeding and that goes the extra mile to provide supports to those who face additional challenges at home. Even at the cost of a potential opportunity for my own kid. Most of the world is not a zero sum game: the solution to scarcity is to invest and make more of it, not to fight over the scraps.

“I am, somehow, less interested in the weight and convolutions of Einstein’s brain than in the near certainty that people of equal talent have lived and died in cotton fields and sweatshops.” — Stephen Jay Gould

> I get this perspective, and it's no judgment on you specifically for holding it

I'll judge them for holding it. They want the benefits of a society, then they should support that society. Otherwise the message is that they're totally ok with having a slave labor class that drives their Uber for them and picks up their take out order for them, but fuck those people when they get sick.

Yes, let me clarify: Fuck everyone and everything, if it extends the life of my family member by even a day. Judge me all you want

Do you realize that if you started taking shots at perceived threats from your window, because "fuck everyone and everything," society would firebomb your home and thus you would have brought harm to you and your family?

Like, taking your supposedly family-first selfishness to its natural conclusion here. Keep prioritizing family above all else, and then apply some rationality and logic: Why do you think your family can exist in a vacuum? What philosophy are you holding that makes you believe that extending Pure Selfishness to include a couple more people thus makes it work?

Like... you're saying "judge all you want" but we're here discussing ethics so... are you saying all families should operate on this ethical principal? What do you think society would look like then? Do you understand what you could justify under this ethical system? Literally anything lmao.

If I kidnapped your children and pressed them into slave labor picking olives from my olive tree, I'd have increased the quality of life of my family a bit! This is ethical :)

Madness, surely? What's your reasoning? Is this American Libertarianism?

Will do, because you're literally a sociopath.

If you value lives of others above yours as you claim to, why haven't you donated all your organs? You could save a dozen lives.

That's a false dichotomy.

The way you phrase it, you would gladly kill a million people to give your grandma one extra day of life.

A million maybe not. But surely more than one. Now we’re just haggling over numbers.

Normally one wouldn't "haggle lives" over hypothetical of how many you'd kill to save your grandma. Normal people would demand to know what kind of system is forcing them to sacrifice lives in order to save grandma, and why the solution isn't to instead dismantle that system.

Example: limited number of donor kidneys. What will you dismantle to solve this? Not everything can be solved by dismantling something. Some resources are truly limited.

If you'd give a donor kidney to grandma so she could live one extra day vs someone who could live years with it, I'm comfortable thinking of you as a terrible person and part of the reason the world is as shit as it is.

Canada is also facing massive wait times. Plenty of people can't even get a family doctor, they simply aren't taking them any more.

Manitoba is sending 300 spinal surgery patients to North Dakota because they can't clear the backlog any other way.


I've faced long waits for care in the US. I've had my "high quality" for-profit insurance deny coverage or second guess my doctors. Any negative concern you have about Canada's system also exists in the US.

I'm not sure you understand just how long the waits are in Canada.


"Bennett was referred for surgery on her right hip in November of 2013 and said she’s been told she won’t get in until early in 2016. She said her joint has deteriorated so much she is unable to work or even function without strong narcotic painkillers."

And you don't think the Canadian Medicare system denies coverage? Or second guesses doctors? It does.

I am not sure you understand how often for-profit insurance just says "no".

"despite a six-year span of growing literature and updated policies, nearly 1 in 5 patients diagnosed with FAI would still potentially be denied coverage. This highlights a continued divide between surgeons and insurance companies."


US insurance will also make you wait, mandating less costly treatments first, or have you go through a lengthy & convoluted appeals process to finally get covered.

I didn't say Canada's health system doesn't have delays or rationing of care, only that the US health system is not superior, suffering from exactly the same concerns you bring up about Canada's health system, yet costing the US like 200% more, while chaining people to their employer.

What’s different between a private insurer saying no and the government?

You realize the private US insurers say “yes” to things the Canadian government says “no”?


"Then I found out that this other country — which I thought had a healthcare system that was so superior to the U.S. — doesn't test for the tumour marker that saved my life, and doesn't cover this drug that is responsible for pushing my cancer into remission after traditional chemotherapy failed to do that."

American here. This is a bad line of argument. Americans only get 1 insurer at a time, so comparing the NHS to the union of all possible insurers is a strawman argument. Each single insurer covers roughly the same procedures that the NHS does (although insurers frequently deny legit claims and will deny all claims past a certain annual/lifetime claims limit).

And your example is at a single point in time. At one point in time, no US insurer covered that procedure (before it was standardized) and eventually if it actually does affordably improve outcomes, it will be covered by NHS.

For me, the most valuable feature of CA's system is that its incentives are at least mostly aligned with your long term health interests. Only HMOs and active duty soldiers (covering maybe 15% of Americans at most) in the USA are mostly aligned this way. The remainder of US health care is minimally aligned, so costs are outrageous and long term outcomes are sometimes good, but sometimes terrible.

The private insurer is 2x the cost. You don't think people travel outside the US to receive care? Medical tourism is alive and well in the US due to the cost burdens for-profit healthcare requires.

Sure. Under the US system, they "fix" this problem by pricing people out of the queues and they end up dying.

I could reduce the demand for anything if I'm allowed to arbitrarily raise its price.

So the alternative is apparently just the government enforcing a queue to the point people can't get the surgery they need? Is that better?

Plenty of people already aren't getting the treatment they need under the US model, only difference will be that your access to treatment is not as directly correlated to your wealth.

That's not true since the lower income bands have Medicaid which is more generous than Canadian healthcare.

> Medicaid which is more generous than Canadian healthcare

You assume that Medicaid is accepted. It's increasingly difficult to find providers that will accept it.

From 2015:

> A 2011 nationwide survey of doctors found 31 percent were “unwilling” to accept new Medicaid patients, with acceptance rates across states varying widely. Across the nation, the study estimated 69 percent of doctors were accepting Medicaid, but state acceptance rates ranged from a low of 40 percent in New Jersey to 99 percent in Wyoming, according to the study published in Health Affairs. This was pre-ACA expansion and prior to any reimbursement fee changes.[1]

> When comparing reimbursement rates among health insurance plans, Medicaid is the lowest payer, meaning it’s not a moneymaker for doctors’ offices. Paired with the administrative requirements of accepting public insurance, doctors sometimes just don’t want the hassle.[1]

[1] https://health.usnews.com/health-news/health-insurance/artic...

> Relying on the patient to gauge what is fair pricing & what is gouging, then haggle when they get the bill...

You're making a good argument against something no one has proposed.

The point of this effort is to be able to know the cost of something before you buy it.

That's it!

How this can "seem like another way to put blame on the patient" is pretty incomprehensible.

Simply put "Couldn't afford the care? Should've shopped around!". It feels like a non-solution solution to access to healthcare. In theory it's great to have transparency, but in reality this is just pushing responsibility & complexity onto patients, all to continue a facade that market-based economic models work well for patient care & will magically drive down costs.

I honestly don't understand your point.

Do you also consider stores having price information bad?

Would it be better if I went to Target, picked what I wanted, and then got a bill with the surprising cost 3 weeks later?

> It feels like a non-solution solution to access to healthcare.

That's correct. It addresses a different problem.

Do you have years of medical & diagnostic coding experience along with medical training to properly interpret pricing data for a multitude of procedures with wide ranging scenarios? You're not going to Target to buy Cheerios here.

Pricing transparency is a band-aid on the gaping wound that is US healthcare. More numbers to consider that may or may not apply based on your insurance policy & other factors. Let's also add some middle-men to aggregate and "find the best price".

Or the opposite approach - stop mandating hospitals must accept any patient, regardless of their ability to pay. I bet hospitals would all of a sudden become affordable as they want to capture "low-income" market share.

"hospitals" aren't required to do that. Only emergency rooms are[1]. The point: not all hospitals have emergency rooms.

And the problem is less about what you claim (although some of the claim is valid). The core problem with required/not-required dichotomy is that cheap preventative care visits are not required, but expensive emergency care is, hence the average cost approaches the latter as people substitute the former for the latter.

> In 1986, Congress enacted the Emergency Medical Treatment & Labor Act (EMTALA) to ensure public access to emergency services regardless of ability to pay.[1]

[1] https://www.cms.gov/regulations-and-guidance/legislation/emt...

Certain procedures are expensive & complicated regardless. Someone having a heart attack, stroke or severe COVID, would require extensive care. If you're okay letting such patients just die due to lack of funds, then this concept might work. Ethically & morally deplorable perhaps, but honest towards the goals of brutalistic capitalism.


The free market works great for things like Lasik surgery and cosmetic surgery. Patients shop around, get referrals, make a call and pay.

The problem in the US is that's not free market. How can it be a free market if the price isn't posted or isn't known until after the purchase? How can it be a free market if people with good insurance don't care about the cost because they only pay some insignificant portion of it?

Why wouldn't a free market collude and monopolize to maximize profit? Idealized free markets require perfect information. Most consumers of healthcare are woefully ill informed on healthcare matters. The problem with free markets is summed up with phrases like: "caveat emptor", "a fool & his money are easily parted", "there's a sucker born every minute", "penny wise, pound foolish".

Discount laser eye surgery has its own issues with deceptive advertising, misleading pricing, patients being rushed & not fully informed of potential side effects or receiving poor post-op care. People really need to research thoroughly before using a coupon for their laser eye surgery. No one should expect the market to just provide a quality product. That's foolish thinking.

The free market doesn’t collide when there is competition. Just like oil cartels, they barely hold together because the first person to leave the cartel makes way more money undercutting everyone else.

And many of those issues of rushing patients and not explaining risks happens in public systems too. You think doctors work for free in those systems?

And in terms of quality you’d be a fool to not check even in a public system. I worked in the healthcare field and quality of doctors varies widely.

OPEC holds huge power over global oil markets, and is not "barely held together". Com'on. Competition colluding or conglomerating is not uncommon. Much of brand competition is actually various arms of the same parent company. The illusion of competition.

My point was the free market you lauded for Lasik is a mixed bag with some potentially good value for money, but also deceptive salesmen muddying the waters for consumers to make valid comparisons on price & quality. It's no panacea.

I am in agreement that it is reasonable for most patients most of the time to be able to receive some sort of useful estimate to make decisions with. The passage of the "No Surprises Act" was a very positive development in my opinion. https://www.cms.gov/nosurprises

> From an instution standpoint there are some bad apples but a lot of organizations that are not complying are not complying because they are facing technology and operational issues that are stopping them from complying. From the trenches in my consulting practice one example is an institution whose has a core element of their billing system, that is largely a black box even to them, using technologies that are decades old.

I recognize this is the reality. But it seems insane that they have not fixed this in decades and instead charge people based on a “black box.”

I’m sure the fact that they make more money this way has nothing to do with their inability to comply.

From my perspective, as a patient and taxpayer who funds these things through Medicare and Medicaid, I think those who are incompetent and shady are the same to me.

I’d almost rather have a health system try to cheat than so stupid they don’t know what’s happening. The company that cheats on billing seems more likely to be competent than the one who doesn’t know how to cost their care and hasn’t known for decades.

It seems like a classic "just so" story to me, perfect for keeping the public in the dark. I'd think a serious and honest country would develop standard systems that is capable of serving the needs of the majority of users (providers and customers) and then charge proportionally for usage, or else just leave it as funded by the government.

You might think that but the US couldn't even design a website to sell you insurance. Healthcare.gov is still a cumbersome nightmare.

It seems to me that the US Government can get impressive things done if they set their mind to it - as examples, consider their prowess at things like propaganda and waging war.

Idk about the propaganda, but the US is really really bad at waging war. The US just has a ton of resources and willingness to spend outsized amount of budget on "defense."

> Idk about the propaganda, but the US is really really bad at waging war.

Can you name any other country who can come even close to the US's (where they have substantial causal involvement) body count in the last few decades?

And for the propaganda part: consider the US public's opinion on the righteousness of their behavior on the world stage, or the manner in which (from an abstract perspective) they evaluate/perceive the Russian/Ukraine conflict compared to when the US is the aggressor.

> Appreciate the complexity of billing codes, these are not created by hospitals but by by the American Medical Association, Center for Medicaid/Medicare and a soup of other organizations.

Indeed. This "complexity" hides so many obvious scams. Errr...well, rather, it sometimes hides these scams. For example, they billed my wife for an "ER Visit" when she gave birth. Even though the ER was in another building. (Well, except for a little sign that said "ER" over the door to the admitting room. We spent 5 minutes in that room, but it resulted in a multi thousand dollar bill.)

This happens regularly and intentionally.

Sure, there's the unexpected things that happen. But, the complexity of billing lets the experts (hospital administrators) deceptively game the system, and get away with it without any recourse. Enough things happen on a recurring basis that its shockingly easy for them to create "policies" about what to code and when to code -- policies explicitly designed to maximize revenue. (Even if they're stretching the truth.)

> This happens regularly and intentionally.

And there are absolutely zero consequences for this, which is why it will never stop. It’s not even negligence, it’s straight up fraud; and if you refuse to pay, your credit can be ruined, so in effect you’re being intimidated and coerced into just paying it “or else”. I sure wish I had the power to send someone a bill for non-existent goods or services and that it could be legally backed by governments and corporations.

It never crossed my mind that OB ERs would be seen as fraud instead of specialized care for readily identified special populations. I guess this is a major case of YMMV but with three* lifetime trips to an emergency room under my belt I think the separate OB ER is a fantastic idea. The OB ER provided rapid definitive care vs the regular adult ED which was a hellscape.

*the third trip, like you, was passing through the OB ER on the way to delivery and I’d never count it normally… then again unlike you my total cost out of pocket was $5. The financial experience of childbirth has been one of the most useful tools in reframing my understanding of total comp as something very different than salary.

> The financial experience of childbirth has been one of the most useful tools in reframing my understanding of total comp as something very different than salary.

Sorry, can you elaborate on this? Childbirth costs and TC vs salary? I’m really intrigued but not totally understanding

caveat emptor: rando on the Internet...

TL;DR: consumption of healthcare on a gold plated health plan meant that my total comp was more than I've ever gotten in salary on the FAANG RSU train and whereas its easy to talk about RSUs its hard to talk about 'golden EOBs'.

The eye opening has roughly two versions all of which you can see in a peer group when babies start landing:

1. The tail event

Lets say you're a SWE making $500k/yr then you have a child and run up a $2m NICU bill and then a $2m cochlear implant bill after that... most people look at your $500k in 'salary' (base + bonus + stock) and say 'wow you're well paid' in reality what they should look at is your $5 copay and $1k total annual and say 'wow you're well paid' (an extra $1,999k in consumption enabled by your work). Remember it's even more extreme than raw numbers b/c your $1m in wages over these two consumption events gets squeezed through an income tax that (in CA) is ~50% vs. your employer sponsored plan paying the $4m in bills (granted crazy hospital Monopoly dollars) without that tax drag.

2. The ordinary frustration

boplicity and I consumed the same service (OB ER triage) and boplicity ended up unhappy to be out 'multi thousand dollars' in user fees whereas I was happy to be out $5. When a peer groups starts having children this first - for many - substantial engagement with the healthcare system shows just how different 'good' employer sponsored plans are. In my peer group share of cost, network of options, extent of benefits were all meaningfully different even among prestige employer plans. The fear of infinity $ as an upper limit paired with the loss of agency involved in infirmity causes a lot of consternation about the money and choice. It's hard to price the absence of that worry and feeling you got the short straw in the relative buying power game devalues your prestige employment.

For my part, I felt fortunate to be on a plan that exposed me to ~zero financial risk or sense of network loss during a healthcare consumption event. This was not always so. As a healthy single 25 y/o with that first package I ignored 'fringe.' It didn't even make the xls doc from the HR people a free gym you use with your boss's boss is hard to price anyway. Now having worked through the GFC / COVID & consumed some healthcare the RSUs are harder to budget and health insurance reads like a deranged lottery ticket that could asymptotically approach 100% of total comp.

Finally, whether any of this 'ought' to be is a separate question. As a practical matter, today, it is so - my employer can buy things I cannot and can do so with dollars I cannot match 1:1. Sometimes I value them and sometimes I do not. If the person sitting next to me values these more than I do then I am are being under compensated. If HR tried to close that gab with salary we'd have pay equity problem. As such, I believe the present tax / insurance system means we can have any two of diversity of employee preference, pay equity, comp equity (in theory ... in practice it seems we can have zero of three).

Anyway, hopefully that clarifies my thinking a bit. As I said, wouldn't put much weight on it.

I see. Thanks for the reply, makes perfect sense and I agree with you

Thanks for sharing! Billing codes certainly seem like a significant source of complexity. Another area that seems problematic to me is an apparent surfeit of middlemen.

What conclusions might we draw from the fact e.g. a "Pharmacy Benefit Manager" is a job that exists only in the US [0]? Why does it feel like my insurance premiums pay for lots of things that are difficult to attribute to actual improved health outcomes?

Appreciate your insight.

[0] https://www.goerie.com/story/opinion/2021/06/12/op-ed-when-c...

Something that is very little known to most lay people but has profound implications on how the industry is structured are laws loosely called "Corporate Practice of Medicine" (CPOM). A little more than half the states have some version of them. Simply put they require that the organization legally practicing medicine must be owned and operated by people holding medical licenses only. This defacto creates a medical entity for that purpose and a sistered non-medical entity for business operations. Not speaking to the broader reasons of why those laws can potentially be good, the practical result of those laws all but requires many "middle men" in the operation of medical organizations.

Its not immediately clear to my why such laws should require crazy corporate structures with many middlemen when there exists similar rules that law firms can only be owned by lawyers, and they almost always just have a fairly straightforward partnership scheme for their firms.

TIL about CPOM, thanks!

Another question I'm curious about, if you don't mind, is why there is no apparent urgency in fixing the painful billing experience for patients. (aka "why don't billing coordinators seem to coordinate with the patient front and center?") Seems like lots of people are fearful of medical billing, and not only because it's expensive.

I realize providers may be out of network, carriers take time to adjust claims, etc. Still, the staggered/surprise billing seems unique to medicine and a 2nd order effect might be people avoiding preventive care to their own detriment.

Say a patient goes to get some procedure done, the medical work is completed in one day. Shortly afterwards they receive bill A. OK, that's fine. But then X months later, they receive bill B with more charges from some provider that they may not even remember.

I thought avoiding that was supposed to be the job of a billing coordinator. Presumably coordinators are constrained by "things" -- what are the factors that make this experience so dreadful for patients and why are they not being changed?

I'm not sure the short answer is adequate but a few things:

1) US healthcare is absolutely huge, it's perhaps 20% of the total macro economy. Changing anything in 20% of the entire economy is going to take a long time.

2) There has been really significant changes regarding price transparency and "surprise" billing in the past 5 years, so there is momentum to improve the patient experience but see #1

3) Regarding hospitals, many hospitals might appear to be one thing but are not (some systems are fully vertically integrated). They are much more like medical malls, often as a result of CPOM. What you percieve as one thing actually involved dozens of different business entities and hence very discoordinated billing.

The equivalent job of "Pharmacy benefits manager" exists in all systems, public and private. Some entity has to manage reimbursement of pharmacy benefits.

Anecdata: I can't say "pharmacy benefits managers" work the same across _all_ systems. When I had health insurance in a western European country, I'd get a prescription, buy at a local pharmacy (paying out of pocket), then submit the claim + paperwork to ins carrier and they'd reimburse me minus a copay, I think 25 EUR or so.

I can't say with certainty there wasn't some kind of "pharmacy benefits manager" behind the scenes, but everything about the transaction felt simple and like a standard claim. Point being, it's not obvious to me that "all systems" require an entity to handle pharmacy benefits in the way you seem to be saying.

Presumably, that is because the government in the western European country is stepping in to regulate prices, so the PBM (i.e. health insurance company), is not having to do that.

A PBM is just the department of a health insurance company which negotiates with pharmacies and medicine suppliers. Pharmacies are required because society decided a qualified person should be double checking the chemicals that get prescribed to people by a doctor.

The health insurance company is an agent on behalf of an unknowledgeable and unable buyer that negotiates healthcare prices and (ideally) adjudicates the care itself to prevent waste or fraud. They would be better labeled managed care organizations (MCO), because people pay them to manage their healthcare in a sense, on top of providing insurance against expenses over the out of pocket maximum.

Technically, one or more of all the managed care organization's functions can be performed by the government as a single entity for everyone, and is in many countries. However, the US has decided to go with a very fractured approach, delineating large portions of the population into various tribes that receive various quantity and quality levels of healthcare that is adjudicated by various administrators. On top of this is 50 states with 50 regulatory bodies with 50 different rules around healthcare delivery.

Hence, there are a lot of systems and negotiations flying around and a lot of variance in delivery of healthcare.

Simply asking for a price estimate for a very non urgent screening a few years ago got me a reaction from the people at front desk that was somewhere between flabbergasted and suspecting I must be broke.

Here’s a write up I did about the experience: https://blog.karlbecker.com/should-health-care-be-profitable

Interesting article, I have some questions:

> I want income for health care companies. I want enough to make sure they are there when me and my loved ones need them. Every company, whether a non-profit or profit, needs income.

I'm curious about the assumption here: why is market-based income necessary for the existence of a health care institution (hospital, doctor's office, pharmacy, etc) ? These institutions exist just fine when they're socialized and nationalized: see... well, any other country on earth lol.

> And the people providing the extremely worthwhile service of healing people, and easing people’s pain, should be paid well.

Why the assumption that they can't be if the system is detached from profits entirely, such as if it's socialized or nationalized?

I think the quote by your cousin Adam is funny, but I think I disagree with his assessment. Similar arguments are made to counter subsidized or socialized food distribution, the "buying lobsters on food stamps" argument basically. It's kind of a funny argument because it's sort of victim blaming: for the first time in someone's life they can eat like the rich people they see in media, enjoy a high quality of food, and like a human can be expected to, they do it in excess, and that's somehow... bad. But also, it's just mostly untrue, and I think anybody can know this for themselves asking a simple question: would you REALLY eat steak every day? (the cousin claims yes?) Knowing what that would do to your health? Knowing you surely would bore of the meal? And shit, if our society can provide a sustainable system where people CAN eat steak every meal (or whatever "extravagant delicacy" you can dream up), isn't that a GOOD thing?

Can't we say the same of healthcare? If we can create a system where EVERYONE can get high quality healthcare at low or no costs, isn't it GOOD that everyone will thus get high quality healthcare? The counter argument may be "we can't create this system," but I saw, no, you definitely can, other countries have and are doing so, I live in Taiwan and high quality healthcare is extremely accessible to the entire population, and a national effort to increase outcomes and accessibility is underway. I like to say, if you've got money for fighter jets, you've got money for free healthcare.

> well, any other country on earth lol

You really need to learn more about the world so you don't say such clueless things in public.

This is honest advice.

dunno looks like a lot of countries to me


Let's do pedantry through, this one time pedantry will definitely be fun

Also, cmon, I won't insult your intelligence by pretending what you're doing isn't: https://en.wiktionary.org/wiki/concern_troll so don't insult mine by denying it

"a lot of countries" is very different from "any other country on earth lol".

Also, "universal health care" is quite different from "socialized and nationalized". In a lot of those countries, maybe most, health care is delivered by private suppliers acting on a regulated market, just like the US.

Hm, I'm losing interest because we're getting lost in the weeds of "what is most / a lot" and "what is socialized health care / universal health care," the latter of which is extremely difficult to discuss in general with Americans as many political / philosophical vocabulary have had their definitions twisted beyond recognition there. This is pedantry.

My point is that universal healthcare is obviously quite possible, yet America doesn't do it.

Realistically speaking, this is bullshit. Billing has all the data that's required for implementation. The fact that most health systems don't want to publish that data is a reflection of the nature negotiated rates and not a technical problem.

If it's a Medicare requirement that routine combinations be billed a certain way, how is it complicated?

Or is the idea that routine combinations are always used to justify the billing code with the highest possible revenue?

I was pretty pissed off when the local ER and traveling doctor used the CT scan I got to justify a more complicated case, when what happened is that the radiologist made a definitive diagnosis for $20 and basically eliminated any liability for sending me home with a prescription for antibiotics.

(a sinus infection irritated the nerves in one of my teeth and I became concerned about the degree of pain during the night on a weekend...not a particularly grave condition in the end, but easy enough to become concerned about pain radiating through your jaw)

doesn’t the fact that the CT scan was ordered make it a more complicated case? vs one that involved no testing?

In terms of risk and unknowns, no.

Which is basically my point. They charged me a lot for a test that de-risked them (and ruled out much further effort on my case) and then charged me more because they ordered it. I suppose in the case it didn't give them a definitive answer it might be more complicated.

>From an instution standpoint there are some bad apples but....

He makes it easy to tell where he is coming from by using the straw man for all apologists for system failure, those pesky few bad apples.

Fortunately he also states clearly the main problem with a healthcare system run in a semi-corrupt, neoliberal developed country (think aging population):

>I've spent the bulk of my career as a CEO and senior executive operating large health systems.

Outside of elective surgical realms, I've also seen and heard of trends of expensive non-treatment treatments that prolong misery. Take orthopedics with routine cortisone and/or hyaluronic acid injections: delaying the "inevitable" and sometimes hurrying it along.

Then there's the outright Medicare fraud of orthotics, braces, and all sorts of overpriced, shoddy paraphernalia that's mostly concerned with coding (billing) rather than patient comfort or wellbeing.

Delaying the inevitable is one of medicines core functions.

> There are tens of thousands of procedure and drug codes (things that are done or given) and tens of thousands of diagnostic codes

www.mcmaster.com has half a million products. Amazon has who the hell knows. Even factoring in combinations, sheer number alone should not make the problem any more complex than any inventory/product system.

Conveniently, I have worked both in a publishing firm with a catalogue of several million books and in a health firm and am neck-deep in translating algorithmic coverage systems into someone else’s algorithmic coverage system. Please allow me to bloviate:

It is logically complicated far and beyond ordering a book.

Understanding what is even needed for billing up-front isn’t possible in all cases. What happens when you have extra bleeding during a procedure and now need additional units of blood and associated equipment and care? How do you bill this in advance?

Then, we have “medically necessary” issues. Your insurance may cover an issue if it is medically necessary, but it often isn’t clear if it is or isn’t until game-day. Then what? Or, of course, the hospital and insurer may have different professionals engaged in a spirited debate over whether or not a given piece of academic literature supports or denies the necessity of a procedure. So there we have an issue that isn’t algorithmic at all (a human debate!)

Then we have all kinds of other fun issues, like the coding being a living document. The AMA regularly “refactors” coding as the medical world evolves. What was billed yesterday as one code may become two or three different items each with their own conditions applied. Except the old code is still supported as well so now someone has to go back and sus out the discrepancy between the ordering provider and the insurance payer.

So, for very rote procedures it actually is easy to give flat rates and solid estimates. I have a local Doc-in-a-Box facility that offers a flat-rate $90 service for a standard visit which even includes things like x-rays and steroid shots. When I went in with a stomach bug and needed some add-ons it was a simple piece-sheet line item as you wish.

BUT! The world isn’t this simple, medicine is a very complex practice, and so we can’t simply estimate a price out-of-the-gate.

As an exercise, think to yourself - my friend walked up and asked me to make his awesome Facebook-for-Cats app. Well, please provide me an exact billing of what you will need in terms of time and cost. If you’re now thinking “well shoot, what features does he need?” You’ve now founded yourself in a bounded-but-open question. These also happen in medicine and are why “just give me the number” isn’t easy.

> There are tens of thousands of procedure and drug codes (things that are done or given) and tens of thousands of diagnostic codes (reasons justifying the procedure), creating a space well into the quadrillions of possible routine combinations.

10^5 * 10^5 = 10^10 which is tens of billions, not quadrillions

That said, a combinatorial space can be simply represented as a tuple of two columns (10^5, 10^5) instead of having to map every possible (including nonsensical) permutation.

Increase for three or four dimensions.

Patients have easily 20-30 codes per one hospital visit / one bill and ordering matters so sadly quadrillions may be an underestimate.

I'm unfortunately aware, but you don't need every possible permutation to have a unique identifier. That's like trying to enumerate all 2^256 or so Bitcoin private keys. It's a stupid way to approach the problem.

Enumerate atomic elements, not molecules. Only the most useful or common combinations need naming.

So this is assuming that someone would give chemotherapy drugs to a flu patient. The realistic combinations would be much smaller.

What are your thoughts on insurance companies like Surest (now owned by UHC, formerly named Bind), who hide this complexity behind a single all-in copay amount with no surprise billing and no deductible?

My employer offered this plan during open enrollment this year and I’ve decided to give it a try after a few years of getting burned on our HDHP with HSA.

I don't think I know enough about it to offer a meaningful opinion. It appears to be an offering that is employee sponsored so without understanding the costs to the employer it is difficult to compare it with anything. A point that I don't think is all that well understood is that some employer funded plans, while administered by someone like UHC, it's actually the employer that has a large say who, what and how much something is covered. Speaking for myself, I would want to consider what my out of pocket cost to see a top specialist of my choosing in my area would be. Also personally I am not a fan of HSA plans.

For families that frequent HN, wouldn't HSAs be the superior option since this demographic is more likely (for better or worse) to have higher discretionary income to weather the up-front HSA costs until hitting the family deductible limit, after which point incremental medical costs are (mostly) covered by the HSA plan?

I agree that HSA plans aren't great for families that have less discretionary cash on hand.

My personal opinion is that human nature and relatively complex rules about what is and isn't HSA acceptable, tends to make it difficult to reap the tax savings that the system is possible of providing. I have worked with a number of startups trying to determine whether their offering can be paid via HSA and the rules are conflicting and ambiguous that without tens of thousands of dollars in legal fees (which even then only offer some piece of mind) its difficult to determine.

It's just a very complicated thing for people to have to deal with, an example of a potentially covered item: "Over-the-counter medicines and drugs - Effective January 1, 2020, expenses are generally reimbursable unless used for general well-being or for purely cosmetic purposes. Over-the-counter medicine and drug expenses that are incurred after January 1, 2020, are generally reimbursable. This may include, but not limited, to acetaminophen, acne products, allergy products, antacid remedies, antibiotic creams/ointments, anti-fungal foot sprays/creams, aspirin, baby care products, cold remedies, (including shower vapor tabs), cough syrups and drops, medicated eye and ear drops, ibuprofen, laxatives, migraine remedies, motion sickness, medicated nasal sprays, pain relievers, sleep aids, teething gels, and topical creams for itching, stinging, burning, pain relief, sore healing or insect bites. See Kits and Vapor units and refills."

But then within each of those there are things that are and things that aren't, sometimes based on your intent. All that together is a lot of work considering the limits are $3,650/$7,300.

In particular a phrase like "...generally reimbursable unless used for general well-being..." is the sort of tortured thing you only find in a bureaucratic nightmare like healthcare.

This was why I originally chose the HDHP a few years ago, as it was cheaper than our traditional copay plan, and I received ~$2k each January to put into our HSA from my employer. However, as we’ve gotten older, we’re hitting our deductible more often, meaning that we’re putting in a few thousand in addition to my employers part, which has also declined this year to $1400. This new plan from Surest is $40 more per month, and we lose that $1400, but there’s no deductible and copays are like $10-20 for dr visit, $30 for urgent care, and $325 for ER visit. These are all-in prices, so no more surprise bills for the random out of network dr that looked at your X-ray, or 3rd party labs.

Why don't we see some doctors opting out and just doing away with all that stuff? I.e. refuse all insurance and just bill for their time (and supplies)?

I would expect the majority to continue with the current system, but it surprises me that (if it's not about money but rather is about complexity) there aren't doctors opting out.

They are. They call it direct primary care. I pay my doctor a flat monthly rate, on top of whatever the price is for any supplies. No insurance accepted.

There are. In fact this is a quickly growing segment. Often these folks cater to richer patients and are called "Concierge Doctors". Atlas MD in Kansas is a very interesting system aimed at all levels of income and they call it "Direct Primary Care".

Which you ideally can supplement with a high-deductible plan for catastrophic care.

>I.e. refuse all insurance and just bill for their time (and supplies)?

The same reason all licensed <trade> in your area are about the same price for the same work.

They paid years of their life into a system that lets them bill exorbitantly. They're not gonna undercut it. And if they are they're only gonna do it enough to get enough volume to keep them busy, which isn't much.

Outside of that DPC model others mention, it's very difficult for doctors to do.

And while most people think of going to a doctor's office - family medicine, internal medicine, pediatrics, or OB/GYN - as what doctors do, they're actually a minority of doctors, and OB/GYN's do a lot of their work in the hospital. Some of us - I'm an anesthesiologist, but also radiologists, pathologists, critical care doctors, and so forth - don't have a clinic at all. Nobody's going to pay me a monthly or yearly fee, and establishing a billing relationship that doesn't involve insurance would be a real nightmare.

If the gov takes 1k in and another 1k goes to insurance companies, it kinda hard to get people to pay 1k(say a Dr offers a service outside both the gov and insurance) to do whatever when they have already paid 2k and gotten nothing. This is despite that just dealing directly with the dr is a 50% discount...

High opex. Most doctors are also joining provider networks and are somewhat shielded from the ever increasing complexity.

Imagine if the government just paid for healthcare!

Or, as I believe Japan does, dictate what a procedure costs.

i forget the details but it also use to be like that in the US though some kind of membership org and in europe by gov committee. Doctors could opt out but got no patients from the system.

Okay. Then what? It would be free? The codes would be cleaned up and complexity would go away? Magic!

Then it would just be yet another complicated bureaucratic government process about which the private sector would be blissfully unaware. The OP is about price transparency to make the market function more efficiently. If you have a single payer, there is no market, just healthcare administration.

This is true. It would be as easy as getting a passport. Perhaps we may even use a healthcare version of a TSA precheck for an expedited line.

Every US citizen already has a social security number which is similar to the Medicare number that all Australians have. When I go to a doctor or a hospital, I just give them my Medicare number.

Imagine changing the constitution!

There’s an article in the constitution that says the government can’t pay for healthcare?

Excuses are excuses. That is you have to force them so they give the info their patients. Well, just continue pay fine until you comply would be an option. Not just it is a black box and I do not care how money change hand. And at what price.

It is a black box after all It is a black box after all …

This hell loop need to escape especially their patients.

Thanks for dropping in and providing a lot of good context here!

I’m a former healthcare venture capitalist who left my role back in May to learn CS and tackle some of these problems from the trenches…where in particular would you recommend I focus my efforts given your years of experience?

There is the classic triangle of patients, providers and insurance. I think in any path you choose you have to think about which leg of the tripod you want to put forward.

There is this wealth of new pricing data but I haven't yet seen it employed in really practical ways that help patients day to day so I think there are some oppourtunities there. I think GoodRX has done a very good job in improving patients decision making around drugs as an example.

The other point I frequently make is maybe not to overshoot too far. There are a LOT of simple problems that need solving. I think I see a pitch about this or that "reimaging healthcare" every day. In practice there are huge and obvious problems in the basics of provider and patient communication. For people with serious illness making sure the patient knows and can get to the right place at the right time is very underserved.

One benefit of this transparency initiative is that patients will come to see how little of their bill goes to physicians.

I hope this succeeds. My daughter was born with many medical issues and understanding the billing was always near impossible. Nothing could be gleaned from the bills which would arrive 6 months to a year later (sometimes 2 years) from the insurance company. In what world can I not know the price of something before hand? If I go to a restaurant and see hamburgers cost 6000$, I wouldn't buy one. But with medical it is always a surprise.

I'm also really hopeful for this. A couple years ago I had a potentially serious injury and the local urgent care clinic said I needed a trauma center. The message got lost in translation and I ended up at a Northwell Health hospital that did not have a trauma center. First they ignored the documents that I gave them and let me get past their triage so they could bill be and then told me that I needed a trauma center. After signing a refusal of care form and paying something like $200 to get out after getting zero care, I went to the nearest hospital with a trauma center where I was very quickly received by a full trauma team, got a CT scan, and determined that my condition was not serious.

I got a bill from the trauma center hospital for something like $500. Based on what I've been conditioned to expect from the U.S. health care system that seemed pretty reasonable. Then I got a bill from Northwell Health where I recieved no care for more than $800! Around that same time the NY Times came out with a piece about Northwell overcharging (https://www.nytimes.com/2021/03/30/upshot/covid-test-fees-le...). It took me months of badgering both my insurance company and Northwell to stop sending me payment delinquency notices.

Now, more than a year and a half later, they started sending me bills for that $800 again! So I'm very excited to see this kind of open source approach at this problem.

This is why you don't go to urgent care clinics. Half the time they don't even have doctors there, just NPs with online degrees.

It sounds like you inprocessed at Northwell Health, went through billing, saw a Nurse/PA/NP, got vitals taken, met with an ER Doc, and received a confirmatory diagnosis, and the ER doc spent the time to read your documentation.

For a hospital, your care is not merely the interventional aspect of medicine, but also the vitals, diagnosis, charting, and time spent on reading your documentation by a medical professional with > 20,000 hours experience & training.

If I take my car to a shop, the shop contemplates my car, and concludes that they can’t help me on that visit (because they’re the wrong shop, they have the wrong part, etc), the usually charge me $0. Maybe $15.

I have never in my life experienced an ER doing anything competent that remotely resembles reading documentation as part of triage. Why on Earth should they get paid more than a tiny nominal fee for the use of the waiting room and a bit of time spent by the triage staff?

My understanding is that this is because the car repair market is heavily regulated, estimates are required for all repairs, and payment is based on a standard number of hours for each job, not actual time taken. The cost of estimates is already wrapped into the cost of the completed repairs, and estimates are required before work is done, so few places charge for declined estimates.


I think it's because car repair shops can't get away with being a total dick.


"Terell's cousin is handy and while he's not the greatest he can probably get 'r done for more time and frustration but a lot less overall expense" is the nuclear option that caps how big a bag of dicks a shop can be.

Barrier to entry is low and they don't have an AMA cartel lobbying the government to protect them which helps a lot too.

>If I take my car to a shop, the shop contemplates my car, and concludes that they can’t help me on that visit (because they’re the wrong shop, they have the wrong part, etc), the usually charge me $0. Maybe $15.

Because you're a regular.

If you're not a regular customer of theirs expect a diagnosis fee that's about equivalent to half an hour of labor.

Yeah, but you are still informed of, and sign agreement to the diagnostic fee.

They also won't charge you a diagnostic fee if they know ahead of time that it is a service they won't provide like in the example. If I somehow end up at the tire shop for an AC service, they don't send me a bill 6 months later for an arbitrary amount just because they had to tell me that I need to go to the shop down the road for my issue.

I don't live in the states anymore, but I genuinely don't understand how any of this is legal. If I started sending out invoices to every client months later for services that they didn't know they were getting, with arbitrary prices, sometimes with egregious errors on them, I would expect a knock on the door from the authorities.

If the human body was as easy to fix as a car you might have a point.

They had a full report from the urgent care clinic including x-ray and blood test results. They added precisely zero value. It was a completely inexcusable failure of triage, solely to extract money. I paid the $200 or so on-site, and even that is not defensible IMO.

I was visiting Singapore, and I had to take a family member to a hospital. We went to the emergency room by recommendation of the private hospital’s front desk.

The front desk also had a menu of pricing options there for us to see - a rough cost of the entirety of the visit’s potential costs was glanceable right as you walked in the door. It was amazing, excellent, and I’ve never seen anything like it anywhere in the USA or Germany.

I hope your daughter is doing well now. I wrote Hacking Healthcare for O'Reilly, yada, yada. If you still have these bills and would consent to sharing them with me they may make a good example to share publicly (redacting any private info) to help explain what happened, what's there and why.

You can email me at du@50km.com .

Thank you for asking. She is 24 hour ventilator dependent (spina bifida, chiari malformation, etc.. etc..). She just celebrated her 5th birthday last month. My wife and I hope she will be able to breath on her own someday too. As for bills, I would be shocked if I could not find any as we have piles of them. We have relocated to France, but had no outstanding balances before leaving. I have noted your email and will check our files for bills this weekend. I have absolutely no problem sharing them. Anything to bring light to the insanity and opaqueness of the US medical system.

>In what world can I not know the price of something before hand?

In a world where you're not the primary payer.

The complexity of healthcare prices is an artifact of decades of negotiations between providers and insurers, with the added headaches of linked diagnosis and procedural dimensions.

IME the pricing is so overtly complex that transparency into it isn't going to make much of a difference, it's just going to create more questions. If you want simplicity, switch to single payer.

Probably because the US healthcare system has been so corrupt for many years that, sadly, people are taking it as the default/normal state. Going outside the US and seeing how other countries handle it is an eye-opening experience.

In my country, it's corrupt and cheap!

In other corrupt countries, even the corrupt people recognize the value to society of having a decently-working healthcare system.

Agreed, it's a huge mess. Often, you are also not always told when something is even a billable item at all. You can find examples of itemized bills including things like band-aids at crazy inflated prices.

I've received bills from entities halfway across the country with no fucking clue what role they actually played in care. It's completely fucked. No other industry gets away with billing this messed-up and sloppy. And I'm 100% sure some of the errors are "accidentally on purpose".

Caveat: I get that humans are a lot more complex than cars.

Medicine is one of the most well-documented, well-studied fields in human history. Every single thing a doctor does and charges for is stored and coded in an electronic system.

It blows my mind that my mechanic can give me an accurate estimate and they are legally bound to honor that estimate. However, my doctor can't even tell me how much my routine medications will cost.

Hell I can't even understand what my dentist and orthodontist are billing me for, it just looks like they're making up all sorts of charges.

The key difference is you don't need the burger but most likely do the hospital thing. This is where the exploitation lies.

Very true. The optional part comes in with the itemization of items in the hospital room like baby diapers or a tylenol. I would definitely bring my own if I knew the hospital would bill me (or my insurance), 800$ for a tylenol. I live in France now, so it is a different story (doctor shortage currently)..

If that was truly the only exception, then it wouldn't be the case that I am only told the price of routine, non-life-threatening visits after visiting. Things like yearly doctor checkups, dental cleanings/checkups, vision checkups, specific x-rays/MRIs, etc.

Yes and no.

When my wife had our first child, the hospital sent the placenta out for sampling without our permission. This "in network" hospital then billed us for an "out of network" expense on a decision they made without our consent. Same hospital also double charged us for anesthesia because they choose to have a CRNA and anesthesiologist in the room at the same time.

Thankfully, my wife works in healthcare so we called their BS. We suspect that this hospital is doing this to essentially birth.

We also need to start acknowledging most medical care is urgent and not a choice.

Happy to see some movement on at least price transparency though.

Most medical care is not urgent. In fact, emergency care is a tiny fraction of all medical spending.

Thus the ability to "shop around" and thus subjectivity of medical care to price competition definitely exists in the majority of cases. If the system were setup to incentivize and support this. But due to lack of price transparency and skin in the game, there is no competitive pressure on pricing in practice.


Your link doesn't support your claim about shopping around.

Most health insured patients can "shop around" in their network, which is a list of pre-negotiated priced providers that the insurance company has approved. Providers that are already vetted to be the lower cost for insurance, created through purchase power. And that's assuming it isn't an HMO, for which there is no shopping around.

There are not enough options for real market competition in healthcare.

Just like how we can shop around for our internet here :)

It's wild to me how folks will continue to support the predatory healthcare industry here.

Yes, increasing competition will lead to better results for society, in all markets.

Through competitive pressures which drive down cost and encourage increases in quality.

There is very little competitive pressure in healthcare from the consumer due to the issues already mentioned above

You're not wrong that competition helps, but you're being naive if you think healthcare is a market, or that it would not eventually be captured like so much else in the USA.

In fact, I think you'll find most of healthcare has already been captured by private equity, resulting in worse outcomes for the both doctors and patients.

Healthcare is inefficient for many reasons, most of which stem from poor laws/controls, lack of individual incentives, and poor transparency. All of which can be solved trivially via well structured laws without radically overhauling the healthcare system.

Protectionism limiting the number of doctors inflates wages, lack of price transparency removes ability to comparison shop, max out of pocket plans remove incentives to consider cost in care. All of these are easy to solve once they're identified and understood as problems.

When you look at disciplines where pricing is transparent and insurance isn't generally involved, like cosmetics/plastic surgery, the costs are quite cheap. Because it actually acts as a competitive market with incentive for consumers to comparison shop

Dang, that must be why everyone flies overseas for hair transplants.

Or maybe. . . maybe you're talking out your ass.


If you're not going to bother to be right about that, I can't take you seriously saying that our situation is trivial to solve, but that also the solutions that work in other countries won't work here. Call be crazy.

Elective plastic surgery is hardly inexpensive in the U.S., or representative of healthcare in general. I don't know why you're so hung up on price transparency, it simply isn't the silver bullet you think it is for reasons repeated throughout this thread.


My comment's point was that it's theoretically possible for healthcare to allow for shopping around, but in practice it's not. Due to lack of price transparency and lack of incentives for consumers to care (max out of pocket)

I love how we go to theory instead of looking at other nations where healthcare works, like Australia. American exceptionalism at it's finest.

America didn’t become great by copying Europe. Or Australia.

There are obvious flaws in the healthcare system that are apparent from first principles. No need to blindly copy others.

Removing incentives for people to use the system efficiently leads to poor outcomes in different ways

I never said blindly, but I do love that you admit to thinking America is great. What other countries do you think are great?

More people want to move here than anywhere else in the world, enough evidence for me.

It's evidence for more migration being permitted from places that are worse off. That is not evidence of greatness.

Out of the frying pan, into the fire.

I think if you visit a place like Australia you'll realize it's much more of a melting pot than here.

Believe it or not, you were raised by American education to believe this is the best country in the world. Take some trips, you'll change your mind if you get out into the world.

This is the entire purpose of this legislation. It requires hospitals to publish their prices for these specific “shoppable” services.

The problem with this legislation is that prices at one hospital are only useful in comparison to another hospital’s prices. Since the law doesn’t provide a facility for comparison, even the compliant hospital’s data is nearly useless. There needs to be a centralized database with compatible definitions for each procedure that allows consumers not just to see the prices, but to directly compare them.

Is most medical care urgent? I dislike asking for citations, but that is quite the claim!

Are you saying the majority of patient-practitioner encounters are emergency visits, or that the majority of spending is on emergency care, or something else?

I'd expect the majority of people's encounters with big medical bills from hospitals before old age are either emergency, or childbirth related, so those are the two things you'll see young and middle-aged people complain about.

But the biggest bills are probably near end-of-life, and mostly not emergency care.

Sure, that makes sense.

We should also acknowledge that it costs money to deliver and we live in a resource constrained world.

That doesn't seem to have stopped most other countries from having free or near-free healthcare. You shouldn't even have to think about money when dealing with hospitals.

This language isn't very helpful. It is likely paid for from general tax revenue. That might be a better implementation but it certainly isn't "free". And if it isn't explicitly paid for via tax revenue it will end up being paid for via inflation if the government spending is out of line with its revenue.

The language is fine because that's what the word "free" means. Do you complain that a cloud provider's free tier isn't really free because it's paid for by other customers?

It seems it's only with healthcare people forget the meaning of the word.

By "free" I meant "free at the time of treatment". Of course nothing is free. Traffic lights aren't free. Road maintenance isn't free.

Many people really don't connect the dots between tax policies and health care insurance/payment policies. Saying that health care/insurance is "free" makes it difficult to have a coherent policy discussion.

I know the ship has sailed on this but it I continue to see people truly believe that they are not paying for health care and that sort of misguided understanding of economics shouldn't be encouraged as it makes it difficult to have coherent discussions about many different public policies.

    College education should be free...
    College loans should be free (even when they weren't when the loan was taken out)...
    Income should be free (UBI schemes)...
If you switch to "subsidized" from "free" the list expands exponentially.

As is common in these discussions, I’ll reference the French system as I experienced it.

If you have to go to the hospital, that’s not billed to you.

If you see your GP, they charge you up front. There’s no copay as in the US system, the doctor just charges what they want. The doctor doesn’t keep any significant medicine on prem. If you need a vaccine, they write a script that you take to the pharmacy and return with. In either case, you submit your paperwork after the fact and get reimbursed. For office visits it’s 80% of the “reasonable and customary” changes. For medicine it’s usually 50-60%.

You can purchase additional insurance that covers more of these costs, but I didn’t see any value in it for my situation.

When I left, French insurance companies were setting up US style networks with doctors. If you saw an in-network provider, you were reimbursed more.

Only the truly indigent get “free” healthcare under the French system.

The cost of the thing is effectively irrelevant if you both need it and don't get the bills for weeks/months. If patients are expected to self-ration, they need the info up front...

Government restricts the resources available for health care with the idea that it costs to much to have extra.

So my local hospital just does whatever and charges Medicare their CAH rates, doesn't matter a lot if they suck or could be cheaper, no one else can open a hospital (both by state law and because Medicare probably wouldn't agree to pay them).

I think it's unethical that this can happen to people, so I justify my actions in these cases as an ethical opposition to being strongarmed:

this happened to me when I was hospitalized for a heart palpitation that matched a side effect for medicine I was on as an emergency that, according to the medicine's documentation, warranted a 911 call. I turned out to be fine, yet my insurance company decided I owed a couple thousand bucks for the ordeal.

I was doubtful and so when I got the bill (3 months later and very unexpectedly), I simply started making calls to get someone to justify me why it was my responsibility to pay the bill and not the insurance company's. The hospital said the insurance company already paid some ungodly amount of money for my bill and the bill was... some made-up clown world insurance company term. Copay, or payable, or deductible, or co-insurance. How many new daft words do they have today? This was 2015.

Insurance company just didn't have clear answers. I read the policy, it was vague enough that I was arguing that the entire hospital visit should simply be 100% covered, I'm guessing the insurance company didn't have a way for their support staff to make the legal argument they'd have to make if I just straight up sued them for it. That's probably the only way to get a clear answer: sue, and get them to trot out a lawyer to say the justification to me.

I honestly was happy to pay what I truly owed, I just wanted to make sure I wasn't overpaying, that's all. But lo, I lost the paper bill, and asked the hospital to send it again in the mail. They did, 6 weeks later. The account number on it was different than what I wrote down. I asked them to check. They sent another one, 6 weeks later, correct account number, my name mispelled. This comedy continued until the bill was sent to collections, a year after the original bill. The collections agency couldn't provide proof of debt, and it was sold again, to a different one. This one also couldn't provide proof of debt. 3 years later I'd still get random calls from some new debt collector. The original hospital had shut down, and so nobody could provably connect the debt they had bought with my phone number on it, to the identity of the person that walked into the hospital. I mean, honestly at this point I'm not even sure if there was a genuine mistake in billing: there's literally no way to know now.

Regardless, I never paid the bill, and this remained my strategy for the miserable few remaining years I had to deal with the USA healthcare system: just make some phone calls and the bureaucracy will get so tangled up in itself it seems I could continually just slip through the cracks unscathed.

Before anyone asks, nope, the unpaid bills never showed up on my credit report.

Great idea!

I'm working on something similar, digitising my daughter's 213 pages of medical bills by building an app specifically for digitising printed medical bills. https://kingsley.sh/posts/2022/digitising-213-pages-of-medic...

Everyone kept saying "make sure to check your statements", but when the statements came, they're 9pt font, 50-70 line items per page. 1 page, yes, 10, maybe, 213 is impossible.

In the middle of working on it last week, I got a $3000 medical bill, for my daughter who passed away 1.5+ years ago, for part of her 7 month ICU stay 2+ years ago.

I'm so sorry you've had to go through all this, and especially for your loss.

I don't have advice or anything. I'm just sorry.

Wow. Would love to help you build this and pay you for Apache 2.0 release of your work with our grant money - emailing you now :)

I would suggest to now compare the prices for standard procedures in the US to the GOÄ[0,1], which is the German central medical fee list for anything medical as agreed between doctors and insurance companies.

Hilarity will ensue, since US pricing is an unbelievable rip-off.

Edit: In addition to procedures, there is a list for fixed drug cost [2]. The site hosts a PDF with pricing for any drug.




The reality of is that for profit insurance companies want an opaque and high pricing structure. This allows them to charge higher premiums across their entire set of customers meanwhile the number of people that are getting seriously sick or injured is small allowing them to create huge profits.

So these higher prices, create higher premiums, which create higher profit, so there is no actual incentive for the insurance companies to get hospital prices down because the majority of their insured users are not going to be getting massive bills throughout the year and also they can still litigate or pass healthcare costs back to the customer due to coverage issues and let's not forget deductibles.

This! And not only are they for-profit, they're public companies, too! Companies that are required to increase revenues, make more money each quarter, etc.

Imagine the long-term cost savings to the consumers if massive insurance companies were banned from lobbying or "influencing" lawmakers.

Just like the problems with pay transparency / publishing in job listings, what good is the publishing of hospital costs, if they inflate the rack rate prices to handle people who walk in without insurance, but discount everyone else to the Medicare rates? It doesn't give you any real comparable reference point between hospitals, does it?

As an example, you get a bill for $100k for a one-night hospital visit for an emergency, but it gets knocked down to $15,000 at Medicare reimbursement rates, and then you only pay $1,000. Which price should be shown? It is any use to show the $100k figure?

Or am I missing something that has changed? I mean, I'm all for these efforts but if there is no consistency / meaning behind the numbers being used, it's no good.

I'm the author of the article.

The inflated price you're talking about is called the "gross price." It's a made-up price, or MSRP. Just publishing this price list isn't that helpful.

The price lists are supposed to contain the negotiated rates with different insurance companies or medicare. Those reflect the rates that your insurance company pays. You pay some fraction of that depending on your plan.

Most price lists don't contain this information, though.

The purpose of the article was to see how many of them contain the elements that are required from the transparency bill, the ones which allow meaningful price comparison between hospitals. And the answer is... not that many do.

But among the ones that do, you can kinda sorta make a meaningful comparison (but there are even caveats there as well.) Feel free to follow up if you have more questions.

You're right! We're linking this data to the negiotated rates :) and building the search engine for both of these at payless.health.

Thank you!

Eh? So even with insurance you pay $1000 for one night in hospital in the US? Or are you just making up an example figure here.

Tangentially related, Russ Roberts of econtalk had a good interview a few years ago with the founder of a free market hospital in Oklahoma. Super interesting.


I think of this every time I encounter a healthcare worker who talks about how it’s “impossible” to estimate and brings out some edge case of a routine $50k procedure costing $500k with complications and leaving out the part how there are many instances where it only costs $25k.

It’s like hospitals pretend to be idiots when other industries can estimate a median cost and price accordingly. And they have estimates good enough to be profitable.

Even barbers charge $30 for a haircut when some take 5 minutes and some take 30. If a barber didn’t post prices because it’s impossible to estimate how many minutes it takes to cut hair I wouldn’t use them unless my life depended on it.

It's much easier to offer estimates for specialist clinics.

In hospitals? The honest answer is they often don't know the true costs. They'll know the costs specific to a department, but the "shared" costs of the hospital, staff (who work across departments), etc are a major shit show.

That's not to say they can't find out, but it's not easy and frankly they don't do it because they don't have to.

They don’t need to know the true cost. They just need to estimate well enough to break even. They do tens of thousands of procedures each year.

The podcast goes into this concept and their hospital isn’t a specialist clinic, they do everything a hospital typically does.

They don't know the true cost for the full stay, but they certainly know the likely daily cost.

They don't.

You might get an operation in a hospital and stay one night. They could tell you the cost of the bed, but what about the lab tests (which is another business unit). Then you've got nurses who might work across two different units. Then imaging which is another unit.

My friend who worked at a major hospital said it's a massive shit show. For simple out-patient procedures, they have the costs down pretty clean. But for in-patient stays, they often have no clue at all what the real costs are.

They know on average. How else would they project how big of a hospital to build?

It’s a massive shit show because they don’t care. There’s no cost incentive to be efficient. And many healthcare providers are cost plus so if they have higher costs it actually results in higher absolute pay.

I'm confused. Is this already a searchable database? Or is this in the 'data gathering' phase?

I'm the author (Alec.)

This is the data gathering phase. When we're able to release a database of these hospital prices with high data quality I think it'll be a pretty big deal, just because it's so much work.

It's hard as hell because of how inconsistently formatted these price sheets are. We'll need to develop a robust ML tool to process all of them in a consistent way, or just put a lot of man hours in. That's something that One Fact is working on. DoltHub's main interest is in producing the source databases, which is just a lot of grind work.

We're crowd sourcing the data collection via a "data bounty." It's like a scavenger hunt where you get paid for the data you input. I designed the table and I'm who reviews the data going in, via pull requests.

Incidentally we do have a hospital price database here (the only open one of its kind) but with mixed data quality. https://www.dolthub.com/repositories/dolthub/hospital-price-...

Seems like this is the actual db, but the only table I see is "hospitols" which just has the websites and... a link to `cdm_source` which seems to be the pricing info for each hospital

Not sure what they mean by "bounty"

> This bounty will be run in 5 parts of 1 week each

Is this some sort of crowd-sourced effort? Like GasBuddy but for hospitals? Their GitHub also some "example" apps with React, Lit, and Next


I guess I should try building one of these examples first

Funny that they obviously have the resources for making example apps in multiple frameworks but all their main websites are just the MarkDoc template with different text haha

Direct link to the hospital price database > https://www.dolthub.com/repositories/onefact/paylesshealth

This is just a database of hospital price URLs. If you want actual prices we have that as well but it's from the beginning of the year:


Thank you for doing this. It's good to know that this information is publicly available. I was not aware of the 2019 legislation and it would be helpful to know what the name of the law is.

I went to urgent care back in 2021 to have a few different tests run, pretty standard stuff. I asked for a price quote and they refused to give it to me. There is no other industry where sleazy practices like this are accepted.

My first job out of college was creating long term facility software, like Epic if you're familiar with that world.

After my second or third major project to support ICD-10 codes, I knew this was an industry I really didn't want to create software for, but also that it was an industry that definitely could use some quality solutions.

"it was an industry that definitely could use some quality solutions."

>> Check us out! augusthealth.com

This law was insanely helpful for my wife as she tried to establish pricing for her own small business. Going from a drone to your own boss, it's hard to wrap your head around how much more you should be charging. It's a lot. Like, multiples.

This seems very cool.

But, at the risk of seeming extra dumb: is there a way to contribute to this project for people who don't know how to work with SQL?

Sure, SQL knowledge is helpful but optional.

There are ways to import CSV or other flat files, either on the command line or on dolthub. You just need to make your file's schema match the table's.

I've seen dolthub's work progress in this space from afar -- they are solving a hard problem!

One of the most frustrating things is that insurance companies seem to push for strategic bitrot, making it difficult to programmatically or frequently collect the information from a large group of payors.

obtuse data pipelines are a strategy..... if the government forces you to make something available, it doesn't necessarily have to be easy to get

This is cool and, I believe, a necessary step.

I know that some hospital price data has been previously available for years on govt websites listed by billing code. You could, for example, see the price differential between getting a procedure done in Alabama vs. Oregon. This article states that hospital data was only available after 2019. Is the distinction that the previous data was only based on Medicare/Medicaid reimbursements? Or that they weren't itemized lists?

Sounds like you’re talking about Medicare rates. A lot of hospitals and payors use them as the basis for their price lists, but unless you’re an actual Medicare patient it’s probably not what you’re actually paying.

This data is collected from hospital “chargemasters” - which lay out the maximum amount a hospital will charge for a given procedure. However, hospitals have negotiated rates with payors that are almost always less than the chargemaster rate and are kept private.

As a broad generalization, you can think of Medicare prices as the minimum a hospital will normally charge, and the chargemaster rate as a legally-enforced maximum.

Now what is needed to get data on outcomes as well? I would likely choose to pay more for a increased chance of success. (Recall the recent coverage in HN of the professional musician for whom retaining ability to play saxophone was of great importance.) I recognize that some hospitals either serve more impaired populations or take on more high risk cases, so the comparison is not at all easy.

Yes! We are working on this and integrating with the OMOP common data model, to be able to link the health outcomes in our data partners' clinical repositories to the cost of care. For example, we work with the NIH All of Us study for outcome data (joinallofus.org -- I signed up both to contribute to this science and to get my whole genome sequenced free!)

I really wanted to build something like this but never found the time. The challenge was ETL-ing all of the data provided by hospitals.

I'm the author. That's right. At least, starting from our database, you won't have to do the hard work of tracking down each of these 5000+ URLs.

I hope this succeeds.

A single MRI can take up to 200 gb of storage space. The health system has about 7.5 petabytes of data in storage arrays alone, all of which is active and separate from backups.

About one petabyte of that data is unstructured (which includes MRIs and other imaging data), and that’s the type of data that’s growing quickest.

This is being done on purpose to obfuscate the pricing scheme. A shame on the industry. I have hope that, together, we can succeed and crack this.

[1] https://www.itprotoday.com/file-storage-and-block-storage/ho...

* not sure how reliable this one source is, there isn't much information out there to verify against.

"Illness is neither an indulgence for which people have to pay, nor an offence for which they should be penalised, but a misfortune, the cost of which should be shared by the community"

As a citizen of a country that has free-at-the-point-of-use healthcare, all this talk of billing codes etc... just sounds like another expensive and complex system to try and alleviate the current expensive and complex system.

This is amazing work. All hospital pricing should be public and transparent.

I've gotten hospital bills and other medical bills with a date and a dollar amount, but never to details. With all the other health care regulations, how is that legal?

The system favors the insurance companies and the healthcare providers, but puts its thumb on the scale for anyone else. And that system is slow to change for exactly that reason. That is, the status quo is quite happy printing money. Anyone else? Not so happy.

If only health care was about health and care.

While I'm sure the transparency is a good idea, I'm guessing is only important because US hospitals mostly charge individuals rather than health insurance providers / healthcare provider organizations ("sick funds") - and thus people are surprised by exorbitant fees and hospitals have a motivation to overcharge, rather than the fees being negotiated and agreed in bulk.

>I'm guessing is only important because US hospitals mostly charge individuals rather than health insurance providers / healthcare provider organizations ("sick funds")

No, they charge the insurance, but US healthcare providers are still required to show individuals the billing details.

This is important because people still pay for amounts up to their deductible and out of pocket maximum, so for non emergency healthcare, a patient still has incentive to compare healthcare prices from different providers.

> This is important because people still pay for amounts up to their deductible and out of pocket maximum

In many world states, if you have health insurance, and are referred to hospitalization, or come in with a wound or other obviously serious condition, your deductible/out-of-pocket for being in the hospital is exactly 0. Israel is in this category for example. This doesn't cover 100% of hospitals but all the big ones and your "sick fund"'s hospital-grade facilities.

In other countries (e.g. the Netherlands), a lot of health care expenses are charged through to you from the get-go, but - your annual out-of-pocket maximum is low, e.g. 500 EUR or 700 EUR or something like that (EUR ~= 1.05 USD right now, was higher when I was in the Netherlands). So, you might be interested in what hospitals charge, but it's not like you would save all that much anyway.

Perhaps confusingly, they charge both. Most insurance requires substantial "co-pays" where you pay a good chunk (20% is common, but it varies, often even within a plan depending on what you're paying for) of just about every bill until you hit some very-high "out-of-pocket max" (usually there's one for individuals, and a higher one for families) and then insurance picks up everything, or you pay 100% until some total-spending value for the year is reached, then it becomes like the prior situation until the out-of-pocket max.

Though most insured people don't really have options to shop around. You go to the few places your insurance covers, which is usually 30-60% of providers in a small geographic area. Which is why the "we want to protect your choice!" opposition to healthcare reform is so damn weird. Most people already have very little choice, in practice, and a lot of the "choice" we do have isn't anything desirable ("which of these shitty insurance plans I can barely understand and am not confident I can meaningfully compare, would I like to suffer through?").

A discussion of healthcare pricing would take hours, but here's a TL;DR:

Most insurers pay negotiated rates, which have no real relationship to list price (uninsured pricing). The law is supposed to (1) make it easier to compare costs, and (2) shame providers into lowering their list prices.

Obviously the industry has been fighting these regulations for years.

The annoying thing is al the games they're playing. Everyone already has a list of prices by CPT code, because it's what billing uses. Just list all prices by CPT codes. The industry refuses.

And IIRC, the insurers are for-profit, right?

What about the hospitals? Are they mostly for-profit or non-profit entities?

Hospitals charge insurers negotiated prices. So these prices mostly impact:

- what insured persons pay until they reach their deductible (and how high that is depends on the insurance plan they have, cheaper plans have higher deductibles)

- uninsured persons

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