Yes, this non-transparent pricing, and weird discounts you can maybe ask for if you know how to ask (and if you figure out who to ask) drives me nuts. Sometimes you are better off being billed via your insurance; other times you're better off not using your insurance (even if you have one) and negotiating a cash price. And it's often hard to tell which one up front.
Supposedly one of the downsides of more socialized systems are that they're bureaucratic, but I think the U.S. system, whatever you want to call it (it's not really either a functioning market or a properly socialized system) is somewhere near Peak Bureaucracy (certainly more than Denmark's, where I now live). It doesn't help that everyone bills separately: if you ever have to visit a hospital, you will get something like 15 different bills, because everyone from the anesthesiologist to the surgeon are apparently independent contractors, or at least bill that way. And you have to go through the same opaque negotiation process with each of them. And many of them are sloppy and contain errors, e.g. billing you for things that insurance actually should have covered.
I'd be fine conceptually with a model where catastrophic care is insured and smaller expenses are paid for out of pocket. But then I'd like: 1) the catastrophic care to actually, 100%, guaranteed be covered, without loopholes, lifetime maxima, excluded conditions, etc.; and 2) the smaller expenses to be priced transparently up front.
I have an appointment with my doctor soon. I asked them how much the appointment will cost. They called my insurance company. The got back to me, and the bottom line is nobody knows, and nobody will know until after the insurance company is actually billed.
For any other service I'd just not buy it under those conditions, but if I don't go to the appointment then eventually I'll die.
Doctors often have a cash price and an insurance price, with the former being significantly less. I have a high deductible insurance plan, which means I effectively pay for most stuff out of pocket. So when I call, I ask them what the cash price is. I then explain my situation and ask if they'll honor the cash price since I'm paying out of pocket anyways. They always tell me no.
I mean, I get that they probably can't start discounting insurance claims because of my deductible or else they'd have to do it for all insurance claims, but it really grinds my gears that for all my insurance premiums, I essentially get the privilege of paying a higher rate.
I haven't tried it, but would it be possible to just not give them your insurance information, and pay cash? I realize then it wouldn't count against your deductible, but you could basically reserve the insurance for cases where you ended up in the hospital then. Or would that approach cause possible troubles with later coverage if something major ended up being a continuation of a visit that started initially "outside" the insurance?
That would work. It just requires some planning (which is my fault for not doing).
The problem is that my deductible is like $1300 or something. Now I don't remember the last time I spent $1300 on medical services in a year. On average, it's probably more like $500-$600 (I'm young-ish and reasonably healthy). So based on that data, I should probably get the highest deductible possible and just reserve using my health plan for catastrophic events.
But my employer only offers one level of deductible, so I can't really shop for a higher deductible. And with my employers contribution to the current plan, it's still cheaper than if I were to buy an even higher deductible plan on my own.
But still, if I have a $1300 deductible but only typically spend $600/year, I should still be paying cash. That said, I should probably be going to the doctor more than I do. I'm getting to an age where preventative care is becoming more important. I have some minor, non-life threatening issues that a doctor could probably help me out with if I was willing to go see a doctor. Under this way of thinking, I should probably commit myself to paying the annual deductible and just go to a doctor whenever I feel like it.
But it's a pain to find time for the appointment, I don't enjoy the medical "process" any more than any red blooded American man, and the whole idea of "going to the doctor just because you can" bothers me on ideological levels... so I don't go. But I keep "using" my insurance because I hang onto the idea that I "should" go. So like I said, it's just bad planning on my part.
That said, I know that's a giant whiny rant. I fully recognize that there are plenty of people who need legit medical care for serious things and can't get it, and here I am complaining that I can't find time in my day to schedule all the medical care I could ever want for $1300.
One of the problems with healthcare in the US that for a long time, lots of people had insurance that would cover everything. So people would go to the emergency room over a stomach ache or schedule a doctors appointment because of a runny nose. Why not? So long as they paid the premiums, there was no incremental cost for going to the doctor. And while you're there, get some tests. Hell, get all the tests! Why not, you're not paying for them. And since the doctor knows you're not paying for them, they can bill whatever they want for them.
The net effect is that you have a bunch of people consuming excessive and over priced medical services. This means lines get longer and overall costs, especially for the uninsured, go through the roof.
On that note, I think the high deductible health plans make a lot of sense. I'm covered if something really expensive happens to me, but I still have to front the first $1300 and then another $1500 or something at a 20% co-pay. So my total exposure is only $2800, which won't break the bank if I get into a serious accident. But it's enough to make me think twice about going to the doc over trivial issues.
Some people would argue that you shouldn't have to think about cost with a doctor - if you think you need to see a doctor, then see a doctor. But that really can, and has, gotten out of control if you completely disconnect people from the price of healthcare the way US insurance has for a long time.
I used to have that view, but from what I've read more recently, the cost of doctors' visits is basically negligible in the overall U.S. healthcare picture. Almost all the money is going into major medical expenses: hospital visits, surgery, end-of-life care, nursing-home care, and chronic conditions with expensive medication. So either doubling or halving the number of times people go to the doctor for colds, by changing incentives on that front, just doesn't seem like it'll move the needle on healthcare costs.
If anything, some of the actuaries seem to think people aren't going to the doctor enough: my dad's corporate health insurance plan recently changed their policies to incentivize going to the doctor more often, by giving you a discount for various kinds of visits: you get a discount if you have an annual physical, and another discount if you have less-frequent major workups / lab tests done.
Depending on which estimate you believe, legal expenses (including direct and indirect) account for about 1-3% of overall US healthcare costs. Not nothing, but not in the range of what we're spending on, say, end-of-life hospital care (10-20%).
Okay, fair enough. I remember reading about substantially higher percentages in the past, but googling just now turned up a best guess of 2.4%. I couldn't find any details on how they calculated the indirect nature of defensive medicine, but what they did have didn't seem to be very comprehensive.
This really doesn't make any sense to me; do you have any sources for this? Everything I've heard about problems with healthcare in the U.S. falls in line with the OP, along with:
1) People go to the emergency room precisely because they don't have insurance, and what's more, they wait until the last moment (ie, when it's most expensive to treat) [1].
2) If people were really getting so many tests done and going as early as possible, surely the U.S. would be far ahead of most other countries in terms of preventative medicine [2].
Isn't that insurance fraud? At least, wouldn't insurance companies try to call it fraud, even if a later visit had nothing to do with an earlier visit?
Why isn't this insurance fraud? If I got into a car accident and the mechanic told me it would be $7k with insurance or $4k in cash, isn't that fraud? (Note: I know mechanics do this, just curious why it's legal)
Doing what you've described would probably be insurance fraud, or at least a contract violation.
To expand on your example, the insurance company contract with the mechanic says that the insurance company will be billed the lowest advertised price. Of course, that contract also says that they will only pay $3k for the services required. The cash customer still hands to be billed the full $7k, however, or risk getting in trouble with the insurance company. That's why it's always a cash discount, and the bill will be for $7k even if they will take less (if you know to ask).
These numbers seem extreme, but they're not that far off - take a detailed look at an EOB sometime.
I'm convinced this is at least partly responsible for the rapidly increasing health care costs in the US.
If you don't know what's going to be done during the appointment, they probably can't tell you what it's going to cost. But if you are going in for a specific procedure, you should be able to get the cost.
Call the doctor and get the procedure code. Then ask for the amount that is going to be billed and the tax id of the person or company that will be sending the bill to the insurance company.
You may need to get multiple procedure codes and talk to multiple billing departments. For example, I recently wanted to find out how much an MRI would cost. There's a fee to perform the MRI and a separate fee for reading the images. These are performed by different people, and therefore billed by different people.
Next, call or livechat your insurance company. Ask them to run a test claim. Give them procedure code(s), the amount billed, and the tax id of party sending the bill. The insurance company can then tell you what the allowed amount is, that is, how much the insurance company and the medical provider have agreed upon for the specific procedure. If you have a deductible that you haven't yet met (and the procedure isn't something covered or partially covered before the deductible, such as preventative care), the allowed amount is the amount you will be billed by the medical provider.
Obviously, this is a cumbersome process. Running the test claim took about 10 minutes in my case. This is apparently not a process that the insurance company has optimized for. But by going through the process, you are sending a signal that price transparency is important.
With MRIs, it turns out that at least one local company has recognized the value of price transparency: https://twitter.com/xn/status/311886680145666048
(They also happen to be about $400 cheaper than the amount my insurance company negotiated with a large hospital.)
I had a Doctors visit at the beginning of the year. Since I am on a HSA plan I have no deductible but rates are still negotiated. I have yet to receive a bill. This is for service rendered the first week of this year. I have received a NON BILL which denotes the costs of service and the negotiated rate having saved me money.
I am still trying to find someone to pay. Now having talked to my Doctor before I have asked the questions about rates and such. The only points that stuck with me are, negotiated rates with government providers are too low for him cover his costs, insurance companies have rates which are more favorable because they need the business, and his higher base rates are because collections is rotten to deal with.
One day I hope to pay my bill, I would have to have a collector show up but my Doctor cannot accept the payment as of yet and I legally cannot use my HSA funds for something I do not have a bill for.
They extend an offer, you agree the price, you agree to buy and they sell. But they're suggesting that you buy, and consume the product, before agreeing a price?
Is it just that they don't know what's happening at the doctors? ie, they could offer a base price of $X per 15 minute appointment; $Y for writing a prescription; $Z for referring on for other tests?
Or can they not even tell you how much a basic 15 minute consultation would cost?
Like so many things, I probably could get my answer if I was prepared to fight for it. But since I have insurance, and I'll eventually pay out my deductible and out of pocket maximum, it's just not worth the fight, no matter how wrong this is.
In a way it's a very small version of someone suing me, and I settle even though I know I could win. Cost/benefit, and the game is rigged against me.
>They extend an offer, you agree the price, you agree to buy and they sell. But they're suggesting that you buy, and consume the product, before agreeing a price?
Pretty much anything custom-made works like that (have you never bought bespoke furniture?) - the seller will do the work and then bill you for how much it turned out to cost. You can sue them if it's unreasonable.
Over here we have a Bismarck health system (baseline coverage is publicly funded, supplementary insurances are available from the same companies for a premium), and the last time I had to go see the doctor it was free. I think I paid 15 NIS (about $4 USD) to fill the antibiotic prescription my doctor gave me.
America really needs to fix its health-care system, by now its decay has become incredibly low-hanging fruit. You have the rest of the civilized world to cherry-pick for efficient, caring health systems!
It seems to me that, ultimately, such practices should be investigated and perhaps prosecuted on some legal basis. The problem is so endemic and systemic that I can't help believing some degree of perhaps illegal (and, at least, it should be illegal) collusion is in place.
One example: How can I know/believe that practices aren't widespread to deny myself and others coverage we are actually due per our contracts?
There is also widespread, systemic spreading of cost that is outside of any contract (i.e. insurance) authorizing and mandating such. Widespread enough to warrant investigation for fraud.
If the regulators weren't totally co-opted and owned by the industry, it would be rife for investigation and perhaps charges of corruption. Under existing laws -- no new laws needed.
By "eventually" I mean a cascading series of events and degradations. I won't die the day after the missed appointment, but I'd almost certainly die within the year from that specific disease. Otherwise I'd die at a presumably much later date, barring accidents and other new health issues. I'd prefer the later date.
Most people understand there's a difference between "we're all gonna die someday from something" vs. "if I don't do X within a relatively few days and do ongoing maintenance treatments Y I'm gonna die of disease Z in short order."
To imply there's not a meaningful difference between several decades' longevity vs. dead in a month isn't fair.
Depends. I don't think I have ever actually heard anybody say something like "if I don't do this, I'll eventually die", without some humorous intent. I had to read the post a couple of times to convince myself this wasn't the intention here.
Type I diabetics tend to be intensely aware of the consequences of neglecting their immediate care.
(Looking at the above, I see that I should make it clear that just I'm bringing it up as an example of a group that approximately thinks like you say.)
In extremely free market health care systems, pricing tends to be extremely transparent.
I had surgery in India. The doctors could all quote a price to me, accurate to within about 5k INR (final price ranged from 85k-150k). A price list with common procedures (blood test, urine test) was usually printed on a sign behind the receptionist.
Note the important point that "system" is not free market, merely at least some pre-planned surgery and common diagnostic procedures have a fixed price.
I'm sure that the average purchaser is at an extreme knowledge disadvantage making comparison shopping nearly impossible, and critical care/emergency care does not allow the time for comparison shopping. Finally you did not elaborate on the competition... is there any? So its a free market in that some prices are posted, but not in pretty much any other way.
I'm not sure if he went to one of these kinds of facilities, but my impression there is a reasonably competitive market in medical tourism: there are hospitals in Jordan that target themselves at enticing foreigners to fly there for treatment, and compete directly against similar hospitals in Thailand, India, and other places. They generally target an upmarket crowd, though, with some increasingly specializing to target Americans specifically. (I've noticed some of their websites attempt to delicately telegraph, "this is a hospital for you, well-off foreigner; don't worry, it's not full of locals.")
The point I was kinda getting at is without a well informed consumer (good luck!) the best free market you can hope for is something rather like the process gamblers use to select a specific slot machine from a bank of slot machines. Or maybe a better analogy would be selecting a poker table in that you can select to sit down at the $5 ante table or the $10 ante table. Oddly enough given the strong asymmetry of knowledge and capital, the house always wins. Not much of a free market.
Although I would agree that in the extremely limited area of price discovery of certain procedures, I'm sure they do better, mostly because we do so poorly its almost just statistically likely by random chance to be better.
I'd be fine conceptually with a model where catastrophic care is insured and smaller expenses are paid for out of pocket. But then I'd like: 1) the catastrophic care to actually, 100%, guaranteed be covered, without loopholes, lifetime maxima, excluded conditions, etc.; and 2) the smaller expenses to be priced transparently up front.
No, for the sake of Return on Public Investment, I'd say we should not only cover catastrophic care but give full public support to preventative care as well.
Good point, and a reasonable objection to my suggestion (not very deeply thought out, I must admit). I would need to look at some numbers, but I do seem to recall that "major" care, comprising stuff like hospital visits, surgeries, chronic conditions, and end-of-life care, takes such a large percentage of the total healthcare spending that scrimping on regular doctors' visits, which are quite cheap in comparison, may be counterproductive.
Yeah, that's the same data I've seen. Life-saving and end-of-life care is usually the most expensive, so the long-term rational way to save money (private and public) ends up being to prevent major health problems from occurring at all.
I can sort of buy that, but I think it might be complex to determine what is cheapest overall, if that is really the main goal to minimize. For example, someone dying of a heart attack in their home is much cheaper than someone dying of cancer after a prolonged 2-year battle. So it would actually cost more money if you successfully prevented the heart attack only for the same person to die of cancer 10 years later: preventative medicine can't keep someone from dying entirely, so it doesn't always necessarily save money, if it pushes back the death to one that turns out to be more expensive than the earlier death would've been. What you want cost-wise is for all ends to be quick and with minimal intervention, whether they're earlier or later ends (actually that's what some might want as the person in question too, but that's a much bigger debate).
Worst-case scenario: you have a heart attack, but someone calls 911 (or 100, or whatever the ambulance number is near you). You get to the hospital, and are treated very expensively to stabilize you and save your life. You now probably have to take heart medicine for the rest of your life, also an expense. Then cancer kills you over a protracted two-year battle, 15 years later.
A few years back I changed jobs; under my previous employer my allergy shots were fully covered under insurance, and I wanted to determine which of my new employer's plans might cover them. At the time I was getting allergy shots on a weekly basis, so if I had to pay it could add up to $80-$100 a month. If "plan A" covered it and cost only $30/month more than "plan B," then it would be worth it to me.
The plan summary from HR didn't say. I called the insurance company, but it was tough to get an answer from their CSRs without being a customer. Finally I got someone sympathetic who gave me their direct line and said if I could get the billing codes, they could run it against the terms of the policies my company negotiated and see what comes up. In the meantime they told me it would cost no more than $25 per injection, which was the limit to "usual customary and reasonable" in my area.
So then I call my allergist's office. They told me I need to speak to their business manager, who only worked 3 days/week, and I of course called on one of those other two days. When I called back, she categorically refused to give me the billing code they'd use. I asked her to clarify whether she was unable to give me the code or if she was choosing not to do so, and she responded that it was the latter.
So basically I just had to wing it and choose a plan. And a new allergist.
feel lucky you don't have a kid with medical problems.
I've had to drag out accepting an offer from a company so I could find out 100% if my child's doctor was covered by their insurance or not. In the end I had to turn it down because he wasn't in the network, and having to pay the 20k out of network deducible would have ate any net gain I would have gotten by taking that job, I had to turn it down.
I felt bad dragging out the process so long, but I really had to cover myself, and at least on their side they were 100% understanding.
This sucked, however we're still lucky. We had her (hopefully) last surgery last week. While staying in the Ronald McDonald house (her surgeon just moved further away from us) we got to hear tales of people having their house foreclosed on, due in part to their kid going through leukemia treatments (they were/are insured btw).
You shouldn't have to lose your house because of medical necessity
And I hope in the future you might have an opportunity to to sign on with that employer later -- it sounds like if they're understanding while you tried to sort out the insurance questions, then they'd probably be good people to work for.
I tried reaching out to them a few months after it all went down, and my wife could pick up insurance. The main contract they had was set to be cancelled (they also canceled contract with 15 other companies) so in the long run it worked out for me.
oh, and my Daughter is fast to recovery, just need to keep her from bouncing off the walls for another with week, which is impossible for any 5 year old.
My allergist charged a "rack rate" of $24 per injection, just under the $25 line that the insurance company said was UCR.
It turned out the insurance company's contract with the allergist said he could charge me no more than $18.50, but the insurance company paid none of it. So even then it was $74/month, given that I had to go weekly.
Because of the stupid game that I had to play, I had absolutely no way of knowing what that discount would be though. Could have been nothing, could have been a lot. Hence "could" add up to nearly $100 a month if I had to pay full price.
Yes, the medical situation in the US is badly broken, and everyone knows it. However, it is unlikely to get fixed within the next several decades. It took decades and an extreme swing in political power (one party fully controlling both houses of Congress and the presidency at once) to get a change to the law that said essentially "Keep doing it the same way you're doing it except that a little over 3/4 of the people with absolutely no insurance will now get insurance." Such a tiny step forward, still unclear whether it will actually hold, and this was the crowning achievement after decades of work.
The way we pay for health care in the US may not improve in a substantial way for a LONG, LONG, time.
No, see - that's the problem. The vast majority of the electorate has no idea either that our system is broken or that other countries actually do things better - indeed, that it is even possible, in principle, to do anything better than current practice in the United States.
One sticking point in my mind is that people always seem to conflate our pharmaceutical and medical technology industry with our healthcare and health insurance system, which are different areas completely.
They think that if we don't have the expensive, privately-held bureaucratic system we do, then GE can't charge what it does for its MRI and CT scanner machines and exit the market, and then Grandma will die a horrible, painful death in a ditch outside Waukegan. Or, if pharmaceuticals don't charge insured patients $10000 a dose of some new drug, that our system will collapse because no one will make medicine in America ever again (never mind that 5 of the top 10 largest drug makers are outside of the US in countries that have abundantly socialist healthcare systems).
I'm not sure I even understand your point. Bayer and Pfizer, for instance, do lots and lots of business in the US. His point is that Switzerland - like every industrialized nation in the world, with one exception - has a socialized health care system, and still somehow manages to have an economy that includes health care providers.
They said "never mind that 5 of the top 10 largest drug makers are outside of the US in countries that have abundantly socialist healthcare systems".
If the companies do (significant) business in the U.S., then the mere existence of those companies isn't useful evidence against the fear "that our system will collapse because no one will make medicine in America ever again". The specifics of where the pharma companies are getting their research dollars are more interesting than the specifics of their incorporation.
(but I don't personally fear that research funding would go away, and I accept that those companies have huge revenues outside the U.S., etc.)
It feels like one of those oddly contingent things that wasn't inevitable. Some decades ago, Richard Nixon and the Democratic-controlled Congress each had health-care-reform proposals, but weren't able to reach an agreement. So, nothing passed. But viewed from today's perspective they weren't really that far apart.
From my reading a great deal of the problems we have now is after decades of government intervention in an attempt to "fix" the system and only making it worse. The legislation you speak was not a tiny step at all, it was a huge leap into making things even worse. The legislation does little to fix the existing problems, in some cases makes them worse, and at the same time forcibly inserts millions of people into the system that most seem to agree does not work. I fail to see how such a thing can possibly help. If this was a crowning achievement of decades of work then politicians have extremely low standards.
Most of the problems I see with the system are inherent in the idea of attempting to socialize costs using the model of "insurance". For example, a friend of mine was born with a heart defect. No rational free-market insurance would sell him coverage at any price he could possibly pay, because the expected lifetime cost is quite high. The only real way to deal with such cases is to spread them across a large population, so people not born with heart defects subsidize those who were (and likewise for other major issues). But of course the population has to be selected in a way that is reasonably representative, rather than only the least healthy people opting in. The three traditional non-adverse-selected populations are: 1) the entire population of a country (the socialized-medicine solution); 2) the members of a large union; or 3) the employees of large corporations (the U.S. solution of employer-tied group plans).
But #3 is showing cracks as corporate-jobs-for-life get less common. In a world where you change jobs more frequently, now there are messes of coverage gaps, COBRA, etc. Not to mention that this arrangement discourages freelancing and entrepreneurship, since you must work for a large corporation with a group plan to be part of a health-care pool, a connection that otherwise seems rather arbitrary (why should where you get risk-pooled for health-care purposes depend on who you work for? only because corporation-tied pools are a way of minimizing adverse selection in the pool).
#1 was the attempt with the legislation in question but it gives too many people an easy way out which is part of the problems it creates. But the other problem is that not everyone can contribute evenly. Thus begins the problem of pushing for fairness so that some pay more than others. Then to be more fair there's a push to increase the limit as to what constitutes "too poor" to pay. Next thing you know politicians are using it to buy votes. Today it's "vote for me or they'll take away your Social Security!" and tomorrow it will be "vote for me or they'll take away your health insurance!"
#2 is the most common way in the US but not necessarily through just unions. It's all about group plans and whatnot in an effort to control pricing. The problem is that this method doesn't cover everyone and discourages certain types of employment as described elsewhere in this thread. In some cases, large unions use the benefits as leverage against their members for various reasons and/or against the employer as a PR tool such as "they are hurting our kids!" type of tactic.
#3 is part of my point as one of the reasons that companies went wild on offering health benefits to workers was to get around a government enforced wage freeze during war. There were companies that offered such benefits before but during the wage freeze it started to become normal to be offered the benefits.
I find it fascinating that after decades of escalation in the problems in US healthcare and insurance the best solutions anyone can come up with and/or get passed is to increase the very thing that almost everyone agrees is broken. "He's been shot three times and he's dying! What should we do?" "Shoot him three more times and see if that helps. Otherwise, we'll have to think of something else."
Has anyone in the world ever tried a variation of selection criteria #1 where the property tax of the residents in the coverage footprint of a hospital pay for the hospital? It seems logical and cheap to administer, which is why it would be opposed in the US, not much room to profit. However it does seem "fair".
I believe Sweden's system is organized roughly in that manner, though not all the way down to individual hospitals. The majority of the funding comes from local/regional taxes that pay for the healthcare system within the region. Then it's supplemented with some national funds that subsidize poorer and more rural regions, and which also provide grants to incentivize regions to do some things that the national government considers priorities. A quick look at Wikipedia says it's overall 71% funded at a local/regional level and 29% at a national level.
Switzerland also has a system based on compulsory insurance within each canton. The state doesn't operate the healthcare directly, but residents of each canton have to buy insurance from one of a small number of nonprofit insurance providers available in their canton, which end up doing the risk pooling.
The Swedish model brings up a good point that the regional childrens hospital in my area would have to gather revenue from multiple county govts not just the city its located in. There is also a Mayo Clinic facility in my state with at least theoretically national coverage which would have to gather money from the feds.
It might be simpler for "regional and bigger" hospitals and specialty clinics to back bill the patients local hospital.
The swiss model looks similar to how we used to bill old fashioned landline long distance telephone lines in the USA. Other than the profit/non-profit thing.
Those in power would disagree. If the purpose is to achieve a local maxima of profit they're doing pretty well. Privatize the gains, socialize the losses.
If the purpose is to provide medical care, well, yeah, its a pretty epic fail. But that's not the purpose of the system.
The system has to be bled completely dry before it can be redesigned and rebooted. Too many people are still paying in. That has to stop, before things can be improved.
Just to compare apples to insurance here, the largest pure auto insurer (progressive) maintains ~5-6% profit margins according to filings, whereas Wellpoint one of the largest insurers in healthcare maintains a 7% margin.
There's more to "the system" than just insurers. The large number of middlemen all extracting a profit is one of the many problems. Don't forget overhead and their middlemen, all the way back to med school tuition...
What I think is really interesting is that my experiences with dental insurance are entirely different. I've gone to the dentist, found I have two cavities, and when I schedule my next appointment on the way out I'm given a detailed treatment plan that includes prices. It even includes details about how some fillings are more expensive because the insurance only covers amalgam fillings in the back but the dentist only uses composite fillings (for example). And it only takes a couple minutes to figure out the prices, and more importantly exactly what the insurance will cover.
I realize that the set of things a dentist deals with is probably smaller than what a doctor does, but it seems like it's a much better model for insurance.
I think this is partly because dental insurance bears little resemblance to comprehensive medical insurance. In fact, for most people with a generally healthy dental history, it's often not worth paying for dental insurance, since it ends up simply being a pre-payment for services. Expensive procedures & oral surgery are often covered for only 50% of the final cost.
In the US at least, I think dental "insurance" is really just a simplified way for employers to offer an appealing benefit to employees.
I agree in part, but the workflow of "this is what's wrong with you, this is what we charge, this is what insurance pays, and this is what you pay" seems exactly the same, even if what's covered and the reimbursement rates are very different.
My main point is that I've never been to a doctor where I've had to schedule a followup appointment and been presented with a itemized invoice (and the dentist's office can usually prepare it in under 5 minutes).
What's always surprised me is how cheap ophthalmic surgery is. I don't think opthalmic surgeons are exactly slumming it, but the cost of say getting a cataract removed is under $4k per eye with no insurance.
That is interesting. I know the prices for things like LASIK are completely transparent, but that's because insurance isn't involved. I'd assume that insurance generally does cover cataract surgery, however.
Some of the reasons might be that the procedure is fairly quick, the eye is easy to get to, it doesn't require general anesthesia, and doesn't require a full OR in a hospital (I think - correct me if I'm wrong). In that sense its closer to oral surgery than a gall bladder removal, for example.
The ability of people in the States to insist that our health care system is "the best in the world" because of the action of the free market while simultaneously not understanding why prices are thus important is what usually leads me to believe that most Americans have no idea what a free market is. (Or what health care is, to be honest.)
Somebody needs to create international healthcare insurance based in stable non-US jurisdiction similar to travelers insurance. Insurance that would cover medical tourism - flight, lodging and care for Americans.
No kidding; after months and months dealing with the actual mechanics of the medical bills for a simple leg contusion (stupidly thought it was broken; won't do that again), if the big C ever hits, I think we're headed to Mexico to avoid bankruptcy of both time and money.
Just dealing with the afteraffects of a simple ER trip for what turned out to be a bruise was eye-opening.
I had the pleasure of dealing with a multitude of bills from random places (in some cases, lawyers' offices, who handle some doctor's bills from first charge--i.e., not collections--and boast on their web sites about being able to return "200% of what's owed"), determining what's legit and what's fraudulent, the paperwork sent back and forth between us and our insurance company and between the billers and our insurance company (who weren't paying anyway because we have a very high deductible, but you have to jump through massive hoops to get them to actually count your payments towards the deductible), the attempts of the medical billers to double-bill and continue to appeal the bill with two insurance companies months after I paid the bill (how they collect that 200%, I assume)...a total mess.
Someone got paid 2k for a deep contusion, but I think most went to middle(wo)men and lawyers' offices.
It feels like most Americans can't afford to NOT travel out of the country for routine medical care.
If you can pay $1300 for the routine stuff described in the article, it'll probably be cheaper to do it outside. I don't know the prices in North America, but based on EU prices I'd guess it should cost less than $500 to fly across half continent and back, and $150 for the actual operation in any good Mexican hospital; which coincidentally adds up to half the USA price.
I have Kaiser HMO in California. I think it's awesome, and the best health care I've ever had.
I'm also from Canada, so I'm comfortable with the idea of socialized medicare. However, when I compare stories between me and my friends in Canada, there really is no comparison. I basically pay a $20-30 co-pay per visit (something that was completely foreign to me when I first moved to the US), and then anything and everything gets done for me. I have never experienced the horror stories you hear about where insurance companies try to opt for cheaper treatments or deny services to save money. Any test or procedure I needed, or even asked about, I could get.
The longest I waited for things like a MRI was 2 days, and 9 days for an endoscopy. My doctor was willing to get me a CT scan the next day for this stomach problem I had. My friends in Canada have waited 4 months for an MRI and 3 months for a CT scan. My dad had to wait about 6-8 weeks to get a pacemaker installed, even though his heart was stopping for 5-10 seconds several times a day. Seeing a specialist takes months in Canada vs days with Kaiser. On weekends, if I get sick I don't have to wait in Emergency for hours like in Canada, I can just set up an appointment at one of the hospitals and see a GP in around 30-45 mins, and they have full access to all my medical records.
The downside is that when I'm out of a Kaiser area, I have to pay out of pocket unless it's an emergency (I believe). The only time I felt vulnerable was when my family was out of state, and they didn't have Kaiser facilities there.
Which is part of the problem with reform: you happen to have a functioning HMO. What happens when you change employers? What happens when your employer doesn't offer insurance? You are one of the lucky few who has the connections, and deep-corporate-pockets (presumably, unless you're paying for your insurance out of pocket) to be able to get good insurance. But that isn't how most the country works. It's probably better for the masses to have the longer Canadian waits, rather than the quick-care American bankruptcies (or non-care).
It used to be like this for most people in the USA with insurance. Slowly, costs rose and benefits have been dropped. What used to be a $20 (or even $0!) co-pay became abused, people would visit the doctor every week, and since it didn't cost them anything, they had no reason not to go.
These days you'll find a high-deductible plan that does the reverse - encourages people to NOT go to the doctor because until they've hit a $3,000 tab, the insurance won't kick in a single dollar.
The 1076 for the procedure and 300 for the visit were the full billable charges for those codes.
If the insurance had covered them at their contracted rate, the provider would have received probably about 250 for the procedure and 50-120 for the office visit.
Because it fell within your deductible, the initial bill to insurance would have been denied payment and sent back with "patient responsibility" and the 1376.00 would then be your problem. Since you don't have a contract with your provider he tries to get the whole thing.
This is where you can discount it with negotiation.
I am a medical provider, I believe that transparency will help the situation. I also believe that prices should be within a 5-10% window of each provider instead of a price variance of 100-400% depending on secretive contracts.
Unfortunately even providers have been trained to game the system to maximise profit and productivity. It is common to hear surgeons talk about complicated patients and tell them to see a university guy because "frankly its not worth the time and effort" when they can get low hanging easy fruit that pays better/unit-time with less liability.
I'd like to hear what the poster thinks he should have paid for his office visit and 5 minute procedure.
Doing some simple math, if a doctor is making $200,000 a year or $250,000 a year working 40 hr weeks with 2 weeks of vacation, their hrly rate would be $100 or $125 per hour respectively.
5 minutes of just their time would be between either $8.33 or $10.41. Fine, throw in a couple bucks for the rubber gloves and scalpel. And something for electricity, paper, etc. Still should NOT me more than 40-50 dollars in my opinion. But I don't know much about this industry...
If the doctor is "in network" shouldn't the patient responsibility be the lower, negotiated rate? I thought was part of most insurance contracts, and one of the reasons insurance is helpful even if someone is healthy and has a high deductible.
What you've described I think is largely responsible for a lot of the rising medical costs.
Perhaps the hacker community could come up with some alternative solution, similar to bitcoin in finance, to try to force out the non-transparent pricing? ;)
Just some anecdotal data from my wife's pregnancy & delivery process and the costs/charges are just from her 2 days of hospital stay for her normal/vaginal delivery without any complications.
- The hospital (NJ if it matters) billed the insurance company $30,000. She was there for usual 48 hours. The insurance company has a thing called "Amount Allowed" which knocked it down to $5880. Then our share of co-insurance came to about 20% of that = $920.
- For baby, separate hospital bill of $8779. amount allowed = $2,232, our share = $566
- The Anesthesia consultant billed separately for $3000, amount allowed = $1100 and our share = $220
One thing that's a bit confusing: In both the UK[1] and the US[2] medication non-compliance is very high. Many people don't take their prescription meds properly. Many people are so bad at taking meds that the meds are ineffective - they may as well not take the meds at all. Rates are similar in the US and UK.
About half of the UK £9billion budget for prescribed meds is sub-optimal spending because of medication non-compliance.
And severity of illness doesn't seem to be a factor. People who've had an organ transplant often die after rejection when they stop taking the meds, even though they know that they must keep taking the meds.
There's probably money somewhere if you can improve medication compliance.
[1] Prescriptions usually cover 28 day supply of medication. Each line item on a prescription costs £7.40; but most people don't pay because there are many exemptions and if you need long term meds you can pre-pay.
I wonder how long this is gonna keep going until someone gets pissed off, and creates a website to take care of the transparency issue by themselves- "upload your hospital bill here. We'll mine your bill for pricing data, anonymize you, and make the bill publicly available so people can shop for better prices".
> "...medical care is one of the core things that a 1st world country should make available to anyone, for cheap, by subsidizing it and enforcing transparency and price normalization for common needs..."
Yes, exactly. This is pretty hard to accomplish in our current state of political inaction, misinformation and 24-hour news cycles. I'm sensing a build up to a tipping point on public awareness about how we're all being swindled by these hospitals and insurance companies, but perhaps I'm just paying more attention to this now that I'm starting to get a little older.
I highly recommend reading the ebook here...It sheds light on actual costs and gives a very detailed analysis on the issues at hand: http://truecostofhealthcare.org
One conjecture he made is definitely wrong. Medical bills for uninsured individuals are usually higher than those for insured (due to insurance companies negotiating a better price).
For any particular place that that holds, I can almost guarantee its purpose is negotiating with insurance. Take away the insured and the price will drop tremendously as there is no need for extreme fake discounts.
I once had a scan done and the office offered a cash price that was lower than the deductible, but if I went through insurance they would have billed higher so that most likely I would have had to pay the entire deductible.
"Is the free-market model even applicable to health care?"
It works about as well applied to health care, as applied to police coverage, military defense, restaurant health inspections, road maintenance, and education. Not as well as when applied to a farmers market or factory widget production.
Its a little harder for med because quite a bit of med care happens to medically uneducated people. Given a couple years of med school and some on the job experience, and a couple days to fully research each emergency room and cardiology department in the country, my neighbor could probably have made an intelligent free market decision when he had his heart attack. However, instead of a free market, the ambulance instead took him unconscious to the nearest ER, where they'll pretty much do what they want and then charge what they want. The true miracle of the situation is it may have been a financial disaster, but medically it all turned out OK. Decades of propaganda has taught me that only a free market can provide decent services, yet at least medical care works pretty well with a feudal system where you simply report to the nearest castle and pay whatever tax the feudal lord demands.
Granted, the OP indicates that indeed it is difficult to get advanced pricing because it entails asking the doctor for the code, then checking with the insurance company.
But what's stopping people from voluntarily posting the procedure_code=>price information they obtain? Are there contractual/legal reasons that prevent you from sharing that information? If patients get that price in the normal course of getting healthcare, then why not share it all, and force transparency in the market?
This comment made me wonder if such a thing (crowdsourced medical pricing) existed: turns out it does [1, 2, 3]. I would absolutely love to see resources like these take off, until using them is as common place as checking GasBuddy before filling your gas tank.
Right, but presumably Medicare's prices are significantly lower due to its negotiating power (which is why "Medicare for All" may not be such a bad idea). As we can see from many of the comments here, the prices vary widely, even when you make the effort to find out what they are for your provider and insurer.
Health care in the US isn't bad (mostly). It just isn't better than in countries where there's 100% coverage of the population. And it's many times more expensive.
There's unlikely to be any solution though, barring a massive shift in public opinion. True reform would reduce a bunch of insurance companies to smoking craters and would certainly involve some sort of tax increase, both of which would be regarded by most in government as unacceptable outcomes.
As it is, the horrible expenses paid by the sick help to subsidize those who can't pay (who are anyway discouraged from getting regular care as much as possible). Costs are already distributed, just not evenly, because you only pay the horrible prices when you get sick. And most people prefer not to think about it until then.
> As it is, the horrible expenses paid by the sick help to subsidize those who can't pay (who are anyway discouraged from getting regular care as much as possible).
The expenses are covered not just (or mainly) by the sick but by the insured. There's a reason my insurance is nearly $500 a month, though I"ve never been sick or injured and rarely visit a doctor (I've thus contributed probably $50,000 to healthcare without consuming any). Given my general health, young age, and low chance of catastrophic injury, the only explanation is that i'm subsidizing other people's care.
Well, you are subsidizing the insurance industry too :-).
There are clearly indirect costs that go into inflating insurance premiums. I find it very hard to understand why it's acceptable to pay in one way (high premiums, catastrophic care bills) but not in another (nationalized health care). I've never heard an argument against it that didn't strike me as pure FUD. [Incidentally, not trolling Republicans here—I'd love to hear a good explanation that goes beyond distaste for anything government-run.]
Oddly enough that's the way it used to be, doctors were doctors because they said so. Although, if you had a friend sew up a bad cut and you gave him twenty bucks for his trouble I doubt the police will come knocking on your door. I suppose if your friend decided to do it as a business off his front porch I'm sure somebody's bound to come around at some point.
I parsed it as: The doctor is charging over 5,000$ an hour for his time, that's terrible. Worse yet even with 200$/month insurance the guy ended up paying 70% of that rate.
For many people moving to the US the cost of medical bills seems insane.
PS: It's not that he is actually charging that for his time. It's just rolling a lot of overhead into it.
We have examples of private-paid costs by the same education-level doctors in first world countries that have higher cost-of-living than USA - say, Switzerland. Everywhere the full cost of the same procedure is at least twice less than USA.
And before you say it, no, legal/malpractice expenses aren't the cause, because in USA that adds up to <5% of total medical budgets and can't explain the other 45% "bonus price".
When I was living in Finland, where I last paid my whole bill by myself (a private, specialist doctor), A 30 minute visit was 90 euros (115 USD).
If you add some tests, they're usually 20-40 euros each. Of course this is free if you go to the public doctors. And now here in Germany, all doctors are private and the mandatory insurance will cover most of the expenses.
Ignoring the actual price, any industry is broken if you are charged random prices that they don't (and can't) tell you before you choose.
At the very least, it is by definition not 'free market economy' since you can't even choose where to buy based on price if they aren't telling you the prices.
It appears most states in the U.S do not require hospitals and medical providers to list their prices
This and the tax breaks given to companies sponsoring health insurance plans that create a nearly immovable useless middle man are the root of all evil in the American healthcare industry.
just to clarify: $300 for a doctor visit isn't inflating costs because he's covered by insurance. in ny, which i think is safe to assume is comparable in cost to the part of CA i'm assuming the OP is in, that's the normal amount you'd pay for a specialist visit.
If your auto insurance included new tires, oil changes and gasoline, imagine what would happen to the price of both auto insurance and gasoline? They'd both skyrocket. So why the hell are we doing it with healthcare? Insurance is about sharing risk and a large part of the cost isn't sharing the risk it is about pre-paying for normal, expected ailments and when consumers become insensitive to cost prices are bound to rise.
The healthcare industry is greatly in need of cost sensitivity and transparency.
What about healthcare insurance includes the cost of "gasoline"? In my knowledge, healthcare insurance doesn't cover food or water (besides, maybe, hospital food while you're in the hospital), and I really don't get the analogy.
I loved the Michael Moore movie Sicko. Regardless of what you think of him in general, he did a good job with it. What surprised me was the fact that 95% of what he found was what insured people have to deal with.
I feel like the only thing that has prevented our health insurance system from touching off a violent revolution is that severely ill people aren't exactly in top shape for carrying AK-47's into executive lobbies.
The whole point of private health insurance is that sick people are the easiest to rob-- they don't fight back-- but they also have no money, so it's best to collect payment while they're young and well.
Of course there is some truth somewhere in the movie, but the majority of it is stretched truths and shots intentionally doctored to make his point.
"The whole point of private health insurance is that sick people are the easiest to rob-- they don't fight back-- but they also have no money, so it's best to collect payment while they're young and well."
The whole point of a public healthcare system is that it forces you, at the threat of jail, to collect payments from you (essentially theft).
He's intentionally missing the social contract that its in direct exchange for health care, which all people need.
(edited to add: There's already a social contract that refusal to provide emergency room care to everyone means criminal prosecution of the hospital/docs involved... its unfair they're not allowed to collect money at gunpoint, but it would be much fairer if they were allowed to do so.)
I oppose mcdonalds because at the point of a gun a policeman will demand I pay them. Sounds awful, especially if I omit the fact I already ate the burger and I'm gonna need to eat another in the near future and the analogy breaks down even further in that McD would need a local geographic licensed monopoly on all food sales such that everyone living in the area must buy burgers from them.
missing the social contract that its in direct exchange for health care, which all people need
You're stating a moral imperative without indicating any boundaries. What are the limits of healthcare that are required to fulfill this supposed "social contract"?
Throwing out fallacy names doesn't address the problem with your statement.
You mentioned a Social Contract requiring healthcare. I'm asking you what the limits are of that supposed contract. If there aren't any in your view of morality, then be honest and say it. If there are, then throw us a bone and let us know where you think they lie.
Aaand that would be a false dilemma fallacy, demanding that we as a nation should not change the system until a dude on the internet explains in full detail his theory of everything. Or the alternative that a dude on the internet should not speak an opinion on "X" until he accomplishes unrelated task "Y".
The meta-point is it is a strong indication of consensus tipping point approaching for a culture when the opposition on a topic has nothing left but sophistry and fallacies to stand in the way of progress, morality, and civilization. There are certain analogies to creationism, AGW denial, opposition to gay marriage. I don't say that (solely, LOL) to tarnish the reputation of the opposition, but to focus on the similarity of technique in superficially unrelated topics, to draw attention to possibly unnoticed similarity of technique.
Try to provide a logical argument for existing barbarism which I can't pick apart as a mere fallacy. I theorize there is no such argument, although proof of a negative is such a bummer. I'm willing to admit I'm wrong and switch my position given a good enough argument, although I predict no argument exists at all, much less a good argument.
All I've seen you do so far is to invent Straw Men without just answering a simple question regarding the moralistic statement you made.
No one is curing cancer here or achieving world peace. We're just discussing topics of the day on HN. My hope is that people can do so in an honest straight-forward manner without warping facts or throwing up weak smoke screens like you've done here in this thread... but ah well.
Supposedly one of the downsides of more socialized systems are that they're bureaucratic, but I think the U.S. system, whatever you want to call it (it's not really either a functioning market or a properly socialized system) is somewhere near Peak Bureaucracy (certainly more than Denmark's, where I now live). It doesn't help that everyone bills separately: if you ever have to visit a hospital, you will get something like 15 different bills, because everyone from the anesthesiologist to the surgeon are apparently independent contractors, or at least bill that way. And you have to go through the same opaque negotiation process with each of them. And many of them are sloppy and contain errors, e.g. billing you for things that insurance actually should have covered.
I'd be fine conceptually with a model where catastrophic care is insured and smaller expenses are paid for out of pocket. But then I'd like: 1) the catastrophic care to actually, 100%, guaranteed be covered, without loopholes, lifetime maxima, excluded conditions, etc.; and 2) the smaller expenses to be priced transparently up front.