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This is cute, but it is based on a flawed premise. There are not "prices" for medical procedures and even the providers don't know what they are going to charge. Anecdata: when my wife was pregnant I asked the hospital what are the basic charges for normal obstetric delivery, since we were paying out of pocket. I got a reply in writing that it was $20k, a suspiciously round number without itemization. The baby comes and there are no complications and no anesthetic and the attending physician never even showed up for some reason. So it was in every way the cheapest possible way to have a baby short of squatting over a blanket.

Needless to say that this American hospital would not even have admitted us without a certified check in advance, so we had spotted them the $20k. Over the next six weeks I get literally dozens of bills. I get a bill from the attending obstetrician who wasn't even present. I get bills for anesthesia that wasn't administered. I get bills in total of over $31k. I was uninsured but I'm not some chump, so my attorney sent these people sternly worded letters and we held the line at $20k which I think anyone would agree is already a ridiculous price in the first place.

Point is, nobody in this system has any idea what the price of anything is. There's no rate card. It's a collective emergent phenomenon that prints invoices. Nothing more.

My question is how are they not criminally charged with fraud when this happens? I could understand if this only happens once in a while, that it isn't done intentionally, but it happens all the fucking time, so someone is clearly intentionally doing it.

If you hold a man hostage for a month or a year you go to jail for a year or two. If you intentionally overbill a man so that he must work an extra year worst case scenario you... send a sternly written letter and pay them the original amount?

WELL, if we're talking about INTENTIONALITY then yes the american medical bureaucratic system as evolved obviously singles out the uninsured and proceeds to screw them over.

If we're talking about mens rea, then I doubt it; my wager is tied to how it's in no one's incentive to care that leads to these outcomes. Medical providers are clueless and totally disconnected from administrative functions, hospital billing systems are optimized towards dealing with horrible leviathans that spew sulphur and vomit acid and all of this operates on a scale that makes makes the cost of delivering babies a rounding error.

I'd imagine someone forgot to properly code the procedures/the paperwork isn't set up to give a shit and they were simply charged the default set of procedures.

Blah blah, single payer public systems, blah blah aligning incentives around cost structures, etc. Atul Gawande has a great few articles on this.

My father is close friends with someone who runs a large hospital in Texas -- he told us that it is quite routine to overbill, and that they allow for up to 5% over billing. It's a line item in their balance sheet and they actually rely in this as a predictable revenue source.

For an industry of people who have had to spend over a decade jumping through academic hoops, and whose job seems to require a great deal of precision, it is unbelievable they lack competence in something most high school drop outs master McDonalds - namely, standardized pricing and itemized billing (not to mention customer service).

Wow, I always figured that many hospitals would overbill because they could get away with it, though I'd imagine many would go much past 5%.

I don't think it's incompetence that makes pricing variable; rather, its lack of accountability. It's hard to find out where the price tag comes from, so why not charge as much as you think you could get from each patient? If you ask your doctor for an itemized breakdown of your bill, they (may eventually) give it to. The prices are often exorbitant and arbitrary.

IMO there is a guilty mind somewhere in that hospital. After seeing bill after bill come back wrong and without blowing a whistle / fixing the problem they are obviously accepting that they are lying to a good portion of their client base.

Dispute all of it and the bill will likely be way less than 20k. I had mallet finger once and I got a bill of thousands of dollars and charge for a broken finger, then a set, and multiple check up visits.

In reality I went to the doctor once, got an xray, he gave me a splint and said don't take it off for 8 weeks. I never went back for a second visit because it wasn't needed assuming I followed the treatment of did not bend my finger for 8 weeks. I called billing and asked for an explanation and the bill went from a couple thousand to a couple hundred.

This is exactly why I get so pissed about the Affordable Care Act! We are not solving the problem of why medical care in USA is so outrageously expensive, we instead are solving the problem of how to pay for it. The problem is, once most people have insurance, there will be no political will to solve the much more complex and important problem of reducing the healthcare costs for everyone.

Incidentally, totally agree. In any hospital, all you have to do is dispute the charges and demand documentation, and all of the sudden the bill is slashed tenfold! So, basically, the system is setup to screw the uninsured americans who may not know their rights or have the ability to challenge the hospital.

Hope is that when big entities like the state or insurances have to pay the big bill, they have far superior means to enforce lower prices. That's not everything that needs to be done, but it is still useful.

They are actually pretty good at driving the prices down to something reasonable in most cases. While the headline prices are absurd, the prices actually paid by public and private insurers, whether Medicare or Blue Cross or Aetna, are much more reasonable. Not as reasonable as in much of the rest of the developed world, but the gap is not as gigantic as it initially seems.

The really big gap between the U.S. and the rest of the developed world on medical costs isn't the cost of individual procedures (once you've taken into account what insurers actually pay), but the much larger amount the U.S. spends on last-6-months-of-life "heroic care". If that were brought more in line with international norms, the overall cost-per-person numbers would be much better.

Where do you find a breakdown of the costs? Anyone have links?

This looks interesting:


If I get table 4 right, people who manage to live past 85 years will have 1/3 of their health care spending after their 85th birthday (not entirely accurate, but a reasonable simplification).

I wonder though, even if the insurers can drive down prices, how do the insurance companies verify that they are only paying for services that are actually rendered? With the massive amount of medical billing fraud, I suppose insurance companies will invest in investigating and eliminating this behavior? Either that, or they will go bankrupt.

A telling thing: if you make world-wide health insurance it's valid for every single country other than the US. If you want US coverage the price will usually double.

ACA is a step towards single payer, which enables capitation model, vs fee for service. Meaning paying to keep people healthy vs profiting from disease. It's all about the incentives.

Medicare is already transitioning to capitation.

Meanwhile, while not ideal, ACA has already significantly slowed down the growth of costs. Amazing what just adding some price transparency can do.

I think you hit the nail on the head. I had a similar story as the OP and after complaining and looking into the price I never heard back from the hospital. In hindsight their actions reminded of highway robbery. This year with the Surgical Center of Oklahoma and the time magazine article on medical billing though a lot of information has come out. Price comparision websites like pricepain.com, clearhealthcost, bluebook of healthcosts etc, are just the beginning. It's almost like a race against the clock where either ACA's price inflation will create so much political upheaval that the single payer system hands this inefficent (non existant!) market place over to the tax-payer (which will mean ever inflating prices) or a solution like this, with dramatically visible pricing information, direct doctor pay, low cost catastrophic insurance will emerge as the saner, cheaper and higher quality solution.

> We are not solving the problem of why medical care in USA is so outrageously expensive, we instead are solving the problem of how to pay for it.

Perhaps, but to the individual, the first problem is by far the gravest. One can feel outraged if the taxpayers are paying too much in general, but that is not exactly a life or death situation like not being able to pay for medical aid.

Also: Why can't you fix both problems?

Fixing both problems is ideal, and we should do both. But, I fear, that after fixing the "how to pay for it" problem, no politician will try to fix the much more complex, and much more important problem of the very high costs. At the rate we are going, by 2021 US is expected to spend nearly 20% of GDP on health care. To address this we will need to cut the spending on last-6-months care as well as reduce procedure costs. Even if we address the latter, I doubt any one in congress has the spine to address the former.

Forcing people to pay for health insurance they don't want to drive down the cost of healthcare seems backwards. The pressure should be on insurance companies to make insurance more appealing.

At this point, it's much easier to figure out how to pay for it than it is to revamp the entire system and stop some powerful players from making as much money as they do. It's much better to have this than to work towards fixing a societal problem for decades and get no where while doing so.

That's not quite true - part of the problem is that we don't know exactly how, in the American system, to reduce the healthcare costs effectively. But I feel like I've read multiple times that the ACA funds pilot programs to try out many many different ways to change incentives to see if they help health care costs come down.

WOW just wow. Would have been cheaper to fly first class to any other country in the world and get the baby there. It's really time for significant overhaul of the health care system here in the US

Yes, in France its about 100 to 200 euros.

That's the total cost to the French medical system for a normal delivery? I find that hard to believe. In Canada that rate is a couple thousand dollars.

Or is that what the patient has to pay?

What the patient has to pay is close to zero, even with anesthesia (which is more or less compulsory -- you would have to make a big scene to avoid it) and complications.

If you want a doctor to attend (instead of simply a midwife) you have to pay him out of pocket (but if you have private insurance it might cover that too).

What it costs to the French medical system is anyone's guess. The French medical system is financed by the taxpayer. In theory, it's financed by a tax on salaries, but since it's in perpetual deficit and the deficit is covered by the state, it's in fact paid for by the taxpayer -- which is just as well, since everyone is covered.

It's a system of fully socialized medecine; there are pros and cons to such a system; it's not all good, but it's certainly not as bad as the American system (before or after Obamacare).

Difficult to say if that's the case for hospitals, since they run on public money anyway, so they could run at a deficit and it would hide the higher cost than what they charge.

But in all cases, social security pays exactly what you are billed.

In most cases you pay yourself the hospital, clinic, doctor, whatever, and social security then gives you part of the costs (depending on the procedure) and if you have one, your private health insurance gives you the rest (or less, depending on your plan, of course).

The tendency is at removing the unnecessary payment by the patient before being reimbursed, but for now this at least serves as a way to ensure you know exactly how much was paid for the procedure, and to prevent too many excesses (since, well, the patient has to be able to pay, even if he gets reimbursed).

>That's the total cost to the French medical system for a normal delivery? I find that hard to believe.

Many EU countries are trying to boost their birthrates, so the state covers most/all of it.

Come to the UK, it's free.

It's also free in Norway.

It certainly is not. It is paid for by one of the highest tax rates in the world. I currently work in Norway and pay more than 50% in income tax and social contributions - and that does not even include other taxes and excise duties like the 25% VAT, the 9USD/gallon gas price (mostly tax) or the new car tax of something like 150-200%, property taxes, road taxes, vehicle taxes, alchold and tobacco taxes...

So no, it is certainly not "free".

(And yes, people in Scandinavia stating things are "free" is a rant-trigger for me.)

And people in America stating that healthcare is not free is a rant-trigger for me.

Everyone here knows that it's not "free" but subsidised by taxes. That's what "free" means when talking about healthcare, free at the point of service, and free as equally available to everyone.

How else would it work? Are the doctors without pay and with no equipment?

It's an important point to make that even "free" healthcare is not actually free - the money has to come from somewhere, and most of it comes from forcefully confiscating it from people.

Not only that, but if you're using money, it's much easier to use someone else's money instead of your own, you just won't be too careful about how you spend it. In fact, if you've got a "limitless" supply of other people's money, you just won't give a fuck about what you do with it. This is one reason why public healthcare (and public anything) turns to shit sooner or later.

> "Not only that, but if you're using money, it's much easier to use someone else's money instead of your own, you just won't be too careful about how you spend it."

Sounds logical on paper but doesn't bear out in reality - just about every country where health care is provided via "confiscated funds" pays dramatically less for better outcomes than the USA where people are responsible for spending their own money.

The Parasite(tm) is more bedtime-story boogeyman than observed reality. They exist, but in far fewer numbers than reported, and their effects on the system far less grave than prognosticated.

This makes a lot of sense in fact, if for nothing else than the simple reason that most people really don't want to be sick or pretend to be sick so bad that they actually spend a lot of time at a hospital.. They have better things to do.

In Canada, where I'm from, most of the people I know avoid doctors and hospitals unless they really aren't feeling good. They don't want the hassle of waiting and waiting again to see specialists or get a procedure of some kind done.

The canadian socialized system is still really, really slow though for non emergency care but I never believed it was because of parasites wasting hospital resources.

>> Sounds logical on paper but doesn't bear out in reality - just about every country where health care is provided via "confiscated funds" pays dramatically less for better outcomes than the USA where people are responsible for spending their own money.

The US healthcare system is truly fucked, but serves as another great example of how people use someone else's money. That's why healthcare is so absurdly expensive there. Patients generally aren't using their own money to pay for medical services, and so, insurance companies get charged ridiculous prices behind the scenes, and the customer doesn't care. Businesses are forced to buy insurance, right?

Well, without the "forced middlemen" of insurance companies, and with customers paying for whatever services they use, you can bet your ass that health care would be massively cheaper. Competition drives quality up, and prices down.

>> The Parasite(tm) is more bedtime-story boogeyman than observed reality

I hadn't even heard of that "theory". But I bet I would have, if I were still watching Bill Maher's show.

You're right in that some parasite patients are not the problem. The whole system is.

Think about it. If you're running a hospital on a "limitless" supply of other people's money (as in, "public healthcare"), you're just not that concerned with efficiency, nor the quality of your services, because you don't have to be. It doesn't matter if your customers are unhappy, because you'll still be getting your money! .. It's blindingly obvious that this kind of system is doomed, but of course, healthcare is not socialized in order to make it better. It's socialized to make the masses dependent on the State.

So I assume you don't buy insurance, for anything ever, correct?

The norm is 36%, if you earn a lot you'll get taxed more. But your income never has a say in you wanting to have a child or not.

Is using Hacker News free?

Comparisons between countries like Norway and the US are a bit misguided IMO. It's hard to imagine that an oil rich country with a homogeneous society of 5 million people at the edge of the world can be fairly compared to the leader of the world's current Pax-Americana with a population of 300 million. Norway enjoys the benefits of being an almost-city-state as described in Antifragile by Nassim Taleb.

There is no free lunch?

There might be. The US government spends way more money per head on public healthcare than the UK (and only slightly less than Norway) and that's totally separate to all the private spending! http://www.theguardian.com/news/datablog/2012/jun/30/healthc...

Procedures are so expensive, doctors so highly paid, and insurers so profitable that the US is essentially subsidizing all that while still not providing universal healthcare.

In the UK we're both taxed less AND don't have to have private insurance due to the above. (It does have some downsides though, particularly in not being able to easily 'shop around' or get access to cutting edge/experimental medicine.. it's a bit one size fits all.)

A top-level policy with Bupa/Pru will get you easy access to top hospitals in the UK (including London), for diagnostics at least. I just got a quote for £70/mo (it will almost double if you claim, however).

EDIT: hm, not sure about 'experimental', but top quality/teaching hospitals anyway.

Nobody in the United States gets access to cutting edge/experimental medicine either. Insurances just won't pay for it. They say "too experimental" and "not medically nessessary" is a reason not to pay. I am currently in a 3rd level of appeal to get my insurance company to pay for my medication they claim is "too experimental" (it isn't by the way!!!)

Really? In Poland the state pays ~$500 and that's it. And they are not famous for being generous :)

Yes, if I had to pay 20k to just have a baby and could fly somewhere else where it's free, I'd chance it.

There might be a problem that many airlines won't let pregnant women fly past a certain number of months, for fear they will deliver the baby in the air; so maybe you have to move to the target country months in advance, significantly adding to the total cost...?

Doesn't need to be free - the very best healthcare in my country (Uruguay) would cost about five thousand dollars per year of coverage, and we're talking about something better than the average US hospital - www.hospitalbritanico.org.uy .

Those five thousand would cover 90% of the expenses involved in all steps of pregnancy (prenatal care and checkups, 4D ultrasound imaging, etc) and the delivery itself.

And living here a few months would cost way less than 15.000 dollars :)

If flying is a problem, you may drive to Canada or Mexico. Mexico has a pretty good private system that is used by the local middle and upper classes. This is from my hometown...http://www.chihuahuamedicalcity.com/

You can take quite a long vacation for 20k.

Companies, like Safeway, that self insure pay $3,000 to $5,000 per procedure. For example:

Colonoscopy: $897 Breast excision of lesion procedure: $2,569 Gall bladder procedure: $4,212 Cardiac Catheterization (no angioplasty or stints): $4,900 Knee Arthroscopy: $3,039

I wrote about it here:


The CEO of SafeWay, started a company that sells this data. Unfortunately its typically only sold to companies that self insure and have ~10,000 employees. You can watch him talk about the data and the company here:


Wow. The average reimbursement for a non-complicated birth in most US hospitals is around $3-5K.

You are correct though, the reason why hospitals do this is because the system is entirely setup to support this kind of behavior.

Next time, try a midwife if you and your wife are comfortable with home birth. In the Denver area it runs about $3k for parental care, the birth, and post birth check ups. Also, you don't have to deal with hospitals. I had one of my kids at home with a midwife and I wish it would have been both. If you actually need one, then the midwife will take you to a hospital.

Unless you have one of dozens (hundreds?) of potential complications that can happen during childbirth and you don't make it to the hospital in time. They you've got a dead or severely brain damaged baby and a potentially dead mom. Totally worth it.

And the odds of making it to the hospital in time if you need an emergency c-section or start bleeding out are pretty slim.

Actually, experienced mid-wives are very good at recognizing problems before they become serious problems. At some point, I was running out of energy and starting to struggle. They have monitoring equipment for the baby, and checked on her first to make sure she was fine. They talked about transporting me, but decided to give me a tablespoon of honey first. It worked, and we were done with a healthy, happy outcome shortly after that.

With midwives, you actually have human attention on you during a birth, rather than doctors and nurses that drop in occasionally and can miss stuff. My hospital birth came closer to having problems because there was another emergency on the floor and no one paid attention to me for hours (when perhaps they should have).

Obviously you haven't done your research on this topic yet. The midwives are state registered and are legally bound to only serve woman who are in perfect health condition, with no complication during pregnancy whatsoever and prefer woman who had previous births without complications. Still, hospital is on standby and yes, it makes more sense if you are not 100 miles away from one.

that's exactly what we did. 12k the hospital, 6k the birthing home and the midwife charged 3k. When we asked her about the price, she "admitted" feeling "guilty". She said "it's still way too high, but I get in trouble from the birthing homes, if I charge less". Talking about "market prices". There are none (yet).

woh woh woh hold on....20k to give birth? I am amazed the US is still breeding.

"I got a reply in writing that it was $20k"

That sounds unbelievable! how can it be? it has to be a marginal case. I know at least two people that had babies in the US and barely pay anything (neither for the delivery nor for other medical acts before and after). They were PhD students or postdocs.

What I am wondering is on average how much an american pays for having a baby?

It's not an edge case: we were quoted that price a few years ago. We carry high deductible insurance, and that was before the recent US health care legislation mandated maternity coverage. (Before it passed, most insurers refused to provide maternity coverage outside of large groups, or charged insane prices, since the probability of a claim was so high.)

In the end, we opted for homebirth midwifery care, which was fantastic in every way. We ended up paying around $2k for six months of prepartum care, delivery, and six weeks of postpartum care. In the event of an emergency, insurance would've covered a hospital transfer.

It was such a good experience we did the same thing for #2, and we're planning on delivering at home if we have more children in the future.

Those people probably had health insurance and did not pay out of pocket, their insurance footed the bill. I know someone who paid out of pocket for a delivery and I think they said it was around $12K.

$20K for a normal delivery? that sends shivers down my spine. I knew healthcare is expensive, but this is insane.

Point is, you got robbed and didn't go to court for it.

>Needless to say that this American hospital would not even have admitted us without a certified check in advance

Well you ended up screwing yourself. Maybe you have never spoken to an American who didn't have health insurance and so didn't know, but, medical bills are settled later for less than half the insurance price and all hospitals have to admit you regardless of ability to pay by federal law championed by Kennedy.

>Needless to say that this American hospital would not even have admitted us without a certified check in advance.

An emergency room cannot refuse treatment to a women in labor.


I worked at ER. No, you don't want to have a baby in ER. ER doctors are dealing with emergency situations and patients (auto accident,cardiac arrests,gunshot wounds,etc). I've seen one baby being delivered in ER, and it wasn't a good experience for the patient. Rather, you'd want proper pre-natal care and comfortable delivery room, with your own doctor. Also, ER treatments are more expensive. Way more expensive.

Wow. Next time shop around a little. We did and the hospital stay for my wife and baby was around 2800. Our doc was 2700. The anesthesiologist was a shocking 2500 though. Our doc and the hospital had to be prepaid, or else we would be charged higher rates. Some places call them "Stork plans"

"I got a reply in writing that it was $20k"

What did the reply in writing actually say?

Seems almost as if this was merely a "retainer" paid in advance against the expected cost.

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