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What happens when someone has an emergency like a stroke or heart attack? Not a lot of time to email all the local hospitals. What happens when the patient is unconscious? What happens if their condition can only be treated by a certain facility or medication?

But yes, surely people are only getting screwed over the healthcare system because they are lazy. /s

That's the only time when one cannot get quotes. Depending on a location ( ave/st in NYC and a time of day ) the ambulance would take one to a specific emergency room in a specific hospital chain.

But again, that's not where most of medical services "waste" is occurring.

Most medical expense is care of chronic conditions and end-of-life care. Not elective procedures.

https://www.qualityhealth.com/health-lifestyle-articles/10-m...

So if it is chronic there's even more reason to ensure that one does not overpay for what one would be consuming all the time?

It's both the duration and increasing severity that account for much of the cost, along with the systematic cost-inflating aspects of the US healthcare system.

Individual actions play little role.

That's just hand waving. If the duration increases it makes absolutely no sense not to attempt to get the cheapest way to manage the condition.

People do it all the time if they are on a hook for payments -- that's why we have drugs being grey important from Canada, Europe and India, especially if those drugs are not covered by the US insurance. Suddenly saving $200/mo per type of a pill becomes important. As soon as it is covered by insurance it becomes "Whatever, insurance pays"

No, it is not.

It's an argument for structural rather than individual change.

Yes, the structural change is "make individuals be on a hook for overpayments"

Actually, the best cost-containment strategy is to make the provider liable.

That's the notion behind comprehensive HMO systems, with fixed capitated premiums, minimal copayments (a very low friction suffices against most frivolous use0, penalties for failed delivery (see also the Chinese doctor model: the patient pays when healthy), comprehensive monitoring and routinisation, a public health model, and som external oversight.

Within the US, that model describes the Kaiser Permanente healthcare model. Or Medicare I'd add a Danish malpractice remedy to that (provision of care to correct or mitigate mis-delivery or errors), but it's remarkably effective.

Pharmaceuticals remain outside the Kaiser and Medicare systems, a chief weakness.

There's also the fact that virtually all improvements over pre-modern longevity come from public health rather than acute medical interventions.

http://1.bp.blogspot.com/-uTWEATUzgxk/TXQoTibILtI/AAAAAAAAAA...

> What happens when someone has an emergency like a stroke or heart attack? Not a lot of time to email all the local hospitals. What happens when the patient is unconscious? What happens if their condition can only be treated by a certain facility or medication?

This is not a rocket science: when one sees a complex problem one does not attempt to solve the entire problem using an full rewrite -- instead one breaks out it into pieces and solves one piece at a time. If the piece is too big to solve that piece is broken down into pieces and those individual pieces are solved.

It is debugging of the problem 101.

> What happens when someone has an emergency like a stroke or heart attack?

Call 911.

Have a toothache? Don't call 911. Call a dentist. In fact, call several dentists. It is, of course, possible to call 911 and have an ambulance take one to an emergency room because of a toothache ( this was a case told to me by a friend who is currently doing an ER rotation. He swore he was not pulling my leg ).

> What happens if their condition can only be treated by a certain facility or medication?

It is unlikely that a common condition can be treated by a single facility.

> or medication?

If we are to optimize the costs of overspending by not selecting cheaper alternatives where we can there would be more money to spend on the expensive "it can be only done here" or "it can only be done using this medication".

That's very interesting information, but I could have done without your snide allegations of laziness towards everyone not in your fortunate position - being both educated and confident enough to research and negotiate pricing, and having a relatively non-urgent problem. The last time I was in the ER I woke up there with no clue as to how I had arrived.

Most of the problems in the health care are non-urgent.

Most of people at the ER are not there "waking up and not knowing why they are in the ER". They walk into ER with something not working for them. That's exactly why it takes 3-4 hours to be seen by the ER doctor.

People like you, who wake up in the ER, are rarities. Those people are either brought to the ER in ambulances or are triaged and seen immediately. It is for those cases one could justify the costs of an ambulance ride and 500% markup of an bandage.

I do not agree that most visitors to the ER do so for non-urgent reasons, although few complaints are so severe. I don't think you've fully grasped the point people are trying to communicate to you here.

I believe I understood it quite well. It just does not match either my experience or what I read.

There are lot of articles on the topic. Here's a random one:

https://www.wmpllc.org/ojs-2.4.2/index.php/ajdm/article/view...

Green triage means that there were no reason for the patient to be in the ER. With the over-triage, green is still over 70%.

So lets presume that between red and yellows it is actually 30% and none of them are triaged up ( based on the article that I linked it seems triaged up red is high single digit which is in the same ballpark that my friends who are in emergency medicine rotation say ). Those would be the only cases where one cannot pick a non-crazy expensive service ( in fact only reds cannot, and yellow probably can which is why their service is delayed ).

So at least 70% pay 7-10x because they showed up in ER rather than in a walk in center/doctors office.

Not to be argumentative, but the stats may not be as descriptive as it might seem. I've seen kids in ER because they put popcorn in their ear and you can definitely say that they should be at the doctor's office. On the other hand, one day in the middle of the night my blood pressure spiked to 230. My heart was racing. I had no idea what was going on. I phoned the hospital and they suggested going to the ER. I did. They took an EKG and everything was normal. Diagnosis: panic attack (which I think was brought on by my previous blood pressure medicine). Doctor gave me a sedative and told me to go see my doctor the next day. I'd be in that green triage, but you don't know until after you are triaged. That's the problem.

Ironically, the next time it happened, I waited all night then went to the doctor. He sent me to the ER, who sent me right back home again. Another time, I had a friend who I suspected might be falling into a psychotic episode. They were acting a bit strange and it worried me. I got them to the ER and boy am I glad that we went. Probably saved a call to the police.

It's these kinds of things where you just don't know that are the most worrying and now that I have some experience with it, I have a much better idea of why some people park in the ER. If you've never experienced, then I am incredibly happy for you because it really sucks.

Of course I don't know that this is where a lot of these cases come from, but in my limited experience this is what I've seen. I think we need some other kind of place you can go that can triage effectively when you are worried and don't know what to do. When I was younger, I got sent to the ER because I had obviously broken my hand. That's a waste of resources. There are better places I could have gone, but if you don't know, then you don't know.

I appreciate your point but I do not think it contradicts the numbers - going to ER and getting a green triage means that the triage personnel determined that it is not an emergency.

According to 2013 National Institute of Health study put the median cost of ER visit at $1,233. In 2015 there was over 130M ER visits. Lets arbitrary assign the cost of interacting with the Triage nurse at the ER to $233 ( which is insane lets do it anyway), then the pool of cost overtriage 130M * $1000 which is $130B. Of those even triaged up 70% is a green triage, which makes it $91B.

If we are to make an assumption that for non-emergencies addressed by ER cost only twice as much non ER then simply by sending people to a regular doctor after people are getting a green triage one realizes savings of $91B/2 = $45.5B

Sibling commenter is correct. The majority of ER visits are actually not emergencies; rather they are frequently used/abused as a convenience (open 24/7) or because payment is not required prior to care due to the unfunded mandate that is EMTALA (debt collectors are a separate discussion).

I had my gallbladder removed in a emergency surgery over a decade ago.

It happened on a Wednesday night. I had excruciating pain, enough to nearly black out -- and a friend took me to an emergency room, where they did an ekg, ultrasound, put me on a morphine drip and operated the next day. Once the pain set in, I was in no position to do research for a variety of reasons.

I'm not sure what kind of shopping around could have taken place for that.

Could you explain how your technique would work for something like my situation?

Isn’t the solution an advanced care directive? Where you make decisions in advance of something happening, just in case you end up in a situation where you can’t decide yourself?

E.g. no extraordinary measures or no CPR, or, get me into one of these nursing homes and not this one.

Even in public health care countries, there’s plenty of decisions that are a good idea to make in advance.

I don’t see why they can’t be scaled toward cash healthcare countries.

Comparison shopping arguably isn’t the intended purpose of advance care directives—which, FYI, can only go into force if the person is legally incapitated, and being in pain, however extreme, is a grey area as I’m sure you could make the case that decision-making capacity still exists. There’s also the issue of having the agent available when such an event happens, and having them be in possession of the directive.

Anyway, even then, it’s infeasible to enumerate all the possible decisions in advance—not only is it impossible to know what your costs will be ahead of time, there’s a lot of variation in cost. There isn’t going to be a single hospital in your region that’ll have the cheapest prices across the board, so it’s not as simple as “send me to the cheapest hospital”.

It will not work for emergencies however that's not where most of the money is burned.

Most of the money is spent on non emergency medical care that can be priced using a phone or an email. That's exactly why medical tourism is possible.

It is a case of vertical capture: should you walk into a Mount Sinai hospital, the $600 MRI of Lennox Hill will cost you between $1800 and $2800. It will be done using the exact same MRI machine. The result will be sent to India probably to the exact same company that Lennox Hill sends the MRI for a radio tech readout, except that Mount Sinai MRI won't be available for 5-7 days vs. in an hour at Lennox Hill.

So why is Mount Sinai is able to charge that amount of money for an MRI? Because it is a vertical capture. Should you walk into a Mount Sinai it is extremely unlikely that you would go out of the hospital to get an MRI. They could probably charge $7,000 and still get 90% of the patients doing it.

Final signed American radiology reports are not dictated in India, especially at academic medical centers.

They've tried; it's blown up in their faces.

https://www.nytimes.com/2003/11/16/business/who-s-reading-yo...

> Personal responsibility is "hard" so no wonder those who tend to outsource it get fleeced.

What is the effect on the market when everyone engages in "personal responsibility"? If everyone finds out about Lenox Hill Radiology and goes there instead of to hospitals for MRI, won't the effect be that demand goes up without supply obviously going up, causing increased prices and wait times? What will be the effect on hospitals that were subsidizing their other business by pricing their MRIs higher?

The reason people don't like "personal responsibility" as a general-case solution is not that it's hard, but that it's not a general-case solution. This article is talking about an actual general-case solution.

Or the effect could be that Lenox Hill Radiology discovers it's getting a ton of MRI patients, has utilization above 85%, and can now afford to get another machine. A group doing a thing well getting more business is typically not a bad thing. Yes, if it's a loss leader then bad things can happen - but that doesn't seem to be the case here.

"Personal Responsibility" is just "making the market actually be a market". Markets are great - but situations where the person paying isn't the person choosing or receiving the benefit tend to be horrible in some dimension.

> What is the effect on the market when everyone engages in "personal responsibility"? If everyone finds out about Lenox Hill Radiology and goes there instead of to hospitals for MRI, won't the effect be that demand goes up without supply obviously going up, causing increased prices and wait times?

The current situation for the same MRI is:

Mount Sinai - cost $2800, wait to schedule 5 days, wait for read out 5 more days.

Lennox Hill - cost $600, wait to schedule ~1.5 hours, wait for read out, next business day.

Distance between two locations: opposite side of an avenue and half a block. Realized savings by crossing a road: $2,200.

Where else is it possible for two identical products to be offered in that close proximity at that kind of a price difference and have people defend the pricing of the more expensive one while complaining that the services that include this product cost too much?

But here's what I think should happen: Lennox Hill would slowly increase its prices and Mount Sinai would drop its prices until it would not be possible to save $2,200 by crossing an Ave and walking for five minutes. Of course if we are to look around this is not current more likely outcome - rather Mount Sinai would buy Lennox Hill Radiology which is an independent radiology center, make it a part of the Mount Sinai hospital chain and increase Lennox Hill' price to whatever level that it currently charges ( hospital chains have been buying up independent centers hurting their cash cows for years ). Unfortunately for hospital chains radiology centers now are a proven way to make money so new ones are popping up more and more.

> What will be the effect on hospitals that were subsidizing their other business by pricing their MRIs higher?

I have never heard of this argument being used by any of the hospital chains to justify high prices for the services that can be done out of hospital and it is definitely the kind of argument that should get traction had it been possible for any hospital to bend some numbers to make it remotely plausible so I would say it is unlikely to be the case.

How did you know it was an ACL injury?

Did you injure yourself and went to a medical center and they told you to go to a radiology center who then told you you had an ACL injury?

I ask because at the end, you said you searched for "sports medicine surgeons" which already looks like you have _some_ knowledge about what was going on.

Which is great. But part of the problem we have is education. Most people don't even know of other options available to them and don't have the vocabulary to effectively search for what they want.

"Torn ACL" is way more specific than "Knee hurts".

> How did you know it was an ACL injury?

Crash on a Super-G, followed by a quick prelim diagnostics of knee stability. Diagnosed as a possible tear of MCL or ACL and possible fractures.

> Did you injure yourself and went to a medical center and they told you to go to a radiology center who then told you you had an ACL injury?

You might find it interesting: all such diagnostics is actually done only using an X-rays and MRIs. Physical evaluation is just used to decide what to X-ray and what to MRI.

> Which is great. But part of the problem we have is education. Most people don't even know of other options available to them and don't have the vocabulary to effectively search for what they want.

Probably, but this is a vastly different problem from "Something unknown costs too much"

The average case where people go to the ER they don't have a week to Google and research their options. More likely minutes to hours. You can definitely find some value in the US medical system if you have the time, like coupons for prescription drugs that aren't covered. But yes, don't go to the ER for non-emergencies and you'll save money and everyones resources. Hopefully that's basic logic to most people.

It took me three hours ( and I waited patiently for more responses ) before receiving the information and picking what seemed like an reasonable course of action. I obviously googled before to prepare myself of having my HSA wiped out. The horror stories told me it would be.[0]

In fact when the walk in center referred me to an ortho and said "It will be expensive. Here's a list of good ones" I asked if it was going to be "$800 dollar expensive?" at which point I was looked at by both the front-desk person and the Emergency medicine doctor as if I had grew two heads in front of them. They said "About 250 to see a specialist and about $800 for an MRI."

One of the two surgeons that I have selected based on their responses who could see me the next day were on the list of good ones ( ~30 ) that I was provided by the walk in center. No referral code was needed.

The surgeon offices, the walk in center and the physical therapists were having near orgasmic reactions hearing that it was going to be paid as a part of high deductible plan because it means that it is paid from a regular Mastercard as if I was a cash patient, immediately, the same day.

[0] I have taken friends to ER. They were never seen faster than 3-4 hours.

This sounds a lot like the Bitcoin Be Your Own Bank™ approach to healthcare. Being your own bank sucks. Being your own hospital is even worse. Socialized medicine can't come soon enough.

What's the incentive for me to save all that money when my insurance pays for it anyway and my company pays for my insurance? Insurance is supposed to do this job - negotiate prices ...etc., but, people are so attached to their doctors that insurance usually caves giving hospitals a much higher bargaining power.

High Deductible Plan. Takes care of big ass expenses, steep cost in the beginning.

It's a start, but imperfect because most people with a high deductible plan will also have a health savings account (HSA). The HSA may even be required, not sure. The problem with HSAs is that although it's "your" money, it can only be spent on qualified health expenses. So there's a reduced incentive to spend carefully, because you can't use the money for anything else.

if you end up with "too much" money in your HSA, can't you just reduce the amount of money that goes into it? obviously you can't just go buy a car with the money, but to me it seems like there is a strong incentive not to overspend from your HSA if you control how much of your paycheck goes into it.

Yes but I always contribute the max to get the most tax reduction. I like paying taxes less than I like paying doctors.

have you already maxed out your company 401k and IRA contributions?

> it can only be spent on qualified health expenses

Once you reach retirement age it can be used like any Traditional IRA account, except for inability to roll it over to another IRA or do a Roth conversion, if I understand correctly.

HDPs can also have unintended side effects like patients delaying getting screenings until conditions are much worse (and more expensive to treat).

Why? HDPs aren't required to charge for screenings, any more than HMOd or PPOs are.

Yes, many screenings are covered 100% with no deductible. But if I think I'm having a stroke and call an ambulance, I'm responsible for the cost up to the deductible (I just checked my own HDP coverage to verify this). This wouldn't factor into my decision, but I'm fairly affluent (and my family actually maxes our deductible each year because of various chronic conditions). Someone that is in a different financial decision will absolutely be thinking of the cost of calling an ambulance (or going to the ER). Of course, if someone dies from a stroke rather than being treated and surviving, the result is lower healthcare expenditures (yes, that's morbid; but we also need to think about the incentives built-in to our healthcare system).

Were these amounts after insurance? just your share out of pocket? Or actual total?

These were the actual costs that I have to pay out of pocket until I reach the deductible of my insurance ( yearly ). I was at zero since it is a new year. In my case it is coming out of my HSA. Basically, cash price.

That means you don’t actually know the real cost since insurance shields you from the actual amount and it can be drastically different for each insurance company. You’re just estimating with a false sense of information.

I actually do because I get to provide the receipts in order for them to be deducted from my "still due" pile.

Pricing of this stuff is easy. One just needs to get off the couch to do that, or at least do as much as one does when looking for super duper 75" TV.