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Comment by francisofascii | Hacker News Reader

Just got the bill yesterday for my "free" Covid test. $250, insurance pays $105, you owe $145. (The test was free, the office visit was not.)

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Who is to blame?

The government for not collecting taxes from you and using that money to pay the doctor?

The doctor for billing too high for the visit?

The insurance company for not covering more of the price?

Personally I would seek to understand why the doctor is billing so much and how that can become more fair for everyone involved.

A big element here is that the free market is being choked out. Consumers walk into healthcare facilities without any idea what they will be paying when they walk out, and therefore have no ability to choose one facility over another based on price.

Because that ability doesn't exist, there is no downwards price pressure anywhere at the consumer level for medical services.

I think we'd see a lot more results if we asked 'why aren't these facilities putting more efforts into reducing costs' rather than asking 'what makes this so expensive?'

> Because that ability doesn't exist, there is no downwards price pressure anywhere at the consumer level for medical services.

It's important to note that the downward pressure you'd see here is only for elastic goods which most healthcare-related things likely aren't.

There are plenty of healthcare related things that one can shop for, such as this COVID test. The price could easily be advertised on the healthcare facilities website. But it’s not because it would hurt revenue since price transparency benefits buyers, and price obfuscation benefits sellers by allowing them to price discriminate and charge each seller the most each seller is able to pay.

> But it’s not because it would hurt revenue since price transparency benefits buyers, and price obfuscation benefits sellers by allowing them to price discriminate and charge each seller the most each seller is able to pay.

Are you against a monopsony in healthcare? If you care about having a fair-shake for every consumer, then that's the most consistent way of wielding power against would-be price gougers.

There’s a balance to be had, a marketplace functions best when there are many buyers and many sellers. Obviously, health issues aren’t a perfect marketplace due to buyers not being able to shop around many times, and due to buyers not having sufficient knowledge about what they are buying due to the complexity inherent in medicine.

In all cases though, I think price transparency is always good as that is what helps to properly allocate resources in the long run. And I think that published healthcare prices coupled with high deductible health insurance is a good idea as it would allow proper information about pricing to be transmitted, at least for minor issues such as covid tests or broken bones or routine visits and procedures.

For more complex cases, I would have to defer to those with expertise on how to ration resources.

> A big element here is that the free market is being choked out.

Given that every developed country has much lower per capita and per GDP costs, and pretty much none have more of a free market in health than the US, I'm pretty sure that's not the problem driving US prices high. I get that free market fundamentalism is one of the most influential religions in the US, but it's popularity doesn't make it contentions true any more than the popularity of Christian fundamentalism does for young earth creationism.

Other developed countries' public health facilities ration care based on medical need rather than ability to pay. There is always concierge medicine but it's not nearly to the extent in the US. Rationing of care this way means fewer medical procedures on the whole.

I've seen numbers to the effect that health outcomes are 30% genetic, 30% diet, 30% lifestyle, and 10% medical intervention. Frankly Americans don't need as many procedures done as they have done. Medical care is rationed everywhere and there is no way for supply to meet demand. The only question is how do you ration it. Turns out rationing by ability to pay leads to unnecessary procedures with no boost in outcomes.

The hard part to accept is that the system that imposes a 3-6 month wait for non-life threatening treatments is better because some number of cases resolve themselves during that time period and reduce total demand.

Overall medicine has limited tools to improve health compared to diet and exercise. We like to believe an intervention by someone else - surgical, pharmaceutical, etc. - can fix our problems, but that's not the case for many people. Medicine can really help with things such as pain management and trauma, but to an unsettling degree we rely on the body to heal itself.

Most developed nations have highly regulated healthcare systems, and part of the government involvement is in setting prices.

The U.S., through everything from safety regulations to IP laws to insurance regulation has destroyed competition, but outside of medicare isn't involved in determining prices. The result is predictable.

Markets work great when the incentives are right. It's hard to get incentives right in healthcare and most nations want medicine to be part of a government safety net, so they go the direction of socializing healthcare. Almost anything would be better than the system the U.S. has now.

> pretty much none have more of a free market in health than the US,

US healthcare doesn’t have a free market by any definition. You would need a buyer and seller agreeing on a price, and without price information, there is no market.

> Personally I would seek to understand why the doctor is billing so much and how that can become more fair for everyone involved.

For the same reason a McDonald’s worker bills closer to minimum wage - because that is the most the buyers are willing to pay. Solution to bringing prices down is to increase supply and/or decrease demand, and increase price transparency.

For who to blame, I think it is shared. The govt could have set a price ceiling for testing so people actually get tested. Yes, I think the bill was too high for the service provided, which was the test and checking vitals. For me I essentially had to get tested because I had a fever and my wife was not allowed to go back to work until I was cleared. Maybe I could have shopped around better.

Part of the issue is that the supply of doctors is kept artificially low in the US. Another part is: why the heck do you need an office visit for this? Why can’t you go directly to the lab?

For the record, it was not a brick/mortar office, but a temporary tent set up specifically for Covid testing.

Horrific to be charged that much for a tent visit :(

A huge factor is multiple insurance companies add a lot of overhead to the system as they all try to negotiate lower prices. It’s common for a doctor to spend more time dealing with your insurance company after a visit than you. Which clearly means they need to dramatically raise prices to cover that overhead.

> It’s common for a doctor to spend more time dealing with your insurance company after a visit than you. Which clearly means they need to dramatically raise prices to cover that overhead.

How do you know the doctor wouldn’t be billing erroneously anyway? People have no idea what doctors do or what is appropriate. The insurance company serves as an educated advocate for the patient (they employ doctors and pharmacists) to reduce over billing.

Yes, the people working at insurance companies could be over zealous, but the same applies to healthcare providers.

If doctors didn’t want to deal with insurance, they are free to hang a sign that says $50 per 15 min consultation.

> The insurance company serves as an educated advocate for the patient (they employ doctors and pharmacists) to reduce over billing.

Insurance company profits are capped at a percentage of payout, and they are part of oligopolies protected by high barriers to entry, why would they reduce overbilling or advocate for patients?

Because if they payout too much then they have higher premiums compared to their competitors, which means customers would opt for a different insurer?

Obviously not forcing everyone to go through healthcare.gov crippled the ability for numerous health insurance to exist and compete, but that is a political problem.

With single payer systems it’s much easier to sanity check what’s going on. For example billion one organization for 20 hours of work per day is laughable, but spread that across 10 companies and they can’t tell. Similarly, having more data allows for better statistical analysis when combined with random sampling.

Yes, but without single payer, I don’t see a viable alternative to insurance companies or a similar organization double checking a doctor’s billing.

One option is to separate the verification process from the insurance companies. In other words you have some list of pre defined standards that are covered at some rate and then an independent agency applies those standards and looks for fraud.

Aka a hospital might negotiate a separate rate for stitches with each company, but they don’t get to decide if it was needed on a case by case basis. Alternatively, apply the Japanese system where all procedures have a single agreed upon rate negotiated regularly.

That function is also performed by insurance companies in the US, sometimes known as managed care organizations. Many large companies self insure and use health insurance companies’ resources to implement their health benefits.

Most, if not all, states outsource the implementation of their Medicaid plans to large insurers like Anthem or UHC or Humana, etc.

An agency outsourcing that function to a private company for all care in a state does not invalidate the savings. It’s a question of efficiency and conflict of interest not inherently a government function.

That said, outsourcing them back to the same insurance companies which also offer plans has major issues.

Belgium

On your own initiative ( partially paid back):

- 9.6€ for the Covid test

- 17 € for the doctor visit

By Government:

- fully paid back by our health care, including doctor visit

I love transparent pricing :)

But the highest COVID death rate in the western world! You gain some, you lose some I guess :)

Different countries have different methods of counting. In Belgium, suspected cases in care homes are included in the figures, without any testing being done (https://www.euronews.com/2020/04/22/analysis-can-we-trust-be...), so the official figures are an overestimate. In the UK, there are two different figures published. The headline figure is for confirmed deaths (i.e. with COVID-19 being listed as the cause of death on death certificates), but the Office of National Statistics less frequently publishes excess deaths (i.e. compared to previous years). The Belgian per capita suspected death count, which is probably similar to its excess death count, does exceed the UK confirmed death count but is well below the UK excess death count.

The per capita figure in https://multimedia.tijd.be/oversterfte/ for VK (United Kingdom) is for confirmed deaths (62.2 per 100,000). In mid June, the total figure was at 42,000, while excess deaths totalled 65,000, so that would make UK excess deaths 96.3 per 100,000, significantly higher than the Belgian suspected figure of 84.4 per 100,000.

Can't really compare all of US to a single EU country and maybe vice versa.

NY has ~19M people, death per 1M ~1700 Belgium has ~11M people, death per 1M ~840

The US has 5 states with a far higher death rate than Belgium: https://www.worldometers.info/coronavirus/country/us/ So far.

That's a non-issue.

Belgium counts any suspected Covid death as a confirmed one, so we have approx. 2* as much deaths in statistics.

It's mentioned a lot, but I guess not everyone knows ;)

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