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Comment by refurb | Hacker News Reader

That’s the kicker - almost no one pays these prices so when they get stupid nobody notices. Unless you’re uninsured then that’s the price they use.

As someone in the healthcare field - the best way I can describe it is that providers and insurers fight it out however they can. The problem is is that patients get the shit end of the stick.

I think calling out that both hospitals and insurers are fucking over patients is a positive change. Hospitals used to always get a pass, but they’re a huge part of the problem.

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But do uninsured people actually really pay this? My impression was that you still can (and should) try to negotiate with hospitals/providers whenever possible and/or ask them to create a payment plan for you. But maybe that's not common knowledge?

Since you're in the space, what do you think of the startup they mentioned in the thread, turquoise.health (or rather the idea behind it, not literally the startup)?

No, uninsured people also don't pay it. They are offered a fraction of the cost if they pay "cash" once you're leaving.

I went to the same ER in San Francisco with the same problem 3 months apart (kidney stones). The first time around I was uninsured and the bill was $2000- they told me that they'll cut it down to $500 if I paid on the spot, which I did. 3 months later I had the same problem, had purchased insurance, my bill came out to $8000 and my deductible was $2000.

Okay, interesting. I had read some articles about medical debt that alluded to those levels of savings for paying cash in one lump sum quickly but still, it's pretty striking that you get a 75% "discount" for cash on the spot.

And not to mention when they say "on the spot," they mean it. In the room, right there, as you're checking out. If you don't have access to any payment methods or you need to wait two days until you get paid or something, you're looking at a 50-100% increase over the final quoted "cash price" even if you're still paying cash.

Can confirm. Had a procedure (hernia repair) and at the time of setting it up my insurance was in flux. I asked for the cash price to move things along and was quoted just ~7k all up. Insurance ended up covering it but received one of those invoices were it starts at over 20k before the magic "discount" gets applied.

I have been assuming the magic discount is some sham the insurance companies push for to scare people into believing they would not get it if it weren't for the insurance.

It's BS IMHO to not be advertising the ACTUAL cash amounts they would quote somebody..

Can you just say "I don't want to use my insurance at this stage and I want the price from last time?"

As always, it depends. There is a certain point at which your visit is tied into your insurance so you can't just undo it. At that point the hospital is now fighting with the insurance company to pay and you're stuck in the middle.

So you paid more on insurance? And the bill while on insurance just happened to be inflated so much that the deductible came out to be the price of the procedure the first time around? That sounds like fraud.

Sounds like health insurance!

If you delay payment you probably have to help pay for those that will not.

One reason that stitching up minor cuts is so expensive could be that those who need that treatment (e.g. because they were in a fight) are statistically less likely to ever pay their bills…

Do you have a source that people getting small cuts stitched up are less likely to pay their bill?

If you dont have 500 available at the time of health issue you pay more?

But it still sounds scammy pricing tactic to me. That is not how stores or anything else works or should work.

Or you pay nothing at all (they aren't going to repo your kidney), or end up working out a deal to pay whatever you can later. They offer the discount because on average they figure the discounted price is higher than what they'll get paid later.

That's not my experience. I was out of state and needed medical attention. I was on Medicaid. Urgent Care straight up wouldn't accept my out-of-state Medicaid plan and suggested I go to ER. They too didn't accept out-of-state Medicaid, listed me as having no insurance, and billed me full-price for the some of the services. There was no discount for paying on the spot. I paid for those initial services and got more bills from the doctor and other departments. They never accepted my out-of-state Medicaid but eventually "gave me a discount." I paid some of it myself but told them if they wanted the rest to bill Medicaid.s

The people who get screwed the hardest are the underinsured (in all cases) and those who have high-deductible plans with coinsurance and HSAs (and have some acute issue).

I work in radiology and entered a few common procedures I see a lot in our data on https://turquoise.health/ (also linked in the Twitter thread). Then I entered information for our own HDHP+HSA plan. Guess what, having insurance costs you 40-60% more if it's an acute issue. So if you're healthy, you have zero incentive to use your insurance if you suddenly need a CT of something. The rub of course is if you pay cash, it doesn't count toward your multi-thousand dollar yearly deductible, so if it turns out to be a chronic issue you just shot yourself in the foot. But if it doesn't, you just burned thousands by using your insurance when you didn't have to.

It's a complicated issue and anyone who says they have the solution, including "just make it free / just have the government pay for everything," is either being disingenuous or doesn't understand the problem. As was stated in the Twitter thread, running a hospital 24/7 is astronomically expensive. Everyone has their finger in the pot trying to get paid for their services in a world of increasingly small reimbursements. Attending physicians as resident-run hospitals will sleep overnight while getting paid literally half a million dollars a year. Insurance companies will just decide not to pay something and will spend years in court to defend their right to pay whatever they want, down to and including $0. Vendors will charge tens of millions of dollars to implement monolithic thick-client applications where everything is so configuration-heavy that you literally can't have a test environment because it won't match. Interoperability is managed by a text-based standard named HL7 that if you're not familiar with, will make you rip your hair out. The standard itself is ignored by every organization who ends up with their own flavor, so every app needs to be configured to support nearly any value in nearly any field. Hospital IT is staffed by people making $40k/yr who don't understand modern computing, and run by executives with no technical background.

Every single entity and company involved in healthcare is complicit in the end result, which is skyrocketing patient costs with at best no change in patient care or patient outcomes.

Thank you for sharing this, really helpful to hear from someone inside the industry and of course, the issue is super nuanced and complex. I just wonder if/when something will give in the U.S.

But you said something that stood out - "Everyone has their finger in the pot trying to get paid for their services in a world of increasingly small reimbursements." Given the rising prices, why isn't the pot getting bigger?

What do you think of Epic systems and EHR stuff?

I have friends that work at Epic but I don't do a lot on the EHR side. I will say I went several years ca. 2010-2019 or so without utilizing healthcare at all, and went from having doctors laugh at me when I asked for my chart and telling me that I wasn't allowed to see it from being able to log in to my doctor's portal and see my actual Epic chart, complete with their shorthand, typos, etc. The first time I logged in, after the initial shock, I was able to correct two errors in my medical history from when I was in HS. So from a consumer standpoint I am 110% pro-EHR.

I think the pot is getting bigger but it's getting bigger for gigantic organizations like Kaiser (not calling them out specifically but it's a name everyone knows). Someone pointed out, either here or in the tweet thread, that the 2011-2020 price increases are just going to Stanford. The physicians don't see any of that because they have their own reimbursement, and the patient gets their own bill. When we ran billing in-house it was not uncommon for patients to call us with billing issues because they didn't understand (nor should they have had to) that our radiology service bill was separate from the hospital. Which was separate from the anesthesiologist. Which was separate from the lab. Etc.

I see the pot getting bigger mainly for insurance companies, and large hospital systems, in that order. Some docs in some specialties are doing as well or better than they were ten years ago but a lot of the primary care specialties just get whatever the Medicare reimbursement is and don't have any control over it. Insurance companies will pay them whatever they decide to pay them. So short of increasing the cash price on that minority patients, all of whom are going to be very price sensitive, the independent docs and small practices can't do much to move the lever. Healthcare software vendors seem to be making out like bandits because their clients are typically the large systems and insurers who are flush with cash.

>just have the government pay for everything

How does almost every other country in the world manage to do exactly this then? Clearly it's a feasible solution elsewhere, so why not in the US? As much as I'd like to believe we're exceptional, I know that in the end we're really not.

I'm not saying that couldn't be part or most of the solution. But there is a decided air of "well all these other countries do it, you idiot, so it's clear we just need to snap our fingers and do it too and everything will be perfect with exactly zero unintended consequences" whenever someone says we "just" need to have universal healthcare and everything else will work itself out.

There are some extremely good elements of American healthcare. Our healthcare education system with all its flaws is among the best in the world. We're a global center of medical and pharmaceutical research. Changes to the provider side need to take that into account or the entire world could suffer as a result.

You can negotiate the costs in bankruptcy

> Unless you’re uninsured then that’s the price they use.

I don't think many uninsured people are paying sticker. Sometimes they automatically get charged with a discount, sometimes they have to call and get it. Some folks don't know to call, but these folks' bills are, I expect, not usually getting paid in full in the end anyhow.

True it’s not the price they pay typically, but it’s the price they start with. It’s “hey, well knock 50% off the cost if you pay now”.

Which is stupid, since the price has no basis with reality.

The insurance companies know this - when they negotiate, they look at $90k for stitches and say “yeah, we’ll pay you $1,200”.

The uninsured get screwed because the hospital acts like their charge master prices have some basis in reality.

In my case, there was no discount.

You were charged the equivalent of 93k for stitches and paid it? That is exceedingly rare.

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