Hospitals lift curtain on prices, revealing giant swings in pricing by procedure
healthcaredive.com
healthcaredive.com
They have a column called "Uninsured cash price." These prices are <25% of the insurance "discount" prices, but the really amusing thing is that this column was set to 0 size so that when you download the Excel sheet you have to know to auto re-size all the columns, or you cannot see it.
And, no, I don't think this was by accident as they have updated this Excel spreadsheet several times and only that one column is always set to 0 size.
[1] https://www.cms.gov/hospital-price-transparency/contact-us
https://www.cms.gov/hospital-price-transparency
Does say "provide clear, accessible pricing information" which I would argue this is not.
edit: Filed a complaint.
EDIT: Thank you all for your efforts.
I'm also going to post a review online, since poor reviews seem to get attention from them.
There is no reason Medicare should be restricted to those over 65, or why Medicaid is implemented differently (and reimburses providers more poorly than Medicare). Or even Tricare. We have at least 3 different taxpayer funded healthcare programs specifically so not everyone can get access to equal care, but so that various classes of people can get healthcare proportional to their political power (which usually scale with money, but also votes in the case of old people).
Add in CHIP and the VA (Tricare). We've taken every vulnerable part of society (older, poor people, poor children, injured veterans) and given them government-paid, universal healthcare. This is around 100 million people.
Everyone left over is thrown into the private insurance pool. These people are typically working age population (18-60), making them both the richest and the healthiest. This is around 200 million people.
This is meaningless if the quality of healthcare is not the same. There are numerous hurdles placed for various different people to get the healthcare, effectively restricting access to healthcare itself.
Taxpayers cover the neediest, leaving the healthiest to for-profit insurers. The healthiest have no incentive to make sure the programs for the neediest actually work or are accessible.
M4A is overwhelmingly popular, at points taking majorities of Republicans. Also, the US government already spends as much on healthcare as Britain and the NHS; US healthcare is just allowed to cost twice as much.
Medicare/Medicaid reimbursements are insufficient to support most medical practices. Tricare is for military & their families. Most active duty military are young & extremely healthy compared to the general population.
Medicare/Medicaid combined are the largest single item on the federal budget. More importantly, they are still growing in costs because of an aging population, and are heading towards 30% overall of the federal budget [1]
Tricare operates as an employment perk. Medicare has a cap on benefits, but is effectively mandatory for 65+, and medicaid operates as a payor of last resort, after folks have run out their lifetime benefits on medicare.
However, an argument in favor of your suggestion is that the vast majority of medical resources are spent on the last 2 years of life, often for terminally ill patients with a ton of co-morbidities that are at death's door anyways. Most medical spending happens in the latter part of life [2]
> 25% of Medicare’s annual spending is used by the 5% of patients during the last 12 months of their lives [3]
[1] https://www.americanprogress.org/issues/economy/reports/2010...
[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1361028/
[3] https://www.acsh.org/news/2018/09/28/true-cost-end-life-medi...
Is there a reason that US doctors should get paid significantly more than their peers in other developed countries?
https://www.medscape.com/slideshow/2019-international-compen...
Big Nope.
Most practices have fairly fixed costs:
Medical malpractice
Facilities rent, or mortgage
Front office
IT & EMR
Privileging/Credentialing
Practice
CME/required education
The only highly variable cost is physician compensation, and considering the limited availability, this will merely cause the retirements and limited access to specialists.
Perhaps you have some evidence to support your extraordinary claim?
I'll provide evidence to the contrary, based on Hospitals and practices refusing to accepting Medicaid [1] patients, or, not accepting/limiting medicare patients[2], [3], [4]
The simple fact is, there is a limited supply of physicians, and many of them don't want to practice the higher volume, 5 minutes per patient, 5 minutes for notes x 12 hours a day type of practice. Not only is the higher volume more dangerous for the patient, it is also more risky for the medical provider, both in terms of quality of life, and also, the risk of an error, or inadequate information exchange.
[1] https://www.reliasmedia.com/articles/147019-when-hospitals-r...
[2] https://www.investopedia.com/articles/personal-finance/10021...
[3] https://www.verywellhealth.com/doctors-accept-medicare-insur...
[4] https://www.hlc.org/news/more-physicians-no-longer-seeing-me...
If the AMA isn't going to fix the physician and residency pipeline, could we not offer visas to physician immigrants who meet first world medical credentialing standards to deepen the supply and therefore support demand? If supply is the issue, we should fix the supple, not destroy necessary demand.
https://www.ama-assn.org/press-center/press-releases/ama-fun...
Basically, you are saying American trained doctors only then, as American doctors are much better trained.
Because my experience is that a physician immigrant has to do the following:
Receive ECFMG verification
Complete missing medical education requirements
Study a boatload!
Pass US medical licensing exams 1 & 2
Find a residency (matching)
Go through Residency again
Obtain certification from ECFMG
start practicing, or
Complete Fellowship, then start practicing
Considering how much healthcare costs in the US and the quality of care received [1], I assert American doctors are not better trained, simply that they are more expensive and there are less of them per capita than other OECD countries [2] [3] [4]. I'm suggesting bypassing the undersized US doctor development pipeline until it is fully funded to produce enough doctors to meet demand and drive down costs.
https://www.ajmc.com/view/the-quality-of-us-healthcare-compa... ("A 2014 report from the Commonwealth Fund revealed continued trends that were along the same lines—despite the implementation of the Affordable Care Act (ACA) in the interim. In the report, the US “ranked last overall among 11 industrialized countries on measures of health system quality, efficiency, access to care, equity and healthy lives.” Significantly, the US was noted to have the highest costs while also displaying the lowest performance.")
[2] https://data.worldbank.org/indicator/SH.MED.PHYS.ZS?most_rec...
[3] https://www.fiercehealthcare.com/practices/how-u-s-stacks-up... ("When it comes to practicing physicians, there are only two physicians for every 1,000 Americans, nearly half the ratio of countries with nationalized public healthcare. Countries with nationalized systems saw the greatest increase in the number of physicians relative to their population.")
[4] https://www.medicaresupplement.com/content/global-healthcare...
https://www.nytimes.com/2020/01/02/health/christian-health-c...
https://www.nytimes.com/2016/12/10/opinion/sunday/should-i-l...
This is not correct for all practices
My wife's practice (of plastic surgeons medical providers only in a reconstructive practice 75%, cosmetic 25%, attempting to be in-network with every insurer, with administrative front-office doubling as billing, and dedicated personnel for resubmits) vastly prefer cash paying because they get the money right then, and they don't have to haggle with insurers around things like pre-authorization, billing, etc. Insurers regularly make physicians go through the ringer to get an pre-authorization for a vital surgery. Even worse, insurers will ask for a "peer to peer" and then have some underqualified medical provider understand what a board certified surgeon is doing, based on a complex diagnosis, and not understanding the actual surgeries or procedures involved. Insurers will forget pre-auths, and then reject billing, and they have a whole bunch of shady practices around, even with in-network practices for cancer cases.
So much of this price transparency stuff is a giant racket because it helps insurers, and not the actual medical doctors, PAs, NPs and other medical providers. However, it is medical insurers & Payors which are driving all the paperwork (Horrible EMRs, ICD codes, pre-auth, auths, etc) along with growing the tsunami of administrative personnel)
Insurers try to use being out-of-network to reject medical bills, so they use it as a weapon vs practices/hospitals, very effectively unless it is an emergent case (medical emergency).
What is completely missing from this conversation is who this benefits, who this harms, and how insurers exploit the status quo.
Cash paying customers should always be the cheapest option, since there is little overhead for them.
Accepting the cash price after billing the person for the full price and writing off the difference.
That is until you call the hospital and find out there's all sorts of "sliding" prices etc...
I had a procedure billed for one of these drastically larger "insured" codes which got denied based on the nature of the procedure from the insurance company (apparently too new of a procedure at the time, however common now).
It all got worked out in the end but what I realized was that hospitals are largely subsidizing the cost of the uninsured by over-billing the insured folk's insurance companies. We've set the American healthcare system up to be a cat and mouse game where those in need are represented the least.
Best insurance here is "don't get sick"
Also this isn't going down to your corner liquor store and flashing your drivers license... that thing is going to get scanned etc.
---
Actual protip: If you're uninsured and need care they legally can't turn you away at an ER. They have to provide the healthcare to get you stabilized regardless if they're going to be able to bill for it or not... which ironically this is a big part of why the insured end up subsidizing the uninsured at the hospital.
Also, if this ends up being you - don't sign anything until you're in the right mind to sign something. They're going to try to pin you to bill your ass off one way or another and if you're half way through a heart attack or something do not sign anything until you can 100% understand what you're legally agreeing to.
Giving a fake name is fraud, and people have been arrested for doing that at the ER. (Fuck America.) But I don't know that there's any legal obligation to give any name at all. If you don't give them a name, you're not lying to them, and oops, looks like they don't have a way to bill you. As you note, hospitals are legally required to provide emergency stabilization without regard to ability to pay.
I suppose the hospital could try to call the police, but AFAIK the police cannot compel you to identify yourself without reasonable suspicion that you have committed a crime.
https://www.npr.org/sections/health-shots/2019/05/07/7207022...
Hospitals that accept medicare do have a legal obligation to stabilize patients. But we're talking 'stabilize' as in 'you're not dying'. If you're alert and capable enough to be arguing with people and you're not a psych danger, you're likely stable enough to legally be thrown out on the street.
The discussion here is whether there is a legal obligation to identify yourself. If there is such a requirement, it would apply to someone who is fully capacitated but refusing to identify themselves. It would not apply to someone who is unable to identify themselves due to incapacity, because such a person obviously lacks any criminal intent.
If there's no risk of criminal exposure, even insured people should start doing this. Hitting hospitals with uncompensated care under EMTALA is one of the few points of leverage we have to fight back against these murderers. Hospitals are, by and large, not innocent parties in this -- several hospital groups are even members of the Partnership for America's Health Care Future terrorist group, which bribes politicians to fight Medicare for All.
It would bring me great pleasure to get to tell a hospital to go fuck themselves and to quit bribing politicians to fight M4A if they want to get paid next time.
Recent New Yorker article looking at the "Costa Rica model"[0] raised this point as well. America, by contrast to Costa Rica, has a very weak public health sector and infrastructure, and this leads to a real weakness when focusing on preventable illnesses and issues.
[0]: https://www.newyorker.com/magazine/2021/08/30/costa-ricans-l...
> All adults have tests and follow-up visits to prevent and treat everything from iron deficiency to H.I.V. It’s all free. If people don’t show up for their appointments, she makes sure their team finds out why and figures out what can be done.
It's common sense why they have better results and outcomes than we do here... Our system is optimized for capitalistic profit. I've got insanely good insurance and I still have no idea how screwed I am if I go to the doctor or especially a hospital. Although I've only had one major billing snafu years back I have real anxiety about going to the doctor here.
And hell, even if I go my PCP is going to be stuck in an "all or nothing" mentality where it's either OTC or getting in their own conflict with my insurer... ie: "If I can't justify this test with your insurer..."
---
Costa Rica's model is better than America's. The reason for this is because it's not optimized for profit, it's designed from the ground up to optimize for patient outcome.
Is there any reason why this kind of windfall shouldn't be illegal? I realize it isn't, but is sure seems like it should be.
I was stuck with a charge from a doctor for 7x the price my insurance would have paid. My pre-ACA insurance refused to cover the procedure and I ended up on the hook for the inflated price. The doctor wouldn't negotiate and demanded the full fee. Neither the doctor, nor I, knew this would happen until the procedure was already done.
It feels like an agreement, to me, when the practice takes on a patient knowing who their insurer is. I feel like the reimbursement rate that insurer has negotiated, regardless of whether the insurer ultimately covers any procedures, should act as a cap for the fees charged to the patient. It feels a lot like negotiating a contract, except that one party gets to unilaterally change the amount of consideration. How does that fly?
because our senators and congress critters are all on the buy for really cheap... it's not even hidden. something like medicare for all is the thing that makes sense but has a hard time finding traction because the people that it will negatively impact have the means to buy those politicians out.
You aren't exactly talking about "balance billing"[1] but you'll be pleased to know the No Surprises Act[2] tries to address this situation with required cost (estimate) disclosures in advance of a procedure and capping the out-of-network amount that can be charged in the event of an emergency where there can't advanced disclosure. The HHS recently promulgated regulations[3] under the Act but the compliance date is January 2022. For some reason I think there is at least one (maybe two?) other proposed rules in the works but I can't recall what they address and I can't seem to find them.
Edit: The other proposed rule is relating to air ambulance services[4]
[1]https://en.wikipedia.org/wiki/Balance_billing
[2]https://www.congress.gov/bill/116th-congress/house-bill/3630...
[3]https://www.hhs.gov/about/news/2021/07/01/hhs-announces-rule...
[4]https://www.healthaffairs.org/do/10.1377/hblog20210913.57633...
Until everyone becomes a contract lawyer capable of devoting weeks to insurance shopping every 6 months, the only good insurance market is a heavily regulated one, even though heavy regulation comes with its own gigantic bag of worms.
One of the worst offenders from the before-times was an insurance plan targeted at college students that had a 10% MLR.
Payers often get incentivized to promote certain drugs via manufacturer kickbacks and I wonder if this system is also used to run around MLR requirements.
And given that the payouts are very nearly a function of how hard the insurance company can negotiate, they can simply choose to call off the negotiations when they reach their target amount.
Private medical insurance in the US is a horridly inefficient system. Separating the claims process from insurance companies hands might help, but their incentives are never going to line up with consumers.
Money spent on paperwork comes out of the same pile as profit. The MLR cap preserves incentive to reduce paperwork, wherever premiums and payouts sit.
Of course insurance companies are also in competition so they have individual incentives to keep premiums cost competitive.
With R = revenue, P = profit, A = administrative expenses, and M = medical expenses, we have:
R = P + A + M
P = R - M - A
P₂ = R - M - (A + δ) = P - δ
P₃ = (R + δ) - M - (A + δ) = P
Does the MLR cap have an impact?
MLR = M / R
MLR₃ = M / (R + δ)
MLR₃ < MLR
P = (R + δ) - M - (A + δ)
Of course if I believe that my company is better able to handle the new paperwork than my competitors, that could help - but if the whole industry believes that's the case then most of them are wrong, and in any event I believe this incentive is weakened not strengthened by the MLR cap.
If paperwork keeps new entrants out of the market, that is something current participants can probably agree on, but that's true in any case and I don't see how the MLR cap makes it stronger.
I don't think this analysis changes if we pull executive compensation out of "administrative expenses" and treat it as something we're maximizing in addition to (or instead of) profit.
So while thinking in terms of total administrative costs seems reasonable there are two different numbers here, administrative costs for the insurance companies and administrative costs for the healthcare industry and that matters.
So again, assuming it’s the regulation not market forces limiting profits increasing Ma directly increases profits. Up to some limit rather than P < (Mm + Ma) * X% it’s P = (Mm + Ma) * X%. Thus creating incentives to increase Ma.
It is true that the MLR cap does nothing to motivate insurance companies to avoid increasing hospital paperwork. I don't see that it produces incentive to create it - yes, increasing payments to hospitals increases allowable profit, but in order to make that profit you need sufficient revenues and customers aren't paying because they want hospitals to do paperwork. I'm of a mind that (at the margin) increasing legitimate (or nearly legitimate) medical spending is typically pretty easy so there is no need to find alternative ways of paying hospitals more; if I'm mistaken about that then you raise an important point that probably deserves attention (if it hasn't got it in some way I'm unaware of).
If the payouts are dropping because there's a massive reduction in claims, then there's a pretty decent chance that paying the policy maximum on each claim still won't be enough.
Plus, profits don't come directly from the premiums anyway. They come from the investments the insurer makes with the premiums. So sure, they can try to convince policy holders to increase coverage which allows them to charge a higher premium, or they can work on their loss modeling and investment strategy to better predict their actual loss ratio (which means they can have less money in reserve and more money in investments) or get better returns on the investments. And those 2 are usually a better use of resources since increasing coverage means an individual conversation with each policy holder. That's a lot of human-hours compared to the modeling and investing.
Or they just stone wall and increase premiums anywhere they can until they hit targets. Like at a previous job I had at a 250 employee company where premiums went up $150/m one year because the previous year had two families had a kid get (very different kinds of) cancer out of the blue. You'd think that shopping around would've helped in that case, but the word got out somehow to the other insurance companies and they were giving us similar quotes.
The power relationship is very very tilted in the insurance company's favor and they can more or less dictate terms.
It's bad enough that I've heard office gossips complain about other employees leveraging their healthcare turning into higher premiums the year after. Like, as evil as complaining their coworker's kid got cancer.
When employees go through big health events it's hard to keep it under wraps in a work environment... especially in this "race to the bottom" society we happen to live in. You can bang on about privacy all you want, but people talk.
I guess I'm shocked it happened in an office of ~250 as I've always seen it happen at much smaller places.
That is how it would have to work if the employer wants to restrict the risk pool to the company's employees. After all, money has to come from somewhere.
But employers are welcome to participate in healthcare.gov plans where the risk pool is much larger (across the whole state), and where individuals in the company cannot be solely blamed for increases in healthcare costs:
It's bad enough that I've heard office gossips complain about other employees leveraging their healthcare turning into higher premiums the year after. Like, as evil as complaining their coworker's kid got cancer.
Employers are welcome to purchase healthcare.gov plans that are not allowed to price based on pre existing conditions:
https://www.healthcare.gov/how-plans-set-your-premiums/
If an employer wants to self insure and restrict their risk pool to only their employees, then they have to pay for it.
Which are stupid expensive for anyone much above the poverty level.
> If an employer wants to self insure and restrict their risk pool to only their employees, then they have to pay for it
A 250 person company wasn't self insuring or restricting their risk pool to only their employees. They wouldn't be negotiating premiums with an insurance company if they were self insuring.
When I was shopping around for health insurance for my businesses, the premiums were the same as what they would have been individually on healthcare.gov. Kaiser has a good report showing the costs are not that different based on firm size:
https://www.kff.org/report-section/ehbs-2020-section-1-cost-...
The cost of healthcare is pretty predictable, and spread over a sufficient population converges to the same numbers. Only option I can think of is people were thinking that the employer reduced their portion of healthcare they were subsidizing, and so people thought premiums were going up since the size of the portion they were expected to pay went up? Most people do not really know to look at box 12 code DD of their W-2 to know what is happening with their healthcare insurance premiums.
And I'm going to guess that your businesses had very, very few employees? To the point of not being worth negotiating with from the insurance company's perspective?
And Kaiser isn't run like most insurance companies.
>And I'm going to guess that your businesses had very, very few employees? To the point of not being worth negotiating with from the insurance company's perspective?
Yes, but that was my point about businesses being able to just buy the health insurance plans available on healthcare.gov. Earlier you mentioned the healthcare.gov plans were:
>Which are stupid expensive for anyone much above the poverty level.
But the data does not support that. Average annual employer sponsored insurance is $7,675 for single PPO coverage in 2019:
https://www.kff.org/report-section/ehbs-2019-summary-of-find...
And average lowest cost monthly gold premium on healthcare.gov is $516 ($6k annual) in 2019:
https://www.kff.org/health-reform/state-indicator/average-ma...
So employers can probably save money going to the healthcare.gov plans, albeit with higher out of pocket maximums probably. But at least a couple kids with cancer would not throw off the premiums.
Unlike property and life insurers, medical insurers generate very little income from investments. Premium revenue comes in at about the same rate as claims are paid out. They don't have large reserves to invest. And most large employers are self insured anyway, so the ”insurance" company just acts as a claims administrator.
Yeah, there's a decent amount of regulation around payouts to protect the consumer, but it pales in comparison to the regulations around making sure that the insurer has enough liquid assets on hand, that the total valuation of their assets (ie investments) remains large enough, and that they're charging a minimum amount of premium for the risk that they're taking on.
...sourced from the premiums. When they pull in more premiums, they have more money to invest.
Ideally the premiums will cover payouts and day-to-day business expenses, so the invested money can just keep being reinvested, hopefully into longer term and more aggressive investments. The premiums and payouts get rolled into underwriting profit/income. And that can eventually get rolled into new investments.
Here, look at state farm for 2019[1].
Their underwriting gain was $777 million on $65.2 billion in total premium. Their investment income was $5 billion with a net worth of over $100 billion, which is more than 6 times larger their underwriting premiums.
Their profit ratio for underwriting is like 1.2% because they're not trying to maximize that profit. A large reason they're not trying to maximize it is that for admitted policies, there's usually an upper limit to how much aggregate premium can go to anything other than paying out claims (eg: [2] and [3]).
So for an insurer, they don't want to set themselves up to depend on premiums to fund the investment arm because 1) there's an upper limit on how much aggregate premium can go towards anything other than claims 2) there's no limit on how much aggregate premium can go towards claims, 3) growing premium haphazardly can result in less money available for investing due to other regulations that limit risk and require a certain amount of liquidity for claims.
[1]: https://newsroom.statefarm.com/2019-state-farm-financial-res... [2]: https://www.law.cornell.edu/regulations/california/10-CCR-Se... [3]: https://consumerfed.org/press_release/auto-insurers-reaped-n...
They don't have control over investment returns for the most part, so premiums are the only avenue for growth that they can do something about.
Deceit can take many forms, and I'd argue that undercapitalization is actually one of them. "There's a trap clause on page 23 of the telephone book contract" is only the simplest strategy an insurance company can use to lemon-drop. "We ask our customers to do an impossible information wrangling task and only review the paperwork if they get cancer, so that we have an excuse to drop them" is a slightly more evolved form. Loading up sacrificial business vehicles with risk and using bankruptcy to discharge obligations is the most advanced form of deceit-based insurance business models, because it provides plausible deniability. "We just tried to compete a bit too hard!" they can claim, even if they knew in their hearts exactly what they were doing: the age old practice of selling insurance that you had no intent of making good on.
Fortunately, we have a long record of historical evil tricks to draw on when crafting legislation, because I absolutely stand by my claim that the natural incentives (the ones that happen without careful legislation) in the insurance industry are overwhelmingly bleak, both on an absolute scale and relative to other industries.
The payouts regulations are still good and necessary because that's way better than requiring people to find out the hard way through shitty claims processes and denials and word-of-mouth reputation, but they're in no way sufficient.
> "Oops we invested badly and have literally no money with which to pay your completely valid claim".
It's 100% possible for this to be a genuine mistake. I'm sure that it happened as a genuine mistake more than once! However, it is also possible to do this on purpose: load up a business vehicle with increasing amounts of risk and extract as much of the premiums as one possibly can before it explodes. If this is done intentionally, it is exactly the same hustle as selling policies that one doesn't intend to make good on, it just uses a different mechanism to shirk the obligation.
Every company that does it on purpose will say that it happened by mistake, of course, and just as I am certain that it has happened multiple times as a genuine mistake, I am certain that it has happened multiple times on purpose.
Undercapitalization is the evolved form of the "sell a trash policy" hustle because it provides almost perfect plausible deniability. It makes sense that the greatest legislative effort would be spent heading it off.
Isn't the latter a strict superset of the former? No payouts is an easily predictable number. And for nonzero amount of payouts, the less those payouts sum to, the more money remains for continuous investing.
Here's some random numbers,say for a hypothetical 100,000 hypothetical year long policies low probability, low variance: E(total claims) := 20, V(total claims) := 1 low probability, high variance: E(total claims) := 20, V(total claims) := 20 higher probability, low variance: E(total claims) := 20,000, V(total claims) := 10 higer probability, high variance: E(total claims):= 20,000, V(total claims): 10,000
Premiums don't usually make their way into investing for a bit. They're used to cover claims and then business overheads and then even dividends first. First they go to claims, because there's usually regulations to prevent price gouging that require insurers to refund premium if the ratio of aggregate premium : aggregate claims gets too high (the regulation is on a state by state basis in the US). Then any remainder goes to any other outlay first, so that the invested money can be/stay invested into longer term investments. Only if those outlays can be completely covered by the premium (and i'm skipping over a few things like regulations regarding various levels of liquidity for different risk levels and other stuff) then yeah it can make its way over to the actual investment fund. But in general the business model for insurers is that underwriting profit, limited as it is by regulations, is primarily used for actually running day to day operations and isn't a reliable source for being turned over to the investing side. The investing side is primarily using the initial capitalization of the insurer and the returns from earlier investments.
One way of looking at insurance is that the insured is actually buying an option against the insured's capitalization with very limited exercise clauses, but the the insurer pays out exercised options with the money from other purchased options contracts.
The privatization of healthcare is a conflict of interest which is a product of our hyper-capitalistic society. You can't make a profit center out of human services without dehumanizing it in the process - the very nature of profit/capitalistic societies means someone has to lose and I see no place for these interests in healthcare or education.
Edit: yep - expected that. Maybe someone argue as to why privatization (which is a product of capitalism) isn't a conflict of interest in regards to healthcare?
The last time you bought milk did you lose or did the grocery store? The last time you paid money for a hair cut, who lost there?
The extreme regulation of all aspects of health care that has developed over the last century has improved some problems and created other problems - the problems specific to healthcare have little to do with the "the very nature of profit/capitalistic societies"
There's way more people involved in that supply chain then me and the store. This is an over simplification.
Outside of the obvious answer of "the cows" - factory farming has been destroying my home state causing huge problems in rural America. Also - the environment. Big time the loser there is the environment for literally any bovine farming.
> The last time you paid money for a hair cut
When I was getting my hair cut professionally I tipped a $20 because I knew the gal cutting my hair working at the midwestern mall Regis Salon was making jack-all. I knew this because I worked at Geeksquad with her boyfriend, eventually husband. If I were not to tip well she would be at-risk for making minimum wage for that hour - and since you can't support yourself on minimum wage I see that as her losing.
I've always tipped my butt off because I know without that they lose.
---
So yeah - sorry... I anecdotally do see losers in the situations you described. I don't have to look hard to see them.
Factory farming probably does cause externalities that aren't addressed. People could choose to buy from grocers who only source from smaller farms but there isn't as much interest in that due to price sensitivity.
>...and since you can't support yourself on minimum wage I see that as her losing.
Even in the case where you didn't tip, she likely would have preferred having the work than there not being a job available at that location.
Many of the current US medical problems (bureaucratization of medicine) actually evolved out of massive government regulation with debatable value. EMRs, ICD/coding, the bureacracu that eats up 25% of your doctor's day? It is mainly for insurance companies and Medicare/Medicaid.
https://healthncare.info/history-healthcare-insurance-united...
> I'm a fairly capitalist person, but there is something awfully and fundamentally wrong about a society that monetizes well-being and health
All the medical providers (doctors/nurses/therapists/techs/PAs/etc) do not work for free, and there is a significant logistics and technology tail in providing medical services at huge scale.
If you really want to go after waste in medicine ask the following questions:
(1) How much are the nonclinical hospital mgmt & insurance executives paid?
(2) What is the ratio of clinical to non-clinical personnel?
(3) Why is the US subsidizing the vast majority of the medical research, and drug profits for the entire world?
These are serious questions because, as my nearby regional hospital group was firing hundreds of nurses during COVID, their CEO was collecting millions.
If by 'profit/capitalistic societies' you mean those allowing for voluntary exchanges between its people, I would disagree. As an adherent to the subjective theory of value, I think it is common that both parties in an exchange would consider themselves 'winners.' [0]
[0] https://en.wikipedia.org/wiki/Subjective_theory_of_value
https://www.forbes.com/sites/jimcamp/2013/03/11/revisiting-w...
The reason I am firmly in this school of thought is that I've made the absolute mistake of a decision to try for "win-win" situations in a capitalistic society, specifically in regards to contract negotiations and ultimately pricing/billing.
When I'm making sure that the person on the other end of the table "wins" I'm putting myself at a capitalistic disadvantage; and - if both parties "won" then didn't both ultimately lose?
I get your ideal, but when money is involved I find that the "win-win" is very much that: just an ideal. And, anecdotally over the years I've found many business experts write on the topic of why "win-win" is a losing position which validates my position on this.
No, because even in a capitalist society "winning" is defined by each party's relative improvement over the state they would be in if they didn't come to an agreement and make the trade—not by some absolute measure of whether they did better than the other party. A "win-win" is simply an agreement where both parties are better off for making the trade. This is the usual state of things when both parties are free to accept or decline and there is no deception (fraud) involved, since both parties need to accept the agreement and they will only do so if they believe that doing so benefits them. In rare cases one or both parties may be mistaken about the benefit, but they know their own business better than anyone else and are best positioned to judge the expected value of making the trade based on the information available at the time.
I'm not familiar with Jim Camp, but the term is vague. The linked article to me mainly seems to argue that:
- the side with a better BATNA has more negotiating power (yes, of course) and
- a negotiator should avoid agreeing to a bad deal out of desperation (yes, of course - but not always easy to do)
I'm not sure how the concept of "win-win" specifically plays into it, so I think this is where definitions are useful.
To me, win-win doesn't make sense for transactional negotiations where there is only one dimension (usually price), but CAN happen for more complex negotiations with multiple dimensions where each dimension has different value to each party (price, time, volume commitments, etc...)
It's not as if public health care doesn't have moral hazards of its own, including conflict of interest. The system may officially be non-profit but the interests of its workers and administrators (profit-oriented or otherwise) do not necessarily align with those of the patient.
I asked why they said it would be covered. They said when they checked with insurance it says it’s covered, but for my age or whatever it’s not actually covered.
So then I said why is it my fault that you gave me something you said was free but actually wasn’t because your check wasn’t thorough enough?
They said they already spent it so someone has to pay…
In the end I didn’t pay for the fluoride after hours of argument.
Next year at a different dentist, same situation. I learned my lesson and just paid for the damn fluoride. Land of the free, home of the brave!
What we really need is for people to stop thinking of insurance as a big blanket you buy that reduces the price of things to zero. That’s not what insurance is for. Insurance is supposed to be a system where you still pay for the cost of the good, but that buffers it for you so when you get an outlier cost, it doesn’t break you. It doesn’t make the costs of things go away. On average, you should end up paying a little more than the cost of your healthcare by purchasing it through an insurance plan. A high deductible plan does this: you actually pay the cost of all your healthcare up until a certain point out of pocket, and if you reach a certain amount (which is pretty high, but significantly less than the premiums on a low-deductible plan), the insurance takes over. This makes you actually aware of the prices of things and is healthy. Not to mention the insurance is a hell of a lot cheaper.
Healthcare should simply be "free", ie budgeted into the operation of a modern society, like infrastructure costs and education.
"No cavities again! Would you like a flouride rinse?" "Why would I do that? I have flouride in my mouth rinse and my tooth paste." "Well, ours is a higher concentration that I paint onto your teeth." "Didn't you say I had no cavities?" "Well, yeah." ".... so what I'm doing seems to be working without your rinse" "Well, it's only $16" "My flouride rinse has the exact same active ingredient as yours and costs $5 for an entire bottle." And it just goes on and on.
I've never seen a dental insurance plan that actually makes financial sense. Most of them place significant limits on expensive and unlikely care, and cover routine care with little or no cost sharing. Insurance is a highly inefficient way to pay for expected expenses.
Was in a similar situation as you were, but unfortunately, what I'd have had to pay was still too much as it was clearly fraud on the part of an outpatient clinic - one side, the clinic, was approved by my insurer, the other side, the surgery center, was not, and they willfully lied about this distinction. I threatened a law suit and they demurred.
I believe this is called 'balanced billing'. Some states prohibit it under certain conditions but it seems either the government or insurance should be prohibiting this practice.
Which is why hospitals charge higher prices to insurance companies.
Insurance companies often blanket deny every single claim made against them. This forces the hospital revenue cycle department to have an appeals nurse review just about every procedure done in the hospital, and justify its use. This almost always results in a "discount" for something by virtue of a care provider not justifying every action they take.
Revenue cycle management departments used to be small, about 1 per 1000 hospital employees. Today, they are so big - and make so much money* - that hospital systems are spinning off their revenue cycle management companies for billions of dollars. Private equity firms have been acquiring in this space like mad since about 2016.
* Really, they are actually getting the money that is already owed.
> And this can really cause issues for people who are insured because if an insurance company decides not to cover something (very very common, even in-network) then the inflated price is what you end up getting billed for.
That doesn't sound like an "inflated" price? 25% of what insurance companies are billed for?
I'm confused. I'm not sure y'all are talking about the same things?
Just like how car insurance is not a mechanic.
1. You have to back up claims like this.
2. I imagine for-profit Insurance companies would love to blame their prices on the uninsured.
3. Many poor people actually have insurance in the USA. Even if they don't apply for it, insurance can be applied for after the fact.
4. The wealthy, and the poor are usually covered by insurance. It's the middle class that needs attention. They have insurance, but it's not great.
I still don't belive our healthcare costs are due to the uninsured. Oh yea, every hospital has a fierce Billing and Collections department.
They are allowed to go after your assets if you can't pay your bill, and they do. Obamacare gave patients some rights, but hospitals blatantly abuse the regulations.
The right to collect in municipal court was never taken away from hospitals.
In my local newspaper, it's not uncommon for a hospital to sue a patient over a bill, and put a Judgment lien on the patients assets.
They claim they only do this as a last resort, but bankruptcy due to medical bills are still the number 1 reason people end up in federal court (Bankruptcy).
Your protections under a bankruptcy are not great either.
There are many hospitals that forced a former patient to sell their home (homestead exemption needs to be higher. In TX, they can't touch your primary residence.). under a bankruptcy.
In CA, for example, the primary home gets a $250,000 protection. (Look up that last figure. I know it's very low in CA, and needs to be raised to at least a million. You have a $600,000 home. You are only protected by $250,000 of it's worth.
So in America, if you do get sick, and can't pay all your medical bills, you have no protections. These for-profit medical companies will come after you with more zest than an unpaid credit card. I think CC companies are less aggressive.
2. I mean, I have no idea but for-profit insurance companies aren't out there really blaming anyone as they're just a faceless corporate entity. I've only heard hospital staff and normal people blame the uninsured.
3/4... no - poor people don't have insurance. I've grown up around people who were not economically privileged/who were struggling and this is just 100% untrue that poor people can get insurance as you posit. I've had private insurance and it's just not something someone can afford if poor. And, if you're referring to things like "Christian Healthcare Ministries" they're straight-up scams. Outside of that, there is no way American restaurant owners, retail franchises, etc will cover an unskilled laborer's health insurance - that just does not happen here.
---
> I still don't *believe our healthcare costs are due to the uninsured.
When it comes to hospital billing - yeah. It is a huge thing that's baked into their SOP. See item #1 above.
https://www.aha.org/factsheet/2019-01-02-uncompensated-hospi...
My understanding is that you would usually pay the price set by the agreement your insurance has, even if they deny coverage of it.
They release 'standard charges' which as far as I can tell means 'the range of charges for this particular diagnosis based on past data' as an excel file.
But the price list is a text file delimited by pipes (vertical bars... |) which just seems unnecessary. They also do nothing to define the variables or column names they use...so that's nice.
It sucks, but, like, I don't really blame people for being in a hurry to fix a problem.
For example, SCO Unix's Informix SQL's `UNLOAD TO <file> SELECT ...` queries output in a format that's very much like what avs733 describes, only that the values aren't separated by pipes, they're terminated by them, so every record ends with a pipe character.
If that's the case, there's unfortunately no built-in option to get it to include column identifiers in the report. :(
The machine-readable part is mandated here: https://www.federalregister.gov/documents/2019/11/27/2019-24...
As a taste of how specific this is:
(5) The file must use the following naming convention specified by CMS, specifically: <ein>_<hospital-name>_standardcharges.[json|xml|csv].
They aren’t always quite as stupid as people make them out to be, these lawyers.
> c) Format. A hospital has discretion to choose a format for making public the information described in paragraph (b) of this section online.
This is how you get Excel files with certain column widths set to zero. All it has to be is searchable, free, public, and updated regularly.
(Can’t find the original source, but it goes “Cant breathe? Put in a tube. Can't pee? Tube. Can't poop? Tube. Bleeding? Tube. Infection? Tube. Heart attack? Tube.”)
A surprising amount of stuff (at least medical billing side) can be flat file moves, especially if you are billing into lots of different systems.
And yes, the idiot new person with a phD says, just quote every field with a ". Great - you program all this up, along with the required escape sequence handling, and then escapes for escapes. \ and / get used a fair bit sometimes already and we are dealing with tons of systems.
I think it must be at this point. The hot garbage that is medical data formats (HL7, in particular) and the ways you can break it as a user, unknowingly and silently. It’s incredible that a format this bad has hung around this long.
It’s not ok that users can type certain characters into a field and break the system.
They likely just exported the prices as HL7 from their EHR system and used Excel's built-in delimiter support, then called it a day
And there is the problem.
There are some clever insurance companies whose entire model is "tell the hospital you don't have insurance, get the cash price, pay it with this debit card we give you."
https://www.brookings.edu/blog/usc-brookings-schaeffer-on-he... (Fixed indemnity health coverage is a problematic form of “junk insurance”)
It's not illegal here, but in any case nobody asks, I just tell them I'm paying cash.
It's pretty perverse that you, an insured person, would have to lie about having insurance because the provider would charge you more for being insured.
Where do you think the money is going? Insurance companies are not as profitable as you might think, drugs are not a massive burden on healthcare expenditures, and many hospitals are non-profits. The truth is that most of the money is going to staff wages; if you want to reduce healthcare spending, the only way to do it sustainably is to increase the numbers of doctors and nurses, so as to drive down their salaries (but this is not a popular option).
That can't possibly be true of a hospital that charged $3000 for something on Tuesday, and $53000 for the same thing on Friday.
(Under reasonable assumptions like that Tuesday wasn't done at a $25K loss relative to breaking even; why would such be the case? And that they are busy with procedures, not simply doing a way overpriced procedure once every few weeks, and then just burning through cash in between that time.)
From Wikipedia:
>"In 2003, of the roughly 3,900 nonfederal, short-term, acute care general hospitals in the United States, the majority—about 62 percent—were nonprofit. The rest included government hospitals (20 percent) and for-profit hospitals (18 percent)"
If you're doing accounting you have a ledger which balances down to the penny, and the expenses are spelled out in there with concrete amounts.
This is why that judge, as noted in the article, rejected the argument that the cost of an X-ray can be unknowable.
Healthcare companies would need to attribute things like depreciation of equipment (MRIs & CAT scanners for example), as well as doctor and nurse time (outside of operating rooms). These things are generally not tracked accurately, and many professionals are indignant at the idea that they could be.
Non profits can be as greedy as any other organization.
Typically the money goes to wages for the leadership rather than profits to the owners.
The term ‘non-profit’ is one I find hilarious. With the smoke and mirrors of accounting and standard insurance company behaviour it can mean anything.
The directors can get bonuses, the cars can be upgraded and the conferences/holidays can get more impressive. It’s surprising that ‘non-profit’ doesn’t generate an eye-roll in more people.
and tort reform to manage the lawsuits to enable lower malpractice insurance costs.
and a scheme to drive down med school pricing. Maybe more competition? Enabling more MD and DO schools? There are <200 medical schools (both MD and DO schools) in the US.
The current bottleneck in producing more physicians isn't medical schools but rather funded residency program slots. Every year some students graduate from medical school but are unable to actually practice medicine because they don't get matched to a residency program. We need Congress to increase funding.
https://www.ama-assn.org/press-center/press-releases/ama-fun...
A great insurance company talking point! The purpose of 'tort reform' is to increase insurer profits.
We need more medical malpractice lawsuits, not less!
I won’t say always, but Medicare price is usually marginal but not profitable. I.e. if you’ve got an empty bed, Medicare is better than nothing, but you wouldn’t actively try to fill beds at sub-Medicare rates even without the hassle of dealing with insurance companies
Having said that, your belief that many hospitals are non-profit might not be as simple as it looks from the outside. I recently read an insider writing something about it on Reddit: https://old.reddit.com/r/SelfAwarewolves/comments/pruk4x/the...
Hope that gives you an additional viewpoint regarding the "non-profit" label of the hospitals.
>"The end result is a privately-owned hospital that operates as a non-profit on the books when it is anything but that... American doctors and hospital executives are printing money using the backs of their patients as the die. They take in millions per year in compensation that was given to them by people who worked hard and fell on bad times. It is one of the most shameful forms of exploitation in modern history."
I'm just unsurprised, as that is consistent with my view of many (most?) non-profits. I also think that the executive pay component is a smaller share than that Redditor seems to.
I'd love to know how much money is spent by hospital admin staff dealing with the insurance industry.
Getting the hospitals to accept a price ceiling which forces the issue is another way to do it.
You can always lower prices by fiat proclamation, but then you have shortages and wait lines as hospitals go bankrupt and shut down, which will hit rural areas particularly hard.
If you want to lower prices and make sure that everyone gets served, you need to be a bit more sophisticated than just cutting hospital revenue in half and washing your hands of the consequences.
They were trying to solve the problem by increasing the supply of doctors into the system. The other proposed solution was taking the approach of reducing the supply of money into the system. Neither are contradictory to "maintaining an equilibrium of supply versus demand" but both are trying to move where that equilibrium is by adjusting the supply of two different things. So however you define "while maintaining an equilibrium of supply versus demand" either they were both doing it, or both weren't.
>then you have shortages and wait lines as hospitals go bankrupt and shut down, which will hit rural areas particularly hard
Sure, that is what happens if you only fix the prices in certain states and not others, which incentivizes the doctors to move from states that have such price ceilings into states that don't. That is why the only possible way to implement that solution is nation-wide.
>If you want to lower prices and make sure that everyone gets served
I don't see why lowering the price nation-wide would reduce the supply of doctors. What are the doctors going to do? Migrate? But no other large economy has doctor compensation as high as the US. So as a country, you are only competing against yourselves.
To the millions of people making a living in the health care system that have no actual role (direct or indirect) in improving the health of patients.
The key problem is that 20% of our GDP goes to healthcare, and similarly 20% of our population is employed in healthcare provision. This isn't just people sitting around doing nothing. It's nurses, doctors, administrators, etc. If you want to reduce healthcare costs in half, so that it is only 10% of GDP, then expect to throw 10% of the population out of work. That will include nurses, doctors, EMT personnel as well as administrators. Sure, you can try to shift that and fire a bit more administrators than nurses, but you will soon discover that's about as easy as eliminating government waste.
This inability to address the core issue arisies from people approaching these difficult problems in administration and systems science from a facile moral point of view. "it's wrong!" they say, to be given a big bill for a snake bite. Well, OK, it's wrong. But that same attitude will tell you "it's wrong" to fire a hard working nurse, or to reduce the pay of a doctor, etc. So now you are left with boogeymen like greedy insurance companies and fat cat CEOs. This is like the person who insists on a tax cut funded by reducing government waste. It's not a serious proposal. And what we have in the US healthcare debate is two sides, the first side is just lying and obfuscating (that is the side opposed to reform) and the second side is so bound in the chain of moralizing that they are unable to make any serious proposals. They can only go after the fat cats, and not the nurses. Thus their proposals will never work.
Same thing for education -- you need to fire most of the university staff and reduce the pay or fire many of the teachers. Same thing for all the difficult problems in life where we complain that things cost too much. It is not shadowy fat cats that are causing these problems, it is too many people employed in the provision of services who are earning too much. Ordinary professionals. The biggest problems of modern life are that professionals have too much power and are extracting too much from the society as a whole. Whether it is hospital workers or government workers or teachers, the issues of skyrocketing costs and bureaucratic bloat are very similar across these areas, and they cannot be solved by getting rid of shadowy fat cats or employees that "do nothing".
But that's the problem with your argument. Of course people have done it, nearly every developed country has.
> If you want to reduce healthcare costs in half, so that it is only 10% of GDP, then expect to throw 10% of the population out of work. That will include nurses, doctors, EMT personnel as well as administrators.
No, it won't. I'm talking about eliminating the positions that would only exist because of the private insurance system. Which is a massive amount of dead weight loss.
It's not remotely hard to understand conceptually, I mean EVERY dollar that's devoted to arguing over insurance bills is completely wasted. As are all the dollars spent on insurance advertising and marketing, and so on. Every dollar paid back to health care companies as dividends, or used for stock buybacks.
That's a lot of dollars.
Every time this argument comes up people in the US start talking about it like "Oh yeah? Sure but what's YOUR solution then smart guy? Stumped you didn't I?"
Um, no. My solution is the NHS. Like you can go there and look at it I swear it's a real thing, they have buildings and everything, just book a flight to London and see for yourself. Or, in US terms, Medicare for all, which is also a real understandable thing that exists, except for the "for all" part.
The US Government estiamtes the total adminstration and health insurance expenditure cost $288B in 2019. Total health consumption was $3.69T. Thats about 7.5% of total health spending. Even if you assume a 2 or 3x multiplier to the effect of eliminating insurance companies you STILL don't get US healthcare spending on a GDP basis in line with international norms.
Insurance companies are awful, but they alone are not the cause of American's health care spening problems.
Total spend is employees * average salary per employee.
Let's take a look:
* For doctors, there are roughly the same number, ~2.8 per 1000, but US doctors earn three times as much as UK doctors[1]. 294K/year US versus 66K/year (UK).
* The US has twice as many nurses[2] per 1000 people (17.4 per 1000) as the UK does (9.8 per 1000), and the US pays its nurses much more. The US pays 77K/year for an RN and 112K/year for an PN and 181K/year average salary for a nurse anasthesologist[3]. Nurses in the UK earn about 1/3 less, a total average of 33K/year[4]
* The US has 315K pharmacists (not assistants) or roughly 1 per 1000, whereas the UK has 43K or .65 per 1000. US pharmacists make average of 140K/year[7]. UK pharmacists make an average salary of 58K per year[8].
* The US has 23,200 microbiologists (earning 69K/year). The UK has 490 (earning 52K/yr)
* The US has 40 MRI machines per million. The UK has 6.
* Now let's generally talk about staffing. The US employs 20 million healthcare workers with a payroll of 1 Trillion (2018)[5] an average wage of 70K (and median wage of 42K/year). This is occupational data from BLS (https://www.bls.gov/ooh/healthcare/home.htm), so you can't complain about insurance employees at hospitals being included.
The UK has 1.3 Million[5] in both hospitals and clinics counting both NHS and Independents, with an average salary of 24.7K/year.
That means, relative to population, that the US employs 60 per 100,000 healthcare employees while the UK employs 20 per 1000. We have triple the number of healthcare workers and our health care workers earn double what the do in the UK.
Now let's talk about this enormous waste in insurance that will make healthcare affordable if only we got rid of it. Total insurance overhead in the US is 7% of healthcare expenditures[8]. So if we reduced it to zero, we would pay 7% less. Whoppee.
Thinking that you can keep paying doctors and nurses triple and have so many more staff and keep their high wages but merely with insurance reforms reduce healthcare spending by half is so wrong I am amazed I even need to say it. It's a terrible, misleading, evasive non-answer.
What we need to cut are salaries and employment. If you don't acknowledge that, then you are not a serious participant in this discussion because you are refusing to acknowledge that this problem has tough trade offs. You are not going to solve it by "cutting waste".
And this is important, because our problem, as a nation, is the general problem of professional guilds extracting too much from the rest of society. We have this problem with higher education, with finance, with healthcare. A large chunk of our professional middle class is employed by these sectors, and their well-being would be threatened if we significantly cut their wages and employment. It is not evil insurance companies, it is not shadowy billionaires, but our neighbors down the street -- the nurses, the college professors, and the X-ray technicians -- who are the ones blocking meaningful reform. And until we are willing to face that and recognize what must be done, then we will not get affordable healthcare. The incurable diseases of the modern west are all due to the professional classes extracting too much. It is not due to excessive "waste".
---
[1] https://revisingrubies.com/us-vs-uk-doctors-salary/
[2] https://www.healthsystemtracker.org/chart-collection/u-s-hea...
[3] https://nursinglicensemap.com/resources/nurse-salary/
[4] https://www.bls.gov/opub/ted/2020/number-of-hospitals-and-ho...
[5] https://digital.nhs.uk/data-and-information/publications/sta...
[6] https://www.census.gov/library/stories/2020/10/health-care-s...
[7] https://www.salary.com/research/salary/benchmark/pharmacist-...
[8] https://uk.indeed.com/career/pharmacist/salaries
[9] https://time.com/5759972/health-care-administrative-costs/#:....
Funny story - these days most DI (diagnostic imaging) machines (CT, fMRI, PET) are owned by doctors or consortiums of doctors.
They are money printing machines.
Doctors, and manufacturers know this. Manufacturers will find you doctors you can partner up with to buy DI assets, and get set up. You can pay off a CT machine in a couple of months, even high end fMRI in under a year. The manufacturer will finance. They'll even help you write CON applications (Certificate of Need, a nice little thing that hospitals lobbied for to reduce competition - if a new hospital wants to open up in an area it has to demonstrate that the existing community healthcare needs are being underserved. And the existing hospital gets input into the process). A nice little imaging production line.
Interestingly, though perhaps unsurprisingly, doctors who own an interest in imaging equipment tend to refer their patients to it at a rate approaching 2 standard deviations higher (comparing specialties like-for-like).
Yes I agree. Take the windfall profit motive out of the system and you’ll see quite a bit of change. Paying doctors less sounds like a great plan.
But we can start with the truly staggering amount of deadweight loss. Do you actually interact with the US health care system? Is it really that hard to understand just how much energy is wasted fucking around with just the billing component alone?
So when addressing a problem, you start with the first order stuff, and then go to the second order stuff, and you do this in terms of impact, not in terms of conceptual clarity.
Cut nurses and doctors, medical staff wages in half, and you save 40%.
The real point here is that you can't have affordable healthcare if nurses are earning 6 figures.
That's why nurses in the UK earn 40K/year. It's the price of affordable healthcare.
That's the core trade off between affordable healthcare and US style healthcare.
But all of a sudden now we do not have the same moral clarity as we did when we were only talking about "waste".
So let's have that debate right now - the real healthcare debate, not the fake healthcare debate -- and stop pretending this is a problem that can be solved with waste while allowing nurses to keep their 6 figure salaries.
It is what we call cheap moralism to decry how unfair high healthcare costs are in the US and then avoid raising any of the tough issues of what would happen to people whose livelihoods depend on those costs being so high.
Many business which successfully reduce costs don't pass on those savings to consumers.
I will also point out medical students graduate (after 4 years college and 4 years medical school) on average with $210,000 of debt and make $60,000 dollars a year while working 60-80 hours a week for 3-8 years of residency. While yes doctors after residency are well compensated they have gone through 11-16 years of post secondary education by the time they achieve these salaries. Cutting salaries without reforming medical school tuition and residency salaries would be a mistake.
What people don’t understand is the appetite for healthcare spending is practically limitless - there is always something more you can do even if the benefit is marginal. As such you have to control spending somehow and the options are (not exhaustive):
- ration care by capping total healthcare spending - “we will do 1,000 hip replacements this year, everyone else waits”
- make the cost visible to patients so they ration their own care - Singapore does this even in their public system. There is no free care, you are expected to pay something according to your ability. This is what the US is trying to do with the move to HDHPs
- closely regulate coverage and prices. Many systems do this.
Instead of giving a hospital your insurance info, say "you don't know if you have it, the last one expired" - even if you have insurance they couldn't prove you did "know you had it".
Then get the bill in the mail.
Submit the bill to your insurance company.
Bill gets paid.
Hospital doesn't get to inflate.
Turns out the translator didn’t know you could resize the rows, so they had only translated the first few words that happened to be visible in each cell.
No one working in a hospital knows how much do we acquire things for, or how much we get paid for doing things in advance. And only like 8 people can tell you that information 3 months after the fact.
Take the simple exercise of figuring out cost/revenue of an aspirin administration.
Cost depends on: 1. Are you an outpatient/Obsveration v. inpatient v. ED? 2. Are you on Medicaid? 3. Is the hospital a part of GPO organization or not? 4. Is contractual obligations of GPO includes/excludes Aspirin?
Reimbursement depends on: 1. Insurance 2. Group which you are under the insurance from 3. Contract language whether its a fee/service or bundled 4. Is the visit covered or not 5. how the visit/procedure was coded (most important and opaque factor)
Everybody in the know, knows that these lists are a joke, but no one can prove it.
The real scam is that the health insurers have convinced people they "fight for lower prices", when in fact they collectively profit from price hikes and the annual marginal increases fuel their growth as well.
Those considerations aren't part of what anyone calls cost. How much does the hospital pay for aspirin? How much do they pay someone to administer it to a patient? That's cost. If it's very complicated to determine what the patient or their insurance pays, well that's part of the problem.
We need to start setting the expectation of transparency for some small subset of info to get further transparency. Change takes time, as much as we’d like it to drastically improve overnight for real life and death situations like medical prices.
The price you charge for the bread might change, but the cost is the same regardless of who is purchasing it. There's a difference between varying costs of an item based on accounting methods, versus varying costs of an item due to who is buying it. There seems to be huge disconnect here between people working in healthcare, and pretty much everyone else.
Heck, sounds like there could be a Civil Rights Act case, if prices impact people differently based on race or sex or other protected class.
You should absolutely be testifying before Congress, not before HN.
Why shouldn't it be? How hard is it for a hospital to project their annual aspirin/paracetamol/? usage and budget for it?
Now try it at a rural critical access hospital for rattlesnake antivenom with a short shelf life, so it usually expires unused. They are required by law to stock it or they cannot have their emergency room open. Estimate the revenue generated from treating the one patient who needs it every other year, and by the way, you have 9 contracted payers with different rates and you don't know which one, if any, the patient will have. Rinse and repeat for every other drug required to provide "critical care". Maybe layer on infusion of exotic chemotherapy drugs or monoclonal antibodies to treat a new pandemic virus.
It's not easy.
Do the same sort of thing for all other short-half-life things that you must keep on hand.
It doesn’t have to be hard. I get that it is complicated right now, but let’s focus on the idea that simplifying it would help everyone.
https://www.cms.gov/Research-Statistics-Data-and-Systems/Dow...
There is a drug called Oncaspar. It's >$16,000 for one patient, and 5 cents for another (acquisition cost). Same drug, widely different acquisition cost.
It sounds like within the industry, hospitals are facing the same problems as consumers, and they need more price transparency from their suppliers as well. Hopefully increased requirements towards hospitals to explain their pricing will lead to hospitals demanding slightly more transparency and slightly more consistency from the other companies they work with.
Seems like 340B (I hadn’t heard of this before, thanks!) may have been created with recognition of this inelasticity.
If we can limit prices this way, all it would take are a few more laws to put more price limits in place.
Read that again and work through your objections. Ideally something's price is higher than its cost so the company can make a profit, but there are so many obvious exceptions that its nice, but not necessary. Thus, who cares how much the pill coming down line costs to manufacture, unless you start hacking into the free market and set price controls, and say that pharmaceutical companies are only allowed to make 20% profit (or however much), Martin Shrekili's play, of buying pharmacutical companies and simply raising prices of drugs, is a legal move under capitalism, no matter how reprehensible that move may be.
jonathan-adly is making the argument that the inherent "cost" of drugs is itself highly variable for hospitals, and that means it's normal and expected that hospitals should not be able to tell patients the price of procedure before it happens. I'm arguing that the "cost" of the drugs is not actually that variable, that hospitals are just downstream of another part of the industry that is engaged in the same price-hiding behavior that hospitals are engaged in.
Of course, under Capitalism "cost" doesn't determine price, the market determines price. But I would also point out that under Capitalism, signing a contract usually involves the terms of that contract being made upfront. Pretty much every other industry in America has figured out how to put a price tag on the products they sell, and I'm not sympathetic towards the medical industry just because up until now it's never needed to learn how. Apple sources its components from manufactures, those manufacturers could change their prices someday. But Apple still puts a price tag on iPhones, and because it needs to put a price tag on iPhones it's incentivized to form long-term contracts with suppliers and to demand a level of consistency in the prices its suppliers offer.
Hospitals haven't needed to do that in a long time.
Price transparency is an important part of most industries under Capitalism, and the medical industry hiding behind variable "cost" as an excuse to avoid pricing their products shouldn't be something we tolerate.
Martin Shrekili's practices (as abhorrent as they might be) are a different conversation. I think that price limits and price transparency are two very different issues.
There's nothing inherent to Capitalism that prevents variable priced contracts.
>Pretty much every other industry in America has figured out how to put a price tag on the products they sell,
Maybe for mass produced products they have, but certainly not for custom work. You aren't paying for a product but for a custom service. Paying a doctor to fix your body in many cases is more complex than paying someone to build a house, a bridge, or a piece of software. You won't even get an upfront price for something as simple remodeling your kitchen. A contractor estimates that it will cost $20k and then finds that a leak in your attic completely rotted some of the framing, now it's $50k. A builder starts digging the foundation to your house only to discover a huge boulder that has to be moved.
There are parts of medicine that could be made more transparent, but there is an inherent complexity that makes complete or even mostly complete price transparency impossible.
Definitely not the norm though, and it is inherent to Capitalism that price transparency is an important part of creating an efficient market.
But sure, it's not a rule. A lot of common things in Capitalism aren't rules, but they're still often signals of a healthy market.
> You won't even get an upfront price for something as simple remodeling your kitchen. A contractor estimates that it will cost $20k and then finds that a leak in your attic completely rotted some of the framing.
A contractor will not however replace the framing and then charge me after the fact. They'll discover the rotten framing, inform me of the new conditions and the new price, and then let me decide. A good contractor will walk me through that process.
> but there is an inherent complexity
Not in the places that we're talking about. The kind of complexity and guesswork and change in procedure you're talking about is not present in the situations that jonathan-adly discusses above. The inherent complexity of fixing someone's body and the inherent variability of what drugs/procedures will be necessary to do so is a good explanation of why pricing a surgery or an entire hospital visit is very difficult. But it is not a good explanation for why hospitals have claimed that the price of a single x-ray is "unknowable".
It most certainly is the norm when purchasing complex custom services.
>A contractor will not however replace the framing and then charge me after the fact. They'll discover the rotten framing, inform me of the new conditions and the new price, and then let me decide. A good contractor will walk me through that process.
If a surgeon could keep your chest open on an operating table while they walked you through the process this analogy would work.
>a good explanation of why pricing a surgery or an entire hospital visit may be difficult. But it is not a good explanation for why hospitals have claimed that the price of a single x-ray is "unknowable".
jonathan-adly has done a great job explaining why drug prices are difficult to calculate upfront.
As for the price os a single x-ray. I'm sure the average cost of a single x-ray could be calculated. But how much is that worth when the entirety of the hospital visit is going to be a variable cost? If you're only interested in a single x-ray, there are already outpatient imaging clinics that will give you the upfront cost.
An x-ray is not is not a complex custom service.
> But how much is that worth when the entirety of the hospital visit is going to be a variable cost?
This is the exact same argument that hospitals used to use against itemized pricing, and yet it turns out that requiring hospitals to give itemized bills on request has pretty solidly been a good thing for consumers.
There are a huge number of reasons for this, not the least being fostering competition and putting natural pressure on the market to justify its prices helps it become more efficient, and these kinds of opaque systems will almost always naturally lead to inflated prices. There's little reason to believe that up-front price transparency for individual itemized procedures and drugs wouldn't also be good for the same reasons.
At the very least, this would help with the many health decisions that consumers make that aren't happening during life-threatening situations. Most of the time that I get an x-ray, most of the time when I'm being offered pain medication, most of the time when I'm making decisions about whether or not to opt for anesthesia before a procedure, I'm awake and not in danger of immediately dying.
It really doesn't make sense to keep leaning on the most extreme life-or-death situations as a defense for why a hospital can't walk me through the price differences in several different brands of pain medication. But sure, we'll make an exception for surgeons operating while a patient is literally unconscious during a time-sensitive procedure. Most health visits (and the vast majority of all preventative care procedures) do not fall into that category.
> jonathan-adly has done a great job explaining why drug prices are difficult to calculate upfront.
Let's make this simpler. johnathan-adly says:
> The cost of the aspirin depends on these things
Here's Rite-Aide's page that comes up when I search for an aspirin: https://www.riteaid.com/shop/medicine-health/pain-fever-reli...
Why is it that Rite-Aid can give me an upfront cost for an aspirin, and a hospital can't? 340B is a rebate system, it doesn't force doctors to avoid talking to patients about the baseline price differences between comparable off-the-shelf name-brand and generic drugs.
The kinds of easy issues you're talking about don't need to happen in a hospital. You can already go to an outpatient imaging clinic for an x-ray, a dermatologist's office to have a mole removed, or an urgent care to suture a laceration.
If you need emergent care or you want an elective procedure that requires a hospital stay, you're into the realm of custom services with variable pricing.
>This is the exact same argument that hospitals used to use against itemized pricing, and yet it turns out that requiring hospitals to give itemized bills on request has pretty solidly been a good thing for consumers.
Has it? Has it driven down prices? Has the demonstrated value been worth the cost? Or has it just pushed hospitals into creating longer bills with more creative items and charges. Creative line items like $500 for aspirin perhaps?
Even better: clearly the market has proven that it's possible to offer these services with transparent pricing. Why can't hospitals keep pace?
This also raises the question why preventative care often falls into the same category. Lawyers have a predictable billable rate, personal physicians and doctors often don't. Most scheduled hospital procedures require multiple consultations and planning before the procedures take place. Most of that stuff is not transparently priced.
There's no reason why a hospital shouldn't be able to figure out the cost of minor anesthesia before a scheduled minor surgery. That's not a surprising part of the procedure, that should be something that's fully negotiated with insurance and disclosed to the patient beforehand so they can decide.
> Has the demonstrated value been worth the cost?
Yes, absolutely, you can find tons of stories online about people negotiating smaller bills because itemized bills turn out to include services that they never requested (and in some cases services that were never even actually performed). If you talk to experts about managing personal health costs, pretty much all of them will tell you to always request an itemized bill after you visit a hospital or doctors office.
It's also absolutely worthwhile because you're seeing creative line items like $500 for aspirin that prove that the costs of the services aren't being based on market rates. That's really important information because it opens the door to other questions like "why are these prices what they are", and "can you tell me in advance before you give me a $500 aspirin?"
I mean... you're saying this is the norm in complex industries, it absolutely is not. Complex industries are complex because they don't know up front what they'll be billing you for. That's not even remotely the same thing as "we think your stay should cost $5000 for reasons we can't disclose, so I guess we'll jack up the aspirin cost after the fact to try and prevent anyone from questioning us."
It is extremely worthwhile to put hospitals in a position where they have to answer consumers why an in-patient aspirin is priced so much higher than the market rate for the drug. I don't know if this is your intention, but what you're implying when you say that the itemized bills aren't accurate is that hospital pricing isn't based on any kind of competitive or visible market rate, or even anything objective at all. Which is a pretty bold claim.
Other industries with high-variability pricing exist, but they're not just making up numbers completely out of thin air after the fact and then lying about line items to try and justify that cost. Hopefully hospitals aren't doing that either. But if they're not, if they are actually basing their prices off of the combined prices of the services they provided... then we gotta ask about that $500 aspirin, because that's a weird price.
1. You shouldn't be admitted to a hospital for those minor clear-cut procedures. 2. Hospitals receive public funds to offset the costs of some services. 3. Hospitals are required to provide certain services regardless of the customer's ability to pay.
>Lawyers have a predictable billable rate, personal physicians and doctors often don't.
Laywers will tell you their billable rate, and can give you a semi accurate estimate for simple services. For more complex services their estimates have enormous error bars.
>There's no reason why a hospital shouldn't be able to figure out the cost of minor anesthesia before a scheduled minor surgery. That's not a surprising part of the procedure, that should be something that's fully negotiated with insurance and disclosed to the patient beforehand so they can decide.
If you're talking about local anesthesia sure, but in that case you're unlikely to actually need to be admitted to a hospital unless it's an emergent condition. If you're talking about general anesthesia then there's a reason that an anesthesiologist or a CRNA with many years of training is required to be present.
> Yes, absolutely, you can find tons of stories online about people negotiating smaller bills because itemized bills turn out to include services that they never requested (and in some cases services that were never even actually performed).
Yes but do you have actual data that the benefits are worth the cost? Has it actually driven down health prices in the US overall? Was the additional complexity actually worth it?
>It's also absolutely worthwhile because you're seeing creative line items like $500 for aspirin that prove that the costs of the services aren't being based on market rates.
I think you're not understanding the point of this. You're not going to actually save money by declining to take an aspirin. Of course hospital services aren't based on market rates. Hospitals are required by law to offer certain services regardless of the ability of patients to pay, most patients are insulated from the actual costs through insurance, many patients have zero out of pocket costs, complex procedures are impossible to accurately estimate, and the free market has an inherent problem with extremely price inelastic services.
It's not a free market, and unless we are willing to make drastic changes to society, it never will be. Pricing transparency for hospital commodities is such an insignificant part of health care costs that it's a gigantic waste of everyone's time.
1. All of these simple procedures are part of hospital visits. If your leg is broken, you're going to get an x-ray. Most surgeries are scheduled, and those scheduled procedures also don't clear this bar. And again, we get into the question of why preventative care suffers from the same problems. Your position seems to be that once any part of the procedure becomes variably priced, there's no point in trying to price any other part of the procedure. That's a pretty big leap to me, that's not how other industries work. And hospitals don't even work that way, because they itemize their eventual bills to insurance companies.
And I guarantee that insurance companies are not saying "who cares about the individual procedures you performed or what a technician's hourly rate is, the whole thing is variable anyway so there's no point in justifying any of it, just charge us what you think is fair."
2/3. I'm not asking them to tell me what their rebates will be or what discounts they might give me, I'm asking them to tell me what the maximum amount is they want for a standardized procedure. Possible rebates or lower prices that they can't predict are fine. I want a max price for that specific item.
> For more complex services their estimates have enormous error bars.
And hospitals still can't even clear this bar, they can't even tell me what a procedure's price is including error bars.
If hospitals could price their services as well as lawyers, we probably wouldn't be having this conversation right now.
> Yes but do you have actual data that the benefits are worth the cost? Has it actually driven down health prices in the US overall? Was the additional complexity actually worth it?
To those people, to the people who reduced their bills, yes. Is your assertion that we should only be looking at aggregate benefits? Community health pools and charity drives haven't reduced health care costs overall, but they have helped individuals avoid bankruptcy, and I suspect those individuals are grateful they exist.
I'm also confused at what you mean by additional complexity. Are hospitals giving itemized bills to insurance companies or not? It's really not a big ask for consumers to want to be CC'd into that conversation that should already be happening.
> It's not a free market, and unless we are willing to make drastic changes to society, it never will be.
Then socialize it. If you want to argue that the free market isn't a good fit for health care, fine. But that's not really an argument for keeping prices secret, it's an argument for socializing health care and taking it off the free market.
Which, incidentally, if your position is that health care should be socialized, line-item pricing also helps with that because it makes it obvious that the pricing is screwed up. You're upset that line-item pricing doesn't solve everyone's problems, but you can't solve a problem until it's obvious that it exists. At the very, very least, itemized bills and transparent pricing show that a problem exists.
That, on its own, even if nothing else mattered, would make these regulations worthwhile. No entrenched system in the world ever changes unless you put pressure on it.
Hospitals can provide an itemized bill after the fact. Not before. They also go back and forth with insurance companies multiple times. It's not actually based on the costs to the hospital. The final itemized bill is the end result of complex negotiation. It isn't actually based on cost.
>"who cares about the individual procedures you performed or what a technician's hourly rate is"
Insurance companies don't care what a technician's hourly rate is.
>I'm asking them to tell me what the maximum amount is they want for a standardized procedure. Possible rebates or lower prices that they can't predict are fine. I want a max price for that specific item.
No surgery is standardized. If you literally want the max price, it's going to be so high you'll never be able to pay it. It won't help you. The individual items don't matter--they're fiction.
>Then socialize it. If you want to argue that the free market isn't a good fit for health care, fine. But that's not really an argument for keeping prices secret, it's an argument for socializing health care and taking it off the free market.
It's not. And it should be public. As long as it's not a free market, none of the normally price discovery mechanisms work at any level in the supply chain. There's no way to provide prices upfront. Any attempt to will fail is just a colossal waste of time. Any list of prices you see is going to be an elaborate piece of fiction.
>To those people, to the people who reduced their bills, yes.
Those people didn't actually reduce their bills because of itemized pricing. They would likely have been able to reduce them regardless. They negotiated with the hospital successfully after the fact the same way an insurance company would.
Hospitals are usually willing to negotiate a bill because they'd rather have some money than none. Whether that's knocking off a line item for $500 aspirin, or nocking 10% off off an opaque $5,000 bill makes no difference.
>Which, incidentally, if your position is that health care should be socialized, line-item pricing also helps with that because it makes it obvious that the pricing is screwed up.
Average prices for procedures can be calculated after the fact. They can be useful in the aggregate. For non commoditized services the averages aren't remotely useful for an individual.
Unfortunately what we actually have, between patents and other monopolies the government has instituted on drug manufacturing and distribution, is nothing like capitalism.
You could replace patents with trade secrets and have many of the same problems (along with some others).
The problem is that when patents are no longer an option trade secrets (or public funding) become essentially the only viable option to pay for the majority of drug research.
If a drug is unique and desirable, forcing doctors, suppliers and patients into contracts that don't allow reverse engineering is the most likely outcome. In extreme cases drug companies could require patients to only be treated in a doctor's office.
In the case of drugs that can't be kept secret, given the time and effort necessary to develop, much of the economic incentive for that research evaporates.
>Patents are thus only viable for those things which would not be expected to remain secret.
That's not how the math works outs. You can easily construct a counter example where a drug has a greater than 50% chance of remaining secret during the length of the patent, yet taking the patent has a greater expected value.
At least we agree on that much. My point is that when the patent is preferable (in the vast majority of cases, as you say) it implies that a trade secret would not have been expected to last as long as the patent—which makes the patent strictly worse from the public's point of view. We've granted a 20-year monopoly in exchange for revealing information which would have otherwise become public, without restrictions, in less than 20 years.
Maintaining tight control over the distribution of the drug only gets you so far, especially when the underlying research is already public knowledge. Trade secrets, unlike patents, don't block independent discovery, and only the rarest and most expensive drugs would warrant complete control over the supply chain.
As for the incentive to perform the research, that ultimately comes from the patients desiring treatment, not the pharmaceutical companies. Eliminating the monopolies would not reduce the demand for treatments, though it would reduce the profitability of individual pharmaceutical companies.
> You can easily construct a counter example where a drug has a greater than 50% chance of remaining secret during the length of the patent, yet taking the patent has a greater expected value.
Yes, if you are not confident that you can keep a trade secret then the patent becomes the better option. (Isn't that what I said before?) "Greater than 50% chance" is not what I would call "confident". It doesn't change the fact that patents only have a positive net expected value to the recipient in the situations where the public is expected to lose by granting a patent rather than having the knowledge kept as a trade secret for a time. The interests of the applicant and the public are diametrically opposed; if the patent applicant wins, the public loses.
Change it to any arbitrary likelihood below 1. The expected value of a drug during the length of the patent maybe arbitrarily greater than the expected value of a drug after that time period due to reasons other than duplication (alternative unrelated treatments etc..). If it is expected that drug will make nearly all of its total value during the length of the patent, then even a 1% chance of duplication means that the expected value of taking a patent is higher.
Such an extreme disparity between expected value during the patent length and after isn't even necessary when you factor in the additional costs of attempting to maintain a trade secret.
>It doesn't change the fact that patents only have a positive net expected value to the recipient in the situations where the public is expected to lose by granting a patent rather than having the knowledge kept as a trade secret for a time. The interests of the applicant and the public are diametrically opposed; if the patent applicant wins, the public loses.
This is wrong because it ignores the additional costs (both direct and indirect) of maintaining the trade secret.
>We've granted a 20-year monopoly
Minor point--most drug patents have an effective date of about 10 years because of the time it takes to bring a drug to market.
>Maintaining tight control over the distribution of the drug only gets you so far, especially when the underlying research is already public knowledge.
Without the potential benefit of patent protection, we'd almost certainly see research become less open to begin with.
>Trade secrets, unlike patents, don't block independent discovery, and only the rarest and most expensive drugs would warrant complete control over the supply chain.
Probably, but those drugs would become immensely more expensive, or the reward available to an individual company for developing them would go down. Every novel drug would likely warrant some extra level of control (and expense).
>though it would reduce the profitability of individual pharmaceutical companies.
The direct cost of maintaining trade secrets would effectively act as a tax on all pharmaceutical companies doing novel drug development. As would the direct cost caused by duplication of drugs during what would have been the patent protection period. Add in the indirect cost of decreased openness, and the only way to maintain the exact same level of drug research we have today without patents would be to increase public funding for drug development.
I think that's probably a better system to be honest.
Your argument about cost to manufacture isn't relevant in the same way that the marginal cost of a flying one more passenger on an airline isn't relevant. We all pay different prices for airline seats. Hospitals pay different prices for the same pharmaceuticals.
There are a lot of smart people working in healthcare. A lot of people go into the industry thinking they know better and wash out. See the latest Berkshire Hathaway + JPM + Amazon failure.
> Hospitals pay different prices for the same pharmaceuticals.
Right, that's exactly what I said:
> It sounds like within the industry, hospitals are facing the same problems as consumers, and they need more price transparency from their suppliers as well. Hopefully increased requirements towards hospitals to explain their pricing will lead to hospitals demanding slightly more transparency and slightly more consistency from the other companies they work with.
Drugs in a clinical setting are priced on a per unit basis (which might be per mL), usually with a flat markup over cost. In practice, that can mean a patient getting IV drug treatment could receive two different charges for the same drug in the same day. If it's a hard to find drug and they deplete batch 1 from supplier A, then administer batch 2 from supplier B, the cost per unit could change by multiplies.
Using the earlier airline example, it's like trying to say what the cost of a generic flight is. The answer is always going to be it depends.
Combining that kind of cost structure with a transparency requirement means you get unusable, and as parent commenter mentioned, laughable results. It's not malicious compliance driving this garbage price transparency, it's a fundamental misunderstanding of how the healthcare system works.
Right, so again, exactly what I said:
> It sounds like within the industry, hospitals are facing the same problems as consumers, and they need more price transparency from their suppliers as well. Hopefully increased requirements towards hospitals to explain their pricing will lead to hospitals demanding slightly more transparency and slightly more consistency from the other companies they work with.
jonathan-adly suggests that it's laughable to assume that a hospital could get a predictably priced supply of aspirin from it's suppliers. And I'm sorry, but no it's not. Everybody else has figured out how to do this. The market has already proven that it is possible to predictably price an aspirin tablet for consumers before you hand it to them.
If hospitals can't do that, then it signals that either something is very wrong with how they operate, or (from the sound of things) something is very wrong with their supply chains.
The value here is in asking why hospitals can only provide laughable answers to a question that other segments of the health industry have been competently answering for decades now. I'm not saying it's necessarily the hospital's fault. I'm saying that something is pretty clearly wrong with their model for sourcing even generic drugs, given that they are one the only parts of the health industry that has this problem.
It's complicated. You're oversimplifying it.
Look, people are pointing me at rare drugs, drugs that don't have generics and that are only available on prescription, people are pointing me at the costs of surgeries and emergency care.
I'm really only asking about the absolute simplest part of this equation. Why can't hospitals predictably price the generic over-the-counter non-prescription drugs that I can buy at predictable prices communicated per-purchase in basically every single grocery store in America? Even GoodRx, for all of the variability on different drugs from different sources, is still able to show the price from each source up front. It's able to pull off transparent pricing.
If hospitals could do even just that, then we could move on and have a conversation about complexity. But they apparently can't even clear the lowest possible bar. Every single over-the-counter drug in a shopping mart will have a price tag on it when I pick it up. It is clearly possible to reach at least that level of competency. We don't even need to talk about the rare drugs or the complicated procedures.
Edit: it occurs to me that you may be focusing on stable, predictable prices over time. To be clear, I'm not even asking for that. I'm asking that at the moment a nurse walks up to me to put an aspirin in my hand, they should be able to tell me what the price is. I'm not asking for standardization across hospitals or static pricing across time, or even consistent pricing across a single visit. I'm asking for the price to be known before the drug is placed in my hand. That is something that pretty much everybody else has figured out how to do, it's the lowest possible bar to clear.
The price (chargemaster) that the hospital might list for all of the a-la-carte care you're provided is totally separate from how they will get paid on it. If you present at the ER and are triaged with stabilizing care, the nurse can't tell you that price because it will depend on your status at discharge, which is not yet known or in her scope of license to determine. If the doctor sees you and sends you home, that's one price (tied to Medicare outpatient prospective payment system or OPPS). Depending on how severe your issue is, the triaging care, such as pain relievers, may or may not be included in the "evaluation and management" procedure coding level you're assigned. There's one of those codes and typically separate bills for both the facility and the attending physician on your visit. If you're admitted to the hospital, what happened in the ER is not really relevant anymore, because now the facility portion of your care will be paid for based on your diagnosis related group (MS-DRG) at discharge, which has no bearing on how many a-la-carte services/drugs you received. Your insurer negotiates payment per DRG (usually as a spread to Medicare) but the hospital, recognizing that they can get screwed and lose a fortune if they have a really complicated case, will probably negotiate a stoploss provision for "outlier claims", saying something like after $750,000 of billed charges, we don't want MS-DRG reimbursement anymore, we want 35% of billed charges.
The regulation, primarily driven by Medicare, prevents any of this from being simple enough to communicate at point of care.
That doesn't even touch the administrative burden of documenting and collecting on all of that care. If your care wasn't meticulously documented by providers making hundreds an hour to type longform notes, it's essentially free, because no provider will risk billing for care they can't support with documentation. Once insurance pays (or not, they might deny the claim), they will often say "yeah we agreed to pay you x but the patient has 20% coinsurance so here's 80%, you need to talk to him about the rest". The hospital and especially caregivers are not aware of how much of your annual out of pocket max you've spent (thereotically they could check with the insurer, but not realistically in an ER), so maybe you have 20% coinsurance or maybe you don't, only you and the insurance company can realistically know that before the hospital sends the bill.
So now that you've glimpsed one hellscape of a reimbursement scenario, which price did you want the nurse to tell you?
It's totally insane and it all starts with CMS and the insurers. The hospitals would love to simplify and have menu pricing for your care, run your card, and send you on your way. No insurer would contract to pay that way because it would "incentivize the providers to administer unnecessary care".
Wait, hold on sec though. I've dealt with navigating inpatient vs outpatient coverage with my insurance compacts. It impacts what they will pay and it impacts what their coverage is, but that's a very different thing than telling the hospital what its prices need to be.
A hospital knows what it wants to charge for an aspirin tablet. Separately, some of that cost is going to be covered by insurance (maybe 100%, maybe 80%, whatever). Maybe there's going to be have to be separate negotiation afterwards to figure out what the insurance is willing to pay. Maybe the hospital won't get to charge what it wants, because the insurance company will whittle them down or move the entire procedure into a separate coding level.
But being able to predict the outcomes of that is more than I was asking. I am fine with a situation where a nurse goes to hand me an aspirin and says, "just so you know, this will be $5, though of course your insurance may end up covering it or negotiating you into a different code where you pay something lower." Because, again, other industries have figured out how to do this. A psychiatrist will not be able to tell you before the visit how much your insurance is going to pay, or even what the final price that they negotiate with your insurance will be. But you'll still know the general price of a session beforehand, the base amount that they want to charge.
Is there a reason why a hospital can't even tell me even just what the maximum amount is that the aspirin they're about to place into my hand would cost inside of their walls?
> That doesn't even touch the administrative burden of documenting and collecting on all of that care. If your care wasn't meticulously documented by providers making hundreds an hour to type longform notes, it's essentially free, because no provider will risk billing for care they can't support with documentation. Once insurance pays (or not, they might deny the claim), they will often say "yeah we agreed to pay you x but the patient has 20% coinsurance so here's 80%, you need to talk to him about the rest". The hospital and especially caregivers are not aware of how much of your annual out of pocket max you've spent (thereotically they could check with the insurer, but not realistically in an ER), so maybe you have 20% coinsurance or maybe you don't, only you and the insurance company can realistically know that before the hospital sends the bill.
This still feels like a lot of words to essentially agree with what I was originally saying -- that the entire process is not used to price transparency, and that this is not the result of an inherent complication in healthcare itself, it's the result of a system that at every level has gotten used to the idea that consumers shouldn't get to know what they pay, and that prices should be determined behind closed doors, not through an open market process.
If from the beginning, nobody tolerated getting mystery bills days or weeks after a hospital visit, would insurance companies have felt this comfortable demanding that hospitals follow a specific payment structure? Would hospitals have been as willing to accept supply contracts where the prices fluctuated so much?
After all of this conversation, we're still kind of back to the original point, which is that it's really good to put pressure on this system, that transparent pricing showcases the various issues with the system in a very public way, and that shining light on those issues and making them obvious to consumers may lead to improvements across the board. If the problem starts with insurance companies, then great. Attempts at transparent pricing open the door for public conversations where the public and regulatory boards ask "why is the insurance company refusing to pay the transparent prices that the hospital is offering?"
I mean, you bring up the (very common) scenario of insurance companies and hospitals disagreeing about what a procedure should cost and only agreeing to pay part of it. That's something that happens because there isn't a market rate for any of these procedures, and there's honestly no way to determine whether the insurer or the hospital is being reasonable. Price transparency helps with that, it gives us a more accurate picture of what the normal variation in prices are for a procedure across the entire industry.
I think that it might be coming across that I blame hospitals entirely for this, and I really don't, I'm focusing in on hospitals to make the point that the pricing outcomes are worse in hospitals than in most other industries. I understand that insurance makes this more complicated, I understand that suppliers make this more complicated, I understand that hospitals are trying to figure out how to bill as much as possible within the scope of regulations that dictate some price limits depending on context. What I'm saying is that price transparency regulation puts pressure on those systems to get better, and that it's good to put pressure on those systems to get better, and (most importantly) that there's nothing about medical care that inherently means those systems need to be this way. We have other examples of parts of the industry that have proven that this kind of complexity for the end consumer could be lower. We could have a medical system with transparent billing, the complications you're bringing up are regulatory, administrative, and contractual; they're not laws of nature. They're complications that were invented by human beings (not necessarily by hospitals specifically) and spread across the entire industry, because there was no incentive not to invent them.
Yes, insurance companies also need transparent pricing for hospitals. That doesn't mean that hospitals don't need transparent pricing for consumers.
Forcing this stuff out into the light helps the system get fixed. This is a pattern I've seen in internal tools development for businesses over and over. When my solution increases visibility into a problem, suddenly people start solving the problem without my help.
It's like that in every large organization. But it turns out businesses are pretty good at tracking costs, no matter how complex.
Besides, the specifics of any single case don't matter all that much. The variation can be smoothed out given enough data and a few common points of comparison.
But all of this is asking the wrong question...not 'how much does this cost now?' which is hopelessly mired in historical cruft but 'how much would this cost if done efficiently?'.
I wonder if the VA has open books...if not, they should.
But prior to this regulation, it was extremely difficult to even ascertain just how dysfunctional it all was. Putting it out in the open means more accountability for providers and insurers. Which in due time means more regulation :)
Which is how it goes when an industry misbehaves for so long. Eventually the public will get fed up, and demand that changes be made. This is just one step on that journey.
Many people may not see the medical cost world as misbehaving at all. It sounds like healthcare companies, from drug manufacturers to hospitals, are charging what the market will bare.
The inelasticity of the products and services for sale are what allows this market to become so out of whack. I don’t need an iPad that badly, but I do need to have these drugs to have a good quality of life.
I’m glad we’re taking these steps on the journey of making costs more transparent and understandable. And perhaps putting into law what we the people think is a reasonable approach to charging for life-saving treatments, rather than “whatever the company can get away with.”
It's true that this can all be explained in economic terms, but it's true in the same sense that the behavior of warlords can be described by economics.
For your simple exercise, it seems like we need to have that breakdown for those four different factors (and have that explicitly listed). Then we can figure out why the cost for a $0.22 jumps to $20 for those with insurance but $12 when paying cash. I agree it probably is a huge plus for you and your job security. :)
> No one working in a hospital knows how much do we acquire things for, or how much we get paid for doing things in advance. And only like 8 people can tell you that information 3 months after the fact.
This is the problem. There has to be prolonged pressure put on multiple parts of the system until it will start to optimize in different directions.
A nontrivial part of why no one knows these things in the hospital is because nobody has to know these things, the entire system (not just the hospital but the surrounding insurance system, the billing systems, the vendors, etc) is used to not needing to care about these things.
So these lists, as imperfect as they are, increase that pressure a little bit. Ideally, seeing the price fluctuation and seeing the reactions of doctors to these lists will prompt more in-depth questioning[0] from regulators, judges, and consumers. The fact that the lists are a joke is why they're not a joke. People need to be publicly reminded, again and again, over and over, that the way health procedures in the US are priced are generally broken, often arbitrary, sometimes opportunistically exploited, and almost always unnecessarily complicated.
The more obvious that becomes, the more attention that other parts of the system will get.
[0]: https://www.healthcaredive.com/news/baffled-judges-price-tra...
If the prices you charge differ from the prices provided by your open data platform, or if some factors are omitted from the open platform, you should get a lawsuit on your hand - and lose it.
If your excuse is that building the open data platform is too complex and expensive because too many variable are involved, explain how you were able to build a reliable system internally - and open that one.
If you cannot do that as well, you know it's time to rethink your pricing model, in order to simplify it.
The end goal of the regulation is to push as many health institution as possible to reach the conclusion that they really need to rethink their pricing model.
People here thinks that their local hospital is Google, while in reality it's a badly managed/badly funded 100 year old non-profit organization full of middle managers who just learned how to use their email.
If your point is "it is not possible to have transparent pricing", that seems also insane.
IMO we should pass a law that says if you can't give people transparent upfront pricing, you can't bill them at all. The idea that you can "figure out a price later" seems absurd.
It's like trying to put a bandaid on an arm that met a chainsaw. Not really a good first step and a waste of time. The solution is to go to the OR, and give him a new arm. The more bandaids and time you waste, the worse it is.
As someone who works in the industry, you gave me a hearty chuckle - well done, too true
Doing it manually seems rife for error and to be awful toil
People are literally dying out here from administrative bloat and you're joking about job security. Your comment comes across as cavalier and even a bit callous.
With that said, I respect the systemic and historical complexity of the problem and don't mean to suggest that you personally are the problem. I understand that you're pointing out the Kafkaesque futility from within the trenches; I think I get where you're coming from.
May I suggest that you rephrase your critique next time in a way that would communicate empathy so that we might in turn empathize with your situation? If these spreadsheets are feel-good window dressing (not that I agree), then state your case and let's stop wasting time on them. What do you think should be done instead?
Let us improve things together.
In your opinion, is this something that could be exhaustively modeled in software? What would the bottlenecks be? I'm guessing probably the biggest is the fact that the necessary data isn't digitized, or if it is, it's not easily accessible.
So long as a shitty excel sheet with inaccurate data fulfills the regulatory requirement, you will find a lot of trouble getting people to pay money for it.
Example, an x-ray. You know you need to pay an x-ray tech X$/Hour and after doing 1,000's of x-rays, a hospital should have it down that somebody with a broken leg will require N hours (maybe .5, maybe 1.5) to setup and take the x-ray. x-ray film costs HAVE to be known. the x-ray machine life time and number of shots should be known. Then do something like a 30% surcharge for admin fees and boom, x-ray cost.
Every other industry estimates this way, what makes a hospital different?
If you know (because you have blue prints) that the materials will cost 1,000,000 to build the plane (because your suppliers gave your price quotes), you can have a very good idea of what that plane will cost before putting it on the assembly line.
But hopefully this price transparency helps us ask the question of why does an x-ray have to pay for a ton of positions which have nothing to do with x-rays, and how do we correct this situation.
No one gets an x-ray for a broken leg then leaves with their foot broken. Even assuming that you are just trying to figure out the cost of an x-ray - there is a radiologist involved (unless you want to read it the x-ray on your own) and how they bill is a whole total beast!
It shouldn’t be this difficult to price x rays at a per hour or per shot basis.
Pretty much every industry has variability in their jobs. Sometimes they eat some money and sometimes they make more based on what actually happens during the job fulfillment.
No one expects (or should expect) hospitals to literally know the amount of parts and labor for every single x ray they could perform. However, like literally every other business, they should know rates and tiers such that on average they make money. Then, disclose that.
The irony, coming from a profession which is notoriously bad at cost estimation.
But in any case, the difficultly is not so much the materials/services as much as figuring out what the patient's insurance company (which is completely different then the practice) will cover and by how much. But of course that's actually what matters to the patient.
They know medicine, not the intricacies of your particular insurance policy.
Source: Am founder of rivethealth.com which does cost estimation.
If they are inaccurate, these hospitals should be sued into oblivion and replaced by trustworthy, competent organizations.
> Cost depends on: 1. Are you an outpatient/Obsveration v. inpatient v. ED? 2. Are you on Medicaid? 3. Is the hospital a part of GPO organization or not? 4. Is contractual obligations of GPO includes/excludes Aspirin?
> Reimbursement depends on: 1. Insurance 2. Group which you are under the insurance from 3. Contract language whether its a fee/service or bundled 4. Is the visit covered or not 5. how the visit/procedure was coded (most important and opaque factor)
Your convoluted process should not be the patient's problem.
Write an app that allows the user to input their provider and group, and search for the procedure to get a price.
That said, these price lists are an attempt to turn healthcare service delivery into commodities. Transparency, yes, but the lie is that healthcare is a market.
The alternative is nationalized care where all sorts of financial flows that now are optimized for profits, are so optimized no longer.
Most people living under and working for a nationalized system tend to like it. Most who live under or work for a commodity system tend not to, except for those positioned to receive profit flows.
But this list doesn't care why the price was charged. It only needs to know, bottom line, what amount of money changed hands for the procedure?
>Cost depends on: 1. Are you an outpatient/Obsveration v. inpatient v. ED? 2. Are you on Medicaid? 3. Is the hospital a part of GPO organization or not? 4. Is contractual obligations of GPO includes/excludes Aspirin?
Wrong.
Cost depends on "how much does the raw aspirin cost in bulk + some standard overhead cost"
We went to urgent care at the same time on the same day, saw the same doctor and got prescribed the same drugs.
About a month later when the bills came, her bill with no insurance was somewhere in the $160 range. My bill after insurance was nearly $300.
I'm still peaved about this.
I heard that sometimes they ask the uninsured to sign away the ability to sue the doctor and get lower prices in return. I am not too sure about details, this is just hearsay.
Perhaps allowing healthcare providers to incentivize things like this is… not great? Because we’ll sign pretty much anything if we’re sick enough.
It's still crazy that the bills were so completely divergent.
I don't want health insurance. I want health care.
I pay for a specific medication OOP with goodrx because it's not covered by my insurance, and paying for it through them would be nutty ($1600/year versus $90/year). But other things I just lump in b/c I use a fair bit of insurance every year.
Edit: CNN hasn't forgotten, notice the obvious negative spin, with literally zero argument of how this may be beneficial: https://www.cnn.com/2021/01/04/politics/hospital-price-trans...
The free market has no place in health care, because in the hands of the free market the first thing that will happen in a life-threatening emergency is for you to transfer 100% of your wealth to the party that has 100% of the leverage.
This is a tired, nonsensical argument. The vast, vast majority of medical procedures are not last minute emergencies. Furthermore, with price transparency you will clearly be able to evaluate which hospitals may or may not be generally in your price range and choose a default to visit for an emergency (assuming you're not carted off in an ambulance).
More importantly, this will absolutely force competition and some degree of price correction.
To me it comes down to - if we are going to pretend we have a market based system for health care (that's what we say we have now), we need pricing transparency to have any hope of it working.
For well-insured middle-class people. Poor working people only get emergency care
For life threatening emergencies, I'm with you. Let's fund that care through the state.
But excluding the market from everything is not the answer. The problem with using insurance for all these non-urgent things is that insurance distorts the market and price discipline goes out the window.
So yeah, there are a handful of people out of thousands where this system works great. We shouldn't optimize the entire system for hundreds of millions of people for these edge cases.
Let me cut to the chase: a better system is probably one where competitive market forces are leveraged to drive down (actual) costs and drive up innovation where it is an optimal strategy, and social program-oriented solutions are deployed when that is the bad, unethical, impractical or suboptimal approach, with an overarching mechanism to regulate over time the transition from the former to the latter. If you remove the incentives that come with a free market for healthcare, it comes with benefits and costs. Stop acting as though it is cost free. It isn't.
I never took issue with your claim that healthcare in the US has problems which are solved through universal systems. I took issue with your claim that universal systems are a panacea that solve all relevant problems, and the implication that trying to hill climb to a better optimum is not worthwhile to improve outcomes.
I never said I don't care about anyone. This is a pretty simple trolley problem. One track has 1 million people tied up, one track has ten. I value the lives of everyone equally.
> I took issue with your claim that universal systems are a panacea that solve all relevant problems
I never said that. I said they were superior to our system, which is apparent in terms of costs and outcomes.
> There is no silver bullet.
> On the contrary,
What I described would move us in the direction of the countries you're talking about.
I have lived in the UK, and seen doctors through the NHS. I have bought cough medicine at the chemist, and no it was not state-funded. I have visited patients at NHS hospitals where you are one patient sharing a room with 20 others in the same ward. I have talked to people on the waitlist for months to get surgery.
I still think the UK system is better than ours in the US for urgent care. I don't want anyone to be financially ruined because of some unforeseeable accident or emergency.
But I maintain that "health care" is way too big a category to be absolutist about using or not using free market principles in it. There are parts of health care where markets do not make sense. There are other parts where they do.
This is really is the ideal place for government in healthcare. Make the laws, set the standards, level the playing field and let the free market work just like in every other facet of society.
It’s funny people who see how incompetent and irresponsible our government is on a daily basis think that handing healthcare over to them is a good idea.
Every president has pushed for this except Bush Jr.
Glad it finally happened even if it was under who I consider to be the worst president* in the last 100 years of US history. Doesn't mean I need to thank him. If you were being tortured in a Mexican cartel prison, would you thank the torturer for giving you glass of water?
I'm Muslim and I've grown up my entire life with that war and its consequences in the background, especially since we mostly consumed arabic media. I've thankfully not been affected directly, but man do these takes completely discredit the side that keeps pushing them instantly for me.
We are at a point where even the notoriously neocon hawkish republican party and their voters are a lot more willing to acknowledge just how horrible those people were, yet democrats have no problem completely rehabilitating the old neocon crew because hey yeah they killed people but at least they were... Polite about it? I get that it's unhinged crusading politics and we just have to paint the adversary as the worst person ever to feel the rush of being morally superior but when you are at the point where you defend George W Bush to own the magahats, maybe take a step back and reflect on what you are doing.
The worst part is that now that bed has been made and apologism for those neocons became a mainstream talking point, everyone is just doubling down because admitting that trump isn't actually even close to being worst would be to admit that maybe the hysteria to score political points didn't warrant sweeping under the rug 2 enormously destructive wars.
[1] as in the privilege of not having ever been affected by the war on terror. Which in turn leads to pretty insignificant events like being concerned about the presidents tweets or feeling that you are part of some sort of feel good #resist movement for 4 years just registering as being more impactful than a region getting destabilized far away
The guy broke democracy and started a trend that IMHO will inevitably break the US. There's no stopping the nihilistic-right's rise fueled by an uneducated white minority bent on revenge via politics for their oppression at the hands of those they vote for. This nihilism, meaning its not that side A is correct or side B is correct: there is no "correct". That's worse than two pointless wars, IMHO, and it springs directly from Trump. A fountainhead of corruption the likes of which modern democracy has never seen. And I stand by that.
Of course it's worse than 2 wars you have never been affected by. The entire USA had a complete meltdown over allegations of Russians rigging the elections, without any American casualty. In fact I'd bet that one of the reason you are saying trump broke democracy is probably related to those allegations. But when the US is destroying entire countries it's no big deal? I hope you can see the cognitive dissonance there or at least why your point of view is very very white centered. And that's without even getting into how the democrats attacked the integrity of the elections for years, rightly or wrongly yet I don't see how that didn't directly undermine trust in democracy. It was a dance-à-deux, and if trump ends up breaking democracy down the line it's not because one side pushed against it. My point here is that no matter how you look at it, the entire thing is related to partisan politics not a righteous crusade that couldve somehow justified arguing that 2 desastrous, decades long wars were in fact less important/bad.
But that's all unrelated. Look, I'm not American, not white and not Christian.to me it boils down to this. I don't think anything is more cynical and cold than to publicly downplay and rehabilitate a figure that caused so much more pain and suffering because that would score points. That's it.
I really didn't want to come off as insulting you, honestly. And I get that some things can't really be expressed in a non offensive way (even if that's not the intention) when it comes to heated subjects like this. That's why I'm not going to touch on some of your other points. Again, it's not because I'd have insulted you otherwise, but because I don't know how to express what the war on terror felt like from the "inside" without inevitably sounding hyperbolic.
Shit. That's an excellent point. Thanks for making me realize it. I'm being absolutely glib about 1M+ deaths. Yeah, that's totally privilege. My bad. I'll go think on that for a while. Yes, I'm a white liberal and I haven't been called out this succinctly and correctly in a long time. I responded like shit because I got angry, my apologies. Thanks again.
I totally realize it's harder to get the whole picture for a lot of people who weren't really affected or involved, just like it is harder for me to relate to let's say the current Ethiopian civil war and it's very harsh effects on the local population since it's so detached from my every day life. Even as a Muslim , I'd probably have been oblivious to the war on terror if it wasn't for my parents being very into Arab politics and the family tv always tuned to Arabic news. Growing up with daily reports of bombings, suicide bombings, mothers crying on TV, and just footage of destruction everywhere is what made me realize and process how much misery was brought upon so many people. it got to the point where the opposite of the normal media sentionalism happened and a few dozen people dying in a suicide bombing/drone strike barely made it in the news. the weird part was that it somehow was never ending.from the invasion of Iraq, to the insurgency to the Iraqi surge to the afghan surge to libya to Syria to Isis to... A bit of very relative peace now? I think everyone would've felt the same if they were in the same situation I think. Even many Arabs and Muslims in the US don't fully realize that either. Cheers!
Every doctor in Canada providing covered medical services is in-network.
Canada has some of the best cancer survival rates in the world, and is substantially identical to the US. [1]
Further the US tends to skew towards early detection without a commensurate increase in survival rates, which means 5-year numbers in the US are higher than elsewhere in the world but it does not necessarily translate to lower mortality.
[1] https://www.ctvnews.ca/canada-gets-high-ranking-for-cancer-s...
Source: currently work at a big hospital in IT.
https://www.cms.gov/newsroom/press-releases/hhs-announces-ru...
I get the whole "do your research", but often it's in areas in-which I have no real capability - especially with healthcare.
---
> And with US health care, it just takes one accident that sends you to the ER and where someone that's out of network performed a procedure to end up with a bill that's tens or hundreds of thousands of dollars.
Agree. And to add, all it takes is one procedure that your insurance company doesn't want to cover to put you into literal billing hell for months on end. My point being, even with price transparency they can just chose not to pay even if they're obligated (and they do this). If there's any way they can weasel out of paying they will.
I'm still 100% in support of price transparency in healthcare however... there's just so much broken with it and I've lived through the hell.
Oh the system has answers – just happen to be high enough at your company, or the spouse of someone who is.
> While a benefits expert at a mid-sized company may create a narrow network, an executive's spouse, for example, may want to go somewhere not in the network. "And there's a pillow talk that happens. And the next thing you know that hospital is in the network," Ladd said.
This whole "employer provides your healthcare" thing we have going on in the US is just nuts.
https://congressionaldish.com/cd227-coronabus-health-care/
“Starting on January 1, 2022, any health insurance company that provides “any benefits” in an emergency department can not require pre-authorization of those services or deny coverage because the emergency department is out of their network. If emergency services are provided out-of-network, there can not be any limits on coverage any more restrictive than what would be covered by an in-network emergency department and the out-of-pocket costs can’t be more than they would be in-network. Out-of-pocket payments at an out-of-network emergency room must count towards in-network deductibles and out-of-pocket maximums.”
https://www.politifact.com/factchecks/2013/oct/28/nick-gille...
> ER costs are also a problem, but it’s an orthogonal issue.
It's natural to want to discuss this orthogonal issue, and the solutions to the two issues are not mutually exclusive.
https://www.amjmed.com/article/S0002-9343%2809%2900404-5/pdf
To shock and awe into future laws
Also get rid of the whole in and out network system.
E.g. when my wife had surgery, the hospital tried to charge $20k for the surgery room and $20k for the recovery room. Our insurance pointed out that by their agreement they aren't allowed to charge for use like that.
Instantly cut the hospital portion of the bill from $49k to $9k.
It's gaps like that that lead to the entire in/out network split.
Silicon Valley/big tech is not the center of the universe. How is what "typical" engineers at big tech companies make relevant to a discussion of what psychologists and other medical professionals make? Are you suggesting that the medical profession is doing battle with big tech for (future) workers?
So yes, it does effect the supply of future and even current psychologists and doctors. Supply is dictated partly by cost of that supply vs the demand in dollars for it, and the cost and barriers to med school and licensing is a big factor of supply costs.
I suspect that the number of people who are driven solely by money and prestige is smaller than you believe, but even so, careers in different fields aren't fungible for the simple fact that even ambitious and smart people aren't universally capable of excelling in any field they choose. A top heart surgeon, for instance, wouldn't necessarily have the ability to be a top software engineer, even if he or she tried, just as a top software engineer wouldn't necessarily have the ability to be a top heart surgeon.
> So yes, it does effect the supply of future and even current psychologists and doctors.
Do you have any hard evidence indicating that the lure of big tech jobs is reducing the number of individuals who are pursuing careers in psychology, medicine, law, etc.? A study perhaps?
That can lead to price discrepancies similar to (although perhaps not quite as severe) as what you see in healthcare.
After that, decouple health care from employment.
Finally, fully excise the connection between health care and ability to pay.
- a mandated MLR of 85% means the insurance companies have zero incentive to reduce the cost of items. In fact, their toplines and real (non%) profits increase as healthcare gets more expensive.
- industry profitability for insurance companies is around 3%. So, their overhead is around 15%-3% = 12%. They have an incentive to do their job cheaper. This pales in comparison to the 85% cogs.
- the small company cfo (me) has negative incentive to get involved in my employees' healthcare decisions. In fact, even being aware of cancer, pregnancy, etc. can be used against management in an employee lawsuit. No thanks. We just accept the situation and pay the bill.
- huge companies that can afford to self-insure can do it as they can firewall healthcare information from employment decision makers.
So, who in this system is going for cheaper healthcare:
- employees ... no
- insurance companies .. no
- healthcare providers ... no
- business paying the bills ... no
This bullshit billing structure is the tip of the iceberg. We have no freemarket incentives to keep down the cost of healthcare (i.e., carveout for high deductible insurance plans). Why would we expect otherwise?
Also, I think emergency healthcare should be contemplated differently than ... I'll call it "premeditated healthcare". In one instance, the individual can make a deliberate shopping decision and weigh cost/benefit. That's fundamentally different than an ambulance taking you to the ER when you're bleeding out ... no price shopping then.
Basically, there's a surgery center in OK which posts every price online and doesn't take insurance. A surgeon who works there talks with the host about how it works and the nuttiness of health care pricing in America.
My wife had her prenatal anatomy scan a few months ago at Stanford medical, $11000 for a 1 hour ultrasound. I personally was on the hook for around $500 and insurance paid $10500.
End of the day, what say do we have as consumers? How did the insurance company negotiate a rate of $11,000? Does the insurance company really care when every year they can just increase premiums and shrug and go "costs are going up! sorry!"
It feels a lot like a pyramid scheme, at some point the gravy train has to stop
Here in the UK we paid for a prenatal scan and NIPT a few years ago (this was in addition to free NHS scans at our local hospital), and IIRC it was £200!
Odd part was in this case, we had a follow up ultrasound for another $2500 for a second hour after they “saw something odd” and it turned out to be nothing. Second hour had billing codes that were 75% less for some reason.
So one group will have one rate with Blue Shield vs what another hospital will have.
Its absolute bullshit.
---
If youre mandated to have insurance - then procedures should be regulated to a set cost regardless of who performs the procedure.
This Frontline documentary talks about this issue.
As this is clearly being systematically abused to extract the most wealth from patients and insurance companies, is anyone seeking to require healthcare providers to not provide such variable pricing?
Hospitals should set a price for a procedure. There will be some variability of course as people need more or less anesthesia, identical surgeries can take longer to perform (=== more OR/surgeon time === more money), etc. But a $22-102k like in the article is absurd. Insurance companies should be required to pay whatever the hospital price is provided it can be justified. There should be specific courts to handle these disputes until the industry realizes it isn't special. Regardless, the onus shouldn't fall on the patient. Outcomes should be limited to: 1) Insurance company pays without complaint; 2) Insurance company doesn't pay, is sued by hospital, and is ordered to pay by the court; 3) Insurance company doesn't pay, is sued by the hospital, prevails in court, and hospital adjusts accordingly, eating 100% of that loss.
But, we'll likely just stay where we are now where people pay $100 for Tylenol PM and insurance companies get out of paying claims because one person out of 12 in the OR were out of network and they're all contractors.
The state of the secular healthcare system is unrelated to the religiosity of the population. Further, in some states (like TN), there are in fact christian organizations that do take on a substantial portion of the social safety net, especially for the homeless. Critics will say that the time limit on food and housing is unethical but I think its important not to create a permanent dependence.
I'm not a religious person but the disdain which people commonly speak of [white] Christianity online is really offputting and, frankly, ignorant.
As always, that which lends itself to regulation via market should be private and that which does not should be nationalized. So which one is medicine?
Medical care that is needed suddenly and urgently must be nationalized because the consumer of this care doesn’t shop the market and therefore the market is not capable of regulating its participants in that case.
Medical care that planned ahead of time, not urgently needed or otherwise allows people to shop the market should be private.
But this is not the issue. Whether or not medicine of one kind or another is private or public doesn’t matter as long as the medical establishment is corrupt and inefficient. Corruption and inefficiency are possible in both scenarios. Too few people in the public appreciate that it is the massive corruption and inefficiency of the medical establishment that is the cause of America’s healthcare problem. Doctors are in hundreds of thousands of dollars in debt by the time they wear a stethoscope. Hospitals are charging ten dollars for an aspirin. Patients can sue and cause material damage to medical practitioners even if the medical practitioner did nothing wrong. The system is broken. It doesn’t cost 300k to train a fucking doctor. It never did in the past and it doesn’t now either.
But in the American system it's setup that you must. This is the whole "coding" thing that you hear people refer to which is taking a procedure and breaking it into individual codes that can be used in billing you/your insurance.
This was addressed in the "Methodology" section of the article:
> Data was collected for three services, determined by specific codes.
---
> I’m very interested in how the community might think it would affect the value based healthcare industry with respect to total cost of care management and bundled services?
You mean... releasing pricing for individual codes.....? Finally showing that hospitals will bill different prices for the same code based on the patient's insurer...?
I read the article and all I got was that hospitals are releasing pricing information under the Trump mandate. I'm not sure what you're positing for an "effect" here as the effect is literally just transparency in hospital billing?
I've heard rumblings of this too but every time I've interacted with healthcare it's still the same coded system that you see in regards to the chargemasters etc... even as recent as-of a few weeks ago this was the system in a modern hospital in a large west coast city.
So, two things:
1. I think we're on the coded system indefinitely, or at least that's only what I can expect given recent experience
2. Even if we were to implement this, providers and insurers will still fight like cats and dogs because there's just too much money to be made here that I can't imagine the same problems won't manifest itself in a "bundled payment" system. I would actually expect this to make matters worse. Often when you bundle something it obfuscates and confuses the value of the individual "things" in the bundle - the middlemen will do everything they can to extract margin from this. I'd personally like to stay with codes to maintain transparency through having an auditable receipt of known services directly tied to a fair price.
Bundled payments give providers the freedom and financial incentive to find innovative ways to efficiently deliver high quality care. No one benefits when hospitals have a separate line item charge every time a nurse administers a pain killer over the course of a hospital stay.
Until someone financially incentivizes a higher quality of care I don't expect to receive it, especially by a bundled pricing model.
> No one benefits when hospitals have a separate line item charge every time a nurse administers a pain killer over the course of a hospital stay.
And as someone who's been billed insane amounts for things like OTC painkillers I disagree with this so hard. I have zero, and I mean zero, confidence that they will not continue to overcharge me. When everything is individually coded then at least a patient can go back and "look at the receipt"...
In my adult life I realize that almost everything is weaponized against me (the patient) in healthcare. I cannot expect in good faith that removing the line items from the receipt will help me in any way. In America, I can only expect this to hurt me or I'd be an idiot.
Sorry to disagree, but there is no way that bundled pricing is going to serve the patient better as it makes auditing services rendered much much harder. As someone who's had to get into the weeds on this stuff between insurer, hospital billing, etc. I can only imagine that bundled pricing would have made my life more difficult as it really did come down to the codes.....
Actually, practices currently bear the risk already, because they are subject to reimbursements unless they are cash-paying. Remember, the patients are regularly not the bill payors - the Payors are actually insurance companies/medicare/or, rare HMOs out of the area.
> They might receive a single bundled payment for a joint replacement including all follow-up care, with penalties for failing to meet clinical quality measures
Certain medical interventions like cancer treatment or joint replacement may require a long tail of treatment, counseling, physical therapy, aftercare, global periods, etc.
The applicability of that is fairly limited since many things do not trigger a global, and don't fit into this definition.
The medical industry is adept at excuse making and impeding change. If we wrap ourselves around every conceivable axle then nothing will be achieved. As it is providers and payers already employ elaborate coding systems to represent work and ascribe costs. Step one is to kick open that door and make this transparent. Should the result prove inadequate to sufficiently represent every imaginable nuance then the medical industry can engage in the necessary rework under that pressure.
of course, we might not like the prices they quote if forced to do this, but it would at least be better than rolling the dice every time.
Estimates are fine, it’s just that they don’t benefit US hospitals. Stop justifying them, they’re scamming you.
I'm in Austria, obviously... The only thing wrong here in Austria is there's still more than one health care insurance (one of regular employees, quite a few on federal and state level and one of self-employed) and there's a separate one for accidents (AUVA) and almost all of them are just playthings to the power hungry and greedy government.
Can even use the healthcare industry standard for EHR which is JSON and RESTful
Germany did this for gas stations:
> Since 31 August 2013 companies which operate public petrol stations or have the power to set their prices are obliged to report price changes for the most commonly used types of fuel, Super E5, Super E10 and Diesel "in real time" to the Market Transparency Unit for Fuels.
https://www.bundeskartellamt.de/EN/Economicsectors/MineralOi...
These files are provided as excel documents in what I assume to be a (hopefully) mostly unchanging location on each site. A script could download all the files, match up the procedures and then push it to a pretty tool for everybody to use when comparing prices.
Most enterprises have terrible dev/IT talent but when it is a cause as important as this, talented people tend to show up to provide a great solution.
What if ... that's actually a very egalitarian approach? Procedure cost is what you can afford.