Surgery estimated cost $1,300. Then the Bill Came: $229,000 | Hacker News Reader

Surgery estimated cost $1,300. Then the Bill Came: $229,000

nytimes.com

257 points8bitsrule251 comments

I don’t understand how hospitals can ever expect a contract with such ambiguous terms to be valid. Contract law requires a “meeting of the minds” — if they withhold price information until after the service is performed, and the final price is orders of magnitude higher than the expectation it’s clear that hasn’t happened.

Contract law is often seen as existing to protect the seller from non-payment, but it equally exists to protect the buyer from stuff like this, and it’s absurd that these companies expect the protection of contract law without giving their customers the same benefit.

I suspect healthcare providers won't give you a price before they are done, because they don't know what it'll cost.

If they open you up, they might have a complication or run into some other issue that must be fixed before closing you down.

Say allergic reaction to drugs or something that require extra care.

I suppose one could argue that healthcare providers should assume this liability and give you a price upfront, factoring into it the risk of complications, etc.

But in the end, if you don't pay for your own bad luck, then you might as well have universal healthcare :)

That makes sense, but even nailing down a price for lab bloodwork turns out to be elusive. I’m dealing with a bill that I discussed with the doctor beforehand that turned out to be 4x what we discussed. I don’t blame the doctor, I don’t think he had access to the true cost either.

Depending on the blood work, it might be worth it to get it done via walkinlabs.com or a competitor.

Up front with the pricing and usually cheaper than the alternatives as well.

None of your hypotheticals actually happened in this situation.

The hospital clerk wrote down that she was "in-network", gave her a quote and then after the procedure, the hospital discovered she was not, and upped the quote by $200k.

Hospitals do whatever dishonest stuff they feel like all time, and the worst consequence to them is that they don't get their $200k and consequentially ruin someone's life with debt collectors.

If every time hospitals tried to steal from someone - because that's what this is - one of their senior managers did a year in the penitentiary, such brazen dishonesty would cease overnight.

They won’t even give you a “no complications” price. Even if they do 10 of the same procedure a week.

> I suppose one could argue that healthcare providers should assume this liability and give you a price upfront, factoring into it the risk of complications, etc. But in the end, if you don't pay for your own bad luck

It's not your bad luck, it's their proffeshional responsebility to providing accurate diagnostics and figure out what treatment you need a nd how much it will cost. Every proffeshion has to deal with this, from lawyers to builders, and they provide estimates or even fixed fee services. If they really have no clue they provide an hourly rate. But no other proffeshion just makes up prices out of nowhere.

The only thing different about hospitals is that you are unconcious and can't control anything.

Let me ask you a question - how does 'free market' and competition work without price information?

Some good news: As of 2022, we have a new "No Surprise Billing" law that covers many of these surprise billing scenarios. There is a specific provision for being charged significantly ($400) more than a "good faith estimate"

More detail about the No Surprise Billing law here: https://www.cms.gov/newsroom/fact-sheets/no-surprises-unders...

Sadly this case occurred prior to the law going into effect.

I’m worried that the hospital forms will start to include a clause to agree to “waive” the affects of this bill

Yes, and it’ll be done via that little electronic signature pad that doesn’t show what you’re signing for.

Agree with you, I always felt frustrated by signing on pads and not only on Hospitals but Banks as well. I tried to fix this by building a platform for using iPad where one can see the whole document, something like docusign but focused on tablet-based signing. We’ll see how it goes

Seems to me that ultimately this will have little to no effect since they gave them an escape route.

> Require that health care providers and facilities give you an easy-to-understand notice explaining the applicable billing protections, who to contact if you have concerns that a provider or facility has violated the protections, and that patient consent is required to waive billing protections (i.e., you must receive notice of and consent to being balance billed by an out-of-network provider).

All hospitals will simply make you wave your rights as part of their onboarding process. These rights need to be something that cannot be waived or they actually just add more work for hospitals (ie, more cost for patients) and more work for patients.

Edit: After further reading, in all emergency care scenarios and certain non-emergency care scenarios, they cannot ask you to waive these protections. Though, I wonder who gets to decide if it was an emergency? Certainly not the patient.

If it’s not an emergency it seems logical they can’t start an operation without consent.

The No Surprise Act was based on research sponsored by United Health. They were very shady about their involvement.

That doesn’t make it bad by itself.

But it does mean that America can’t pass regulation of the insurance industry unless the insurance industry likes it.

It also might be a way for big players to marginalize smaller players - like Facebook supporting privacy legislation.

These are the extreme cases but this happens all the time, including to myself (albeit only for a few hundred dollars).

It’s shocking that somehow the system we’ve come to amounts to “we don’t know the cost, we’ll talk to your insurance after and bill you some amount.”

Yeah, it's either that or "we'll cover what we think is a reasonable amount for your zip code". Which is usually SEVERELY UNDER the market rate in that area.

As an American, I was shocked when I lived in Ireland and saw prices for stuff upfront.

Getting stuff done privately in Ireland is great and fairly cheap. But relying on the HSE can leave you waiting years for basic treatment.

It’s not that shocking if we take seriously the logical conclusions of a society that mediates relations between people by way of their relations to capital, i.e. capitalism.

Insofar as the domestic American economy functions as the core of a global empire, it is uniquely prone to these seemingly nonsensical conclusions. The United States is on its 4th generation into being the most unchecked industrial capitalist empire in history. I think it would actually be more surprising if we had a sensical healthcare system.

When my car breaks, a mechanic can give me a detailed estimate which is very close to the final cost every time.

There is no reason inherint to capitalism that healthcare couldn't work the same. Every other industry under capitalism has sane billing practices.

Regardless, healthcare is far from being an "unchecked" free market. The government deals more in healthcare than any other market, except maybe student loans.

Car mechanics are also bound by estimate accuracy laws in many states. If they go over without approval then they aren’t entitled to more money.

I understand that medicine and mechanics aren’t the same thing, but I also have gotten elective procedures where the cost, down to the penny, was quoted up front.

The disappointing thing to me is all the time spent on this case: lawyers, administrators, jury members, and so on that could be doing something different, hopefully more meaningful to society.

People blame the hospitals but this the game they have to play in order to cover their costs [1]. Just seems like a tremendous waste of resources and social cost.

https://truecostofhealthcare.org/hospital_financial_analysis...

I'd be curious how much money is spent each year on the bureaucracy of healthcare, from employees who do little besides manage health insurance, insurance company employees, billing specialists in medical establishments, etc, etc, etc.

Private medical services are a very profitable business for certain professions that buzz around doctors and nurses. People without knowledge about medicine and whose only interest is a private company's benefit.

> Hospitals over-bill persistently and excessively to the point where hospital billing charges have ceased to have much meaning beyond their ability to shock and frighten people. The

> While Medicare and Medicaid control their costs by tying their payments to the actual cost of medical services, private insurance companies appear to be just paying a fixed percentage of what they’re billed. That alone gives hospitals a strong motivation to inflate their billing charges by more each year independent of their costs.

Medicare isn't that great, too. My wife worked health care and Medicare patients were difficult because of the weird paperwork

Very few medical practices or hospitals can survive solely on patients paying Medicare rates.

As long as the public isn't interested in seriously considering alternative systems like Medicare for All, nothing is going to change.

There's a reason that private equity has consumed our healthcare sector: it's incredibly lucrative and inherently disadvantages both the patient and provider through vast amounts of process.

Pretty much every healthcare startup in the US is just trying to figure out how to insert itself into this endless bureaucracy and draw money out of the system while trying to add value in some way.

Value optional.

Thing is, we didn't have socialized medicine in say the 1970s, and I don't remember things being this bad or regulated. What happened?

Maybe just "time" happened? It takes time for the rot to properly develop.

» Thing is, we didn't have socialized medicine in say the 1970s, and I don't remember things being this bad or regulated. What happened?

Or even more simply, we grew up. I was born in the late eighties. I was simply too young to understand that the civil war was not about states' rights. It was about slavery. I thought adults knew everything and as I became an adult I realized I knew nothing.

That or a lot of what was previously swept under the carpet or dog whistled is now out in the open.

Back to the topic though, I agree with you Probably the easiest explanation is healthcare is now a bigger slice of a bigger pie about 20% of a USD 20T GDP iirc. There is simply too much money to be made here. There is only so much investment opportunity that has any good return so smart money will chase anything that resembles guaranteed returns.

Thoughts?

EMTALA was passed under the Reagan administration. This forced hospitals to treat the uninsured, but it provided no funding to pay for those treatments. So the uninsured who don't pay are subsidized by high costs to the insured who do pay. In the 1970's, hospitals would just let the uninsured die in the parking lot / street.

So that's the change.

https://en.wikipedia.org/wiki/Emergency_Medical_Treatment_an...

"This forced hospitals to treat the uninsured, but it provided no funding to pay for those treatments. So the uninsured who don't pay are subsidized by high costs to the insured who do pay. "

They are way overcompensating for this. I think it's just a BS excuse like pharmaceuticals having to be outrageously expensive in the US because other countries are negotiating better prices. I have read some studies where they concluded that the losses through uninsured people aren't really that high. They are only high on paper because they account for them with their chargemaster prices which are way higher than what they would get from insured people.

Greed happened. Hospitals consolidated and bought up small practices.

There are a ton of reasons why, but here are a couple of the big ones.

The US is still at the forefront of medical research and technology development in the world. However, many other countries won't pay "market" rates for newer technology developed here at home, so companies often overcharge domestically as a way to recoup revenue they can't collect in other places. Note that American hospitals (particularly newer ones) tend to be obsessed with having state-of-the-art technology, and they're damn sure gonna get paid for that.

Another major factor driving healthcare costs is the increasing barriers to access for millions of people. Lots of folks don't realize this, but the US already has a quasi-socialized healthcare system mandated through Federal law. Basically, it's illegal for hospitals to turn ER patients away that cannot prove ability to pay, so folks without insurance often come to the ER for routine medical treatment because its the only way they can be seen, and they know the hospital isn't going to chase them down for their bill because they can't pay for it anyway. Who winds up eating those extra costs? Folks with insurance. I used to work in an ER and I saw this happen all the time.

Do you have any data proving those points? Both are highly questionable from economic PoV. USA is not doing the majority of research, for sure (e.g.EU does a lot too), and it’s not that expensive. Besides that, drugs and equipment are not the only cost drivers. In other countries those who cannot pay for the insurance get it from the taxpayer money, basically the same redistribution just called differently. This does not explain why in USA costs are much higher than in countries where redistribution is codified in the law.

The data on biotech and pharmaceutical patents per nation is easy to look up and firmly supports the parent posters point- Google is your friend here.

Your second point is a false equivalency as from a private payor perspective the cost of providing care to the indignant is reflected on their localized hospital bill, not on their federal taxes. In struggling rural/inner city hospitals the majority of payors don't cover the cost of the care received (and that includes medicare/medicaid patients), which means hospital bills will be highest in poor regions despite higher rates of federal coverage/subsidy.

> firmly supports the parent posters point- Google is your friend here.

Well, you need to change your search engine, because DDG could help you finding this report:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2866602/

42% of innovations for 40% of GDP of innovating countries isn’t exactly majority. UK and few other countries are more inventive than USA in relative numbers and the rest of the world - more in absolute numbers.

On second point thanks for clarification. So, if I understood it correctly, it means that this redistribution model is inefficient, because it creates two tier insurance system, with hospitals serving as second tier insurance. This even sounds crazy.

The glory days of the semi-welfare state in the US were indeed the 1950s-to-mid-1970s. A lot of those were regulated monopolies - in the case of health care, Blue Shield was a single, private but regulated insurance company owned by hospitals (some portion of which weren't for-profit). The main way Blue Shield was regulated (and it was definitely regulated) was it allowed to maintain complete control of the health insurance market, so that it operated like "single payer" without officially being "socialized medicine". The elimination of this system indeed brought us to the disaster that we're looking at now.

Boomers are old enough now to fuel the growth of medical profiteering. In the 70's 65+ was 10% of the total population and they spent less time in that age bracket before death. Now they're 16% and living longer.

Public support isn't the question. The public does support Medicare For All[1] but that doesn't matter given the election and decision making process of congress - essentially that it's controlled by forces that profit from the present system.

https://morningconsult.com/2021/03/24/medicare-for-all-publi...

This 100%. You have to flush out the reps who won’t vote for it regardless of constituent support and desire. Determine how many you need to replace, identify the weakest incumbents/most likely races to win, select challengers, fund them, and you hopefully unfuck US healthcare in the end. Maybe you need a few candidates to pull a “reverse Sinema”; run as a Republican, win, and then turncoat and vote for Medicare for All (with the understanding you’re probably only serving one term, but who cares if you get the policy done, 1.8 million voters over the age of 55 die every year, you’re just pulling progress forward with some political sacrifice versus waiting for cohort succession). Politics hacking and social engineering at its core.

If you’re not one to wait, the only other option is moving to a better country.

Public support for Medicare for All is going to look much more interesting in a few years when the Medicare trust funds are running out and they have to cut costs by 15% or more, and it’s clear there’s actually a price tag on the proposal.

And then we'll see the corner we've truly painted ourselves into.

I could imagine a scenario where an angry public demands the government take control of hospital finances.

Not that it's necessarily a good thing, but I could see it panning out that way.

Acting like social security or Medicare funding levels are fact of nature rather than a political football is parroting right wing talking points. The social security trust fund has been raided by congress multiple times and if it or the Medicare gets low, they can put that money back.

More broadly, by having a single payer, a reasonable Medicare For All program would in total save Americans vast amounts of money though of course as a program it would have a cost.

Politicans hiding the cost of things is the fact of nature. No proposal for Medicare for All that has ever been floated has ever seen a realistic price tag attached. The trust fund's depletion is no fact of nature, it is merely an occasion when this will become a little clearer to the public.

When this happens, voters will not like what they are being offered quite as much as they do now, when the costs are some distant abstraction; there will be a whole lot more hesitation and skepticism. And if pointing this out is a "right wing talking point" then go ahead and call me Margaret Thatcher.

Sadly politics today is endless arguments about minutiae rather than actually solving problems. The culture wars exist for a reason. The longer we are at each other’s throats the longer the wealthy can reap the rewards of rent seeking behavior.

"As long as the public isn't interested in seriously considering alternative systems like Medicare for All, nothing is going to change."

I resent the Democrats and Biden for not embracing Medicare For All. This would be the most straightforward path to a halfway sane system.

Even if they did completely embrace it it still wouldn't be happening. There are plenty of current Democratic Party priorities that are dead on arrival in the Senate.

>dead on arrival in the Senate

Democrats fully control every single committee.

You can pretend like they’re the problem and resent them as much as you want but which 10 Republican senators are going to vote with the Democrats? It’s endlessly frustrating when ~48/50 democrats would vote for something and 0/50 Republicans and people either “both sides” it or inexplicably blame the democrats?

The Democrats supposedly stand for health care reform. They don't have a coherent plan and they aren't even trying. The Republicans are pretty hopeless in that area anyway.

>inexplicably blame the democrats?

For several periods during Obama's first term, his party totally controlled the legislative process. The Senate Democrat caucus had a filibuster-proof majority. They could have passed Medicare for All, Single Payer, immigration "reform" -- all of it. Ask yourselves why they did what they did instead.

They had a short period with 60 senators until Ted Kennedy died, so they had to reconcile in the senate what was already passed in the house — they had 59/60 senators who wanted to pass Obamacare with a Medicare public option but Lieberman refused and again, 0/40 Republicans helped in any way. So we got the ACA, a flawed piece of legislation but one specifically chosen to engender bipartisan support since it was largely based on the free market Romney/Heritage plan from MA.

And then what health care proposals did the republicans pass when they had legislative control to make things better? Literally nothing. Vote after vote to repeal the ACA and “a plan” to replace it that’s been 6 months away from being released for the past decade. It’s insane people refuse to admit this out loud.

>0/40 Republicans helped in any way.

Republicans had no access to even read the bill draft. They were limited to voting for the proverbial pig in a poke (remember Pelosi: "You have to pass the bill to see what's in it.")

Which is both a misquote of Pelosi and obviously false because they had been working for months to build a bill that Republicans could support. Enzi, Grassley, Snowe were involved from February onwards and Obama addressed a joint session of congress in September and the final bill wasn't signed until the following March.

Why on earth would you believe people who have lied about every other facet of the bill (Death panels! unconstitutional individual mandate that they used to support!, illegal immigrants!) when it comes to their culpability for failing to improve it.

More specifically, Pelosi's quote about understanding the benefits of the bill after it was signed was in March 2010 on the eve of Obama signing it. The bill he was signing was voted on by the House in October 2009, and the Senate that December.

There are quite a few countries that do not have single-payer and do just fine. According to the book The Healing of America, these include France, Germany, and Japan, all of which get top-ranked results at much lower cost. The key difference is that the government sets the price list for all services.

That would be a big change for the US, but not as big as nationalizing the entire industry.

"doing fine" is a pretty bold claim. I doubt there is a healthcare system without issues. Germany is changing a lot, and not for the better, because the system was not really sustainable as it was.

Well ok, "doing among the best in the world, as of the book's publication." If our standard is perfection then nobody measures up.

Medicare for All can't function well as a single payer system - single payer doesn't work because it kills off the benefit of market-competitive forces; in single payer systems there are gatekeepers who decide what's covered, what's not covered, who might be eligible and what the criteria for them to be eligible is - which all acts as a single point of failure.

I like Andre Yang's proposal - where you allow private insurance but you also have a government offering to compete - both the government option and private options acting as counterweights against the other in terms of competitive forces.

This has the unfortunate failure mode where the well-off, powerful or influential get much better private insurance, which means that no one with means is advocating for the quality of the public option, so it declines or becomes uncompetitive in marketplace bidding.

Private insurance alongside public could work if it followed a strict "school-voucher" model, i.e. it gets the same funding per-head that the public option does and the customers have to show means to self-insure for any coverage shortfalls vs. the public option.

It's a shame that the Hippocratic oath didn't contain the sentence "I shall not overcharge my clients or bring them in financial jeopardy".

It isn't doctors who do this. Doctors, by and large, would love to just treat people. And while doctors do make quite a bit compared to other countries [1], the litigious nature of the American patient and the high cost of education make these wages almost a necessity in order to pay off insurance and student loans =[

https://www.investopedia.com/articles/personal-finance/08061...

Doctors are also very self-interested and want to advance their careers.

So if the top surgeons at a hospital want the newest, most expensive toys, and will leave for another hospital unless they get them, it might be that the hospital administrators buy unnecessary machines just to keep their best people around, at the cost of increased bills for everyone.

In this story, the surgeons may not be explicitly greedy, but the system sets them up to cost everyone quite a bit.

How true is that really? What’s the difference in lifetime earnings between a UK and US orthopedic surgeon net of insurance and loan payments?

My sense is that the difference in pay dwarfs the difference in costs.

The AMA is a professional organization for doctors and they have opposed all kinds of changes designed to reduce medical costs because it would hurt their members’ bottom line.

The system is a racket and doctors are in on it.

> The system is a racket and doctors are in on it.

This is a bit much. You're right that the AMA is a big part of the problem, but fewer than 1 in 5 U.S. doctors are paying AMA members. [1] That's down from about 75% in the 1950s.

[1] https://www.physiciansweekly.com/is-the-ama-really-the-voice...

I had no idea they represented under 20% of doctors. I thought it was 3x that. Thanks for the information.

The AMA is a private organization. It doesn’t represent anyone other than it’s leadership. Most doctors aren’t members.

Anyone can create a group and call themselves a “professional organization.”

Anti-abortion groups have their own ob/gyn association.

> and the high cost of education

Why don't they study abroad, e.g. in Europe, where education is more reasonably priced?

I was reading and, evidently (this is internet study, so take it with a grain of salt) it is very difficult to get a residency in an American hospital from a school that isn't in America. While you could do your residency in another country and then retake your tasts, I guess, and become a doctor here, I don't know if you would have to do another term of residency. I couldn't find that answer as easily. Also, studying abroad doesn't end up being that much cheaper if you aren't a citizen, so if you're from America it kind of ends up being a wash, it looks like =[

Covering their costs is a bs framework. Hospitals are de facto partnerships run for the benefit of certain insider employees. Their “costs” are whatever the market will bear paid to those same employees.

Ditto for universities.

Universities get away with absurd pricing because the government guarantees the loans. If the govt stopped backing the loans, the tuition costs would plummet and the govt wouldn't need to back them anyway.

They don’t have to play this game. For reference, see most other countries who have taken the slightly more enlightened step of a socialised healthcare system.

It's kind of useless to say this an not name at least one such country. Notably, many of the places with "better" healthcare aren't obviously sustainable e.g. France.

It's not just the social medicine. It's totally possible to go to a private hospital in other countries and get a reasonable final quote before any procedure is done.

This is the nature of the US society.

People blame the hospitals but this the game they have to play in order to cover their costs...

If you do things that literally ruin people's live, I don't care if you "have to do it" to keep your business going.

As to lawyers, in a society with money and contracts, these exist. What I would hope for would be a statue with in the case of the abusive billing, the victim can sue for ten times the amount of the bill, just for starters.

This is true. Capitalism is at it's best when it manageably distributes supply and demand forces in a minimal surface, maximizing net utility via the price level and transactions. It's at its worst when those at one side of the transactions (healthcare buyers) are systematically denied information and held hostage via contracts.

The American healthcare system operates on this, and it's such a valuable tactic that it's worth more to waste resources on managing this degree of litigation than just charge reasonable amounts.

In more cases on average, the healthcare providers must be making a net profit via these tactics, otherwise they wouldn't do it. The fact that this tactic is even theoretically profitable means the system is fundamentally broken.

Your own link disagrees with your conclusion.

> this the game they have to play in order to cover their costs

Another possibility - cut back on the 20% that goes to executive salaries: https://jamanetwork.com/journals/jama/fullarticle/2785479

Or cut down on these guys:

https://www.beckershospitalreview.com/compensation-issues/18...

I studied in US and one of my classmates from Norway was mildly hit by a car when she was biking. Just to be sure she did not break the leg she took an x-ray. The bill accidentally was send to her address with a request for $8000 (luckily covered by insurance).

We almost don’t pay anything in Norway in comparison, I think the maximum yearly amount is $150 if you have to go a lot to the hospital.

I have operated my arms several times after different action sports accidents as a child, with no cost (under 18years you don’t even pay the $150).

Such a peace of mind to know we have good health service if we need it. Possible reasons why we kick ass in winter sports?

Healthcare could be better compared to some of the most advanced cancer treatments in US, but not sure if most Americans can get them?

US healthcare is a cruel joke.

You even see this in international coverage - global except for US.

Though my current one excludes canada and caribbean too for reasons I don't quite understand. Tainted by proximity perhaps

It is this reason why I compare the US hospitals to white-shoe mexican cartels. The latter use simple intimidation to take what they want. Our hospitals identify a potential victim in need who needs immediate help, and thus can't negotiate, force you to sign a blank check (using verbal intimidation), force you to waive your right for protection from racket (binding arbitration), lie about costs (they call it a good faith estimate), then estimate your net worth and demand half of that. When you refuse, they send their white-shoe gangsters (lawyers) and take that half. A carnival of greed and moral depravity.

> A carnival of greed and moral depravity.

This seems to sum up the US healthcare system perfectly.

Apparently the top goal in US medicine is profit. Providing health care is secondary.

> force you to sign a blank check (using verbal intimidation),

Well, in many cases it's more than just verbal intimidation; it's threat of imminent physical harm.

You know that you won't get better terms by shopping around, either.

In the U.S., insurance would reimburse upwards of $100k to hospital for this procedure.

The same procedure in Germany would cost $20-$30k.

I guess that's why some insurance companies are paying for medical tourism.

It would be nice if this was the public debate we were having. Recently they dragged oil company execs in for a light video chat based grilling in the house. I would prefer to see the medical insurance companies pilloried, but and for those pillorings to yield something of substance. I imagine that every minute of talk about abortion or immigration has the insurance companies and its benefactors thinking "wow, we're still getting away with it!"

"I imagine that every minute of talk about abortion or immigration has the insurance companies and its benefactors thinking "wow, we're still getting away with it!""

That's how the US political system works. We are only allowed to debate a small range of issues that don't affect the income of the capitalists.

There are many things for which I envy USA, health care system is not one of them, not at all.

Archive: https://archive.ph/9ezo4

This whole insurance getting discounts seems pure insanity. Maybe simplest would be to mandate single price or range for any operation. Can't ever give discount on that. If you want to do charity cases set entity that you sponsor to pay for things and maybe legislate that receiving such support is tax free.

It still boggles my mind how the US is the "first world power", and yet there is so much gun violence, those healthcare problems, homelessness, high co2 per capita, obesity, the prison system (especially in Louisiana where it's almost still slavery for inmates), money in politics, inability to get abortion...

All those issues are usually found in third world of developing countries, so I'm often quite confused...

>Obesity

Sadly, in the US, there're obese people who're strongly into nonsensical movements like HAES (Healthy At Every Size), fat positivity. They think being obese is good, healthy, and doing nothing to address is a great thing. If one so happens to tell them about the health risks due to obesity, they are termed as fatphobic.

Surpisingly it's easier to just un-learn what you know about personal health to protect your self-image than it is to lose weight and keep it off. I say this as someone who has lost weight and kept it off.

On one side, the food industry is largely responsible for this, and the other side, fat people are ill, but they're often being told they're responsible for their weight.

It's a bit like telling depressed people they're responsible for their mental illness.

From the inside, it very much feels like the decline of an empire. We're really getting it from all sides, and people just in general seem pretty unhinged.

>the US is the "first world power", and yet there is so much gun violence, those healthcare problems, homelessness, high co2 per capita, obesity, the prison system (especially in Louisiana where it's almost still slavery for inmates), money in politics, inability to get abortion...

Exactly. It's horrible here, so people should stop emigrating to the US for starters.

It's hard to understand that the most predatory industry in the US is health care and people are OK with it. It's easier to deal with loan sharks or used car dealers vs hospitals and health insurance.

I don't think people are okay with it. It seems very likely that our politicians are bought and paid for and that's why there's no one truly representing the public's interest.

If you read the article, the hospital made a mistake, didn’t know she’s an out-of-network patient, so got the insurance wrong.

If you only read the title, it sounds like the hospital scammed her. All the reports on this news sound this way.

The downvotes are crazy. I in no way indicated that the woman should pay the full amount because of the hospital’s mistake.

Also, if you have an open mind, you could see another perspective: her insurance is amazingly good, cutting $23k bill to $1.3k.

> If you only read the title, it sounds like the hospital scammed her. All the reports on this news sound this way.

Well, personally: if I'm told that something will cost me $1300, and then there's a mistake, and they'll actually consult a big pile of papers that I'm not allowed to see to decide what to charge me... that sounds like a scam.

With an accurate estimate and correct information about the hospital not being in network, she would have chosen a different provider for her surgery.

> Also, if you have an open mind, you could see another perspective: her insurance is amazingly good, cutting $23k bill to $1.3k.

? Hospital estimated $1300 after her insurance, and provided no other info. Then she was billed $229,000. No one cut her bill to $1.3k, other than the legal system requiring the hospital to honor its original estimate after litigation.

One should not need to pay $230k for back surgery regardless of circumstances.

What’s your point against my comment?

Let's say I bought a server from Dell. They quote me a cost of $6000. Maybe they assumed I was part of an MVP program that I hadn't been aware of. I have it delivered and installed and later the rep invoices me the price at 1 million dollars for the server because they made a "mistake" on the discount. I may have signed a resale agreement telling them that I'd pay for the hardware sent to me, so tell me how this is fair and equitable trade practices? It may be viable to ship the server back and call the sale a wash, but there's no rolling back medical treatment.

What’s your point against my comment?

I'm not OP, their point is that in any other consumer-facing industry you can't just give someone an estimate, provide zero other guidance on pricing, get them to sign a contract that says they have to pay you whatever you want (and if they don't sign, they don't get potentially lifesaving care), and then after delivery of the good/service you then charge an entirely different amount which is 200x higher because 'oops yeah our bad we got the estimate wrong by a factor of 200 but you have to pay that now, tough luck'.

In reality, consumers in the USA seem to have more protection buying a can of beans than they do in paying for cancer care - but this doesn't have to be the case!

Did you read my comment? Where did I support the hospital?

I can't tell if you're trolling or being serious?

> If you read the article, the hospital made a mistake, didn’t know she’s an out-of-network patient, so got the insurance wrong.

Surely you understand putting this with nothing else next to it is making excuses for the hospital and implying the patient is in the wrong?

Where did I imply the patient is in the wrong?

At this point I think everyone decides you're trolling. I hope that's it, rather than just being so bad at understanding what the comment you're replying to is saying.

Seriously, where did I imply the patient is in the wrong?

I had more, but I'm cutting it to the minimum:

It sure sounds like you took the hospital's side in the dispute. You then didn't offer any clarifying details as to your stance-- instead going "huh-huh--- where did I say that?! where did I say that?!" This doesn't help communication, but it sure does help confrontation and wasting other people's effort in communicating with you.

Where did I take the hospital's side? I said the hospital made a mistake. I am not satisfied with the title of the report because I think the hospital's mistake had a valid reason, it's not an intentional scam. It's not like the hospital intentionally hide the price and then charged her with a high price for no reason. I think the out-of-network insurance mistake could actually happen. That's my whole point. You guys are second-guessing my intention. It's not my fault at all.

You could have clarified that at any point without having lots of whiny, shill-sounding comments.

> It's not like the hospital intentionally hide the price and then charged her with a high price

Actually, this is exactly the practice with chargemasters: no one is able to know the price because the hospital holds the pricing information confidential.

The hospital making a mistake and then over-billing her is scamming her. Made a mistake? Take responsibility.

Leave it to the New York Times and its editors to omit the fact MEDICARE FOR ALL would eliminate this egregious charges to everyone all the time. You already paid it with taxes and save your self from bankruptcy. They don’t even mention it. They are not the arbitres of truth. Our healthcare is awful.

Ok this is a silly question but would a simple law that's says "you must provide an estimate before any medical procedure and cannot charge over that". And these charges must be available on your website and fixed for 60 days.

then you might see some competition ?

I mean my NHS - born heart hurts at the idea but still ...

There have been lots of discussions lately on various crypto scams, but the biggest scam no one wants to fix is the American health system. Until you’ve experienced it yourself it almost sounds unbelievable how bad it is. Calling it a scam is an understatement.

No good precedent set with this case. Hospitals will simply update their service terms to be really clear that you’re agreeing to what the “chargemaster” says you owe. They’ll mention it like 5 times so they don’t lose on these terms again.

Really a shame.

The judge specifically mentioned that they chargemaster is not shared with the patient as a protected trade secret, so I think this sets a precedent that you can't be held to terms about price if you aren't going to disclose the price.

The most revolting part of the US medical system IMO is the complete lack of transparency in prices.

In the ideal case, people would know what they would pay in each hospital when they are still deciding where to go.

In New York State, if your insurance covers the procedure, it is illegal for the hospital to bill you above and beyond that amount.

All these complicated solutions, Medicare for all, etc. and one law solves this.

We need a better black market for medical services at least there is some honor among gangsters. These hospitals seem to be set up to find people in duress and not merely rob them, but loot their net worth. It's predation.

Seriously, as a manual skill, how hard are 80% of superficial surgeries really compared to learning an instrument or classical music, learning to code, baking, cultivating a respectable golf handicap, or getting good at a sport? It's hard to reconcile stories like this with talking about health care workers as heroes, when it sounds like people who work in US health care, if they are not themselves, they at least work for someone who they know is in fact, dispicable.

Skilled piercers and body modification artists already perform lots of "superficial" cosmetic procedures, sometimes for orders of magnitude less than plastic surgeons would (which are, of course, not covered by insurance). I've even seen some artists correcting procedures that "real" doctors botched and wanted even more money to fix—a common one is keloid removal.

You are correct the vast majority of medicine as is normally practiced are skill that can be easily picked up, but you know good old humans, they make a mountain out of a mole hill, so they make a bunch of regulations...

What would it take to “fix” the US hospital system, and prevent others (the UK’s NHS, Australia’s public hospital’s etc), from falling into the same trap?

Can anyone in healthcare on HN comment on how a surgery could cost 229k?

Really curious how that number breaks down in terms of equipment, salary, medications, etc.

It doesn’t. Chargemaster rates are meant to be slashed 50-90% when they get to the insurance company.

We got a bill for $560 today that $500 worth just… disappeared when insurance said “nah”, because that’s the deal the two of them have.

If you don’t have insurance, or they pull the “it’s not covered” you get to fight the hospital yourself.

What will it finally take to cut this cancer called “healthcare” in the United States? There is nothing promoting health or care in it

The fact that the "chargemaster" (never heard of this) is a proprietary trade secret is absurd.

"hospital (...) told her she would be personally responsible for paying about $1,337"

LUL 1337 scammers

The biggest problem here is this "full cost, because it was out-of-network" nonsense. I don't understand how healthcare networks are legal – they essentially create two separate medical systems, one of might not accept your so-called "insurance" at all.

I know that universal coverage is a pipe dream in the US, but making these coverage networks illegal and forcing insurers to cover procedures at the same rate regardless of network would be a good first step. And it should be a bipartisan issue as well, somehow I don't see conservatives clamoring to keep paying higher prices for ambiguously defined "networks".

Single player now

Actual quoted cost was 1,337.

Nice.

Ah thankfully it’s not a Libertarian world yet, where the State’s only purpose is to guarantee the rule of law, and the freedom to engage in whatever contract.

No one knows what that would look like … wait, Dentists. Mexico. Thailand. Singapore.

The obvious reality is that something structural is causing this massive price inflation, and the government is heavily involved in this structure already.

> Before her surgery, Ms. French signed two service agreements promising to pay “all charges of the hospital.”

> In Centura’s view, the service agreements “were unambiguous and French’s agreement to pay ‘all charges’ ‘could only mean’ the predetermined rates set by Centura’s chargemaster,” the court said.

> But the court found that Ms. French wasn’t responsible for paying those rates because she didn’t know the chargemaster even existed and hadn’t agreed to its terms.

> “Indeed, Centura representatives testified that the chargemaster was not provided to patients, and in this very litigation, Centura refused to produce its chargemaster to French, contending that it was proprietary and a trade secret,” Justice Richard L. Gabriel wrote.

Beyond ludicrous...

It’s amazing that any of these “agreements” are ever upheld by courts. As standard procedure, you have to agree to any and all charges, but in most cases they refuse to give any estimate of what those charges might be. They are “trade secrets.” But if you don’t agree, you cannot get lifesaving care. It is unconscionable. In this case, she is lucky they gave her that insurance estimate. Usually they refuse specifically for the reason of what happened in this case. They expect you to agree to pay whatever they decide later. And people keep trying to argue the US has a great healthcare system. It is beyond broken. The very rich don’t have to worry, the very poor don’t have to worry. The rest of us can get screwed if we have the very bad luck of being US citizens who happen to get sick or into an accident.

Totally agree. All these agreements are signed under duress and ask the signer to agree to pay an amount while making it impossible for the signer to know whether that’s possible.

If you don't sign and you need treatment to live, aren't doctors obligated to treat you per the Hippocratic oath?

Are you dying, like, right now? Or are you just going to die in a few months? Come back when you're dying.

You can always try a different hospital for better service. Of course this won't work in situations where timing is critical, but most surgery is scheduled. We might as well treat it for the business that it is. If they can't give you a reasonable estimate up front, then don't sign the paperwork. If they care about earning your money they will negotiate with you, and it's always better to negotiate terms up front proactively than deal with it reactively. The strongest power a consumer has is to vote with their money.

> If they can't give you a reasonable estimate up front, then don't sign the paperwork.

That's the issue, they don't give you estimates that they are actually bound by.

And if you're an hour away from being in the operating theater, and they have all the specialists there, and in that moment you choose not to sign-- it's more their problem than yours.

…no it isn’t? You need to get surgery, they want to provide surgery

That's what makes it your problem. They can just say 'no' until you sign the document agreeing to pay whatever they bill you later.

I think GGP commentor typo'd - it says the opposite at time of writing.

They'd likely ask you to sign way before that..

You're assuming the hospitals don't all do this. You're basically discussing market dynamics with a legalized cartel.

This is like when people point out problems with fiat currency which are very real, and then people suggest theoretical solutions from cryptocurrency. It doesn't actually help solve the problem in any meaningful way, and you are living in an alternate reality from the problem space we are discussing.

People say it's impossible to negotiate prices at modern grocery chains. They only had brand name lactose supplements. The manager gave me a hard time about it, I asked about a price matching policy, shrugged, and let me pay the generic price. I'm sharing this anecdote because I don't think people try hard enough and you might be surprised if you do. You won't win every time, but try asserting some authority.

By assuming markets are so rigged against you, it discourages people from even trying. Price discovery can only happen if you attempt to be firm. If you'll roll over instantly, then sure, they can do as they wish.

I've had the misfortune of suing insurance companies in the past; I'm very aware of how the system works. You are technically correct. It's just that you're grossly exaggerating exceptions as though they will ever be useful to a majority of people.

I'm not sure it exists. Every hospital I've ever contacted is a complete shitshow and can never accurately tell you the price of something ahead of time.

Dealing with our fertility doctor was great though. They knew the price of everything. But they were ran out of an office, not a hospital.

It’s funny how anything elective or cosmetic is like that. To be clear, infertility is a serious medical condition, and I’m not making light of it. The distinction I’m making is an economic one. When patients have more choice as to whether to even be a patient, you see much, much more consumer-friendly openness about pricing. So it is possible. Fertility treatment is a great example. So is elective eye surgery. These areas of healthcare are very different from the “sign your life away now and we’ll send you the bill later” standard of most healthcare.

If something goes wrong in the surgery and you need emergency care do they just cover it free through their own for of elective surgery insurance, or is it an opaque cost?

This reminds me of the situation with the telecoms in the east europe - it's almost the same. There were no incumbents, so both internet access and private healthcare are leagues above US. It's just not comparable. Also include online banking here.

You need stuff done - you go and get it, end of the story. No bullshit, no courts, no nothing, and it's orders of magnitude cheaper.

Bascially, the joys of free, open, not schizophrenically regulated market mechanisms and competition, unlike the U.S. healthcare system, which despite many common claims to the contrary is a shitshow of protectionism, half-assed regulation regimes and all sorts of bizarre half-measured meddling.

Dentists can usually give precise charges.

Kaiser Permanente usually has a precise copay for just about anything they do. So you have a good idea what the charges will be going in. And nothing like an extra $10,000 because one of the surgical team was "out of network".

Maybe in some libertarian dream land only, not in reality. You think a hospital will personally negotiate rates ahead of time with a single patient? Absolutely fictitious.

They could offer a flat rate based on the length of the procedure...

Huh? Over here in Germany, every single step of a treatment is documented and has country-wide standard rates. The actual cost depends on the specifics of the treatment, expressed in various parameters like required personell and their working time, goods used, complexity etc. In the end of course the insurance company pays for everything, but you still get to see how much everything costs - insurers are of course very keen to keep costs down. On the other hand, I know a few MDs which constantly complain how much of a hassle it is to document everything, but live over here in „liberarian dream land“ is very much real and a joy as the patient.

You can try to comparison shop all you want, but no hospital will give you details in the chargemaster if they aren't legally obligated to.

Even if you are in a position to shop around, journalists have documented their futile attempts to do price estimation for routine procedures. Here's one example: https://youtu.be/Tct38KwROdw

There have been recent laws that requiring publishing some of that information (which are being heavily contested), but comparison shopping remains effectively impossible in the US.

I tried this exact thing when my wife was going to have a baby.

None of the hospitals within 100 miles, the doctors, or the the insurance company would give me so much as an estimate, and this is for something that they do every day.

This whole nonsense with chargemasters is an industry standard practice. It's hard to find a hospital that will open the book for you.

You need to wake up and stop accepting this as normal or okay.

Hospitals are not just any business and if it starts to hurt us as a society we need to interven.

No, you cannot

I have no time to look it up RN, but I read a few years ago about a new hospital President/CEO who literally could not get a cost/price list for the services their hospital provided - obviously a key management data set, yet it did not exist.

Just because you think something SHOULD exist, does not mean that it does.

The cost accounting for most hospitals is totally opaque. How do you assign overhead to each activity? Does the ER make or lose money?

How much of a nurse's time to give patient a Tylenol? Zero? Five minutes? And how much does that nurse's time actually cost the hospital?

Nobody has the slightest idea.

> How do you assign overhead to each activity?

Every business has to deal with this problem, and hospitals have already done so, because they do somehow come up with the amount to charge you.

The possibilities for manipulation?

Or simple overcharging.

This SHOULD be true, but it is not.

Once again, SHOULD =/= IS

Just because they quote charges does NOT mean that they have solved the problem or that the charges are accurate.

There is absolutely nothing that requires the charges to have any relation with the actual costs, even if they are known, particularly at the item level. Only the total charges must exceed the total costs (less any external support e.g., from govt, philanthropy, grants, etc.), and that is on a basis of multiple years before any serious reckoning happens.

IOW, they can and in fact do literally just make it up. Also, charges that are heavily scrutinized may have some relation to costs, but other charges may be "just add a few zeros" to make up for it.

If you have some detailed and complete internal accounting data from any major hospital that proves me wrong, please post it. But when I read about congressional testimony that a CEO of a hospital literally cannot get the same data that you claim exists because 'of course it's been solved because every other business solves it', I find it difficult to believe you.

I can also state from running a business that the relationship of costs to charges is very loose. Sometimes I will sell things below cost for a number of reasons, and for some customers (e.g., those with high bureaucratic overhead requirements) the charges will be substantially higher. And when those charges are made, I may do detailed studies of what the increased costs are, or I may just say "one data point shows that's going to cost 4% more, but I don't like it, so add 7% - basically a whim. And no one in the world besides me knows the difference (and I forget about it after a few cycles and it becomes the baseline). So, yeah, perhaps stop posting speculation.

Regulated utilities, for example, are under constant scrutiny to be sure that they are allocating costs appropriately, and that any subsidies conform to public policy.

Somehow the medical industry has so far largely avoided such oversight.

Even within a single enterprise, misallocation of costs can lead to inefficiencies.

agreed. You are under huge distress and don't have a viable alternative and your life is in danger and you sign what is really, a contract to pay with the amount to be paid being blank. So essentially and legally speaking, how is this different than blackmail?

is there a limit? Can you legally enforce a hidden 1 billion dollar debt to someone?

It would be dischargeable in bankruptcy so there is a practical limit.

Usually courts won't uphold "unconscionable" charges.

Charge someone $1 billion to change a tire. Nope, nope, nope, as an example.

but somehow 229K is Okay? Where is the limit

Hospitals seem to have the world hypnotized.

> And people keep trying to argue the US has a great healthcare system.

I’ve never heard anyone argue this. The common argument is that it really sucks and that proposed changes suck as well. So the argument isn’t “don’t change because it’s great.” The argument is “It’s terrible and I’m worried that if you change it, it will get worse.”

I've come across a number of HN commenters claiming US healthcare is better than the EU or UK. I'd argue it's pretty broken compared to both. The UK's NHS is far from perfect yet serves the majority of people well without bankrupting them. Countries of the EU will have varying quality of healthcare, yet I'd still trust them over the US due to my fear of the US's highly profit driven system (which can cost you more than money).

I suspect those claiming US healthcare is superior are able to pay quarter of a million without blinking - however they still run the risk of unnecessary surgery and aggressive prescription of addictive substances.

I think we can separate the administration of the care from the are itself. I believe the US has among the best care. I also believe our administration of said care is among the worst, if not the worst.

True, I wouldn't be surprised if the US was amongst the lead in quality of medical procedures - when that procedure is necessary... but beyond administration, there have been numerous instances of doctors being exposed for electing patients for unnecessary procedures driven by profits, and other procedures being recommended when scientific evidence suggest the procedure has no clear benefit - no matter the quality of surgery, it always comes at significant risk and cost to your body, it's not a magic wand; it's a traumatic intervention that requires your body to go through a lot of recovery with possible lasting effects. This can be true to a lesser extent for less severe medical interventions too.

So my point is, what use is excellent "care" if not only it's life endingly expensive, but it's also prescribed immorally to the point of actually causing harm!

One measurement for medical intervention is caesarean births versus natural births by mother’s age, which hugely jumped in the states in the 2000’s: https://www.statista.com/statistics/206438/us-cesarean-deliv... (although rates are highly influenced by consumer demand?). Chance of caesarean jumped in percent from ≈⅔age to ≈age (e.g. ≈20% for 20 year old). High variation between states, although some of that might be state demographics of mothers: https://www.cdc.gov/nchs/pressroom/sosmap/cesarean_births/ce...

And a comparison against caesarean rates in OECD, which can be higher rate of caesarean per birth: https://www.statista.com/statistics/283123/cesarean-sections...

The people who make this claim will cite easier access to desired procedures, and higher quality treatment. They will then make the claim that care is rationed in other countries, and point at some anecdote about someone who had to wait a year for an MRI or wasn't allowed to get the optimal treatment.

These arguments are at best disingenuous

Every time the Single Payer option is this discussed, you hear people say how care in Canada and UK is broken, indicating that it's fine in US, which is not the case.

> And people keep trying to argue the US has a great healthcare system

I've never heard anyone argue that the billing and payment aspects of the US healthcare system are great.

I have heard people argue that the quality of care (by various metrics) or availability of services are great, but that's a different argument, and not mutually incompatible with having a broken payment and billing infrastructure.

> The very rich don’t have to worry, the very poor don’t have to worry.

I'm not sure how you're arriving at the conclusion that "the very poor don't have to worry"

I wonder what would happen if a patient swapped the form with an identical looking form with different verbiage, making the hospital responsible for any overage past what insurance would pay.

I very much doubt anyone would catch it until the bill was contested later. What would a court say? Would it be as legally binding as the standard document?

Edit: Or imagine a disgruntled employee in the copy room changing the form?

There is a story is someone doing something similar with their credit card [1].

Not sure how well something like this would fly in the states, but it would be interesting.

[1] https://www.nasdaq.com/articles/updated-russian-man-turns-ta...

It would have to be signed by both sides to count. I've done it before, but you can't just try to sneak things through if they don't sign.

In my experience these forms are only signed by patients, so why are they valid in those cases?

The signatures per se don't really matter. What matters in contract law is if there was an actual agreement. The signatures are just evidence that there was an actual agreement. They are neither necessary nor sufficient. This is why verbal agreements can be binding contracts, it's just that these are harder to enforce because it's harder to show that a verbal agreement was actually entered into.

Well if the patient swapped the form, it would be pretty clear they didn't actually agree to the terms of the original form.

And if they swap the form in secret in order to trick surgeons into performing an operation which they haven't agreed to pay for, it's pretty clear that they're committing fraud.

What do you mean "in secret"? The hospital received the form in full detail. There is nothing secret about it. It's like claiming the ToS are secret because none reads it.

No, it's not at all like that. If someone hands you papers to sign and you give them different papers without telling them so, that is clear intent to deceive, which makes it fraud, or at minimum makes the contract void.

People keep saying “in secret” but that’d only be true if it happened after it were filed or some such. Giving someone an amended contract isn’t fraud.

Giving someone an amended contract isn't fraud, no. Giving someone an amended contract while making them think it hasn't been amended is a different matter, though.

Fraud is a strong claim, and it's not clear that there is even an implied contract formed - a contract requires defined consideration. An arbitrary amount conjured out of a hat after service is not well-defined consideration.

From my understanding, the medical billing system is so fucked precisely because hospitals bought laws making it so they can arbitrarily bill patients without forming a proper contract (otherwise there would be no way to charge someone who was admitted while unconscious). In the absence of such laws they'd have to fall back to an unjust enrichment claim, under which it would be pretty hard to justify charging someone $25 for an aspirin.

When I was registering as a new patient at a dentist, they gave me the standard form that would let them do things like contact my employer if I didn’t pay my bill on time. I stroked a bunch of that stuff out and initialed it.

If it ended up in court and they produced that form, would my amendments mean anything? Is it a contract when only one part signs it?

The hospital would most likely have a very easy argument that since it's not actually their standard form and you didn't tell them about it, they didn't accept the agreement in any way. And they'd probably try to get you for fraud as well.