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Comment by 404mm | Hacker News Reader

I live in north Texas, and the situation here is pretty much on par with the article.

Urgent Care & Emergency Room combos are here on every corner. It’s a lucrative business, so it makes sense that private equity firms are gobbling it up. But I think the more interesting problem here is one level up. Why are there so many of them? I see two possible reasons:

1. Anytime one of my family members gets sick, it’s rather hard to make an appointment with the primary care provider. They are usually booked, and it takes a day or two to get in.

2. Bills from the primary care providers tend to be significantly higher than a bill from urgent care. Anytime I go to a doctor, it’s around $300 for a basic consultation visit. Any problem easily adds $50-100 to it. My typical bill from an urgent care visit for sickness is around $150.

Both places are in-network. Anyway, that’s my experience.

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3. Demand for immediate care is high.

The next "one level up" might explore how much is because the community is quite morbid and unwell, because modern culture has displaced traditional home/self care with consumerized services, or because of other things.

There are people I know who are largely healthy and who consult paid medical services many times per year for everyday disturbances, and others who take decades to overcome procrastination to even get a physical. The demand for commercialized health services is very much a cultural thing, especially for everyday wellness, and that culture has been evolving quite dramatically.

Meanwhile, there's no ignoring that obesity and sedentary living are rampant, that a recent pandemic spooked people about infectious disease and its possible consequences, etc.

You're thinking about the pocketbook economics, here, but looking at it through these other lenses might provide further perspective too.

It's a shame that we have not preserved more local, "community medicine" that you mention. Unfortunately, the reason is that we have destroyed the community by moving to a model where advanced technology is our primary aid instead of other human beings.

> traditional home/self care

Not sure what you mean by this? If I have a broken bone, I'm not going to set it myself at home and take a few aspirin. Same if I'm puking my guts out.

If you just mean getting exercise and eating healthy then I fully agree with you. But, when you're actually sick, and need to see a professional, that is the right time for "consumerized services".

You're welcome to take it as foolish pre-modern ignorance if it strikes you that way, but actually yes: many people do not think to go to a doctor for minor bone injuries or vomiting, and many more than that wouldn't think to do so for more common everyday illnesses like a familiar sore throat, rash, nosebleed, fever, etc

For some, this is rooted in a confidence in their own personal-community care, for others its an insight into what few actions a doctor might take themselves for these issues, etc

There's lots of ways to explain it, and certainly many of them can be easily criticized by people who see professionalized medicine differently, but you may as well let go of the idea that everybody out there approaches it in the same way that you do. It's probably not even all that consistent among your own circle of family, friends, and acquaintences.

We're still only in the beginning of what seems to be a sweeping cultural transformation around how people see health and medicine and the perspectives people bring are still quite diverse.

At the same time, the overall direction in recent decades is definitely towards seeking commercial medical care for more concerns as well asserting that this is an entitlement that all people should have access to.

I haven’t heard of some of this and it raises a whole lot of questions. Can you tell us more? What is a “minor bone injury?” What sort of alternative healthcare do they use instead to treat it?

Maybe give us an example of some people who do this?

Well, to make an example that doesn't stretch into ethnic traditions and stays within the contemporary and modern experience that you and I probably share:

Consider two non-professional runners who develop a stress fracture. It's a fairly common injury for distance runners who push themselves too far. It presents as a certain kind of pain and that pain becomes aggravated under certain conditions. It's generally easy to self-diagnosis, and more serious fractures are generally evident because they're far more disabling and intensely painful.

One goes to a doctor, who quickly has a strong guess as to the problem. Nonetheless, they send the runner for an x-ray to confirm, then take another appointment to review the results and prescribe a treatment. That treatment will amount to rest and patience, and (with some doctors) some prescription for the pain. Total cost billed to someone is probably on the order of $1000.

The other is pretty confident in their self-diagnosis and can't fathom the time demands, financial cost, and social resource consumption of bringing in a industrial apparatus just to confirm that diagnosis and be told to take it easy on their affected leg for a few months.

Both examples play out everyday, and there's essentially no difference in health outcome for the vastly most common case. It's true that the latter is at higher risk of missing a more serious complication, but it's also true that the former invites costs, consequences, and risks of their own.

Okay, thanks for clarifying!

I kicked a table and am 90% sure I broke my pinky toe which turned black and doubled in size. I didn’t go to doctor because I knew they wouldn’t do anything. A month later it’s back to normal.

A friend did the same but got a doctor scan; they confirmed it was broke but did nothing else.

So, I don't agree with GP, but my grandmothers (on both side of the family weirdly) had IV bags for the longest time for when people were 'puking their guts out'. I even was the lucky recipient of one when I came back _extremely_ hangover from a party at ~19yo. Both had nurse training (one because she was one, the other because she was trained by the church to work at a mission before she met my grandfather)

They mean you take aspirin and hope it goes away.

I suppose I’m guilty of the demand for immediate care too. Not because I go to the doctor immediately after I get a symptom, but because I try to get better on my own until I reach a point where I think I need help, and at that point, I no longer want to wait.

I cannot just schedule an appointment for 3 days ahead because “late” cancellation costs $$ too.

You also have Insta-clinic in chains like CVS. Not sure it's a bad thing. Came back from a trip with minor but persistent cough symptoms that were a LOT like the time I had COVID even though I tested negative. Got an appointment the next day at a clinic with a nurse practitioner who prescribed me an inhaler and said it was a "virus" after listening to my chest, etc. I think I maybe had a $40 bill.

Told my primary care at my next appointment and she basically said she'd have done the exact same thing.

For some reason these all seem to be closing down. I don't think there any of the CVS Minute Clinics left in California. They used to be in every third CVS or so.

There are still plenty in Massachusetts. Maybe there's some regulation in CA that makes them financially unattractive.

It's funny, my first job out of college was machine learning for a company processing medical bills to detect fraud on the part of hospitals. It was a very eye-opening process for me as to how American health care is perhaps the worst designed system conceivable by man -- as in, it's genuinely difficult to imagine how the various regulations, incentives etc could be made worse from any perspective (left or right) or measure (human care, cost, equality, whatever). Medical diagnoses are systematized in a rigorous manner through a series of codes (ICD9s, CPTs, DRGs etc), but there is no real set or expected pricing for each code apart from Medicare and these strange agreements between particular insurance providers and particular hospitals (i.e. what defines "in-network" or "out-of-network", where pricing is more or less random). Bills also have an explicit location type (Inpatient, Outpatient, Emergency room, Ambulance etc) and Urgent/Emergency Room care is significantly and consistently the most expensive to the insurer (most American insurance is, after all, high deductible emergency insurance) and thus one of the major vectors of fraud was passing bills off as such. One of the real aspects of madness in the whole system is the pricing disconnect and lack of transparency between all participants: hospitals ask an agreed upon price to insurers who pay it with few questions asked, as hospital pricing drifts up insurers raise premium prices, employers keep paying premiums, and individuals either pay something contractually determined by their insurance company or an essentially random price if uninsured.

TLDR; it isn't at all surprising to me that yet another vulture on American health care expenditure has discovered how profitable emergency rooms can be and that we see such a mad proliferation of urgent care facilities on every corner.

The FTC really should put a stop to labeling community ERs as Urgent Care when they aren't subject to the same billing regulations and are just an excuse for a predatory money grab.

From what I see around me, they advertise that they are both Urgent Care and Emergency Room. UC hours of operation end in the evening, and coming in past the COB automatically puts you to ER billing and pricing.

But if you come in during UC hours and the procedures are outside of UC, you can still end up being billed as an ER customer. The difference is usually in thousands.

$300 is your part of a regular doctor visit? Or the total bill?

Do you have one of those high-deductible plans designed to discourage people from seeking any healthcare?

When I was covered by an employer plan, a lot of people seemed to gravitate towards high deductible plans because they were cheaper so long as you didn't consume a lot of healthcare. (Personally, I never did but a lot of people were adamant that you saved money that way.)

You really need to look at how the employer funds it but often those are cheaper no matter what.

I won't argue. I'd have saved a lot of money over the years with a high deductible plan.

not if you have a chronic illness. my wife hits her deductible every year just getting the annual MRI she's required to get.

My high deductible maximum out of pocket is lower than the available other plan's premiums+deductible with equivalent care policies. I save money on a high deductible plan no matter what happens to me medically.

I’ve long been a proponent of high deductible plans. The part you’re missing is that you also get the opportunity to contribute pre-tax money to a Health Savings Account, which is money that you get to keep (and even invest) over the long term. You can spend that HSA money on medical expenses but if you save it, it turns into another tax-advantaged savings account like your IRA and 401(k).

I agree. I think I just had a very conservative mindset with respect to medical insurance which led me to a traditional plan. HSA would certainly have been a better choice in retrospect given that deductibles were never really an issue.

It's kind of silly they tie these together. Why can't I also open an HSA if I'm on a traditional PPO plan? Or if I have no health insurance as all.

Because a healthcare plan isn’t insurance. You used the correct term. If you want a prepaid healthcare plan that’s fine, just stop calling it insurance since it’s not.

Totally agree it should be available for cash pay.

It's insurance in the sense you have annual out-of-pocket maximums--which is really the key feature for a lot of people. I can cover $5K or $10K for a year but not, say, $100K or more.

HSAs can be wonderful, but you absolutely have to have a good one. Some of them still pay less than 1% interest and charge monthly fees. The ones which can be invested and have no fees are an amazing savings tool.

Indeed—the people who get by far the most benefit out of them are those who can afford to pay for everything without taking money out of the HSA, then claim those expenses much later in retirement (when you can also just start taking money out). To them, it’s another tax-advantaged retirement account, significantly raising their max annual contribution limits.

But--most importantly--it's a retirement account that you can spend early, if you have to, if you have unexpected medical expenses (which is the main reason an otherwise financially responsible person would have unexpected expenses). And in that scenario it's a much appreciated buffer for needing to withdraw money from another retirement account.

But frankly, even if you are spending the money on medical expenses in the same year, you're also getting a lot of benefit out of spending pre-tax rather than post-tax money.

This is true, but you can always roll over an HSA from a bad provider to a better one.

> The part you’re missing is that you also get the opportunity to contribute pre-tax money to a Health Savings Account

Post-ACA, high-deductible and HSA-compatible are not the same thing anymore. In my state, for example, there are no longer any HSA-compatible insurance plans but there are several high deductible ones.

That's unfortunate.

HSA contributions max at $8300 for a family.

If you require care for chronic medical issues, that often not even one treatment. So, the annual numbers might work out, but you're still left with a massive cash-flow issue at the beginning of every year (because there hasn't been time to fund the HSA, you have to float the deductible + co-pays/% up to your max OOP).

And that's assuming your income supports the max HSA contribution in the first place. Maybe after a few years, it balances out a bit, if you're lucky.

> high-deductible plans designed to discourage people from seeking any healthcare

This is in fact not the purpose of those plans.

They try to actually be insurance (ie, in case of unexpected high expenses) rather than a combination of insurance plus pre-payment of typical expenses.

It may not be the intent of those plans, but if it's the result, then that's what matters.

But do they actually have that result? Or do they simply put people off of all early care

as they say on the internet .. por que no los dos?

1. they do (post-ACA) function as effective bankruptcy insurance

2. they likely deter the people enrolled to avoid early/minor/preventive medical visits.

High deductible plans are great. They are designed to allow you to take pretax money out and use it to either invest like an IRA or spend it on healthcare.

In other words they are actually insurance. Not a prepaid healthcare plan. No one should be using “insurance” to cover every day expected expenses like random doctor visits for the flu.

They are a small fight against the massive principal agent problem which is the sole issue anyone should be focusing on if they care about healthcare costs.

> No one should be using “insurance” to cover every day expected expenses like random doctor visits for the flu.

The inhabitants of just about developed industrial/post-industrial society other than the USA seek to differ.

That's largely how, e.g. dental works. You (outside of certain company insurance) pay for dental on your own which is also sanely priced.

"No one should be using 'insurance' to cover every day expected expenses like random doctor visits for the flu."

If it was like $20, sure, but when a "routine doctor visit" costs $300 I'd rather use insurance than deal with the mental load of deciding if it's worth the money. I wonder how many people develop more serious conditions because their high deductible tips the calculus towards avoiding the doctor.

I was referring to the total bill, in both cases. Sadly, yes, I do have a high deductible plan.

The $300+ bill usually gets adjusted to about 50% by the insurance (I’m in network), and then I pay my share, depending on the state of my deductible and out-of-pocket expenses. (So in my case, 90% before deductible is met, then 10%, until I reach my OOP max.)

UC bill is processed in a similar fashion, and my actual responsibility tends to be less than from my primary care doctor.

These pain points are present in the UK as well; a ton of people have to go to A&E and wait for hours there because their primary caregiver / GP is booked full. 1-2 days wait up to a week for non-urgent care sounds fine to me, but at $300 it's a bit ridiculous.

People end up getting worse and cost the system more, so the cycle continues.

Triage is hard. People may be mis-judging which is the appropriate service provider for their needs. If they don't know what's wrong they may worry that they stumble into a GP, and he just calls the ambulance/steers you to the ER anyway.

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