I usually don't make political comments but one thing that was disappointing with Obamacare was the fact that it did not address this root cause and instead touted that now anyone can get insurance. Sure, someone with pre-existing condition is now probably a little better off but overall, obamacare did not address the main issue: getting rid of middlemen (insurance companies) and let doctors/hospitals work on fair and transparent pricing. Isn't that what America is all about ? Free Market, eh.
If I may steal the legendary MLK's words, I have a dream. A dream where I can call any doctor/hospital and ask what will it exactly cost to get a simple X-Ray done without saying "Oh no, I ain't got no insurance". Just a dream.
In fact, if we accept insurance/Medicare/Medicaid and OFFER a cash discount to an uninsured patient, we are one whistleblower away from a Medicare Fraud investigation.
Why should mine be?
Why should mine be?
You pick your rate. Whatever you like. Now charge that to every one of your patients with no discounts or negotiation. That's all I want you to do. Don't do anything different for insured patients either, your rate is your rate and the insurance company must pay it, or pass the rest on to the patient. Simple as that. The doctor down the street is free to pick his/her rate too, but they must charge that rate for all of their patients.
Long post:
Good point, except that get to see I see the invoice AFTER a service has been provided to me, sometimes MONTHS after the encounter EVEN AFTER SPECIFICALLY asking for an estimate upfront.
If you know a provider who works otherwise, feel free to answer this question: https://www.quora.com/How-do-I-find-a-general-physician-in-S...
No providers office I know of are willing to provide estimates to patients for procedures the same office requires the patients to be financially responsible for!
The reality is that the provider is like a programmer who builds what I discussed with her to build only that I get a $10k bill AFTER THE FACT without having a say in whether I am OK with it or not and she just went ahead and did the project for me without even asking me if I wanted her to do it.
If I don't pay, my credit will be trashed with a collection entry.
This is unacceptable. I am not sure if you agree.
Case in point: I went to a specialist to figure out the ringing in my ears. I made it clear to both the administrative staff and the doctor that I should be told of any charges outside the office visit fee before such a charge would be incurred.
The specialist looked into my ears and said my ears looked fine and the ringing could be due to stress.
A month later I got a $1500 bill for "in office surgery". Apparently, if a specialist inserts anything into my body, it's a surgery and billed in addition to an office visit fee.
I do NOT believe this is proper. The provider took full advantage of my inconvenience.
I am lucky it was a $1500 bill and not a $15000 bill. It could very well have been and I would have NO recourse.
I am happy to pay your negotiated rate as long as you tell me what that rate is and how many hours you estimate it will cost me.
What I am NOT happy to do is be forced to pay an amount that I had no say in the first place.
Providers ARE exploiting their patients and getting away with it by placing the blame on the faceless insurance companies.
Patients are not walking blank checkbooks. They are suffering and under pain and looking to you for a remedy.
Providers have a right to make money. Providers DO NOT have a right to exploit.
First point: If you're willing to pay cash and bypass the insurance / CPT / ICD10 / RVU rigamarole, I'd like to direct you to any number of concierge physicians who will gladly take your money, provide you their cell phone, and give you 24/7 availability. Simply Google "concierge physician san diego", and you'll have your pick of physicians from UCSD or Scripps or other great places in SD.
Second Point: You're conflating a whole lot of stuff. Your insurance doesn't pay us enough to do the whole "personal estimated bill". That's the patient's responsibility. You and your insurance company are the only people who know the status of about 10+ variables which will affect your out-of-pocket-cost. What's your deductible's status: Have you exceeded it? What's your out of pocket max for the year? Do you have a copay or coinsurance for ambulatory services vs hospital provided services? Are we in-network with your variant insurance company's policy? There's no API for us to query all this information from Aetna/BCBS/Humana/et al, and given how insurance companies LOVE to put up barriers to care via prior authorizations, that API is never happening unless mandated by federal law or built by yet ANOTHER company.
>The reality is that the provider is like a programmer who builds what I discussed with her to build only that I get a $10k bill AFTER THE FACT without having a say in whether I am OK with it or not and she just went ahead and did the project for me without even asking me if I wanted her to do it.
This is a false equivalence. The medical equivalent to this scenario would be calling and speaking to a physician on the phone about whether you even need an appointment and then receiving a bill for a consultation with lab testing. Our taking an interview with you, reviewing outside notes/labs/imaging, doing a physical examination, and providing our expert opinion IS our deliverable product, NOT the procedure and definitely NOT the medication we prescribe. You wouldn't engage a business consultant or a lawyer for advice and not expect to pay for their time? Why is it different with physicians?
The "I WANT AN ESTIMATE UP FRONT" request is fine for some areas of care, but if it were up to me, I'd simply give you my charge-master-highest-rate and say "I don't know what your particular insurance company has negotiated and which contract will be in effect at the time of bill submission, so the resulting charge may be lower than this. It will not be higher". For example, I'm in Radiology, so my billing is different. My deliverable is not an in-person consultation, rather a diagnostic imaging examination, interpreted to the best of my expert opinion. I can provide a concrete, encapsulated, whole estimate of charges for both the technical and professional fees, and that estimate will be the maximum I charge all 3rd party payers.
I agree with the answer provided by Quora. You're asking someone to do ALL the work, before you even decide to pay them. This is the equivalent of asking a lawyer to evaluate a contract and then offer you a per-paragraph rate of evaluation based on the projected complexity of each section, before you even then decide to pay them a dime. That estimate is difficult to perform without going ahead and just doing the work. If you're going to play that game in medicine, just pay the physician hourly like in law in 15-minute increments or get a concierge doc.
Stop talking about what the patient will have to pay out of pocket and start talking about how much you will receive. I agree that how much of that is covered by my insurance is between me and them, but it starts with what YOU charge for services. And back to my original point, that should be a fixed rate (of your choosing) charges to all of your patients (and their insurance company).
If I charge under what they will pay, they aren't going to reward me with all that savings.
If someone wants to negotiate with me directly, I'll charge you some other price, then write off the rest, just as if you are phkahler insurance co. It's the only "legal" way to offer a discount.
I respect that you are a MD from Harvard Medical School. Obviously you are very smart, and hard working.
Deep inside you, something must be telling you that it would make no sense for a provider to be in business of seeing patients if they were making no money in it.
I am also confused if you disagree with me that it is reasonable to be told of costs that one is expected to pay BEFORE one is made to incur those costs?
Someone is paying you and for the computers and GPUs you run your code on. Infact you made a very similar comment: https://news.ycombinator.com/item?id=10930242
But let's keep that aside; that's a completely separate discussion.
To clarify: I did not ask the provider to tell me what my OOP will be. I am educated enough to figure that on my own. I know how to call my insurance company and speak in English.
All I want the provider to tell me is what they typically bill during a routine service so I can figure out how much my visit will be billed to my insurance company.
I am more than happy to talk with my insurance company to figure out how that cost will be settled.
I don't want the provider to do anything extra for me.
> I'd simply give you my charge-master-highest-rate and say "I don't know what your particular insurance company has negotiated and which contract will be in effect at the time of bill submission, so the resulting charge may be lower than this. It will not be higher"
GREAT!
That is fine and I would welcome it! Seriously. Let me sort out what I need to pay and what my insurance pays.
Just tell me what my maximum financial liability could be and I am a happy camper!
I don't think you still have understood my "rant" but in this case I was not told about the possibility of a "surgery" before, during or after the appointment, with me asking the doctor and office staff at each of those steps if I owed anything. I came to know about it months later when I got the invoice with a due date.
Anyways, I do not want to repeat the detailed discussion that are already in the comments on the Quora post. You are welcome to expand the comments and read them yourself once you are over being condescending.
FYI, the last comment I made there clarified I am more than happy to pay for the consultations and estimates. No one works for free.
I would rather pay $500 for consultations and estimates to figure out what I am going to get and whether its worth it to me than $1500 that I had no say in that just happened to show up in my mail.
Since your first line is all so very dismissive of my whole rant, I will not longer engage with you, as it's probably wasted energy.
You read the anonymous answer, you agreed with it, got what you were already decided on and did not even bother to read further.
For your sake I hope you never get a medical bill you never even thought you would get that would end up destroying you financially and put you in extreme debt.
This actually happens to people in the U.S. on a regular basis, and I dont think that's normal.
I cant personally imagine why smart people even think this practice is OK.
What happened to me during that visit can be summarized by: "oh that peek we did into your ear? yeah, that's $1500. sorry we didn't tell you in advance. If you don't pay it, we will trash your credit".
For other people possibly reading this: the office did not even tell me that the visit might involve extra costs INSPITE of me EXPLICITLY mentioning that I would need to be made aware of such.
TLDR: I am HAPPY to pay for costs that are shared with me BEFORE they are incurred SPECIALLY when I am asking to be made aware of costs that I am expected to pay.
He directly addresses the inaccuracy of that claim in the following 10 minute video, "The $55,000 Appendectomy: What Everyone Should Know About Hospital Bills". [3]
[1] https://www.reddit.com/r/IAmA/comments/4lgnif/i_am_david_bel...
Even so, my last visit was less than $100, including blood work. There wasn't even an in-network discount or anything. So I doubt I'm subsidizing anyone, and I don't think the hospital is suffering too much from treating everyone.
The problem we have here is the exact same problem as with taxis/Uber (and telcos somewhat. and actually that public code thread we argued about the other day, too). Rather than just directly subsidizing infrastructure for poor people, governments enticed businesses to provide some service at a loss by giving them special privileges across the board. As the market finds more efficient solutions, the reality disconnect becomes painfully apparent. Market consumers grow sick of the incumbents' overhead, while simultaneously the businesses gradually renege on their unprofitable obligations.
I would seriously consider going without insurance except for the highest cost goods & services (say over 100k) except for the fact that it will cost me more to go to the doctor for a check then my insurance company currently pays.
The group discount without the risk sharing would be a very interesting product for me. I wonder how many other people would be interested in such a thing.
I think a fundamental problem of trying to privately implement this idea is that medical businesses have an extreme amount of overhead simply to deal with insurance companies, but they don't precisely ascribe it to insurance as payment. From a doctors' office's perspective, the "actual cost" of providing you cash service still includes paying all their back office rather than just actual services rendered.
Coming from the other direction, you have high-deductible plans that effectively do this in many more words. Plus that whole tax subsidy that fueled the growth of this institutional cancer in the first place.
This has just let the drug companies to raise the price without any backslash because the end user is "not" paying the price. However, the rising premiums and plans with high deductibles meant that the drugs are still not affordable even if you are covered by some insurance.
What is the solution to this? Single-payer health care?
Its a market with inelastic demand - people will literately die if they don't buy the product. We, rightly, through regulation demand high quality assurance because if something is meant save someone from a quick death it better be reliable and not cause greater harm due to product defects. This means the entry barriers are quite high making competition difficult. Without price controls there is literately nothing but the CEO's conscience to keep from pushing the prices up. If the product will stop you from dying and nobody else can offer it, then there is basically no price you won't pay.
Second in the case of off patent medicines, some are harder to make or not prescribed widely enough for the generic makers to bother with. These seem to be the things at risk of price gouging. There was an example of something off patent sold by Pfizer to another company who now charge 10x more, as there is no generic alternative. That's now at the competition authorities.
So we mitigate a lot of this, but we apparently don't avoid it entirely.
EDIT: Programme page with mp3: http://www.bbc.co.uk/programmes/b07j7j6m
The slight complication is that people will die without their meds, but the market doesn't care about that. It's only concerned with money.
I remember there was the controversy in the '08 election about Gov. Palin charging rape victims for their rape kit, and several people refuted it by insisting that they actually billed their health insurer [1]
Forget for the moment whether the argument worked or not, or is valid or not; the fact that they thought it was responsive says volumes about the typical person's "bottomless vault" model of insurance.
[1] http://www.politifact.com/truth-o-meter/article/2008/sep/22/...
I have to unfortunately be very vague because I don't remember the actual reference, but I remember a similar problem where the lobbyists didn't get what they wanted , and discreetly added it into some kind of unrelated bill in the midst of some fine print.[2] An excellent use for using something like natural language processing is to find outlier items which simply do not belong in a law which is being passed.
[1] I am also told that from the perspective of the R&D labs which spend a ton of money up front to produce the drug that this is the only way to recoup costs. And the costs for the R&D labs are usually blamed on excess regulation, so that is apparently a sort of justification for these subsidy requests (which still doesn't make sense).
Edit: [2] I bring this up because the article mentions the following and I think the euphemism has at least one possible explanation:
"But a review of Mylan’s lobbying history makes clear that the company has an exceptional track record at influencing government policies, both in Washington and in state capitals. Heather Bresch, Mylan’s chief executive, called the effort “our unconventional approach to growing this franchise” in remarks to Wall Street analysts last year."
Why is it even needed? I know some people say "education", but that's backward.
You have a problem. You go to your physician. He works out a treatment plan for you.
For drugs advertised for specific conditions? To enlighten you to alternatives? You can oftentimes assume that alternatives exist, for most common complaints.
For those that don't? Those ads are such a dragnet of wide ranging and vague conditions that oftentimes, the majority of the population would qualify ("Are you feeling run down? Do you have trouble getting to sleep? Ask your doctor about trying XXX". No. Ask your doctor about your conditions. Let them decide whether to try XXX. Or YYY. Or just to get more sleep).
There's no justifiable need that I can see that prescription medication need be advertised to anyone other than physicians and practitioners.
Oh, and it's not "often" that they spend "more". There is not one of the top ten pharma companies that spends more on R&D than marketing. Every one outspends on marketing. And by "more", the smallest gap is "four times more" leading up to "seventeen times more".
And we wonder why healthcare is so expensive here...
Because, contrary to popular belief, doctors aren't gods, and have about the same fraction of slackers as any other occupation. Unless we're ready to have a really aggressive program for revoking licenses of doctors who don't keep up with modern advances, they can and do miss available treatments.
"Hm, I could eagerly search all the latest treatments that might be relevant to my patents, or I could write them up something based on gut feel and what I learned in med school 30 years ago. Both pay the same."
Any patient engaged enough and knowledgeable enough to participate in improving their care plan is also knowledgeable enough to know that TV commercials for drugs are complete garbage and offer 0 substantive benefit.
Well, originally you said that no doctor could ever learn about anything that they didn't already aggressively seek out due to their diligent efforts to stay in compliance with the continuing education requirements.
Now you're recognizing that it happens but the costs outweigh the benefits.
Could you update your original post and be a bit clearer about your actual claim in the future? I wouldn't want people to be misled.
Hmm.. maybe you misread the original comment?
I specifically said no patient will learn something from a TV commercial that their doctor/nurse/pharmacist aren't aware of. It wasn't a comment on the infallibility of medical education but the uselessness of pharma advertising.
Of course knowledgeable patients can improve their own care by aggressively researching whatever condition they might have.
Because the US has the strongest freedom of speech protections in the world.
Extending personhood rights to corporations is a really bad idea.
Which is to say, they are made up of people. My right to free speech is not diminished by the fact that I choose to work with other people for a common goal.
1. https://www.youtube.com/watch?v=KlPQkd_AA6c My second favorite republican quote that was mistakenly maligned by the left. In first place is, of course, Rumsfeld's rumination on the nature of unknown unknowns.
I believe it's also allowed in New Zealand.
But I totally agree with you, it's a ridiculous practise
Are you not bothered at all about the EpiPen situation? Martin Shkreli doesn't make you angry?
A pharmacologist friend once told me that the best way for a drug company to get a customer for life is to make sure they don't cure or kill them. She was joking, but I think it's true.
And no, the Epipen thing doesn't bother me. It's narrow minded to think about issues one crisis at a time. The only question is: how do you create a system with the proper incentives? At the end of the day, Mylan runs a very capital intensive business and has a profit margin about half what Google or Apple do. I think it creates perverse and absurd incentives for it to be more profitable to be in the advertising business than to be in the business of saving lives. That's the bottom line.
Yes they can. The Hatch-Waxman Act was written specifically for this. Also see:
http://www.citizen.org/congress/article_redirect.cfm?ID=6435
You never said whether or not Martin Shkreli makes you angry. Should investors be encouraged to find undervalued drugs, buy the IP, then raise the price through the roof? That would be good for society?
Part of the reason the advertising business is so profitable is due to companies spending so much money on ads. We banned many kinds of cigarette ads because of public health concerns and I would argue that there are legitimate reasons to ban many types of drug ads as well.
As for Shkreli--he's an asshole, but it makes no sense to focus narrowly on isolated abuses. Does FDA exclusivity for orphan drugs make up a non-negligible percent of healthcare spending (I think the answer is no)? If not than its just rage-bait, not something that we should base policy judgments on.
The big problem here is that manufacturers of generics have almost zero ability to invest in even minimal R&D. So they won't take an out-of-patent drug and use it to treat a long-tail disease. The orphan drug program is limited to diseases affecting less than 200,000 Americans. In the decade before Hatch-Waxmen, only 10 such drugs came to market. Since then, 400 have. So is it reasonable to judge the whole program by the Shkreli example?
I take it nobody in your family was affected by the price of a Daraprim tablet going from around $10 to $700 per pill?
> The big problem here is that manufacturers of generics have almost zero ability to invest in even minimal R&D.
Because that's not what they do. That's like complaining that Belkin makes lightning cables and they aren't even investing in developing new computers.
No, but I buy Epipens for my daughter. That fact is, of course, irrelevant. Systems shouldn't be designed by hyper-focusing on corner cases.
The nice thing about corner cases is that sometimes they are the tip of the proverbial iceberg. Maybe a market solution only fails in a couple of corner cases or maybe there's a fundamental problem with trying to apply market solutions to something like healthcare.