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Comment by rayiner | Hacker News Reader

Transparent medical pricing is not possible so long as hospitals have an obligation to treat sick people whether or not they can pay. Hospitals heavily cross subsidize between insured, uninsured, and Medicare/Medicaid patients. As long as we put expectations on doctors and hospitals that compel them to do that, they cannot provide transparent pricing.

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The work done by David Belk MD shows that these costs are an extremely small cost of hospitals, and that you're basically promoting a myth. [1][2]

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...

[2] http://truecostofhealthcare.net/conclusion/

[3] https://www.youtube.com/watch?v=jkAY15p2DN4

Hey! My appendectomy was around $50k. I didn't have insurance, and it ended up being cheaper since I just ignored all the medical bills.

I'll have to check that out. My primary care physician is located at a teaching hospital that is surrounded by extreme poverty. A few years ago he said that I was one of the few patients that have insurance, and one of the few that comes in for preventative treatment (no surprise, given the lack of insurance). This isn't emergency treatment though, this is normal doctors stuff, the hospital he works for makes a point of treating everyone.

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.

THIS. Many Americans don't seem to realize we already have a "socialized" medical system - everyone paying into everyone else's costs - it's just that it's brokered by private companies instead of the gov't. Which means that it's less transparent, less regulated, and subjected to a bigger rake [1] than if it was run by the gov't.

[1] https://en.wikipedia.org/wiki/Rake_(poker)

But if you call it socialised it's anti American.

I think I'm missing something. Why does the fact that the price is inflated by subsidies mean they can't advertise what it is?

It is not possible in the current setup, yes. But if there was no insurance company to deal with for little things like X-Ray, that's the question. Why is transparent pricing so difficult for a hospital management to come up with if they don't have to answer to an insurance company OR even the Govt. for that matter ? Private Hospitals are mostly run like a business anyway so why not this part ? The status quo is not good enough and that is the point I am making.

Are we going to allow doctors and hospitals to turn away anyone who can't pay the advertised rates? Like we allow every other business to do? And will we require Medicare and Medicaid to pay those advertised rates, without the discounts they currently get? Jose are the things that force cross-subsidization.

The hospitals that are covered by EMTALA (duty to treat) are those that "receive federal assistance, maintain charitable nonprofit tax status, or participate in Medicare". A hospital is free to get off the federal government gravy train if it thinks it can make more money that way.

You can't have the government distorting the market by bringing half of all potential customers under a single taxpayer-funded system then pretend that hospitals have a real choice in whether to participate in those programs.

Many are not part of the system, so they really do have a choice. Granted, location is a big part of this, and it's much simpler to operate this way when population density is high and there are other hospitals in the area.

I work for a medical group that does just this. It is indeed possible and profitable. You just have to pay taxes on earnings.

All ERs are bound by EMTALA. It's hard in this modern era to have a hospital that doesn't have an ER.

Those hospitals' standard rates should be paid by direct reimbursement from the government at their set rate. In the event they're out of line with the expected market (no idea what that distribution looks like, but obviously there would be one), then the hospital would be investigated for price gouging all their customers (as customers of this industry are less able to shop around).

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 wonder if it might be possible to start some kind of group buying organization to negotiate insurance like rates without the actual insurance.

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.

This would be pretty great, but so would real healthcare reform where businesses were simply required to publicly post uniform prices.

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.

Isn't the risk sharing a component in the discount? That is, aren't the providers more likely to collect from people participating in a risk sharing arrangement?

You're exactly right. We need publicly available databases on what they charge for every procedure/test/product they perform/sell for every insurance plan and for paying out of pocket. We need competition.

which would be completely solved by single payer would it not?

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