'Legitimate' US healthcare pricing could reduce costs by a third | Hacker News Reader

'Legitimate' US healthcare pricing could reduce costs by a third

modernhealthcare.com

213 pointsforrestbrazeal200 comments

It's hard to overstate how bizarrely opaque healthcare pricing is in the US. Despite the quality of the care ranking favorably worldwide, medical bills are an after-the-fact surprise.

In the diplomatic, foreign exchange, and expat communities living in the US, a common advice is "don't get sick". Those who can afford to travel often get care "back home" or elsewhere in Europe or Asia, because the costs can be determined in advance -- not to mention almost always cheaper.

Meanwhile, Americans are subject to surprise pricing, supposedly-helpful "Explanation of Benefits" forms that itemize procedures into miniscule sub-steps costing several hundreds of dollars each, a complete inability to reconcile a bill with the corresponding insurance claim -- to say nothing about trying to correct a paperwork mistake should it occur, or even being able to detect it in the first place.

Few people ask what the price will be in advance. I do know people that do, and they can and do shop around. You can get quite a bit better prices that way.

Few procedures are an emergency.

I've tried to do that for relatively routine care and it's a headache and a half. I spent half a workday (because, of course, I could only do it during business hours--good thing I have a job with a flexible schedule) calling up doctors' offices and waiting while they figured out how much they charged for a new patient appointment. If ZocDoc reliably had that information, it would make shopping around easier (my insurance had a directory but most of the price info was wrong).

In the absence of that, it's just not so easy to shop around for medical care.

I never had such problems. I asked, they answered (even if they had to go ask their accounting dept). I then asked for a discount, and got one. Doctors' offices are a business, and if they balk, tell them you're going to their [insert name of nearby competitor]. Don't let them get away with pretending not to know - after all, they are perfectly capable of sending you a bill.

I'm genuinely curious where and for what types of procedures you have had so much success in getting pricing/cost info up front for.

As most of the people in this thread have experienced its a maddening process. I've tried several times for routine procedures and its a huge headache that takes lots of time and lots of waiting on hold.

One way is to show up in person and ask. It's a lot easier to negotiate face to face than over the phone. It's the same when negotiating a price for a car, a hotel, stay, etc. I answered your other question elsewhere in this topic.

If the bill is potentially one of those crippling high ones, I'd suggest it's worthwhile to invest the time doing this, despite it being maddening.

Hmm. Driving from provider to provider when trying to "shop around" is really not that feasible for most people.

But I suppose it could work better. I'm skeptical though. Finding the appropriate "accounting" folks in person would be a nightmare. A lot of the hospitals and providers I've dealt with use "third party" billing so your in person strategy with these types of parties would basically be impossible.

I don't think you appreciate how fortunate you have been.

I recently served jury duty on a civil case where the heart of it was about determining medical costs, and listened to people whose expertise was to determine what was reasonable and customary pricing for a given service tell me price ranges that spanned orders of magnitude sized differences in price. They needed access to multiple private databases (whose costs were prohibitive for a single use case) to determine these prices... but even with those databases they had to temper what they found with their own expertise as the data could be incorrect or incorrectly encoded. They also explained that prior to providing a service, you might anticipate only one item to be charged, the end result might actually be an order of magnitude more items charged, some of which were literally additional instances of the anticipated services.

A few years ago, when it was rolled out, I was trying to help my mother-in-law shop around for Medicare Part D plans. This should have been the easiest thing to price out: I had a list of prescription items, I knew exactly what doses and medicines she needed, and how often. I got a list of eligible providers, and proceeded to determine their their pricing and coverage rules. I figured it should be as simple as building a spreadsheet and doing basic linear optimization. First, it turned out to be very hard to get pricing, particularly in an easy to digest fashion. Beyond that, I was told the pricing could be missing some entries, could be incorrect, or could be out of date and/or could change in the near future. I also found that coverage policy invariably had subjective elements that made outcomes nondeterministic. Nobody was willing to stand behind a fixed price.

Most of the time it is a #@$@#%ing crap shoot.

> Doctors' offices are a business, and if they balk, tell them you're going to their [insert name of nearby competitor].

This seems like the absolute worst way to chose a doctor. I know some people in England chose hospitals based on car park charges, and I guess that's worse, but still.

And ask for the price with insurance or out of pocket. Sometimes out of pocket is 50% less. Truly insane.

Very often, the answer to that question is not known. I went through this when my wife was pregnant with out first and I was in graduate school. We were sitting down with the accounting rep from the hospital planning the next few months and she had zero idea of what the cost was going to be for routine procedures.

An accounting rep with no idea what the bill would be? I'd laugh at them and ask for someone who was actually from the accounting dept. Don't put up with that garbage.

What would your reaction be if you went to a dealer to buy a new car and he claimed to be unable to come up with a price?

Except the problem is that in the car situation you're the one paying for the car, not a third party. This is more like your car getting totaled, and your auto insurance company saying "you go pick a reasonable new car, we'll negotiate a price with the dealer (in secret) and then you'll pay 20% of whatever we agree upon"

You seem to be literally the only person who has been able to get straight answers from anyone on anything related to health care.

As you can probably see from this thread, most of us would have the same reaction: impotent frustration. I can go to another dealer if I don't get straight answers. I can walk away at any point up until the final signature. This is simply not an analogous situation, as evidenced by the repeated testimony of everyone here.

And this guy: https://www.youtube.com/watch?v=Tct38KwROdw

Honestly, having asked the question, I can tell you while so few people ask. The answers you get and the effort you have to put in to try to get a real answer is @#$@#$ing absurd.

Sorry, that should be "why so few people ask". Autocorrect is so mean.

Nobody asks because no one knows the price.

"Shopping around" for healthcare in the US is impossible.

Staff are not allowed to tell you negotiated prices. They don't even know. On top of that, medical billing will jack up the prices by adding extra billing codes.

Healthcare in the US is a scam. Without transparent prices it will stay this way.

> impossible

That's certainly not true. Try it. I've negotiated with a lot of outfits who claimed their prices were not negotiable. That's just a crock.

A good friend of mine is a successful businessman, and certainly does not need to negotiate. But he negotiates everything - it's entertainment for him. I'm constantly surprised at the amazing deals he gets on supposedly "non-negotiable" items, including medical bills.

> That's certainly not true. Try it.

Your suggestion is laughable. We asked three different hospitals what the cost for our daughter's birth was going to be; none of them could provide us with the answer until after the claim was submitted to our insurance. The out of pocket from the hospital we picked was $12k.

Now negotiating a bill down after the fact? Sure, if you can't afford to pay and document it, it can be done. But if you can afford to pay? Be prepared to be raked over the coals.

US healthcare sucks, and your anecdotal evidence is weak at best.

We had a home birth, and the billing was pretty straightforward. We paid $5k for the all care through the birth. However, we knew that if at any point the pregnancy became abnormal enough that we needed to transfer to hospital, we would be stuck paying whatever the hospital and our insurer agreed to, and we wouldn't get any of the $5k we paid to the midwives back.

You can ask them what the uninsured bill would be.

I did. They would not provide the cash price. It does not exist.

Why would I want to know that? It has no relation to what my actual out-of-pocket expense is going to be.

And I can have the exact same test done twice and get different bills.

I've definitely asked the price of some non-emergency procedures in advance before and it was rare I could get a straight answer (I live in California). But maybe for some things it's possible.

When I needed an MRI, I called five different places and only one of them would actually tell me a price. All of the others said "we don't know the price until we submit the claim to insurance". Not sure if they were telling the truth or just being lazy at their jobs. Either way, getting a price in advance is not as simple as just asking.

Sometimes they need a little prodding. Tell them you're getting a price from [name of competitor].

Tell them you want to know the "cash" price.

In fact, they know two exact prices: (1) the price they will bill your particular insurance company & (2) the lowest price in actual total they can accept

Unfortunately, there's no benefit to them to tell you (2). And without verifying your exact insurance coverage (i.e. submitting a claim) they have no idea how (1) relates to your eventual out-of-pocket costs (and they're disincentivized from telling you the billed rate in case you're actually another insurer trying to negotiate lower rates).

I'm actually not sure that they know (2), as I've read a number of articles and posts which say that almost no healthcare organization uses cost accounting.

If they can send you a bill with a figure on it, they can produce a quote.

That's not true, due to price discrimination. They can't precisely tell how much they can get paid for something until they submit invoices to insurers.

If you opt to submit the claim to your insurance company yourself, this is not an issue.

I think you guys are getting screwed.

1) unless this is the first time they've done it, they'll at least have a range and an explanation for the difference.

2) They're motivated to not tell you. By staying quiet, they prevent you from shopping around. They maintain the ability to decide charges rather than having to negotiate. Telling you only once you owe them is something other businesses would love.

Is there a doc in the house who can give us their perspective? What's up with this pricing?

Not a doctor, but I have spent ~10 years working with data on the reimbursement side of a large hospital. Please see my comment above.

I can confirm that, at least for an N of 1. Contracts with individual insurers are typically negotiated to be set to a percentage of (known) Medicare reimbursement for a given procedure. As it is with any negotiations, more powerful insurers get better rates. The costs are usually monitored at a macro accounting level, since what really matters is staying in the black.

As an aside, in addition to other confounding factors, cost accounting would likely affect physician compensation since it would shine a light on their actual effort. Expect that to Just Not Happen in an organization with more than one provider. They enjoy their compensation, and they will fight to keep it.

Edit: perhaps the physician compensation scheme I am familiar with is wildly atypical. Hence the N=1 disclaimer.

> Contracts with individual insurers are typically negotiated to be set to a percentage of (known) Medicare reimbursement for a given procedure

It's usually pegged at multiples of what Medicare reimburses (ie, "300% of Medicare rates")

> Expect that to Just Not Happen in an organization with more than one provider. They enjoy their compensation, and they will fight to keep it.

It has nothing to do with physician compensation, because most are salaried now anyway, and they make a lot less than people think. The problem is that they literally do not know what the reimbursement rates are.

By law, nobody can be charged less than Medicare.

Given that the median salary for a physician (not specialist) is $180K, I'm not sure what you think people think they make if they think it's a "lot more" than that.

Actually, as pmorici notes, there are three relevant prices. Without insurance, you will be charged the "cash price", which is always far greater (maybe 3-4 times) the price that they have negotiated with your insurance company. For large insurance companies, that price can be close to the lowest price that they will accept.

Even if you have insurance, they may be able to bill you for the difference between the cash and negotiated prices. It depends on relevant law and terms negotiated with your insurance provider. It's prudent to ask. Also, providers will sometimes "accidentally" bill you for that difference, even if they're not permitted to.

> Also, providers will sometimes "accidentally" bill you for that difference, even if they're not permitted to.

It's been my observation that hospital billing departments do many things "accidentally". Strangely, these never involve under-billing. A lot of bad things would have to happen to them (and insurance) before I'd start to feel even a little bad about it.

when something involves lots of process, mistakes are inevitable. sometimes by mistake, sometimes maliciously.

It's worse than that, because there's adverse selection. The hospitals that make errors in the client's favor or that don't make errors at all are more likely to go out of business than the ones that make errors in their own favor. So guess which ones are still around when you need a hospital.

In other words, just because the errors are accidental, it doesn't mean they happen at random.

(This argument applies to any shady business practice that "looks" like an accident, for example dark patterns on websites, or having great customer service for taking your money but terrible customer service for refunding it.)

When the same agency is the one influencing, if not directly creating and enforcing, the process, my sympathy tends asymptotically to zero. Especially when said processes are largely driven by a motivation for profit, if not merely to exist as a middleman.

Anecdote: My son broke his arm when I was between jobs and had no insurance.

The doctor had an x-ray machine on premise, but he admitted to me that his costs for it were high and that I could get a better price at the imaging place across the street.

Once there, when I explained my lack of insurance, I was told that not paying up front adds $75 because billing is a PITA.

Even though an insurer might be able to negotiate a good rate, they can't beat cash on the barrel head because cash pay doesn't require nearly as much work.

it's actually a little more nuanced than that. Hospitals/providers have what they call charge master. it is probably the cash price you are mentioning.

Even uninsured can end up negotiating the bill, albeit after the fact.

Sometimes, insurance might negotiate lower prices than what a certain procedure/treatment costs, i believe that's not uncommon. They make up for it from other procedures in general.

1. The lack of health care cost transparency reduces price competition. 2. people not asking for price in advance, or not caring because the are already past their 1. deductible 2. out of pocket maximum makes healthcare expensive[a]. Similar to reference pricing, high-deductible health plans (with added HSA benefit) makes people think twice before going to doctors. I also felt a lot of people are not price conscious about healthcare - just yesterday a friend mentioned "i picked the most expensive plan so i don't have to think about it". Completely reasonable, but one reason why prices get higher each year.

[a: reference pricing] http://www.nytimes.com/2016/08/09/upshot/how-common-procedur...

> Even uninsured can end up negotiating the bill, albeit after the fact.

Yes. One could say something like "I know that you're billing me three times what you get from insurance companies, and I know that you'd pay at least 50% to a collection agency, so will you accept 40% now?"

> Sometimes, insurance might negotiate lower prices than what a certain procedure/treatment costs, i believe that's not uncommon. They make up for it from other procedures in general.

True. Also from payers with less negotiating strength.

"Yes. One could say something like "I know that you're billing me three times what you get from insurance companies, and I know that you'd pay at least 50% to a collection agency, so will you accept 40% now?""

Unfortunately, this misses another pertinent point, that the provider/facility will be able to charge off and deduct as a loss either that 50% of the original amount they're going to charge you, as well as getting 50% from collections, or 100% if they're... 'creative'. This can often reduce incentive to negotiate.

that's still a hassle, though. there is a point, but it probably works better with individual practices than large hospitals.

Maybe so. But wouldn't that increase the incentive to negotiate?

How practical would it be to recreate the charge master through crowd sourcing? If everyone scanned their invoices and submitted the hospital name and insurer, a picture would very quickly emerge that might allow consumers to get a reasonably accurate view of what line items are typically in a certain procedure and what it all costs.

There's nothing which prevents the sharing of this information, is there?

Same. I spent 20 minutes on the phone with someone, got frustrated, and asked flat out, "are you telling me there's no way to know how much I will pay for this procedure until after it's done?". The answer was "yes".

Part of that is because of insurance companies. They don't know exactly what your coverage is in all cases so they know what they'll send to the company but how much they pay will vary a lot from person to person often by a lot.

I wonder if someone has made a video of this - asking for a price and getting a response like "we can't tell you" or "we don't know." It shows how absurd the system is.

Why yes: https://www.youtube.com/watch?v=Tct38KwROdw

My experience is that few physicians have any idea what various procedures cost, especially in a hospital setting. Advance cost information is very difficult to obtain, and often there isn't time to obtain it.

I'd like to see at least the protocol used in automobile repairs. You get an estimate and approve it. If the estimate turns out to be incorrect, you have the option of deciding on another course of treatment. This scenario can't work in many situations, such as surgery, but knowing some costs up front would help everyone make better decisions.

If adherence to estimates can't be made to work, I'd like to see limits on how long after a procedure you can be billed. At present, it's not at all unusual to get a bill months after a procedure from a completely unexpected source. There's usually no way to determine whether the amount billed is correct.

"Shopping around" is often a fantasy because you will very rarely actually get a price.

I've tried asking multiple times (for non-emergency procedures) and each time they've said they don't know. (Kaiser)

I ask, every time. They will do just about anything to not tell you, or to tell you only the insurance rate. You're screwed if you go to the ER. I had to get an EKG done - they managed to charge my insurance over $1000, something that in almost any other country would be around $50, and even some hospitals in the US.

I think the hugest problem in the US thats not been looked at is regulating the providers - I don't think competition alone will help in emergency situations, but at least with doctors visits knowing how much something would cost would be incredibly helpful.

I'll echo what others have said. I have requested rates multiple times, and gotten numbers, but the numbers they give is the amount they bill insurance. However that number is practically meaningless. Even for something as simple as a yearly preventative care visit, my wife and I each went to a different doctors, both of which billed the insurance about the same amount, and both of which were in-network. However, they had different negotiated rates with the insurance, and coded things slightly differently the end result being a factor of 10 difference in our out-of-pocket expenses for the two visits.

None of this information was available in the computer systems of the providers who file the claims, nor have I been able to get it from my insurance in advance.

it's because they don't know. What insurance provider considers preventive care is different from what doctors think it is.

Recent anectode: 10minute chat to doctor about general health costed my wife 200$. She didn't get any blood work done, it was the price of the "visit/consultation". It was supposed to be preventive care, but not coded as such.

I remember accompanying a friend and having her arrive at a hospital for an extremely expensive, previously planned plastic surgery procedure and being confronted with unexpected, unannounced costs of several thousand dollars.

It was one of the most traumatic experiences of my life.

Eh, I've tried that many many times for many different things, and I've never been able to get an exact price quote beforehand. The response is always "you need to talk with so-and-so" who is always someone or something else. It's a maze of runarounds, with no one willing to commit to anything in particular.

It's one of the many things broken about the US healthcare system. In no other market would a seller be able to get away with not providing a contractual quote before the service is provided.

It reminds me of the many ways that Congress could legislate better behavior from existing players in the health care field in order to achieve their objectives.

My wife went for routine blood tests yesterday and they didn't even bother to tell her that the insurance her employer switched to in 2017 treats this lab as out of network (it was in network with the previous insurance just a week ago). She could have gone to an in network lab a few blocks away if they'd told her. Now we're worried about a huge unnecessary out of network bill in addition to the in network deductible / max out of pocket we were expecting to hit with her cancer treatment.

That's quite absurd. Especially since it was a routine place you were going. You might try calling your insurance (if you havent) and talk them into reducing the bill: you just didn't know and your wife sticked with where she has been going to in the past. If you can, if your healthcare is through your employer, try writing to your benefits team as well.

PS: My prayers are goes for your wife. I hope she beats the cancer.

Go back and ask for the cash price if you pay it right there. It should cost about 1/3 of the normal price. The cost of billing insurance companies and all drives the price way up.

I throw those bills in the trash, nothing ever happens. Admin staff at medical practices are horribly incompetent generally. You can push them before the fact aggressively to figure out your eligibility under insurance, and then you'll still get an incorrect bill afterwards for an amount you don't actually owe.

This idea is based on healthcare not being a scam. You can ask for a price and then will tell you a price but even if you pay that price, up front, in cash, you will later get bills for more "services", received or perceived. In any other industry people would go to prison.

There is way too much money in the current system for pricing to become legitimate. All the waste and overcharging is someone's profit. And the Republicans certainly won't do anything about this in the next years. Because "regulation" is bad.

It is the way that the licensed practice of medicine is so heavily regulated that creates the noncompetitive environment in the first place.

Though I wouldn't expect Republicans to ever admit that, at least congressional ones. If the regulation existed under Reagan its the best thing ever (see: if establishment corporations abuse it) and if wasn't its communism (see: donor corporations don't want to be regulated).

The services are too expensive, yes, but that's not what I'm getting at. I'm saying that even the inflated sticker price won't prevent tons of random other bills from flying out of nowhere. Once I got an anesthesia bill -- for almost ten thousand dollars -- after an event that didn't involve anesthesia, at which the anesthesiologist was not even present. There was just some stored procedure in their database that fired off bills.

The financial part of medicine seems pretty unregulated. They can charge phantasy prices and frequently charge for services never delivered without consequences. In other industries this would be plain fraud.

An insurance free market would fix this. Everyone knows that.

Except, of course, you shouldn't be able to buy over state lines. That's for your protection for some reason.

And once everyone has free market insurance then everything will be fine. You'll be able to choose the plan that can help you cover your bills.

Your bills will still be generated by a labyrinthian and byzantine system that no one including the people in charge of running it actually understand driven heavily by profits, phases of the moon, insanity, and corn prices.

But you'll have free market insurance (sort of)! So everything will be fine!

Realistically, I get the feeling that we've found new ways repeatedly to direct our system down blind allies to the point where I wonder if we can ever find our way back out without a massive disaster/collapse.

It's also not a service people can easily "shop around" for in an emergency, or go without. Heck, the information asymmetry, alone, between the buyer of the service and the person offering it (that is, the information required to evaluate if they're getting the correct treatment at an appropriate cost) ensures the market will not be a fair one.

Anyone who's gone to a mechanic that's performed unnecessary work knows what that's like... and that's just a car.

The current situation isn't like a mechanic at all. If a mechanic tells me I need some work done, I can call various mechanics and ask what they would charge to do that, and they'll tell me.

If you try that with a hospital, they'll tell you no. Go ahead and try asking your doctor what something will cost.

If I could ask for a price up front, then people who aren't in an emergency could shop around. That would force hospitals to actually compete, which would normally mean most providers would be within a range of the average market price.

So when an emergency does occur and you were taken to a random hospital, chances are that hospital would have prices close to the market price.

My comment about mechanics was specifically with regards to information asymmetry.

That is, 99% of people do not know enough about cars to determine if they are being fleeced.

Now imagine dealing with the human body.

Information symmetry leads to market failures:

https://en.m.wikipedia.org/wiki/Information_asymmetry

> If you try that with a hospital, they'll tell you no. Go ahead and try asking your doctor what something will cost.

My experience is they will tell you, and you can ask for a better price, and I've always gotten one.

The idea that one cannot negotiate with the hospital, the doctor, and the dentist is just incorrect. Try it next time.

I've noticed that insurance pays at most 50% less, in many cases much less than that. And the medical provider accepts it.

Your experience is literally unbelievable to me. I don't doubt you, I just cannot believe there isn't more to the story.

In another comment you seemed to indicate that you are perhaps uninsured and paying cash for everything? That would go a long way toward explaining why you have experiences that run dramatically counter to almost everyone else on this thread. It also seems like important information to be included, if so.

I am insured. You can opt to be billed by the provider, and submit the claim yourself. If you're unsure how this works, read the contract you have with your insurer, or call them on the phone. They may also be able to give you advice on negotiating for lower bills - after all, that lowers their cost as well.

I have a high deductible, so usually wind up paying the entire bill out of pocket. There's no reason to go through the insurer for that.

In general, doctors find the system as bewildering as you do. They might be able to give you a ballpark figure but you'll need someone in the billing department for a hard figure (if you can get one at all). Although they will still likely need an exact billing code for the procedure first.

Right now you shop at the copay level as a function of insurance. PPOs were a great scam to force coinsurance onto the masses.

Most health care is not delivered in an emergency.

And even when it is an emergency, prices for everything could still be made available.

Hospitals do decide how much they are going to charge for everything before you get the particular procedure. It's just not published.

If they won't tell you, tell them you're going to their competitor hospital. That's all it takes to loosen things up.

It's not even the same ballpark. At any reputable mechanic you can get a diagnosis done for free or low cost, and there exist books that estimate the time cost and replacement parts needed for pretty much every repair. There are some known unknowns going into it, like finding worn parts that need to be replaced, but I find that auto repair shops are pretty upfront about possible additional costs. I haven't had any similar experiences in healthcare; I don't think I've ever gotten an answer from a medical practitioner or office manager about the cost of a visit, procedure, lab work, or to what extent it would be covered by my insurance. Even for a vertically integrated HMO like Kaiser, simply no-one you can talk to knows.

I have asked, and also asked for a discount if I paid on the spot. You can often get a third off the price that way - just by asking.

It's the same with auto repairs. I'd take my car to the dealer for repairs, the service dept quotes me a price, I say that price sounds a little high, the price drops 30%.

In any negotiation, you're going to get the sucker price if you don't ask what the price is, or make no attempt to negotiate. Nobody is obliged to give you their best price automatically.

If you don't mind me asking, what kind of medical office/procedure were you able to get a cash price and discount on, in what setting, and which employee did you ask? I've never heard of that happening in the US before the fact; I have heard about negotiating down your medical bill with hospitals after the services have been rendered, though that seems like a crapshoot to me.

One example was having a skin lesion removed, a surgical procedure. I asked the dermatologist/surgeon, it was a procedure she did in her facility.

Another time I visited a neurologist, the woman behind the checkin front desk told me what it would cost. I said that sounded high, can I get a discount? She chirped sure, 30% off for cash on the spot.

Doctors routinely offer discounts for cash on the spot, because then they don't have to deal with patients who are slow payers or don't pay at all.

If they don't, find another doctor. They aren't rare. Heck, dentists are always advertising and offering discounts. They're businesses.

You can get at least 3% off just by using a check, because then they don't have to pay 3% tribute to the credit card company.

I don't recommend being an ass about it. Just be nice and ask for a discount.

"You can get at least 3% off just by using a check, because then they don't have to pay 3% tribute to the credit card company."

Tried this by offering cash on some kitchen remodeling work we were doing. I was talking to the sales person and - we were already going to buy - but I asked if they offered cash discount. She got flustered - almost insulted - "these are our best prices!". I tried to explain running $4000 was going to cost them probably close to 4%, and I have more consumer rights re: chargebacks if I'm not happy. $100 off? $150 off? Nope... flat out refusal ("that's not the way we work!"), so we paid with the credit card. But they just lost that money anyway. :/

Negotiations don't always work, that's for sure. But it is a learned skill, and one can get better at it. There's a good book on it, "Getting To Yes".

AIUI, if you take Visa, you aren't allowed to advertise a lower cash-only price. So maybe they were freaked out about losing the ability to take cards.

Also, I'd be concerned about a personal check for that amount. The last car I bought I put $2K on my miles credit card (the max they would take) and a check for the rest. They made me fill out loan paperwork anyways so that they would have recourse if the check bounced.

i paid for a car with a check ($11k). they just held the title until the check cleared...?

That's interesting, thanks for sharing. Maybe it's common with specialists, but I haven't had that experience with things like X-rays at my GP (before I was kaiser) or anything at Kaiser, like getting blood work done in the ER. I definitely shop around for dental procedures/don't pay for dental insurance, but there's no tax penalty for not carrying dental insurance..

Can't reply for walter but...

I've had a few experiences over the last decade with healthcare services. Had a consultation, some bloodwork and a other bits and bobs - nothing serious. Got a bill a month later for.. $430. This was done through insurance from my employer at the time, but my portion was still ~$430. I went to their office and said this was a little more than I'd be able to pay quickly (not a total lie - would have hurt at the time). Office manager there said "if you can pay cash we can call it $300 and be done with it". I paid the $300 cash and it was fine. This was a small private dr office in a professional office plaza place. Looking back... they could wait another few months for $430... and maybe have to take me to collections, or take $300 cash on the spot. Whatever averages they saw on collections, this was probably not a bad deal.

Few years later, I have same insurance provider, but self-employed, so 'individual/family' plan. My wife got very sick, and we ended up in ER. X-rays, drips, sent home with medication, etc. Got a bill almost 3 months later for ~$3000. Called hospital and asked for some sort of discount. I got (same line from 3 different people on different tries) "this already is a discounted price, because you have insurance, these are the negotiated/discounted rates". Looking more closely at the paperwork, the 'retail' price was somewhere north of $5000, but the insurance company's 'negotiated' rate was ~$3000 ($2800 IIRC).

It never hurts to ask, and maybe ask a lot, but it's not some magic "you'll always pay half price by just asking for a discount". And the point many others have made before - when you're having to go to ER, you don't have the luxury of shopping around, and generally the majority of folks you're seeing there are in no way cognizant of billing/pricing stuff (especially on a sunday when we went).

Here's the problem. If you do it outside your insurer, it no longer applies to your deductible. If your annual procedures don't hit deductible anyway, you come out ahead by getting the discount. Otherwise you'll pay more out of pocket for the unclaimed procedure.

It's worth having a talk with your insurer to be sure how that works in your case, as every plan is different.

Of course, it's easier to do a diagnosis with a car, cars are much better understood than human physiology. Medical science recently discovered (well, recognized) a new organ in the body.

I went to the doctor for a non-specific illness. The doctor ran $3000 worth of tests, and by the time the last of the test results came back, it had gone away. The doctor shrugged and said "Huh, I dunno what that was. Probably some kind of infection".

Some things are more clear (i.e. a broken arm), but if it doesn't heal well and the $1000 estimate for an X-ray and a cast turns into a $10000 surgical procedure plus 6 months of therapy, are you going to expect the doctor to just eat the cost? Are you going to shop your painful broken arm and medical records around to 3 different doctors to get a new estimate?

I believe they have to give you a written estimate, and if costs are gonna exceed that by 10 or 20%, they have to get authorization from you, and so on. Completely unlike health care.

And yeah, there is a "book value" for repairs (body and mechanical). Sometimes they can do it faster, sometimes much faster. They're charging you retail price for parts, not wholesale. Etc. Of course you can negotiate and save money, but it's worlds different from health care.

Doctors that specialize in things insurance rarely covers, like cosmetic surgery, are often quite upfront with costs. The complexity of insurance seems to be a big part of the problem.

And you see that with cars too. If someone is having an ordeal related to auto-maintenance, you often hear insurance mentioned...

It's compounded by the fact that you often don't have any real flexibility in how you fix the problem.

To extend your analogy, let's say I want to fix a broken headlight. I know how to do this, and can get better headlights than the one that would be offered through the two mechanics in my neighborhood. I can do this myself more cheaply. Or maybe my friend who used to work as an airline mechanic wants to do it as a favor. Or who knows.

With medical care, you might realistically only have one option due to problems with insurance coverage, so even if you were given the price, you'd have no choice. But even if you had two choices, you don't have a third option because it's legislated away. If I need my medication that I've been taking for four years without any problems, and it's a low risk med anyway, why should I have to go to see a PA, NP, or MD to get a prescription for it?

It's not just that the costs are opaque and hidden, it's that you are legally mandated in certain respects to accept them. The alternative is generally only to not have the service done.

Imagine that you get charged for a $600 gown after the fact, but you can get that same exact gown from the manufacturer or any other company for $80 -- You should be able to reimburse the hospital to replace this item at that cost and a max of 20%... this would keep them from raping people on items of no importance.

>You can ask for a price and then will tell you a price but even if you pay that price, up front, in cash, you will later get bills for more "services", received or perceived. In any other industry people would go to prison.

Not arguing with you, but there's another field where this is common: Law.

I haven't ever got a surprise legal bill, and I have a fancy famous lawyer that you've heard of. I don't think there's any comparison.

Yes. My wife recently went for a physical, something covered fully under our plan. We were surprised to see a bill follow and a separate consultation charge (not covered) alongside the physical charge (covered and zero rated). It turns out because she asked the doctor a question the doctor decided that was outside the scope of the physical and constituted a separate consultation. Of course how you're supposed to know what is or isn't in scope I have no idea.

I can one-up you: I had a doctor start up a conversation about going to the same college I did, which put the physical at just over 15m instead of just under, which doubled the bill. I don't think the doctor was maliciously driving up the price, just too abstracted away from the billing department.

How is that one upping at all? That seems quite reasonable and accidental.

he's just mentioning that the fact that doctors are not the ones billing you could cost you double or more.

I just meant one-upping the absurdity of his story, not like his internet points or whatever it is you think I meant.

His wife got charged more for asking a doctor a single question. I got charged more for a doctor asking me a question.

not trying to prod but just curious what was the general nature of that question she asked?

Anything that turns the "preventative" visit into an "evaluation and management" visit will often result in additional charge since they have different billing codes. Preventative visits are usually free under the ACA, but the E/M visit will require a co-pay. My parents moved and were looking to get an annual physical, and most of the clinics they called said up front that they would require a separate, paid, "meet the doctor" new-patient visit before they would schedule for a annual physical, even though they didn't want to have any of their conditions managed and just wanted an annual physical exam.

At open enrollment this year, our insurance rep explicitly told us not to ask questions at the yearly physical. Absurd.

Wow. Had the same experience. I thought it was a joke. He literally said "anything you say can be billed against you" like it was a detective show or something.

I had no idea this was a real thing! So doctors must be added to the list along with tax collectors and police where you just stay quiet during confrontations. Wow.

And we wonder why we have such bad health outcomes in the US

I had to fill out a waiver before I took my last physical that acknowledged anything outside the standard physical would be billed separately. It looked like it was part of a federal standard - the Center for Medicare and Medicaid Service's National Correct Coding Initiative. Your doctor should have some discretion though.

I had the same experience. As a part of small talk at annual physical, I asked a question to the Doctor to which they gave an answer which I already knew ("You do not need to worry about this"), and I got charged for that.

My workplace pays me incentive money for getting an annual physical. So, now I just go to physicals, stay quiet just so that I get the incentive money.

I wonder how doctors feel that their patients are scared of asking them any questions.

This is a little sketch - if the question you asked didn't required any additional work (specialized physical exam, detailed history taking, additional medical decision making), billing for it as a separate evaluation and management visit (as opposed to a preventative visit) isn't kosher. Often people come into their preventative visit wanting to discuss their insulin regimen, blood pressure history or a new acute problem, and this is the situation where the second charge is appropriate.

if the question you asked didn't required any additional work [such as] medical decision making

That effectively of reduces the scope of meaningful questions I can a doctor to near-zero, right?

same for me. HSA with seed + incentive (i think i also guess where you work :)). I think some institutions like PAMF might be doing this more than others, at least that's my observation. i swore for not going there unless it's a medical emergency.

exactly this. happened to my wife as well.

As a healthy person, my lesson learned is do not ask doctor a question, unless you have legitimate reason.

Happened to a friend of mine who shopped around and got a commitment in advance for the price. He reminded them of their commitment after they billed him for all the extras, and refused to pay it. They withdrew the extra charges.

He's lucky they just didn't send it to collections as many institutions would do if a patient refused to pay.

The hospital had no case as they had made an agreement. Collection agencies cannot collect money that you can document you do not owe.

I can't believe a doctor or hospital would agree to such a commitment. If the doctor wants to do an extra test or procedure to make sure the treatment is working as expected, then he's in a bad spot -- he either does it for free, or he faces malpractice liability if there is a bad outcome, regardless of any contract you may have signed with him.

The extra charges were bullshit, they were not the result of complications or other unforeseen circumstances.

This is not common. Not sure why you feel so compelled to disagree with all the other posters regarding their headaches with healthcare billing/cost experiences throughout this thred. Odd.

I contacted multiple hospitals for cost estimates on a simple procedure (hours of phone calls) and only one would actually give me an "estimate." They went out of their way to explain that this was only an estimate and it could easily end up costing more than this due to a number of factors.

I really doubt any hospital will ever give you a committed price for any procedure. I would love to be proven wrong from any other posters :).

Get the estimate in writing and then compare it with your bill. If there are more charges, they'll need to explain how those are unforeseen factors, or you can legitimately refuse to pay for them.

You can also show the estimate to other hospitals - this will often loosen them up about quoting a price because they'll want the business.

Uh, what? There is nothing binding about the estimate (unless you're in the auto repair industry), so you cannot "legitimately refuse to pay for it" unless they explain "how those are unforeseen factors".

Typically, indeed, you'll find wording to that exact effect. "This is only an estimate. Actual costs may differ."

Ask for a binding estimate.

My wife's wheelchair that the insurance company is paying for costs $6,000. The "loaner" wheelchair she's using now costs $400. The $6,000 chair being built is essentially the same as the $400 chair. Fraud like this is the reason we have the most expensive per capita healthcare in the world.

My mother needed a wheelchair, we went to Amazon and bought a $300 one instead of the $6000 one the insurance company wanted us to buy. No difference that we can tell.

good thing is those are the things you can shop around -easier-. when you are in a hospital getting care, you have very little idea about how much it's going to cost you.

Also don't throw stuff away. I had injured my knee and has surgery to correct it. I bought a walker until I got better. When my father got sick he borrowed my walker instead of buying a new one.

If you look in thrift stores you can find canes and walkers as well sometimes.

It is just like OTC aspirin, bring in your own bottle to save money as if a nurse gives it to you, you are charged $50 a pill. Buy one for $1 at a Dollar Store and use that.

Exactly. Insurance companies don't care, because a lot of commercial clients are self-insured, and they just pass on the cost. If anything, they make more money off of administrative fee by selling higher ticket items.

The only true way to fix this is to set costs centrally.

Wouldn't the insurance company be interested in a solution that cost less? For example, if you told them you found a store that sold a new, cheaper wheelchair (another comment says they're on Amazon), wouldn't they rather pay for that one, given the option? Or are there liability concerns that would get in the way?

If the price is over the maximum deductible for the patient, insurance companies are interested in more expensive things. This gives the insurance company latitude to increase costs.

Since there's a legal limit on profit margins, increasing costs will let them increase revenue elsewhere...earning 8% on $2000 is more interesting than 8% on $1000.

Doctors don't care about the price because they're not paying. You don't care about the price because it's over your deductible. Insurers don't care because they have latitude to raise prices every year. manufacturers don't care because the decision makers don't care.

The French system has a "base price" that they will reinburse for medical supplies/tools. Doctors can go over, but then it's out of pocket for the patient.

I've often heard/personally espoused the belief that health shouldn't be treated like a commodity. Interesting argument here that if health were only "truly" treated like a commodity, we'd have much fairer pricing. Capitalism has many faces, of which the free market is only one aspect. The healthcare industry in the US functions a lot more like other examples of what Naomi Klein might call "disaster capitalism": preying on the fact that health is by its very nature un-commodity-like to extort the sick.

The problem with this whole line of reasoning may be that health just can't be fairly priced according to free market principles, and that acting like it can be will just continue to enable the status quo.

I worked for a health care insurance company during the 2008 debates on the cost and quality web applications.

Like people have mentioned, they only gave a range, and a useless one at that. This was during the big push to HSAs and how healthy people could save using them and roll that money over to an IRA later in life to aid in retirement, or kept in the HSA for medicare costs.

We read Redefining Health care at work and there was a lot of talk, but always with the for-profit ends (even through we were a non-for-profit, not to be confused with a non-profit).

I left the US for a while and I found it interesting that in other countries, doctors could always tell me a price. An office visit was never more than $70 and when I got better work visas, the doctors offices even worked with me to get a better rate (even though I didn't have a full residence visa needed for Medicare).

Every lab I went to for imagination told me the price on the phone.

The Affordable Care Act is terrible. I does help the very poor, but everyone in the middle still struggles between many terrible options. Contractors often get the worst plans that have little to no substantiation.

I have not seen a doctor for a year and only have minimal effective coverage ($17). Full plans from my employer start at $400/month. I've open enrolled in an ACA plan for next year, but it's still $200 a month and I plan on quitting my job and travelling. Because it's based on last year's income, I can't switch to a low income plan until the following year.

Employers should have been banned from offering plans at all, or at the very least, giving any discounts. But really, we should have a single payer system. The current state of health care under the ACA is still not good, and far from our European counterparts.

I'm convinced employer paid insurance is the single biggest problem. Very few people buy plans in the healthcare marketplace, most get it from their employer, and most of those have no idea what that plan costs compared to other plans.

With employer paid care, the employer is the primary customer. A level playing field would be everyone having to go direct to insurer/broker or healthcare market. And people would be so irritated with that process, which also requires annually reevaluating to get the best price, as a society we'd either go back to bartering chickens or go single payer.

Part of the original plan for the Affordable Care Act was, as I recall, to require members of Congress to use the government-run marketplaces. Congress refused. Not surprising -- they probably have the best health insurance in the US.

If Congress were forced to "dogfood" the health system the way ordinary people experience it, I suspect Republicans would be falling over themselves to enact a single payer system.

Yes but Republicans do everything they can to avoid government doing anything; or make it work badly on purpose whenever they can't prevent it, because government that works better than the free market is incompatible with their narrative that the government sucks and can't do anything right except blow people up on the other side of the world.

Ridiculous healthcare is one of the perks for govt officials. Any one of the Congress people or Executive administrators can get a full body scan on a whim (e.g. it was all the rage in washington during the first bush administration through the second bush terms). You get a clean bill of health for your campaign, or you get whatever you find, treated and maybe get well enough for the next campaign cycle.

I think the pricing is an implicit way the cog in the engine works.

I don't necessarily agree with it, but I see it and always think about it when anybody points out how expensive medical care is here in the USA.

Biotech R&D advances in the USA are funded by monstrously price gouging insurance companies.

Are you a biotech innovator? Your best bet is to start in the USA because you can charge a lot of money and nobody will lift a finger that influences your market potential like what happens in other countries.

Hopefully a large pharma company will buy your small pharma or medical device company because they have 2 things you don't:

1. Distribution - 1 sales rep for every doctor

2. Synthetic Scaling Insight - They have deep insights and grandfathered advantages in this arena, lest you can double down on putting in 40M-100M to make it happen.

---Or so this was the way it was explained to me through hundreds of interactions trying to build a genetics company in the USA. ---

The hunt for drug targets is the elusive hunt for the black swan. There's 8-10 new genetic tests that come out each day but very few if any of them can be tied to something specific, because it's tough.

Data doesn't necessarily make it easier, despite the notion of big-data optimization.

As such, prices will get higher, before they get lower. That or drug dev. stagnates.

The elephant in the room anytime we talk about US healthcare is our flawed food environment - Sugar. It's creeping up on other countries fast.....

> They can continue to set their own rates, but a different rate for each patient must be prohibited.

This is a terrible idea. That means no discounts for people in need, and no doctors saying "don't charge her for that aspirin" as both would become illegal.

I'm all for transparency in pricing, but the lack of flexibility in charging customers is already a big problem. When you go to the hospital, everything is charged at max-price, then insurance companies pay out their negotiated rates. People without insurance don't have the ability to negotiate and end up with ludicrous bills that even the most generous insurance company wouldn't pay.

Instead of subsidising those in need through price changes, the government can simply subsidise those in need directly, paying part of the bill itself. This is how it works in many other countries.

The 46% of the country that gets to decide who runs the country hates doing that.

No, it would just take some more creativity on the part of the doctor/clinic/hospital. Perhaps in the form of "pro bono" work where they waive the standard fees for their work.

Isn't what you are describing (individuals being charged more than insurances who have negotiating power) exactly what this suggestion is trying to prevent?

That's the stated intent, but the plain reality is that it evens the playing field for insurance companies at the expense of leaving the uninsured and underinsured out in the cold.

This is the same as the used car problem. Flexibility in pricing and negotiation increases prices overall, because the base price now needs to be set higher than the objective price of the good. Plus the seller will be much more skilled at negotiating.

In the current model, people without insurance see their prices increase compare to people without insurance. Hospitals charge double to these people because they expect to recover 10% of the bill, so they compensate for that in the model.

The way to capture needs-based payments is an across the board discount. Charge everyone $100 for the treatment, and then offer 90% off for people in need for the entire bill.

This will clarify the real costs and discounts being provided, and reduce ambiguity.

This is the tip of a really trashy iceberg when it comes to general healthcare costs.

Not only is consistent prices by patient a problem, but prices by procedure and by hospital has a huge range as well, as documented many times. An operation can cost $10K at one place and $100K at another. This isn't news though.

http://www.huffingtonpost.com/2013/05/08/hospital-prices-cos...

What isn't talked about is this: when you want to get a procedure done, and your insurance will cover it the same at each place, how do you choose your hospital? Location is usually a big factor. You'd also probably want to go to the place with the best facilities. What ends up happening is that hospitals will build these expensive facilities in good locations to attract, for lack of a better term in this story, customers. Billion dollar construction projects. Do you think their prices went up or down during this build?

That all is raw cost. Now throw in what you pay. If your insurance covers the 95K of the 100K, but won't cover any of the 10K, you're going to choose the 100K procedure. The health care insurer eats that 95K and then raises their prices across the board. Everyone nationally loses, except for that hospital, which is now closer to paying off its new facility.

This situation in reality is much murkier, and I skated over plenty of details I'm sure, some I didn't even realize I skated over.

Now, state of the art medical facilities are a good thing on their own, but there's a game being played here with the prices of the facilities themselves and how they are paid for. With the lack of transparency, we aren't really able to determine much.

All of these dynamics come from the complexities of a system that badly needs to be simplified, regardless of if you think it should be done by the government or privately. You can probably already see here how a single payer system or some sort of direct proportionality costs could make a big difference. I can't say I have the solution, but I think this part of the narrative is often missing.

The other day I went to the doctor and had a minor procedure done (I had two moles I wanted removed) and asked "How much will this cost if insurance doesn't cover it?"

The answer: "I don't know"

How can you not know what the cost of a routine procedure like that is? If a simple thing like that can't be give a cost what hope do we have?

Edit: If anyone is curious, $580 but my insurance covered it.

How big was the medical facility? Might be the case that the doctor genuinely doesn't know since the hospital operations folks determine the price?

That's quite possible. And let's ignore insurance for a moment.

How is the doctor supposed to responsibly recommend treatment if they don't have the faintest idea of what it costs? If you need some kind of drug in the doctor can think of to that would probably work just fine, would it be really useful if the doctor knew that one was $1/pill in the other was $45/pill? If the difference in the price for the patient ends up being significant maybe that should be something to take into account.

However if you set up the system so that the doctors never actually know what it costs…

Sorry I was sleeping during the last message... but pretty big. Not a Hospital but it is 5 floor and if I were to guess at least 25 doctors.

This is not inconceivable. The doctor may know her own fee, but is also ordering services such as use of the clinic, assistants, supplies, and so forth. She has never had to pay for any of those things. She doesn't even know what business entities she's dealing with, possibly an impenetrable rats nest of LLC's. I've read that over half of all doctors are self employed, meaning that their salaries are not a good measure of their incomes.

Were I inclined toward cynicism, I'd say that the purpose of the complexity is to make it impossible for anybody to figure out where the money is going, or who is actually gouging whom. Somebody is gouging us, but we'll never know who, and everybody can claim it's somebody else.

In my view, the only way to get to the bottom of where the money is going, is to manage the whole thing. This may be why nationalized systems cost so much less. The people who are gouging would stick out like a sore thumb.

> also ordering services such as use of the clinic, assistants, supplies, and so forth

For things like moles, a big chunk is the pathologist's professional fee, as well as the technical fees for whatever additional studies may be needed. "It's just a mole" can become "I'm very sorry, but you have melanoma, we'll be excising most of your cheek on Tuesday."

One reason for the bizarro healthcare pricing situation is that hospitals can claim the writedown (difference between huge fake price and actual price) as a loss when filing taxes. A few changes to the Internal Revenue Code would help put a stop to this.

IRS code is the same way we got in to the nonsense of almost everyone getting their insurance through their employer, which led to the situation where there was almost no market for individual policies. That meant they were insanely expensive and the cost effective only way to get healthcare was to be employed by a big company. And that meant switching jobs could be insanely expensive. And that meant you could pay people less because you had a form of lock-in. Don't want to lose that pre-existing condition coverage.

One little text change, design to either give companies more compensation options or promote health insurance (I'm not sure which) had a really huge unintended effect on the way the entire employment system runs.

a little context on the healthcare insurance by employer system: During WW2, the US banned increasing employee compensation, so employers looked for alternatives and they figured insurance would be one area. That's how the US got into the mess of "employer takes up the bill" :)

ref: http://www.nber.org/papers/w14839.pdf?new_window=1

So wars have long lasting impacts on the society, taxes and insurance are some important examples.

I didn't realize it was a war thing. Thanks.

I know this is reference pricing rather than legitimate, but it seems likes a start:

https://www.mdsave.com

Truth in billing, which is required of telephone carriers would be huge by itself in the medical field. Also, being able to opt out of a $600 gown, etc...

> Truth in billing, which is required of telephone carriers would be huge by itself in the medical field.

It would be, but Medicare would never let that happen, because opaque billing is how they ensure they can reimburse below cost and get private insurers to essentially subsidize Medicare patients.

This is a claim often stated, but rarely actually demonstrated - ways in which Medicare doesn't cover costs, that is.

If the ACA had sought to create a competitive market between the consumer and the provider instead of between the consumer and the insurer, it would have been a truly revolutionary leap forward.

Instead, we got entitlement expansion.

It got A LOT more people covered. It made it so you don't have to worry about losing coverage when you switch jobs due to pre-existing conditions.

No, it wasn't real reform. They could've allowed you to shop for plans offered in other states for example. But it was a truly useful step forward for TONS of people.

The methods of Medicare pricing were established by DeBakey's subordinates when Johnson pushed Medicare through. It's backroom deals all the way down.

It's like he's never heard of "price discrimination" ( https://www.joelonsoftware.com/2004/12/15/camels-and-rubber-... ). Yes, medical care in the US is priced to basically be as expensive as you (or your insurer) can afford. That isn't uncommon, as Spolsky points out. Airline tickets are priced the same way. But so is everything that has a premium model and a basic model, etc.

Ok, that article linked was brilliant. It points out all the hypocrisy of being too analytical about pricing.

The real question is how can your customers pay for it.

> Healthcare providers must likewise be required to publish their rates in a uniform format such as industry standard CPT codes or a percentage of Medicare rates.

This proposal does not address the primary reason that price transparency is really goddamn hard: Even if you know exactly what a provider will charge for each CPT code, you don't know which CPT codes are going to be billed for a particular patient care event.

Inconsistent cost per line item is not the key problem with transparency. Tools like Castlight actually do a pretty decent job of guessing how much each item on a provider's CPT "menu" is going to cost a patient. In many (most?) situations, it is simply not possible to predict which CPT codes are going to be billed for a particular patient's care. This is the key reason price transparency tools tend to give a range rather than a specific price for a particular procedure.

(Also: Big picture, the idea that this would decrease costs by 33% is absurd. If healthcare providers had to publish real legit price sheets that were used by real consumers, prices would converge within a market, but they would not converge that low. Published pricing is not going to cause these businesses to collectively roll over and give up 33% of their revenue.)

There are many factors contributing to this actually.

1. Doctors overprescribe because they are afraid of mistakenly underprescribing (we are a litigious country after all). This end up costing patients more tests/procedures, and cost doctors malpractice insurance premiums. 2. Procedures are billed differently per insurance policy. There are millions of variations of anthem PPO, and what they cover and how much they pay differs.

3. You, as the policy beneficiary, only care about your out of pocket cost. You don't really care about the price unless 1) you pay some percent of the money (reference pricing), 2) you are below your deductible.

So you are right, price transparency alone is not enough, but it is indeed a big step. If you knew in advance the price of thing, you probably wouldn't pay 400$ for a bag of saline solution [1]

[1] http://www.nytimes.com/2013/08/27/health/exploring-salines-s...

> you probably wouldn't pay 400$ for a bag of saline solution

Hey, this is a great example: I might very well pay $400 for a bag of saline solution even if I knew the price in advance, because I don't care about the price of the bag. I care about the all-in cost of my treatment. If that total cost happens to include a $400 bag, I don't really care.

The "$30 Asprin" narrative sometimes misses the big picture of healthcare costs. The price of an apsrin or bag of saline solution is inflated to cover the enormous fixed costs of running a hospital with an ER. Could the ER charge $4 per bag or $0.25 per asprin? Of course, but if they lose their per-unit margin on the saline and asprin, they're going to jack up the price of some other CPT code because they have to cover their fixed costs somewhere.

that's a great point, and something that is actually telling about the us healthcare.

The 400$ saline bag is probably an illustrative example, but i believe it's a pretty common line item for most surgeries. I don't know enough about medical procedures, but i assume it's not one of the rare items/prescriptions where the high cost is somewhat justified.

I care about "all-in" cost of treatment. I don't see that. I don't see that until it's too late. I don't get charged for "all-in", i get charged per individual item in that "all-in" care i got.

I constantly feel like my doctors are hamstrung in providing me with the best medical care because of this. It's hard to recommend the best medical option for your patient when you have no idea at what point in time they will be able to afford it. It's fine to say a simple surgery will fix a problem for me but if you don't know how long I'll have to save to afford it it could snowball into a larger/more difficult surgery.

This week my wife and I went to the hospital here in Waterloo and delivered our third child. Total cost was $16... to park our car overnight in the garage.

Now, our delivery was as close to perfect as you can get. We were only there overnight, but there are a million unknowns with a baby, and I'm just so thankful knowing that no matter what might have happened, we would have received what we needed, when we needed it, and if it wasn't available at our local hospital, we would be transferred to where we needed to go— all at no charge.

There isn't really a message here, just grateful to live in a country where my medical professionals can recommend me the care I need without having to have a conversation about costs. And most importantly, that that same care is available to everyone in my country, not just those who happen to work a salaried white collar job.

Cost us $5,500 with "decent" insurance (fortune 200 company, $3k deductible, 20% after that) for my wife to have our first (normal delivery) here in the US of A. God bless America.... 'cause it needs it.

What was the out of pocket? Thousands of dollars, correct?

How many bills did they send you and for how long? How many billing errors were made?

This is not normal in a developed country.

My favorite part is when they bill the baby for the cost of its own birth against its own seperate deductible.

hah - that's news to me. It could have been more interesting where they charge half of the delivery to the mother, and half (where the baby is out in the world) to the baby :)

Make that baby pay for it, America... oh wait!

California's assembly passed a law requiring hospitals to charge Medicare's rates to self-pay patients. Schwarzenegger vetoed it.

It seems like a similar price inflation affects anything sold to the military. Every time I hear comparisons involving the size of the US military budget, I always think "yeah but everything they buy (including hammers + toilets) are 5x-10x the price, so their effective budget is only 10%-20% of that"

To get a closer-to-real cost of healthcare, especially surgical procedures look at veterinary care in the US. Similar tools and equipment, similar medicines, similar training, except pricing is not defused by third party payers and padded by liability insurance costs.

If Thailand can do it, why can't we?

https://www.bumrungrad.com/en/realcost-thailand-surgery

The problem with this thinking is you don't know what services you'll require (apart from routine checkups and specific treatments for already diagnosed problems). It does me no good to have a list of all the thousands of possible things a hospital might do along with a price for each one.

That's definitely part of the problem too.. but that exists because of the pricing structure hospitals use.

If I go into a store and buy a part, they don't say, well let me call the factory, and they'll get a list of all the things that were done to create this particular part, and a price for each. The store comes back with a list: Raw materials: $ Packing materials: $ Surcharge for production delay caused by spill: $ Resurfacing of part because of material defect: $

If a manufacturer tried that, they would be out of business immediately. Yet that's exactly what hospitals do, even down to a charge for the 2 cents worth of aspirin.

In normal businesses, they charge a price for the product that covers the details, the mistakes, the extras required to delivery the product. The mistakes, etc are averaged out over all of the items produced, along with the cost of the misc supplies, equipment, etc.

The current system sucks but I have trouble picturing your alternative. If a person has abdominal pain it could be caused any number of things - some of which could have no cure at all and some of which will just go away on their own. What price list could they possibly consult?

that's a very good analogy. thank you.

> "Congress need only mandate that all hospitals, physicians and labs publish legitimate prices—like all other businesses"

Is that true for ALL other businesses? I know some businesses are under control of price fixing legislation, but is that true for all?

college tuition

I guess that excludes enterprise software companies.

I would wager it is not true for any business.

As others have pointed out, it's not true for some industries: auto repair, enterprise software and college tuition. Also, cell phone and Internet service "bundles".

All of these industries have at least one thing in common: they're kind of scammy.

Sure it is. Auto shops have a labor rate. Say, $150/hr. That's the price. For parts, you'll pay the same markup as the next guy. You can negotiate, but you can negotiate ANYTHING.

They also have a big book of how long each individual repair should take.

If your insurance company has preferred repair shops, do you think the insurance company is paying the standard rate? They do have a better negotiating position than you do.

Of course, this isn't as big of a problem as it used to be, back when they didn't post an hourly rate.

College tuition (at least, my state college) is straightforward. They even gave me an extremely detailed breakdown of every single fee that was a part of my tuition.

I was about to say, college tuition is pretty clear cut. At least in the early 2000s, what they mention on the website and the estimated books/equipment costs pretty much lined up with what I saw on each bill. Some people paid less because of grants (although some people did have their grants disappear when FAFSA decided to change the income brackets), and I guess some people didn't look at the cost, but instead at their student loan returns.

But I was an engineer. I'm sure there are other fields that might have crazy hidden lab costs.

Some people have grants or scholarships, some get free tuition, mostly at the discretion of someone in the administration. And some of us worked our way through grad school, paying MSRP.

Error in the article: auto insurers also have negotiated rates with service providers, including body shops and auto glass repairers.

but there is less variance in prices, more flexibility in shopping, and less variance between estimated and final cost.

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