U.S. health care's widespread overbilling problem
axios.com
axios.com
Let me add my big one: price transparency.
I had a simple test the other day. I could not get a price. I could not get a price with my insurance, or without it. I called at least 9 times. I got 5 call backs from people who asked me to schedule the procedure but no price.
On the 10th call, I finally got someone to tell me what the out-of-pocket price would be without insurance. She told me a range! It was $96-$115. This was close to the range that google says was about average for the procedure.
So this was not a case of over-charging, or unfair pricing. I really did not know if the test was $10,000 or $100 till this call.
If they just made the pricing transparent, I think a lot of the problems would evaporate.
(Although I think the profit centers would suddenly become the emergency medicine section of the hospital.)
I know this article focuses on fraud, but the non-fraud part of the healthcare is just as broken, and probably costs more.
If the Republicans want to reform health care that's where they should be starting.
They don't.
I think only certain 'legal persons' and their executive officers and major shareholders want that. Patients, not so much.
Basic supply and demand theory depends on consumers having perfect information. A free market cannot work when a consumer has no information.
However in healthcare that's not an option, there is no competition. The cost of fixed cost procedures (e.g. lab work) are unknown. You can't shop around for surgeries or doctors. Everything is wrapping in mystery even after the fact, there is no final bill. Even if you pay everything you're asked to, you might still get a bill 2 years down the road for reasons no one can suitably explain.
The same is not true with healthcare - you may go in for a $20K stent, but have a serious complication that needs $200K open heart surgery -- you don't really have the option to say "put everything back together and I'll live with it".
It's not just an expectation, it's the law in many places. When I was a pro mechanic in Indiana, anything over original estimate + 10%, and authorization from the customer is required. Well, not required I guess, since if you show up and the bill is 20% over, you just pay the original estimate. (Yes, in the worst case you might have to sue to get your car back. Personally, I've never known that to have happened, because most shops aren't looking to rip you off.)
But, as you point out, me being in the middle of a top end job is a little different than a surgeon who's working on a running engine when it comes to needed extra work.
Complications during surgery aren't necessarily caused by the surgeon or known ahead of time. The same is true of other things like home renovation where "we won't know until we open her up" is a common enough phrase.
Case in point, we want to remodel a bathroom that has a 7ft ceiling and my wife wants the ceiling raised to match all of the others. Why is it 7ft instead of 8ft? Can it be raised? Without significant cost? We won't know until we get in there.
I don't think that's the case. For example, if you get a lipid panel, it's going to be coded under a given CPT. The billing department should be able to obtain the cash and insurance price. The problem is that they're not forthcoming with it (at least in my experience even when I had the CPT).
I don't think price transparency will fix much, though. The average person I know has employer-provided insurance and doesn't think a bit about the costs of procedures. Price transparency combined with individuals having to pay for their healthcare expenses would help, but there's blame enough to go around for every player in the system, too.
At best in the US is a ambitious term and accepted colloquial term refers to comedy by/for AA audiences. At least places I live in the US (MI, CA, NY).
Anyways English is a fun, dynamic, and at the same terrible language. But I'll take your word for British flavor of the English language.
While that has been true for decades, in my experience, those employer-provided plans are beginning to transfer some of the cost to the consumer through higher deductibles and copays.
My last few visits to the doctor tend to support this, as in both cases, the doctor offered cost-saving options and advice.
> ... average number of patients who need to be treated to prevent one additional bad outcome ...
Here is an example for aspirin preventing a first heart attack or stroke (NNT is ~1,667): http://www.thennt.com/nnt/aspirin-to-prevent-a-first-heart-a...
The guilt tripping of father of sick cold is pretty disgusting tactic.
The recommendation that you go twice a year literally originates from a toothpaste ad in the 1950s. It was an arbritary number intended to encourage you to get preventative care, aided by their toothpaste. (In those days dentists were mostly tooth pullers)
My dentist with many years experience diagnosed it. I went to the doctor who confirmed it was GERD.
I lost my job but when I was working the insurance paid for two cleaning per year. I chose to keep the insurance but it's a lesser plan that only covers one cleaning every nine months.
Twice per year was good for me since I got lazy about three or four months after visiting the dentist. I needed the twice yearly pep talk.
And I should also say that 75% of people who are diagnosed with IPF a fatal lung disease have GERD. My father has IPF and GERD I have GERD but I hope I don't develop IPF. My grandfather died of emphysema at 52 I really hope there's no connection! So yeah a dentist could point you in a direction that may help you more than you realize.
I'm told diabetes and maternity are the most common reasons people access the additional cleanings.
* I realize this is priced into the default premiums.
When they won't provide price information, act as if they've just told you that it's going to cost more than $100,000 and repeat that to them. If they then say "It's not going to cost that much!" "Oh, you mean you do have some information on how much it costs?" Then work them to more detail from there "Well, is it more than 50,000?"
You may also be running into a situation where the person thinks you want an exact price and doesn't have it, so be sure you tell them you're looking for a ballpark number - or if they've irritated you and you wish to unleash the snark, "Ma'am, I'm trying to find out whether I'm going to be feeding my family on rice and beans for a week, a month, a year, or until we lose the house and my child's getting meals at the women and children homeless shelter while I'm out on my own."
Edit: It doesn't quite have to be as ludicrous as I started - a simple "Oh man, I really can't afford $5,000 for that test right now." can also get the conversation started and information flowing.
Sure you might shop around for a non-emergency specialist one-off procedure like an MRI, but the cost of MRIs is a drop in the bucket and wouldn't meaningfully impact overall healthcare costs if they were an order of magnitude more expensive. If you have "normal" insurance plan your insurance provider has presumably already shopped around and only providers willing to take the reduced rate are "in-network".
Don't get me wrong: you should be able to get a cost estimate up front and it is silly that it is so difficult.
Price transparency isn't the major problem in healthcare. The free market and profit are the major problems with healthcare. To set prices a free market requires price discrimination and the ability to price some people out of the market. That translates into debilitating illness (a deadweight loss to our economy overall) or death for serious medical issues. A free market in healthcare absolutely requires that some people be allowed to die of treatable diseases in order to maximize profit.
To put it another way: As a technical matter it is impossible to discover the maximally profitable price for a treatment without raising the price beyond at least some people's ability to pay.
Consider:
1. If you don't have insurance, how do you know where to go?
2. If your insurance company wants to reward you for picking lower priced options, how do you comply?
3. If the government wants to lower systematic costs, how do they give you incentives?
Without basic pricing information, all the benefits of a free market are absent, and so are the benefits of any incentive system.
High deductible health plans are becoming more and more common, from what I gather.
https://en.wikipedia.org/wiki/High-deductible_health_plan now at the high end of that a $13,100 family plan does provide more incentive again unless there is something significant wrong when again the incentive to price shop suddenly goes away. Worse, medical spending tends to mostly be by a few very sick people vs. the healthy making high deducible plans have limited real impact.
I was looking into sleep studies recently, a quick google suggests a cost range of $600 to $5000. I'd definitely shop that around, and if a place won't give me a price then I wouldn't consider doing it.
But like you said, I'm pretty small potatoes compared to sick people.
Recently I went to a doctor for a minor problem, but did not get pre-authorization. I knew exactly what it was going to cost for the visit, and knew it would not be covered by insurance. What I did not know is, due to lack of pre-authorization, it also would not be counted against my deductible! Dicks.
I think major medical (true insurance for unpredictable things like congenital disease or accidents) should be something everyone gets, and it's paid for with taxes. Done. And then for poor lifestyle choices like smoking and having a crappy diet, you should either die (seriously) or you should pay the system out of your own pocket to take care of you (start a gofundme, see if anyone cares about your problems).
There is no possible way to fix healthcare in the U.S. with the multilayered middle man, for-profit approach we have, where everyone touches it wants their cut.
Every state should probably require every food related corporation to be a benefit corporation, with clear phrasing that an equal motive to profit for that business is incentivizing customers to eat healthy. If the incentive is just profit, you get crazy things like government subsidized sugar farmers and boner pill pharma.
EX: Some non smokers get lung cancer, so a percentage of smokers would have gotten cancer either way.
I have (excellent) employer provided care and I knew my cost would be low. But I will post this when I find out.
The number of times I've seen a bill that made no sense and been told, "oh, yeah, you're not misreading it, it's a bill, but you can ignore it because [reasons]"... WTF are they doing? Seriously, no-one else gets away with being so entirely sloppy.
Then there's the wonderful "we sent you one bill for a trivial amount which you probably lost in the pile of 50 other damn bills from 20 different providers, many of which were bills but didn't actually need to be paid (see above), plus twice that many not-bills-but-still-kinda-look-like-them statements of benefits and whatnot, didn't send a followup or call you or anything, but now you're in collections for $90 or whatever and your credit's dinged, sucks to be you".
Then if there's a dispute with insurance the hospital/providers will harass you until it's over. And sometimes just try to bill you even though they know it's being disputed. I guess they think you're not already spending enough time on the phone fixing their screw-ups.
I'm not necessarily in favor of fully nationalized healthcare exactly (some form of universal health care, yes) but it'd almost be worth having the government directly take it all over just to drink up those sweet, sweet hospital billing/admin and insurance company CEO tears. I truly wish everyone involved all the worst.
Anecdote: my mother-in-law was a smoker, felt dizzy one day, went to the ER and died five days later from a brain tumor. Got the Statement of Benefits (or similar): the cost was $140k; Medicare paid $40k...
This idea of medical procedures having random prices is the sort of thing you have to deal with at veterinarians where a simple procedure can cost anywhere from $75 to $500 depending on the place you're going to.
My car was recently hit in the parking lot. The body shop said, here's the cost of the repair of the items we can see, but with the warning that it could go higher if we open things up, and find additional damage. Same with people.
The other thing is the you know with a car exactly what you will end up with in the end. And with simpler medical procedures that is true, but as they get more complex - the more you are navigating a mess of interlocking procedures, probabilities, and outcomes.
Build "open source" coding, grouping and costing schemes and tools to maintain those schemes. It would look something like: 1) a software tool to maintain coding systems, grouping, and related costs (essentially a database front-end); 2) something like Wikipedia/GitHub that maintains version history and controls for coding, grouping and pricing schemes; 3) crowd-sourcing so healthcare professionals and organizations could help maintain the data; and 4) a non-profit, non-governmental organization (maybe something like the Mozilla or Apache foundations) that runs to help govern and provide structured releases of the open coding/grouping/costing data.
These are just my ideas, but having worked in this industry on the problem of health insurance/healthcare fraud and "healthcare cost" - there are a bunch of organizations making a small fortune controlling these schemes (ex. the AMA) - something ripe for disruption (I hate using this word, but it's the truth).
You need quality coding/grouping/costing schemes and systems for the industry to function, but it should be many, many times more open than it currently is.
Having a price list in hand doesn't suddenly make the price conscious consumer more of an expert regarding the necessity of various services estimated. Nor does it really encourage competition between competitors.
Here is a planet money podcast which goes through some examples of significant expenses being saved.
http://www.npr.org/sections/money/2015/10/02/445371930/episo...
There are several systems, but let's take a look at Outpatient procedure pricing...
A good outpatient pricing guide is here: https://www.cms.gov/Outreach-and-Education/Medicare-Learning...
And coupled with the OPPS dataset here: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Paymen... as well as a couple others, along with a quick read of the federal register, you can kinda figure it out on your own (/s).
Every bill you get must also have the codes and modifiers on it by law. Its interesting to download the dataset and look them up.
--EDIT-- I incorrectly linked to the COBOL PC Pricer code above for OPPS! Here is the pricing data: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Paymen...
You seem to be talking about medicare and medicaid, and not about private hospital services. Is that correct?
Fraud does happen most often against medicare/medicaid (as covered in this article with one trick known as "upcoding"), but I believe these codes are used with insurance providers as well. If a hospital or doctor is in your provider network (HMO/PPO) then there is a pre-agreed cost between the two set on these fees. Out of network occurs when there is no agreement, so there is no "trust" between the two and the insurance provider offsets the cost to you because they are legally able to do so.
In my opinion - overbilling is really caused not by pricing complexity, but by the control of the hospital and insurance provider duality. If there was no such thing as a network, and you were covered everywhere, then shenanigans with certain hospitals and providers would be more difficult.
If you're getting something like a chest x-ray (posterior and lateral views), or an abdominal ultrasound, or a lipid panel, you should be able to call around to various labs with the appropriate CPT code(s) and ask them what the price would be.
What's you're talking about would be something like if they order a test and based on the result of that test, they need to perform more tests to confirm or eliminate a possible diagnosis. But for each test, you should be able to get the price since each test has a couple of possible CPT codes that it would fall under for billing purposes.
What you're sharing is great information and a fine foundation for people to build on. But pateients shouldn't have to go off and do a pile of research, they should be able to get a straight answer from their health provider when they ask for one.
If you have a pet and have to visit the vet, you already know they prefer to get paid up front. They'll generally tell you there's a fixed fee for the consultation/ Then depending on what's wrong with your animal they offer a treatment estimate, which is prepared within minutes and about which the administrative staff are generally competent to answer questions (eg why there might be variations in price for some items like anaesthetic). Animal medicine is at once less complex than human medicine (narrower range of treatment options, fewer administrative/legal considerations) and more complex (considerable variation among species).
I've been to good vets and bad vets, but the administrative aspects of both regular and emergency care have been painless and yes, transparent. Until we get universal healthcare, veterinary service would be an excellent model to imitate.
Regarding pets, they are not beholden to hospital/insurance provider duality, and it follows that since it is out of pocket, you would not be able to afford a $60k set of procedure if your dog had a broken leg...so the prices stay affordable.
> "Do you think I have others?" said Lord Vetinari. "My motives, as ever, are entirely transparent."
> Hughnon reflected that 'entirely transparent' meant either that you could see right through them or that you couldn't see them at all.
-- The Truth, by Terry Pratchett
As far as I recall, Medicare pricing is defined by law as a percentage of the lowest price the provider ever charges to anyone else. For the sake of this comment, call it 40%.
If Medicare pricing is public, you can look it up and try to negotiate for 250% or whatever of the Medicare price.
Lack of price transparency bothers me as well and I wish we had it.
However, I don't know if there will ever be enough pressure to manifest this. Price transparency really only matters to the person paying the bill. Our society is very rapidly evolving to consider any healthcare cost of any kind to be an insurmountable burden that no normal person could ever be expected to pay. I suspect that the incomprehensible, ridiculous healthcare schemes that we are living through currently are just death spasms on the way to fully socialized medicine.
I'm sure there are rare people here and there that care how much a mile of highway costs to pave or how much a mile of city sewer line costs to install ... I would expect the same number of people to care about the cost of a medical procedure when their own cost is $0.
On the other hand, if prices are not managed properly, premiums get higher and higher. So even if insurance pays, you should care that prices are reasonable.
If you don't do routine maintenance, the engine breaks down and _you_ have to pay for it.
If you don't do routine checkups, you get sick and insurance has to pay---and also, if you die those sweet premiums stop coming to them. Insurance actually has a vested interest in paying for your checkups and screenings, just like in countries with socialized healthcare.
No offense meant, but I find this attitude really odd. I'm not from US and only have an overall idea how things work there, but I wonder... Isn't that still your money, even if you pay $0 directly and the rest comes from the shared pool your insurance payments or taxes are also in?
I just tend to believe there ain't no such thing as a free lunch - someone has to pay for the medical services, highway pavement or sewer line installation. People can't be expected to work for free, right?
So I think anyone participating in a collective funding effort should have at least some rough ideas how the money they pay are used. If we don't care about how government or insurance company (or whatever entity we pay our share to) manages things - we would surely end up with insurmountable burdens called "things running out of control".
Well, please do read the first sentence of my reply - I do care and I do wish that price transparency were extant.
Further, as a net tax payer, in California no less, I am quite interested in the actual costs of things like road paving and bridge building and subway tunneling.
But neither of those (net tax paying and interest in the pricing of social goods) are common traits.
I think the issue is that most of these services are so cheap that the cost isn't ever a major factor. "No one cares" is probably more accurately stated as "no one is forced to care, because the general public can have confidence it's handled mostly responsibly".
In Michigan, for example, to completely tear down and rebuild new a lane-mile of freeway that is rated to last 20 years, cost roughly $2 million dollars in 2016. So, a brand new stretch of freeway, 4 lanes wide and 100 miles long, would cost about $400 million dollars. (That distance covers, just as an example, an entire trip from Chicago to Milwaukee)
That cost sounds insane at face value, and gets everyone worked up about "costs". Until you math that out and realize it comes out to 33 cents per citizen per month. At which point, freeways seem like a crazy good bargain. Even if you go crazy and build 20 times more freeway than that, the total cost is still cheaper than a Netflix subscription.
They're not all that low of course, but this tends generally holds true of many social services or utilities (water, sewer, electrical, firefighters, schools, police, etc). High upfront cost, high "sticker shock" value, but as a common good everyone can benefit from it becomes a pretty reasonable cost per person. Far lower than it would ever cost to do so any other way.
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The only thing that doesn't seem to work that way in the US is healthcare. And I don't know why, but I suspect it's because it's so privatized and unregulated (so lots of profit and overhead) and also so intentionally hidden in terms of cost (so there's no way to look up costs, the way you can with any normal social service).
Always thought their approach was quite clever and I think they did end up having some success though I'm not sure the overall impact has been as transformative as was originally hoped.
It results in tools like this: https://cha.fhsclearquote.com/ You put in your zip code, how far you want to go, find the condition, and it gives you a list of hospitals, average charge, case volume, and 5th and 95th percentile costs.
I'd love a more nuanced analysis that looked at outcomes, too. Still. It's a great tool for planning purposes ("If I have an emergency, take me to . . . ")
You'd think it hasn't, and the missing focus on outcomes gives it away.
So now when I'm signing the papers accepting responsibility for the financial obligations if my insurance doesn't, I ask what it's going to cost if my insurance doesn't cover it. The nurses have no idea. It has to get "coded" before it's billed, and then after the bill is declined the coding people can tell me what I owe them. It's ridiculous.
Doctors have a similar problem: too much uncertainty which can't be eliminated until the treatment is completed. They can't even tell you how much an office visit costs, because of the variability in how much time each patient needs, involvement of nurses and PAs, and any tests that must be performed.
Lab tests are a little better: they tend to take a predictable amount of time to perform, and the analysis is pretty standardized, but there's probably still some variability when the results are not routine. That explains the fairly narrow range you were eventually able to get.
I think we've got the wrong pricing model in mind for healthcare. Instead of itemizing every little action, test, and pill, we should be aggregating these costs. Pay medical professionals fixed salaries, fund institutions using budgets for fixed costs and consumables costs, and pay for it all via taxation as a common good, like public education, libraries, defense, etc.
Having said that, though, unlike developing a new piece of software we have vast stores of data about procedures, complications, and outcomes from other patients who have already undergone the procedure. Surely there's a pricing model, if we are bound to fee for service, that could use this trove of existing data to provide more transparency.
I'd be happy with knowing pricing within half an order of magnitude.
For example, if Procedure A tends to be more costly when the patient also needs Procedure B, that's significant. But if the aggregate information includes the fact that the same patient needed both A and B, that might be usable to identify the patient, and so the relationship can't be shared in the data.
You're probably thinking more along the lines of unnecessary tests being performed, or prescribing drugs "just in case". I have a dermatologist near me who I like and who is widely known, but every time I see her if she prescribes one drug for me, she prescribes 1 or 2 others as well for the exact same thing.
I believe that this sort of waste comes partly from a financial incentive (line items on insurance claims, or justification for them, and in my dermatologist's case kickbacks from drug companies), and partly from as a defense against being accused of malpractice. It could also be simple laziness too: order a test and let the lab try to figure out a diagnosis.
Any major overhaul of the healthcare system along the lines I proposed would need to deal with these issues as well. The financial and malpractice incentives could probably be eliminated. Maybe laziness too, assuming doctors had to get annual reviews for salary adjustments, just like everyone else.
What the OP found on the 10th attempt to get a price was somebody who was willing to look up claims for other people who had the same test, determine what the reimbursements were, and let him know the cross-insurer range of those amounts. Or maybe the range was over the claims sent to the insurance companies, rather than the amounts the insurers actually paid. If that's the case, then the range reflects actually differences in the test processing rather than differences in the insurers.
Not in all cases. If your doctor orders labs or procedures, then getting the price should be straightforward. The fact that it currently isn't is a problem.
Just today I went to an major-hospital urgent care clinic that has an upfront $50 fee to "be seen". I normally avoid the system like the plague it is (hence not wanting to pay into its protection rackets), but my girlfriend had gone last week for the same week-long fever and had a good experience, so I figured I'd give it a shot.
The person working at the desk told me that there "could" be "extras" that would be beyond that fee. Okay, cool. The physician's assistant recommended a chest x-ray, added it was around $75, then confirmed it was $56, and I quickly agreed. My girlfriend was a bit miffed she had turned down the x-ray without knowing the actual price.
When it came time to settle up the bill, they had added on a $130 charge because the PA had added on some billable event for her seeing me, despite that this should have clearly been included in the "$50 to be seen".
This is textbook fraud, yet it is allowed to persist. I complained, and was met with the standard "it's nobody's fault" attitude, because these people are really just skinjobs on an opaque computer system. If I had been my normal self (currently dealing with some major life events), I would have only paid for the x-ray and told them to shove their unauthorized charge up their ass. Alas, they dropped the fraudulent charge to $80, but the bad taste remains.
If I had been told the higher charge up front, that would have been completely acceptable - and if I thought it too high I could have gone to a competitor, or simply not gone (never before in my adult life have I gone to the hospital for a fever).
And that doesn't even address the travesty of the only result coming out of this visit was receiving a prescription for the exact same antibiotic my girlfriend had received a week prior! It would have been much easier for her to buy two simultaneous doses from the pharmacy, but the cartel has that locked down as well.
the new billing fun I have is required visits for prescription refills on some medicines and that to me is just overbilling in a different form. I didn't need to visit other than to get permission to refill; no it does not necessarily need to be a controlled substance
In America, price negotiation is done between providers and insurance carriers. This has a few obvious effects. First, it gives us the in-network/out-of-network distinction. Second, it introduces complexity in the math sense to pricing - providers aren't charging one price, they're charging a wide array of prices, although those prices don't really vary much.
The network thing also has the effect of reducing consumer choice in providers. I can use whatever doctors/facilities my insurance has in-network, unless I'm willing to cough up the difference out of my own pocket.
Of course, fixed prices would be that wicked socialist government control we're told is ruining everything.
Even without insurance all our procedures cost total less than ~$100 apiece.
The most expensive thing I've ever had in japan was my full body workup last year for $500.
It included: stomach ultrasound, 5 blood tests, eye exam, MRI(brain) and barium scan. All without insurance.
By comparison, in the US I was charged $1200 to get my daughters arm cast changed (no xray, just a nurse changing the cast), and $800 for an ultrasound.
It is literally cheaper to fly to Japan and get treatment without insurance than to use my health insurance that I pay $1300/month for.
Also, as a bonus, because of the set prices of medical procedures in Japan, insurance is super cheap. For a family of 4 it was costing me around $500/month when I used to live here.
In bigger cities, you'll definitely be able to find doctors who can speak English easily.
I hope the nurse got paid at least half of that.
There are options for transparency that don't involve a government takeover of health care. But the brinksmanship in the politics of health care --- almost entirely the fault of the GOP --- is keeping us from exploring solutions.
Medicaid varies because states have way more control and many states (especially Republican-leaning ones) have slashed their rates as part of a concerted effort to kill the program. Not that it matters - in Texas you generally can't qualify for Medicaid if you're childless or have a job. The income requirements are insanely low.
If a doctor doesn't like the rates Medic[are|aid] are paying, they're free to not accept Medic[are|aid] patients.
Also, Medicare and Medicaid can't negotiate drug prices.
Standardized pricing gets rid of the problem of charging different customers (slightly) different pricing, and having massive negotiations on a per-carrier basis. This sort of thing isn't a matter of "competition drives down cost". It's just stupid and inefficient.
Highly offtopic, but thanks to anyone who helps me with this: wouldn't ensure be a better fit here?
In the majority of the 1st world where the goverment and general population accepted the fact that healthcare is a special case outside normal economic rules. That's why get things like single payer, price controls.
That's not the prevailing belief in the US. The majority of people in power (not sure about general population) believe that healcare is like any other business subject to the same rules. Single payer is government interference into the market; price controls are definitely out of the question. Price controls might even be unconditional (if challenged, depending on context).
Also, the various lobby groups representing doctors are very powerful much like unions used to be. However unlike labor unions these groups have broader cross party relationships. These groups tent to oppose any kind of limits on pay that could directly impact their constituents.
When you put that in perspective it's obvious to understand why we end up which such convoluted solutions as the ACHA in order to expand/guarantee medical coverage to people.
I ended up negotiating a price for the CT on the spot; none existed. They simply couldn't tell me how much the test cost. I had to extravagantly over pay in order to get the test done at all.
$0. By definition.
But I think you may be confusing a health insurance provider (equivalently, a health care payer) with a health care provider.
Pricing isn't transparent because people usually aren't paying with money they perceive as their own. What do you care if your insurance company pays $200 or $2000 for that MRI? Eventually that difference shows up in the form of higher premiums, but that's far too complicated for people to respond to intelligently.
Let's go one step further and imagine a world in which we completely replaced Medicare with a catastrophic coverage system. If you have a heart attack or something we'll take care of you, but for your day to day healthcare we'll just cut you a check for however much the government was previously paying. You can choose to use that money on anything you want whether it's healthcare related or not. You want to see price transparency and the power of competition to lower prices? Boom, done.
Giving cash (or cash equivalents) to people is probably not a good solution.
The hospital industry claims non payments total around 6% of hospital expenses.
http://www.modernhealthcare.com/article/20120106/BLOGS01/301...
I do wonder if they calculate that 6% on what they bill though, rather than on what things actually cost. The margin on an unpaid bill isn't really a cost.
"[…] 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.)"
This is an amusing pastime if you can afford temporary depressions in your credit score.
They're actually good at it, and it were a startup extracting those profits they would be applauded for it.
I used my hsa to pay the balance of about $800
9 months later, instead of refilling with the correct insurance company, they sent us a $20k bill.
After we called them and said, hey you know you should probably refill with the right company, they did. The insurance company declined because they took to long to refile.
The hospital never bothered to follow up and explain the situation until we called the insurance company ourselves and had them restart the process.
In the meantime our secondary insurance approved the part of the bill that was for my son, rather than my wife. The hospital sent me a new bill for $200 for their deductible.
From here, there was an extended game of back and forth where they'd send me a bill and I'd call and ask if they figured out the rest of the insurance and what happened to the HSA check we sent them. This went on for 13 months.
My son is now walking and this week they finally sent us to collections.
I called and threatened to take them to court, and finally talked to a supervisor who admitted that they owed us $600.
But what about collections?
Sir, that was a different bill.
Why can't you take the money that you owe me and pay the bill that you just sent me to collections for?
Well you didn't ask us to do that. I'll go ahead and do that now.
I resisted throwing my phone through a wall just barely.
It's a ridiculous system.
As long as Americans can't stomach the idea of turning away people who cannot pay for emergency care to die we have socialized medicine. I don't understand why we can't, as a society, have a "grown up" conversation about this fact.
Instead of this perverse system of "shadow" socialized medicine, fraud, and over-billing, why not just make it come out of everyone's taxes? That way everyone pays a very modest amount in tax and no one has to be financially ruined by flukes of nature.
Also kills a huge amount of overhead in the billing departments, collection agencies, insurance companies, etc.
(No system is perfect; there is always room for improvement and trade offs)
Just two weeks ago, my wife had an emergency appendectomy. She went to the free clinic first thing Sunday morning as she had terrible pains all night. They immediately referred to the local hospital. She had the ultrasound in the afternoon and Surgery at 3:00pm. She's been off work (more or less) for 2 week recovering. The only thing we paid for is parking.
This[1] redditor in the US has the same surgery and it cost $55,000 dollars, which insurance covered a lot of but still left him with an $11,000 bill. That's just one simple surgery and that's not a small amount of money.
[1] http://www.cbsnews.com/news/cost-of-an-appendectomy-reddit-u...
longer wait times for non-emergency treatment and (most of the time) not being able to pay cash and get the procedure done without the wait. personally know ppl in Canada (Toronto, so not some little town in the boonies) who had to wait few months to get an MRI.
on the US side - takes 2 weeks or so to get the insurance company's approval (they do this dance with a mandatory x-ray and electromyogram appointment before approving) or $500 or so gets you in like tomorrow.
the kicker of course is they will charge the insurance company $3k.
that said - the current US system needs a major overhaul, no doubt. both Obamacare and the not-there-yet "Trumpcare" are lipstick on a pig solutions though.
On the other hand, my experience with the US is that the service is great. They'll even send you for unnecessary tests just because. And it's all pretty fast. But then you have so many people who get nothing at all. And then many of those who do get something are totally bankrupt.
There is no system that can give anyone health care and not have a triage system. So you might have to give up some comfort so your neighbors can live.
I remember reading in the news they were considering charging a nominal fee, like $5 to cut down on these types of visits. On the US side you'd pay around $50 for one of those visits (unless you go to your doc) - wait time is like 10 min.
I actually wouldn't mind something similar to a Canadian system - if they can manage that without tax increases :) - plus a private "network" someone who can afford paying for a private insurance (or using straight up cash) can use.
Actually making an appointment with your family doctor is also free. You don't have to go to a walk in clinic.
I really want to see actual studies on this. We Americans LOVE to throw this in the face of the countries with single-payer, yet we conveniently gloss over the fact that many Americans PUT OFF health care procedures because they can't afford them. I've done it and I know many, many others that have as well. Oh, this is going to be 1500$ out of pocket and doesn't need to be done today? Great let's schedule it for 2 months out.
Additionally, Americans also have wait times for non-emergency procedures. Colon cancer runs heavily in my family and so all of the older members get regular colonoscopies. I have several anecdotes of family members having to wait 6 months before they can get it and get theirs done.
AMERICANS ARE NOT ANY BETTER WHEN IT COMES TO WAIT TIMES. However, the onus is typically not on the provider, it's on the patient. So we describe the situation differently even though it's the same outcome, the patient has to wait for treatment.
In comparison, e.g. most European countries use a combined two-tier approach, where the role of the government is to ensure universal basic coverage and affordability of that coverage, but not to replace private insurance entirely.
Source: lived in US for 20 years.
They just don't want to give their money to a bunch of bureaucrats, who spend it mostly on themselves, and seem to multiply like rabbits.
[NB I'm just out of a UK NHS hospital so therefore feeling very warm and fuzzy about our favourite chunk of socialism].
You won't find many conversatives in other countries who want to give up their socialized medical system.
Americans aren't generous. Americans are preoccupied with moving money. The more it moves, the faster it accumulates to the top of the economic pyramid.
In fact, a single payer system would sharply reduce the number of jobs for health care administrators -- to the point that I've seen a blog post somewhere pointing out that these people would need income support and retraining. The economies of several small cities depend heavily on these jobs.
As someone who just had a few days in an NHS hospital I'm pretty much delighted with the experience. When was money mentioned? Not once, not once.
Seems a tad callous even by my standards as a staunch classical liberal; may be all other medical services but not emergency services.
The "conservatives" who bellyached that the ACA created "socialized medicine" willfully ignored (or were ignorant of) the fact that the mandate to treat emergency patients regardless of ability to pay "socialized" medicine when it was passed (by "conservative" stalwart Ronald Regan) in the EMTALA[1] in 1986.
[1] https://en.wikipedia.org/wiki/Emergency_Medical_Treatment_an...
The doctor then demanded full payment for his non-discounted rate-- 6x the insurance reimbursement rate.
To my mind, acceptance of the "deal" was done when the doctor took me on as a patient and agreed to perform the procedure. At that time the practice had full knowledge of what the reimbursement rate would be. I see the doctor's "windfall" of demanding the non-discounted rate as being fraudulent.
He made an argument (that I considered specious) about "fairness" to other patients and problems he'd had in the past with patients mistreating the office staff because of perceived "unfairness" in his offering discounts.
My attorney advised me that I'd likely spend more money fighting the doctor than just paying him. Because I care (probably more deeply than I should) about my credit rating I opted to pay the doctor and put the whole mess behind me. I also ditched my pre-ACA insurance that carried this never-expiring pre-existing condition waiver and moved to an ACA plan with no such waivers.
The surgery center that was involved in the ordeal was much more reasonable, BTW. They charged me the amount my insurance company would have reimbursed them. When I brought this up to the doctor (who is also a partner in the surgery center business) he simply stated that his office's policies differed from those of the surgery center, and that his policy was to receive his full fee.
I've often thought this could be solved by legislation (something like the uninsured cannot pay more than the lowest insurance + copay amount), but lots of folks are against such price controls.
The whole system is fucked.
I am referring to the system that facilitates American residents getting healthy and staying that way.
What is the basis of my claims? I admit that I am a healthy 33 year old white male and I probably have only seen that tip of the iceberg. I am also a father of 3. My oldest daughter was born with a chronic health problem, diagnosed at 19 weeks gestation.
Since her birth, a little over 7 years ago, we have received a bill from the hospital that provided her care at least once per week. This continues today, despite not having had any services provided in almost a year.
If I paid all of these bills, bankruptcy would be my only recourse. I try to communicate with my insurance provider (employer provided), to determine what's legitimate, and what should be covered. In the end, I'm mostly left to my own devices to pay for the services that I think I received. Every year we pay the deductible, and every year we get billed for significantly more.
As another example, not along ago, my third daughter was born. Due to the complications of my wife's first pregnancy we received care from two different OBGYN facilities, one local to us, and one at the delivering hospital.
Though the local facility was only responsible for less than 10 checkups, they claimed that we still owed our entire deductible to them, prior to delivery. We paid half.
A week prior (this much is hilarious in itself) to delivery by a doctor from the other facility, we received a bill for the full deductible amount, due to them also.
When the delivery actually happened, it took less than 2 hours, and we stayed one night. We also had 3 checkups at this other facility. Our bill of course is the same as everybody else's, regardless of whether they had a C-Section and stayed for 5 nights, or had 30 hours of labor. I could actually be OK with this (I'm onboard for socialized healthcare), if they could get the billing part right.
Again:
* I am constantly billed directly by healthcare providers over and above what my insurance policy says I should pay.
* I pay almost 25% of my yearly earnings in insurance premiums.
* I end up deciding what I will pay and what I will not pay. I admit that this is probably not the best situation for anyone.
The whole system is fucked.
Everything that touches healthcare billing is scammy, incompetently managed, and often outright fraudulent. Good luck getting any compensation or justice other than what you were originally entitled to, though.
I live in Canada. For the next couple weeks, I'm unemployed. During this time, I'm planning to get some health checkups done, possibly get a referral to a sleep clinic, and maybe get my hearing checked. I don't have any fears or worries about this.
Friends always tell me I could be making so much more money in America... It's not worth the stress, the bullshit.
While this in and of itself is not a problem, the United States also spends more on health care as a percentage of GDP than any other advanced country in the world and has worse health outcomes – with lower life expectancy, higher infant mortality and higher obesity rates than comparable countries like Australia, Canada, the United Kingdom, Germany, France and Japan." - http://theconversation.com/three-reasons-the-us-doesnt-have-...
Super size that...
Isn't the primary purpose of insurance for exceptional and accidental situations? If that's true, then why am I using it for predictable monthly expenses?
Children 0-19 years old, $10/month with at least one parent membership
Adults 20-44 years old, $50/month
Adults 45-64 years old, $75/month
Adults 65+ years old, $100/month
Employer groups with 5+ employees, $50/mo/adult
https://www.youtube.com/watch?v=bGZaRnC1wNg to hear one doctor talk about how this works out in practice.
Google Direct Primary Care + your city/state to see what's available. It's SERIOUSLY better than the mainstream option. I've been doing it for nearly a decade now, and would never go back. Combine it with a cost sharing plan (NOT insurance) such as https://www.libertyhealthshare.org/3-program-options to achieve superior care at lower cost.
Suddenly you are no longer a healthy individual you are an individual with a history of condition X and Y which you have never even heard of. And because a doctor wrote it down it's now a reality and the patient is a liar!
Side note, I work IT in healthcare, so I sometimes view "interesting" things to say the least. A while back I stumbled upon a document that was accidentally shared. It showed accounts receivable in collections agencies for one hospital in our system. Between 2009 and 2012, there was $154m dollars in collection agencies from delinquent accounts. Remember, this is just one hospital that is actually in a more upscale location. We have some hospitals who are always in red due to their locations.
Then you deal with inflated prices for services and drugs. I really don't even know if they can ever fix this part.
Fortunately, Medicare is looking at this problem now. http://www.compassphs.com/blog/health-navigation/medicare-to...
Well-baby checkup: $120
School sports physical: $150
Blood tests: $80
Minor broken bone: $400
Major broken bone: $1200So add what all car shops say:
Hourly rate: $100 / hour.
And begin with a 30 minute to 60 minute diagnostic estimate (providing findings at 30 minute increments).
Note that the same guild system is in force in just about every other country.
> Everything else is window dressing
I think most reasonable people can figure out a) the difference between the US healthcare system and nearly all other countries, and b) what that difference might mean for costs. Here's a hint, it's not "the guild system limiting the supply of doctors".
While it doesn't help your wife, this information can help readers that either want to go into medicine themselves, or have family members seeking such employment.
Applications to med schools have been down for the last few years, and the trend is worrisome. Your doctor-bashing stance is common but uninformed.
Edit: http://gamapserver.who.int/gho/interactive_charts/health_wor...
https://en.m.wikipedia.org/wiki/Usual,_customary_and_reasona...
Resource-based relative value scale - https://en.wikipedia.org/wiki/Resource-based_relative_value_...
It took the government 20 years to figure out that they couldn't give the medical system a blank check.
/methinks a helpful medical reform would be to get insurance-paid doctors on fixed salaries. Under the present status quo, some doctors bill insurance companies for as much as they can get away with.
If you look into how the RBRVS are calculated, there is effectively a privately run panel that determines input variables and factors that are used in the RBRVS calculations. At some point, someone has to determine the portion of the calculation that represents "physician value added". While it is true that RBRVS is an alternative system to pure UCR rates, I can assure you that UCR rates still play a major role in many health insurance lines of business and calculations.
By the way, RBRVS aren't the only system that organizations have tried to use to figure out how to bill/cost services - there are also DRG groups (diagnostic related groups), ASC groups (ambulatory surgical center) groups and others.
RBRVS were mainly made to try to control physician office costs in Medicare and are used by HMOs that offer Medicare plans. While other HMOs and private insurers use RBRVS, there are a lot of them that still use UCR (calculated internally) as well.
There was a huge problem around 2009/10 with a big company, Ingenix, that was offering a commercial UCR database which was probably of poor data quality - based on surveys of regional prices from doctor's offices. There were lawsuits, etc. over that and many insurers moved away from commercial sources of UCR and instead brought that in-house. Here's a link that talks a little bit about that: https://www.managedcaremag.com/archives/2009/5/ingenix-after...
Price transparency could help (if it could be achieved), but there are a lot of for-profit organizations who actively try to keep their strategies internal. Transparency might not be enough without pricing controls, but exercising control would be extremely difficult for legal/political/profit motive reasons as well. For that matter, coming up with singular pricing systems that govern controls at scale is incredibly difficult.
I have a doctor who gives his patients a receipt that they can use to "try" to get reimbursed by insurance. He takes cash or check, has all the patients he wants, and zero employees.
Stanford hospital billed us for an IVF procedure. However, we were in Paris at the time they claimed my wife was undergoing the procedure.
It took going down to the billing office with our ticket stubs and pitching a fit to get it zeroed out.
I agree there's lots of room for improvement in medical billing.
No choice, no competition, no money left when they're done with you.
When I'm particularly exasperated with the healthcare system (usually in the weeks/months following some kind of medical engagement) my answer would be "I don't give a damn which we choose. Let's just make a decision to either socialize medicine completely or let people die."
(My mood is unreasonably caustic after dealing with anything medical. The stress of dealing with healthcare billing, health insurance, and the patriarchal attitudes of medical practitioners raises my blood pressure and gives me near panic attacks.)
When I'm in a more calm and normal mental state my answer would lean toward socializing as much of the healthcare system as possible.
Literally nothing is a bigger fear-factor in my life than medical expenses. The fact that the entirety monetary value of my life's work could be destroyed in a moment by a medical issue freaks me out. The fact that I cannot, in any financially viable manner, insure against this kind of event amplifies that fear.
I feel comfortable in saying that, at least in an abstract way, I am less afraid of death than of leaving my family destitute as a result of unforeseen medical expense.
I know people must get sick of the "holier than thou" attitudes of the nations with universal health care, but it's stories like yours that make it all the more sad... living life only one medical emergency away from financial ruin and destitution...
It's truly a tragedy. It would already be awful enough that you'd be in ER facing a life-threatening situation, but add on looking forward to the bill... holy. fucking. shit.
Worth noting that the book describing the principles of the UK NHS by its founder was called "In Place of Fear":
https://en.wikipedia.org/wiki/Aneurin_Bevan
Medical emergencies are stressful enough when there is no money involved - I have no idea how people cope when there is a stressful financial situation added on top as well.
We detached this subthread from https://news.ycombinator.com/item?id=14736827 and marked it off-topic.