What Happens When Doctors Only Take Cash (2017)
time.com
time.com
Sounds like the medical industry had better lobbyists.
Therefore, any market for individual purchase of healthcare (whether via insurance or directly) can only have faulty price signals.
Systems based on markets with faulty price signals are wide open to manipulation.
The perpetuation of such markets is contemptible, and particularly so in the case of healthcare since there is a straight line to be drawn from dysfunctional systems to human suffering.
Perhaps it is just to make sure they always get the max from the insurance companies. Or maybe they are able to write off the portion that the insurance company won't pay as a loss or bad debt.
Personally, I believe this practice to be outright blatant fraud. There is a complete lack of price-transparency for the end-user, whether there's an insurance company involved or not. And for people who supposedly champion the so-called "Free Market", Congressional Republicans are certainly quiet on this one issue, when they're criticizing the current healthcare system and regulations.
The real problem is that I rarely have any reason to ask if my insurance is going to cover all of it.
"Adam Ruins Everything" had a really good segment on this.
The mechanic gives you a quote. If the costs changes they get your explicit approval.
That would be nice to start there on the medical side.
No one minds if there are common sense exceptions.
Of course there may be emergencies that come up that are unpredictable, but that doesn't mean you can plan for some of it!
On the back end, there is the cost of lawsuits that also drives up prices systemically.
And, finally, not everyone pays their bills to their insurance companies. Everyone else has to pay those costs.
In these ways, insurance will always be an every increasing spiral of cost, eventually.
> On the back end, there is the cost of lawsuits that also drives up prices systemically.
Here's one example. A (probably not domesticated) cat scratched someone. They went to get shots. Waited a couple of hours and got the shot. Bill in the mail for about $8k. Somehow, I really doubt Humana paid their 80% which is $6,400 but of course the patient has to pay the 20%. I suspect what is happening is that Humana pays close to $0 and the patient picks up the whole tab of $1,600.
I totally get your point, but is that real example?
http://health.costhelper.com/cat-scratch-disease.html
Typical costs:
- For patients covered by health insurance, out-of-pocket costs typically consist of doctor visit copays, prescription drug copays of $5-$50 or more, or coinsurance of 10%-50%. Cat scratch fever treatment typically is covered by health insurance.
- For patients not covered by health insurance, cat scratch fever treatment typically costs less than $10 for over-the-counter pain relievers. For severe cases in which antibiotics are required, it typically costs from $30-$90 for oral antibiotics. For example, Drugstore.com charges about $30 for a two-week course of the generic antibiotic rifampin. It charges about $80 for a two-week course of the antibiotic ciprofloxacin. And it charges about $90 for a two-week course of the generic oral antibiotic azithromycin.
- In the extremely rare cases in which serious complications occur and hospitalization is required, cat scratch fever treatment can cost tens of thousands of dollars. According to Medscape.com, the median hospitalization charge[1] for cat scratch disease is about $46,140.
Yes, it actually happened. Overland Park, Kansas around July 2013 if I remember correctly. Also no fever. More like rabies and tetanus shots from what I heard.
What if we could force all hospitals to disclose all financial transactions publicly? Would that help?
Nobody can afford that. Especially with how drug prices have escalated. And in some of these chronic conditions, the end-stages become very costly.
Insurance absorbs the early costs of regular care, which PREVENTS both chronic conditions, and these costly end-stages. (This is widely-accepted science, not insurance company marketing).
So this catastrophic-only model simply is not tenable, will not work. Unless either these treatment prices come way, way, down. OR: we address the real source of the problem, which is that incomes have not come up to meet these niche costs which have inflated greatly, yet somehow avoided being measured and added to overall inflation statistics. ("hedonic adjustments", anyone?)
Trump actually campaigned on lowering drug prices. Yet for all we've sacrificed to endure a Trump presidency, they've done absolutely nothing to address this problem. And they won't. I assure you.
Therefore - the shitty-compromise solution must be: government pays. Because they're too cowardly to fix the problem any other way. Government pays until government can't. So they just borrow more. Not even "plain speaking" Trump has the balls to work these two problems. (Drug prices, and income stasis).
Does that include a situation where say, when emptying out the oil, the nut over the drain breaks off which necessitates changing the oil sump, except they then discover the engine mounts are rusted and now the engine needs to be lifted and the mounts replaced? (I'm not a car guy, but I hope this demonstrates the thought even if inaccurate)
Yes it does because the mechanic is required to call you and say, "Upon further examination we also need to do ______ with will cost $XYZ. Do you want to proceed with this?".
If you say no you can pick up your car and go somewhere else. It's not that the mechanic is taking on the risk of an oil change turning into a full engine rebuild. They're simply required to announce what they're going to bill you for before they start work.
That way if the mechanic say, "It'll be $500 for me to change your cabin air filter." you can find a new mechanic.
But, that idea ignores a fundamental problem with expert-based markets; it's impossible to me, as a non-consumer, to make a rational decision about which mechanic to use because to me, the mechanic is a black box. I don't have any way to immediately fact-check what they're telling me, and in the worst case, if a mechanic does something wrong, I may not find out about it until it's far to late to hold the do-er accountable. Thus, I can change mechanics based on the limited information I have available (price signals, perceived reputation) but, A) this distorts the market to optimize for low prices and perceived reputations instead of efficient prices for quality work, and B) I don't ultimately have any way of knowing whether I'm making the right decision when participating in this market. At least, not in the time frame where that knowledge is useful.
The same, holds true with 'free' health markets; I'm not a doctor so I can't accurately tell if my doctor is lying to me, which should cause similar distortions in an ostensibly free healthcare market. Additionally, as with an auto mechanic, if I need something done -now-, my demand for that service becomes completely inelastic, which means prices for emergency services/procedures should become obscenely high.
They already are today, and people are -already- getting forced into bankruptcy by emergency medical expenses, so I can't speak to whether or how a market sans insurance might change that phenomenon, but it seems to me that the goal ought to be to eliminate it entirely, and that in turn a 'free' healthcare market cannot be the end goal.
That said, I don't think I know enough about the subject to pick out a particular optimal solution to this problem. I like the -idea- of single payer or other universal healthcare solutions, but I haven't studied any of them in enough depth to analyse them critically; dealing with healthcare in the UK was a joy while I lived there, so I wouldn't mind having that experience here in the US, but that in turn requires a lot of government funding (among other things), and we can already see that that's unsustainable in the short term by what's happening to the ACA.
Customer comes in for an oil change. Change the oil, go to start the car, it won't start. A bit of diagnosis later, and the ignition control module has coincidentally decided to die. It's an old GM, so thankfully it's only $35, but still: the car was running when the customer dropped it off. I hate those phone calls. Customer said, "okay, do it". Had they not, we probably would have just dropped a module in and eaten the cost. I mean, what are you going to say? "Umm, yeah, it's just coincidence that you need to spend $35 more before you can drive it home"?
I also tell customers ahead of time the possible outcomes of the work. Honda comes in needing a top-end job, but it has over 100K miles on it. I tell the service writer that we can do the job, but it stands a chance of blowing the rings. (New valves with better sealing on the top end, now the piston rings are the weak link.) Customer is informed, I do the job. Two weeks later, the Honda pulls up blowing smoke. Told you so. I forget the outcome, but I don't recall pulling the engine on that one.
But they don't always say, "yes". Customer comes in looking for an estimate on a brake job. You know that grinding you hear when your pads are shot to hell? Imagine what happens when you let that go for, say, a couple of months. Imagine no more, I'll tell you what happens: it'll grind the rotors down to the cooling vents such that what's left of the brake pad backing plate no longer has a solid surface upon which to grind. Of course wheel bearings are shot, calipers need replaced. It was a long time ago, but many hundreds of dollars were estimated. Of course this is on a piece of shit that isn't worth fixing for that much. The vehicle is not safe to drive by any means. Customer doesn't want to do the work (duh). What did I do? Put the wheels back on and let them drive off. We're mechanics, not the state police, but trust that there was discussion of what "the right thing to do" was.
Your surgeon is in the middle of heart surgery. You wanted an estimate on a (cardio) valve job. Surgeon gets in there, your arteries are all clogged up. Wake the patient and ask for approval on the extra expense? Button 'em back up and negotiate the cost later?
So the car analogy doesn't work for all cases, or very well at for human beings.
Many medical procedures and therapies have very predictable costs and outcomes. And have checkpoints to re-evaluate whether to proceed further.
And accountants and could probably also price in the cost of the occasional problematic case and include a buffer in the standard price to account for it.
There are plenty of straight forward ways to provide prices for the vast majority of medical procedures, if the proper incentives were in place.
Also, funny comparison, try to make it with software engineering.
If you held a mechanic to the same standard, they "wouldn't know the cost" either.
Maybe the doctor's office doesn't know your out-of-pocket cost, but they generally know (within a reasonable rage) how much they will bill the insurance company for. Perhaps an underlying problem is that a health insurance-medical pratcice contract prevents the medical practice from revealing the negotiated+contracted costs.
In the case that the nurse/doctor/surgeon decides to change the prognosis/prescription during the visit, there are provisions for that type of action with auto mechanics, too.
Try estimating software development costs with no idea what is to be written. With software at least no one will die, and probably no one will sue if you are wrong.
We don't know either. In fact you have to build infrastructure just to know estimates, which will be cleared months later, and a result might be less or more price. It is not a transparent system for the provider either, specially when you are a small one.
> In the case that the nurse/doctor/surgeon decides to change the prognosis/prescription during the visit, there are provisions for that type of action with auto mechanics, too.
I honestly think the problem is fee-as-service, where you have to make very complex calculations based on how each thing is claimed. It would be very different if work was provided per-hour basis, or even per-result (complex, but market is leaning towards that right now).
Figure a software engineer consultant charging differently per language, platform, stack version, LOC, cost of materials etc each time he works an hour. IF you are an engineer try to picture how that works.
1- You diagnose a problem to solve
2- You look into a list of 70k items to look for the corresponding code to that problem (C10.023 Turn iterative code to recursion)
3- You now write what you are going to do to solve it
4- Now you have to pick a billing code (CPT code 94102 -> Iterative on GC language to functional programming language ). You estimate 94102 will pay 50$, but are tempted to put 94103 which will pay 75$, from Iteractive non GC, because actually your custom language settings have GC turned off, but are unsure if the insurance company will believe or care
5- The client asks you how much will charge, considering he is personally liable for 20% of it because the actual client doesn't re-imburse everything.
That was a single visit. Doctors get 12-16 a day.
What I'd like to see for medical services, is something like an apendepticamy takes 1 hour to perform, plus 4 hours of prep, and 2 hours follow up spread over several weeks. The procedure uses one primary surgeon, one assistant, 2 nurses, an and anesthesiologist, each charging x per hour (depending on role / specialty). The hospital charges y per hour for the room, z for the supplies.
All of this is known ahead of time. Yes, there can be complications. Just like a mechanic can run across rusted on bolts that take longer to remove. But going by book time for everyone works out in the averages.
Heck, both dentists and optometrists work in this fashion for most of their services. Why can't the rest of the medical world get it together?
Every procedure, every Tylenol, every operating kit has a code and a price and that is all itemized and billed.
Try calling up your mechanic and asking for a quote. Tell them your car is not working right and you don't know what's wrong, but you want a quote before bringing the car in.
Now, if you call a medical practitioners and tell them exactly what tests or procedures you want, they can probably look that up for you.
Take Florida Statute 581.026, titled Florida Patient’s Bill of Rights and Responsibilities
Subsection (4)(c)(5) reads: a health care provider or a health care facility shall, upon request, furnish a person, before the provision of medical services, a reasonable estimate of charges for such service.
In one case I represented a patient who video recorded asking a health care admin for an estimate and getting an answer of under $2,000. The bill ended up being somewhere between $12,000-$14,000. A single letter citing the law and the patients entire bill was discharged by the health care facility.
Or pushed it onto tax payers somehow.
Also as the system gets itself more expensive, the mechanics that make it more expensive can also become more worthwhile! Its a spiraling costs issue.
Man healthcare in the U.S. is so broken.
If they ate the cost, someone else paid for it. Which means that prices in general take this into account. I'm not judging OP, but saying that the ability to apply that technique is not= the solution to the general problem. (Healthcare is expensive).
What you want is a buddy like Ed who can get the cost knocked down by 90% https://youtu.be/pY-BGNjI2Rg?t=6m18s
Instead, the only plan Republicans can come up with is kick more people off their insurance, and don't change anything else.
They evolved from a reasonable idea into a monster that just drains our system and do not provide enough value to justify their existence in my opinion.
It is quite incredible that the U.S., the symbol of freedom, can't freely import drugs from abroad. Considering the rampant use of pharma specially, dropping the costs 1/2 of meds would lower the cost of healthcare overnight by an enormous amount.
An interesting bit of data that highlights just how profitable this industry can be comes from the wikipedia page for McKesson Corporation[1]:
> On June 24, 2013, The Wall Street Journal reported that McKesson Chairman and CEO John Hammergren's pension benefits of $159 million had set a record for "the largest pension on file for a current executive of a public company, and almost certainly the largest ever in corporate America." A study in 2012 by GMI Ratings, which tracks executive pay, found that 60% of CEOs at S&P 500 companies have pensions, and their value averages $11.5 million.
And no: marketing is not necessary for these products. TV commercials and other ads to public: not necessary.
Doctor pay is really high in the US and its very regulated. Its expensive to be a doctor (long schooling, expensive mal praxis insurance), license ceilings, state-licensing and effective banning of doctor importation.
Doctors get a decent share of the cost (1/10 i read somewhere), buts its still not the bulk. Nevertheless, just allowing doctors to come in and have unlimited licensing would hit costs a lot.
I'm not an economist, but it seems like a 5% margin on a $850 billion market is worth a 10% margin on a $425 billion market.
Its a big market, but insurance companies are not the ones making a killing.
First, there are a lot of tests and procedures ordered by doctors that only have some, but very small, benefits for the patients [0]. Doctors are incentivized to do this because each procedure has a set price (negotiated with insurance companies and Medicare / Medicaid) and the only way to get more revenue is to perform more procedures.
Second, patients themselves order a lot of procedures out of fear. Arguably, they can be better off without these procedures. A prime example is end-of-life care, where patients and families often want to "do everything possible" even if those intrusive medical procedures bring nothing but a few weeks of miserable living [1]. Those end-of-life procedures are extremely expensive while having questionable benefits in terms of bringing a "happy" life rather than just a longer life [2].
[0] https://www.scientificamerican.com/article/unnecessary-tests...
[1] https://www.npr.org/sections/money/2014/03/05/286126451/livi...
[2] https://www.amazon.com/Being-Mortal-Illness-Medicine-Matters...
Another relevant effect worth noting here is CYA medicine: doctors order tests aimed at catching highly unlikely conditions to protect themselves against the hypothetical lawsuit that asks "why didn't you test for that?" Whatever the truth is about malpractice suits, the perception in the industry seems to be that these cases are overwhelmingly biased against doctors if even one question can be raised about the course of treatment.
They charge whatever the fuck they want.
Also; equipment manufacturers and drug companies: who both abuse the shit out of our patent system. But even off-patent drugs are being priced ridiculously high now. Barriers to competition are still extremely high.
Since manufacturing capacity of IV bags was taken out in PR, there is a national shortage. This is NOW causing rationing (in effect). Prices are going up, but nobody's addressing the manufacturing problem - because: Puerto Rico.
So health insurance remains an enormous untaxed income benefit, one that grows in importance as health care costs spiral up. As a wise person once said; If you want more of something, subsidize it. Thus our present health insurance regime.
I can't remember where I heard it, but IIRC employer-sponsored health benefits had to do with a fringe benefit that employers could give to attract employees during a national wage freeze (perhaps WW2).
I just found this timeline[1] that confirms my broken memory (@see 1943).
[1] https://www.ebri.org/publications/facts/index.cfm?fa=0302fac...
I come from a large family (8 kids). When by mom was still alive, I asked her if making medical claims was a pain. Nope, she said: tell your information to the doctor, and sometimes she'd have to pay part of it.
Now, even with "gold plated insurance", many of my families doctors don't handle insurance; we pay them directly, and we have to deal with the insurance companies ourselves. My wife spends countless hours dealing with what I assume is willful incompetence. For example, filing four identical (other than date) forms for a series of physical therapy sessions, and having the insurance company approve two and reject two because the codes were wrong. Or the it was unreadable. Followup calls get a different person every time, and when they review it they say: oh, I don't know why it was rejected, that is fine. I'll personally make sure it gets fixed. And then it doesn't get fixed. Having to call five for six times for one bill is common.
Eventually science progressed to the point that medical care was an inevitability in people's lives; which is a surprisingly recent development due to modern medications, lab tests, improved treatments and surgeries, increasing preventive care, etc. Faced with this sea change, developed nations around the world transitioned to some form of universal health coverage.
Only the United States persists in the delusion that an insurance-based system is an efficient way to provide healthcare.
My understanding is that benefits like healthcare were a means to attract employees by increasing their compensation without giving them cash per se. I don't know all the one and outs, but that is my understanding of the actual origin. Of course, like anything, it then evolved.
I very much disagree. When I didn't have medical insurance, doctors charged me twice what they charged the insurance companies. Insurance companies have a vested interest in reducing the costs of medical care, while doctors have a vested interest in increasing them. Screwing patients out of payments is not an aligned business model, but it only becomes worse when you don't have someone there fighting to reduce costs on your behalf, willing and knowledgeable enough to know when a medical test is superfluous, or over-priced.
Doctors are still prescribing name-brand drugs when equivalent generics are available. That's some really basic stuff that we're still struggling with. Forget it when a doctor asks for a test that you don't even know enough about to say what it does, let alone if you're getting fleeced for money. Insurance companies get to be the bad guy in the middle who both doctors and patients can blame for not paying for things the patient shouldn't have to pay for in the first place.
But remove that stop-gap and you're relying on the blind trust of the doctor to do the work of appropriately minimizing costs for patients in the face business pressure to do otherwise. And if there's anything I know about human nature, is that we're capable of doing what's best for us, while honestly and truly thinking that isn't the true motivation. I've had mechanics try to sell me on nonsense that more knowledgeable friends of mine recognized as a scam. You don't want that when it comes to what is already one of the biggest expenses in a person's life.
You've identified the symptom but misattributed the cause. You ran afoul of the charge master system of billing, which is a byproduct of our insurance-based healthcare system and the laws which uphold it. In short, providers are "forced" to set their base rates high in the knowledge that insurance companies (their most significant revenue source) will negotiate a fraction of the posted rate. Meanwhile, federal law enforces (under very stiff penalty) that individuals cannot negotiate nor be given a discount from the base rate.
You are also correct to identify the inherent information imbalance in the doctor/patient economic exchange: you as the patient will never know for certain if the recommended course of treatment is appropriate. Realistically only a doctor has enough information to tackle that question. In a cash-based system you are indeed susceptible to abuses.
(In fact, this is one of the main arguments against concierge or "executive" medicine: they will frequently throw in wasteful and dangerous tests like full body scans which have absolutely no justification in medical science.)
But by the same token, insurance company incentives aren't aligned in your interest either, so there are even more abuses on that side.
I believe a single-payer system is the best compromise -- the government's incentives are best aligned to improve the health of the populace (securing a healthy workforce) at the least cost. ("Least cost?!", I can hear the scoffs as I type.) Only government systems have enough scope and lifetime to realize the long-horizon payoffs of preventive healthcare, and cannot so easily escape their failures (the way insurance companies could with lifetime caps). Many people are surprised to learn that Medicare is at least on par in terms of efficiency and above par in terms of patient outcomes and satisfaction.
https://oig.hhs.gov/fraud/docs/alertsandbulletins/2004/fa021...
It points out a pair of laws -- the Federal Anti-Kickback Statute, and the Social Security Act -- which may have caused some confusion about discounts and waivers. Hospitals, the memo assures, are free to offer discounted services under a specific set of conditions such as methodically established patient financial need, an inability to collect on bills, and given that the waiver does not in any way entice business (i.e., you can't advertise it).
But the implication is that you can't give discounts willy-nilly, as a provider, or risk federal audit.
A separate but related issue is that under-billing may be considered fraud by CMS. A doctor cannot provide a service which they do not bill for, nor bill for a code which is lesser in magnitude than the actual service provided. I can't say if anyone has ever been investigated for under-billing.
In any case it's worth adding that aside from legalities, there are severe ethical ramifications of offering discounts to certain patients and not others unless that decision is made by some impartial measure. You could imagine all kinds of kickbacks, favors, enticement, coercion, biases, and so forth rearing their ugly head if doctors are given the freedom to bill whatever they choose (less or more).
If you are talking about the US, we have several times in the past negotiated our bills down as much as 20%. It does not appear to me that there is anything illegal about that.
But it does gall that they try to charge someone without insurance and with no bargaining power the full rate, well knowing it’s a fake rate.
I should have been more careful with my terminology. I used "insurance" as a shortcut for private, for-profit insurance, excluding government insurers like Medicare.
There are other non-insurance interventions like forcing hospitals to provide emergency care.
Here, everyone is insured. If you break your arm, you get it fixed. If you get cancer, you get therapy. If you get the flu, you get a prescription. The overall cost is paid by the entire population, through the insurance system.
For what is the alternative? Maybe the overall monetary cost would be lower if everyone had to watch the price, but you would pay for it in human lives and suffering, when people have to decide between dying of illness or dying of hunger, or between lifelong pain or clothes for their children.
We have the most expensive medicine in the world, but it's all treatment, not prevention and both only for those who can afford it.
When I was looking to have a very serious health problem taken care of, I heavily researched getting the procedure done anywhere in the world. It was pretty obvious that all the best places to have it done were in the US. The facility we went to had quite a few patients from other countries - and we're not talking 3rd world countries. Many of these patients had already had care in their own country, where the care was botched or insufficient. They were coming to the US to get it done right. On their own dime.
Not sure how Germany is, but average wait time for an MRI in Canada is over 10 weeks.
https://www.fraserinstitute.org/studies/waiting-your-turn-wa...
In the US you can go right into an MRI on the same day. This is key to getting an appropriate standard of care.
In Canada, average wait time for an ultrasound is 4 weeks. Our pets get better care in the US. I really don't see how people tolerate such things.
I wonder if the insurance we're talking about covers the kind of procedure people from other countries do in the U.S.
I absolutely trust medical professionals in my country and I believe we have some of the very best healthcare in the world - way better than in the U.S. - wait time for an MRI is same-day if needed (same as you say for the U.S.), surgery is 13 days and the cost is maybe 30 dollars for the ticket. No deductibles, no hidden costs. Zero people became bankrupt due to medical emergencies in my country (plenty of other causes like high taxes, but nothing directly medical-related).
But if I had the millions and I had to have open-heart surgery I would possibly choose the Cleveland Clinic, and similarly for other very serious health problems, the equivalent top clinic.
Its true administration is a huge expense, but I doubt it can make medical care cost 1/4.
Also healthcare services can never be "all round service" because any complication could mean a million things from scans to medication. Even on primary care you cant really promise to give 100% service for a fixed fee without ending up working like an insurance.
Unfortunately,
1) The price agreements between hospitals and insurance companies are confidential, as both sides compete in their own industry and don't want to reveal their hands.
2) Consequently, chargemasters post some ridiculous price per procedure (with discounts available, naturally, to insurance carriers, who are the bulk buyers in the business). Which makes chargemasters similar to list prices you see at most retail establishments - only schmucks are expected to pay those.
Of course regulation requires administrative staff which costs more money as well.
Malpractice is ungodly expensive too.
Other costs are the requirement that hospitals treat the uninsured. I was listening to NPR when the ACA debate was going on, and the CEO of a local large hospital said about 25% of his costs are due to treating people who couldn't pay. That's a huge number.
https://www.aha.org/system/files/2018-01/2017-uncompensated-...
It's around $40 billion per year in recent years (for all US hospitals). With hospital spending around $1 trillion, it's 4 or 5% across the industry. There are of course individual hospitals that face higher costs.
Would still be lots of net income though (for the uncompensated care to represent a larger fraction of total costs).
Could also be including Medicare and Medicaid (which the numbers in that pdf explicitly exclude). They pay, but not always enough to cover the cost of care delivered.
This is the number one issue that makes any kind of market mechanism impossible. These prices have to be made public. There should also not be much variation between prices for different insurers and not-insured. Hospitals should state a standard price like every other business has to do.
I will gladly develop a cure for cancer, for the low, low price of $20B.
..that price would include everything from airfare to the organization's only facility..
Lodging and travel expenses are not included in the price of the procedures.
"Expenses or fees resulting from complications subsequent to the completion of the surgery and discharge from the facility are also not included." https://surgerycenterok.com/pricing-disclaimer/
Complications e.g. infection can run up expenses almost without limit. And you're likely to be in no condition to get up and take your business elsewhere.
Oh good God, I’d never thought of this... I’ve broken more bones than I care to count (wrist, triple torsion fracture in my ankle, two ribs twice, shoulder) and I’ve never paid a penny (here in Italy). I’d never even remotely contemplated it might be a cost beyond the annoyance.
edit: I was being sarcastic
Not /s if you look at actual argumentation on soda taxes.
Rand Paul made a similar case last summer that if the government is seeking to to provide care for people who can't afford it, it should put the money into care instead of into insurance companies. It would be much cheaper an much more effective.
Note that if you go to the highlighted facility, you can still contact your insurance to pay for the procedure - its just that the doctors in this case are not doing that for you. I've never understood why doctors involved themselves in dealing with insurance companies. It's the patient's company, so the patient should deal with it. If more doctors did this, patients would realize that the real problem is the insurance companies. Market forces might even cause insurance companies to provide better service.
This seems like a problem. How is this not an anti-trust violation? In order to benefit from the insurance contact you purchased, you must use a provider who will submit to an insurance company's capricious payment system.
I expect that your statement is about public health insurance in post-communist EU countries (I have no experience of this). Public health insurance in Australasia is very good (though has arguably been better in the past in some senses and could obviously be better in the future).
This is part of why Obamacare is fundamentally broken. Using the existing commercial insurance system to try to provide universal coverage injects unavoidable extra expense and complications.
Really happy to hear about the trend the article is describing.
I am not advocating for this cash only option to be the entire system. I am merely saying that Obamacare is broken and I am glad to see alternatives emerging, given that Trump has so far failed to provide a real solution at the federal level.
According to the CDC, 75% of healthcare spending in the US is spent on chronic conditions or issues comorbid with chronic conditions.
So system changes that only help with chronic conditions could still be very worthwhile.
Outside of an expensive, time-consuming, and almost always useless appeals process, that flat rate is all the doctors are going to get. They can take it or leave it.
There are medical codes for every imaginable procedure, and essentially every medical code has a fixed, preset amount that the insurance company will pay to have it performed.
The point is that there's no shopping around in the emergent cases. You can't say "Well, in my incapacitated, mid-stroke state, let me check the menu of the 3 nearest hospitals for the cost of a stroke admission." It ranges from "nothing to do here, looks like it was a TIA, patient demands to go home" to "We need to take your wife to the OR for an emergent craniotomy and clot removal to decompress the foramen of Monroe. Right now. Because minutes are brain cells."
Why would "shopping around" matter if the amount the doctor was going to get paid was fixed (and published) in advance?
I don't understand why you think that pre-published fees would make this (alleged) problem worse rather than better.
In the (unlikely, IMO) scenario where one hospital really was massively more expensive than another, patients will almost certainly know that in advance, just as they know that they're going to pay more at Wolfgang Puck's restaurant than McDonalds.
Doesnt this expose the facility to additional risk? Overall healthy patients and those with sufficient insurance coverage do not have a reason to visit this place, while those without insurance coverage (who I assume are likely to be less healthy and hence have more complications) are more likely to visit the place.
If instead they accepted insurance, and charged people based on complications, they would have a more average risk profile while being able to maintain higher profits, and keeping a USP of transparent charges (which would apply to non insurance patients w/o complications)
So there is a sort of built-in insurance to this system. Those who don't have any complications are paying more to cover patients who do. They're simply passing the first line of medical costs (known, anticipated, where a price estimate can be created) on to consumers while letting insurance handle un-estimatable medical emergency type situations.
"To keep our prices as low as possible, cashier’s checks or cash are the methods preferred. Credit cards are accepted on a case by case basis. Human resource departments or divisions of self-insured companies can make other arrangements if necessary."
(They also have a partnership with some sort of personal loan/financing company which presumably would take credit cards or bank transfers.)
"Cash only" means "not insurance claims" in this context - usually when you go to the doctor you give them your insurance information and your expected copay the doctor (actually their admin staff) then submits a claim to your insurance company for payment. If the company doesn't pay, or pays less than expected, they will bill you.
Large "cash" transactions aren't a problem.
Multi thousands of dollars+ "cash" transactions are done all the time (such as a down payment on a house), you go to the bank and get a cashier's check. There's no reason you couldn't take out cash instead of getting a cashier's check, but it wouldn't be secure or practical. And your payee may have an issue with accepting physical cash from a risk perspective.
One of the doctors charges $50 to set the broken arm. The other doctor charges $500.
Which one are you going to take your child to? Most likely, the $500 one. Because going to the bargain basement doctor is not something you do when dealing with medical issues if there is absolutely any way to afford it. It creates what I call 'reverse capitalism.' You can only draw more customers by charging the highest price in the area.
If your customers stop even being the ones footing the bill, it accelerates to a patently insane level. That makes footing peoples insurance bills a ludicrous and idiotic business to get into. Unless, of course, you've got protection from the government or special considerations where antitrust laws do not apply to you so you can engage in price-fixing, intimidation, and other tactics.
Made to compete fairly, medical insurance companies would be out of business overnight because it's a downright stupid business to begin with.
People are price sensitive regarding their own life and their children's. You can find how much they value things with "revealed preferences", an economists principle.
Its a bigger problem that as a consumer you don't have to or face the decision of choosing by price, eliminating marketing mechanics from healthcare.
...said no one ever.
Also, most care is not urgent care.
We tried to intervene by offering them money, but they refused to take it. We got their church to intervene, after 3 days.
Very fortunately, xrays showed it was a minor fracture, no surgery needed. But that poor kid.
The customers are the tax payers in many countries, and the bills there are much lower than in the US. Yes, those systems have problems, but this one is on a much smaller scale.