Medicare will require hospitals to post prices online
msn.com
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I'd imagine hospitals hate this. Many of them are paranoid at what will happen if there is more transparency -- there's a union fighting Stanford hospital now and playing radio ads about high infection rates at Stanford. Other hospitals are worried about whether similar things could happen to them -- and hold their data tight to make sure no one has ammunition to do similar things. Hospitals in many cases market based on brand value rather than quality. In a closed world, hospitals can define quality any way they want. Everyone is #1 in something. If there's an objective standard for quality based on integrated data from hospitals nationwide, many brands will be tarnished. I'd be interested to see how hospitals respond to this push towards openness
Which means that anyone those insurer contracts don't cover, is getting royally screwed. Thus, healthcare is simply unaffordable to someone who doesn't have those insurers acting as a payment intermediary.
This one of the dirty secrets of the whole US healthcare coverage problem that I never see politicians (or talking heads) on either side actually acknowledging.
If you're serious about learning, stop listening to these people (seriously, it's a waste of your one precious life) and try taking a healthcare economics class or reading Paul Starr's Social Transformation of American Medicine.
This "negotiation" you mention works 1. If you know the price up front 2. have the leverage to negotiate.
And guess what, you have neither of them. This law changes one of those, so that shopping around is at least possible.
Aside: I'm surprised a lawyer didn't sue a hospital over Informed Consent via no billing knowledge.
If you don't know the bill, they can't tell you the bill, and they have no way to get the bill until weeks later, how can they "negotiate" when nobody knows?
Frankly, that claim sounds like a pile of you-know-what. My bet is they take your money, and then bill you for the rest.
In emergency situations this is hard to do, but I've done it numerous times when needing non-emergency health care. I even call around asking about prices and the cash discount. Oddly enough, a co-worker and I both had the same procedure (back issues ugh) last year at the same doctor. He used his insurance, and I asked about and went the cash route. I ended up paying less for the exact same thing because of how his deductibles worked.
It was the end of the year and I guessed I would not hit my yearly deductible so paying cash was the right move.
When I had knee surgery years ago, and had good insurance at the time, I asked the doctor about the price just to see. He was quick to say if I wanted/needed to pay cash he could work something out.
So they are out there, but you might have to do some digging.
And again, emergency situations are a completely different beast.
I've used the high deductible plus HSA approach since it was an option. I don't know if this varies by state or plan, but all I ever pay is what the insurance company considers allowable.
Why is this concept ever even deemed acceptable? Why do you get the privilege of "only paying what the insurance company deems allowable, minus what they cover", but someone else has to pay in full?
This puts you in a state where you basically require insurance to get care at a reasonable price. Where its cheaper to have coverage and pay out of pocket, than to pay out of pocket without coverage.
Whether full coverage should be something the government works on as policy and whether subsidized private insurance is the best way to get to full coverage are different questions, but the most talked about parts of the ACA directly address people in that insurance gap.
This might concern people initially (because the discounts are currently so high) but for practical reasons after the ban is in effect the costs will go back to more or less pre-ban levels, but now simplify billing (reducing costs) and benefit people without insurance (no more absurd inflated bills).
Insurance discounts themselves are problematic, and also result in this silly "in-network" "out-of-network" system we have. In particular where you could go to an "in-network" hospital but get an "out-of-network" anesthesiologist or lab giving you care without warning.
Exactly this. The numbers that hospitals bill are largely fictitious compared to cost of care. What a lot of people don't realize is that hospitals use inflated billing from paying patients to cover the costs of uninsured patients that the hospital is required by law to treat in the ER.
A lot of people against socialized healthcare don't realize that the system still takes extra money from those that pay and gives it to those that can't--just through hospital billing.
It would be refreshing to have a conversation with someone who holds such a position that was willing to say that hospitals should turn uninsured and poor people away at ERs and let them die in the streets. Its at least more honest.
Then again this goes against my theory that socialized aid should come directly in the form of the thing needed - voucher for healthcare, food (or very specific food vouchers), rent free housing or vouchers for housing, rather than cash which is a bit silly to give to someone the government failed to give good financial education to (speaking from experience here...)
There's a reason theres a huge market for under the table financial management among the trapped impoverished.
Even the Singapore model (which looks capitalistic on the consumer end) relies on huge amounts of government price-fixing on the hospital side of things.
It's a bit like assuming grocery stores must give away food to anyone or people will starve in the streets. In fact, there's other ways to get food to those in need.
2. Charities. You can start your own: give 5% of your income to underinsured. For example:
http://www.philanthropyroundtable.org/almanac/hall_of_fame/j...
At the urging of Frederick T. Gates, perhaps his most trusted philanthropic adviser, Rockefeller became increasingly devoted to medical research. In 1901, he funded the Rockefeller Medical Research Institute in New York City. Modeled on the Institut Pasteur in France and the Robert Koch Institute in Germany, it was the country’s first biomedical institute, soon on a par with its European models. The results were dramatic. Within a decade, it created a vaccine for cerebrospinal meningitis and had supported the work of America’s first winner of a Nobel Prize in medicine. Today, known as the Rockefeller University, it is one of the leading biomedical research centers in the world. Twenty-four Nobel Prize winners have served on its faculty.
But don't force charity on others who may be struggling.
Having worked in non-profits extensively, it's also disingenuous to claim that non-profits answer to anyone other than their primary donors, whose priorities are frequently not aligned with regular people.
2. Charity has had thousands of years to solve societal problems, yet it didn't. What you're describing is a pipe dream.
Within the span of a less than a century, countries around the world have addressed healthcare effectively such that care is available to most, if not all.
[1] https://en.wikipedia.org/wiki/Martin_Shkreli#Daraprim_price_...
That's a shockingly high amount, especially if you don't get healthcare out of that.
16% of my taxes go to pay for my health care system, which covers the whole country. For someone on a median income that's 3% of their income. For someone on a top 10% income that's 4.15% of their income.
To spend 5% of your Gross Income on the NHS in the UK, you have to pay 31% in total taxes, that's an income of £75k, that's circa top 5% income.
But there is an issue in certain areas of people using ERs like a GP because the ER can't legally turn people away due to EMTALA
A lot of people seem to think ERs are simply required to treat everyone, which is not even close to true.
The difference is that healthcare costs are so outrageous, that the "people who can't afford healthcare" bucket includes families solidly in the middle and even upper-middle classes. Which includes most of the nation.
(I guess more so in areas where freestanding urgent care is a less interesting investment)
There's even hospitals that provide urgent care style care (and billing!) in their ERs, undermining the argument that this isn't viable.
You won't ever hear them suggest people should die in the streets - why that'd be just unhospitable!
They'll instead say - "why don't they have insurance? Why don't they get a job so they have health insurance? Why should I have to pay for people that don't feel like working when I go to work every day without complaint?"
If you suggest all the myriad of reasons the trapped impoverished don't have a job, they'll counter with "those are obstacles to getting a job, sure, but it's not impossible."
If you point out that many people have jobs that don't offer health insurance, you'll either get a sarcastic reply about Obamacare, or the question "why don't they just get a better job? Why don't they go to night school and get a degree?"
Empathy has been replaced by the desire to be infallible in debate.
Take a non-strawman like Paul Ryan, who is in every way a typical Republican, and his proposal is not to abandon Medicaid, but to make it into an Obamacare-like system whereby people are provided subsidized insurance.
Ah, Paul Ryan.
>There’s nothing inherently wrong with high-risk pools, but they have to be adequately funded in order to work properly because the people in them are so expensive to care for. Many states had high-risk pools before Obamacare was enacted, but they charged much higher premiums than normal and excluded coverage for certain services. The federal government also had a high-risk pool temporarily, but it grew too expensive and had to cap enrollment. According to some estimates, the $10 billion a year allocated in the AHCA would still not be enough.
https://www.theatlantic.com/health/archive/2017/03/the-bigge...
> Unless the amount of the credit is linked to the cost of coverage comparable with what people received under the Affordable Care Act (and subject to indexing), it will represent a reduction in coverage (or higher costs if people want to "buy up"). If people will be reduced to buying catastrophic coverage, their deductibles may be larger, not smaller than they were under Obamacare policies. That's a step backward for many Americans, who complain that the deductibles are too high already. Moreover, depending on the differential between the credit for older and younger Americans, older people (who use more health care) may wind up paying more.
>Equally problematic is the use of health-care saving accounts in lieu of the subsidies available on the Obamacare exchanges. If working-class people do not have the extra income to contribute (albeit on a pre-tax basis), once again they will be worse off than they were previously.
> Without massive new taxes to pay for it, it's hard to deliver more coverage for less. In other words, Republicans promised more and are delivering arguably less than Obamacare does.
http://www.chicagotribune.com/news/opinion/commentary/ct-pau...
I do believe that making hospitals publish their prices would be a good start. The first thing I think that would do is bring to light the difference in price between paying in cash versus using insurance. From there we could make arguments why the same service has a 10x to 100x difference in price depending on how or who pays for it.
- Compulsory basic insurance (private or public) (Switzerland)
- Private insurance + equalization pool (Netherlands)
- Compulsory HSA + government price fixing (Singapore)
- Socialized general coverage + private supplementary coverage (France)
I will admit that I have not read up on those countries healthcare plan but I think it is a lot more complicated than saying lets copy X countries plan. If you made a big change there would be a lot of second and third order effects that we would have to deal with and we may not like those out comes.
I could see California residents arguing why they should pay for the medical expenses of tourist.
I don't think anyone in the discussion thread is advocating carbon copying another country's healthcare.
I think that both we and everyone in this discussion can agree that what we are doing now is not working and is unsustainable. We are just arguing over the best way to fix it. I personally believe that easy (cheap) money makes things unaffordable where is seems everyone else wants to spend or devote more tax dollars to an already broken system. I would just like to fix the root problem and not the symptoms.
Are you suggesting that healthcare legislation should be drawn up in a vacuum? It's important to compare and contrast the benefits and pitfalls of other countries' systems. It's really all we have to go off of evidence-wise. It's also good to look at them for inspiration. There are a lot of different ways the public and private sector are being combined to make far more cost-effective healthcare systems than in the US. You are correct that some might not work in the US; that sort of reasoning needs to be weighed into whatever overhaul happens.
> I would just like to fix the root problem and not the symptoms
What are you suggesting as the root issue?
The main point to my arguments is that cheap money makes things expensive. Meaning is the government or somebody else subsides healthcare it will get more expensive. Because why not. Hospitals are trying to compete with other hospitals so they want the biggest budgets for paying the best doctors and newest equipment and technology. So why not charge just a little more then you need to get that. Then the next year comes around and the hospitals need more money so they charge just a little be more this year and it goes on and on.
You could probably start to fix things by making everyone publish their prices and charging the same price for cash as they would to insurance. From there things would start to unwind.
We could point finger all day long about who is responsible but at the end of the day nothing changes. I think politics at this point is more about entertainment then anything.
Not everyone gets cancer, the medical insurance profit model is predicated on a bet that most people won't. The more people in the coverage pool, the less likely you will be paying out for every single person.
Socialized care is just the expansion of that model to encompass the entire country's citizen population. What would have been privately-captured profit from people that were healthy members of the pool can instead be used to reduce the premiums paid by all members of the pool.
Another example is eye surgery. Originally the procedure was expensive but now it is more affordable because it is not covered by insurance. Comparatively, plastic surgery is relatively affordable because it is not normally covered by insurance.
Reducing or eliminating health insurance would also eliminate a lot of the medical administrators that provide zero care but due incur a cost due to their salaries.
As far as getting rid of the profit motivation but capturing the profits and giving it to those without health insurance I believe that you would also eliminate any reason to innovate and create new drugs.
I will admit that if you got rid of health insurance tomorrow that there would be a lot of short term pain. But I also believe that in the long run people would be better off because they would be able to afford there healthcare.
Using a different example look at the cost of college. I believe that we could fix that problem one of two ways. The first way would be to get rid of government loans and grants. The other way would be to allow people to file bankrupcy for student loans. The first way would attack the problem by getting rid of easy money. Because easy money makes things expensive. The second way could work by shifting the risks of the loans from the student to the banks. The problem with this solution would probably make it harder to pay for degrees that don't pay well.
To summarize my arguments, cheap money makes things expensive and is destroying almost everything is this country.
Edit: added the college example.
I would argue that rights are things that we declare by agreement as a group, not physical objects or measurable qualities. Of course healthcare is not currently a right; we haven't made it one. The question is: "Should healthcare be a right?"
Too much could be written about this argument but to me a right can't be provided by someone else's labor.
Now that I think about it, a right is also something that can't be taken away. No one should be able to prevent your free speech (1st Amendment), defend yourself (2nd Amendment), or violate your privacy (4th Amendment) without due process.
In this case no one is preventing someone from being able to care for themselves. We are just arguing over who pays for it. It is probably a bad example but everyone has the right to use the roads for transportation. We just don't have the right to the car, insurance, and gas.
Edit: Added more comments
https://en.wikipedia.org/wiki/Negative_and_positive_rights
You're also touching on the difference between Natural and Legal Rights.
You can't have rights without guaranteeing action. My right not to be tortured requires all sorts of individual and societal interventions in order to fulfill. There's no classification of rights into positive/negative and certainly no difference in validity between the two.
I don't know where you get this. In my experience nobody who advocates for socialized healthcare is under this impression. They know how the system works, just don't think it's an efficient way to run it (it isn't).
The way the incentives are structured on the American healthcare system now are beyond ridiculous and having public published prices is a way to start a much needed debate about the underlying issues, with data and facts instead of political viewpoints.
It's absurd that having a baby in an average facility in the US "costs" five times more than a private hospital in Switzerland. I put quote marks on cost because that's usually billed price and insurance tend to negotiate down, so in reality is more like twice the cost, but still absurd at any level.
Did you misread? I said that many that are against socialized healthcare don't realize that wealth redistribution is already happening in the American system.
In fact it's really the opposite; it takes extra money from those who can't pay (the uninsured) and gives it to those who can (the insured), because it's the insurance companies that negotiate the lower rates.
If you're uninsured and rich, well, you're paying sticker price and making the hospital very happy.
If you're uninsured and somewhere in the middle, you could be helped by the hospital, you could be screwed, really depends on the hospital.
Private insurance companies pay more than Medicare/Medicaid on basically all procedures. The price they negotiate is lower than the list price of a procedure, but remember, these sticker prices are hugely inflated. Hospitals will often raise the list price to renegotiate higher prices with insurers. In the end, I would suspect it is largely private insurance providing extra income for the hospitals (more common than cash patients, and they pay a greater % of the list price than Medicare).
Here's more info: https://www.nbcnews.com/health/health-care/hospitals-highest...
A lot of people against socialized healthcare are perfectly aware of this cost shifting.
It's a voice backed with $3.7 trillion in total economic value per year (18.x% of the $20 trillion US economy). In terms of size, it would just about be the fourth largest economy on earth, comparable to Germany.
There are millions of very well paid hands in that pot of gold, from doctors & nurses to scientists and pharma sales reps, hospital admin and insurance industry employees. Consider for a moment that US drug costs - the most notorious example of abuse in US healthcare costs - are about 10-11% of the total US healthcare expenditure, and our per capita spending is about 2x what it should be: ie nearly everyone in healthcare is partaking in the plunder. That makes for a very loud voice.
I don't have a view on who should pay for it, but there are only 3 categories of payers in healthcare: 1 government and 2 private (insurance and self-pay). The compensation is funded by one of those sources.
The crippling healthcare costs borne by individuals entirely consist of rent-seeking. It's also important to say that a lot of that money comes back out in salaries for the massive workforce required for the unnecessary administrative overhead, adding to the economy, and of course in non-imported luxury goods purchased by the rent-seekers themselves.
So, what is it that you are actually trying to say?
>Is there a reasonable alternative? I'm not trolling, but letting people die of treatable maladies doesn't seem like the right move.
I answered a tautological statement with a tautological question based on the logic the poster omitted.
Can you tell me who besides the government or the market (ie consumers) will prevent people from 'dying in the streets'? Perhaps by kidnapping another country's doctors and compelling them to provide care...
>I'm not trolling
[1] https://read.oecd-ilibrary.org/social-issues-migration-healt...
Perhaps keep 3rd party insurance but ban it as an employment perk, that would incentivize the market to play to the greater public instead of just white collar salaried employees.
People with severe disabilities may not be profitable, but I'd still like them to have the option to live.
Government-funded health care suffers from all the same economic problems that privately financed health care suffers from, and the government is just as corrupt as any private organization, plus there tends to be little incentive for efficiency, so government programs tend to be extremely inefficient and wasteful.
I appreciate (and agree with) your concern for the disabled, but letting the government be in charge is a recipe for making everything worse.
Except we have pretty much the entire developed world's healthcare systems to debunk that claim. They have similar life expectancies, medical outcomes, infant mortality, access to care, wait times, etc. for half the cost.
* 31st for Life Expectancy [1]
* 32nd in infant mortality [2]
* 5th for colorectal cancer survival [3]
* 1st for breast cancer survival [3]
* 19th for cervical cancer survival [3]
* 7th for heart attack mortality [3]
The actual numbers are reasonably close, but the cost is also about 25% more per captia [4] than the second highest-spending country.
[1] https://en.wikipedia.org/wiki/List_of_countries_by_life_expe...
[2] https://en.wikipedia.org/wiki/List_of_countries_by_infant_an...
[3] https://en.wikipedia.org/wiki/List_of_countries_by_quality_o...
[4] https://en.wikipedia.org/wiki/List_of_countries_by_total_hea...
Except the biggest one: the need to maximize the extraction and distribution of profit to shareholders, while funding the cheapest and least amount of care possible without jeopardizing that imperative.
People such as scientist Stephen Hawking wouldn't have a chance in the U.K., where the National Health Service would say the life of this brilliant man, because of his physical handicaps, is essentially worthless.
Forgive me while I laugh uncontrollably
https://en.wikipedia.org/wiki/Investor%27s_Business_Daily#Er...
> In July 2009, an editorial in Investor's Business Daily claimed that physicist Stephen Hawking "wouldn't have a chance in the U.K., where the [British] National Health Service (NHS) would say the life of this brilliant man, because of his physical handicaps, is essentially worthless." Hawking has always lived in the United Kingdom and receives his medical care from the NHS.
So, yes, the government. It may not be monetarily profitable but money shouldn't matter to build a humane society.
"It's crazy that I live in Canada, but now I'm looking at having to sell my house for coverage of my medication."[1]
[1]http://www.cbc.ca/news/canada/british-columbia/a-tale-of-2-f...
> Helen Anderson, provincial lead for systemic therapy for the BC Cancer Agency, said that Ibrance is currently under active review for coverage in B.C.
There are several expensive medications that the Canadian health system has elected not to cover.
Here is another example where if the husband didn't have drug coverage through his employer, he would have been on the hook for the entire cost. Eventually he had to shell out $3,000 per month.[1]
At first, he says, his company insurance covered the price of the drug. But years later – Gary’s employer changed insurers and he was now on the hook to pay more than $3,000 a month.
[1]https://globalnews.ca/news/1654757/canadian-patients-struggl...
No, but if that's the standard, I'm fairly certain we can find a lot more "no insurance, couldn't get treatment at all" stories in the US than we can "Canadian needs unusual, not-yet-approved medication" ones.
> There are several expensive medications that the Canadian health system has elected not to cover.
You'll find the American medical system does the same.
https://www.mercurynews.com/2007/12/21/teen-dies-hours-after...
https://www.today.com/news/man-battles-health-insurer-drug-c...
All medical systems will have rules and timelines for approval of drugs and procedures. Sometimes they'll lead to unfortunate situations.
In the US, though, approval's just the first step. You might then have to scrape together the $6k deductible for your family's bronze plan. You might have to wait until next year to switch insurers to one who covers that particular med.
Covered in Canada? Maybe never. And that's one of the best drugs out there to treat that type of cancer.
I'm not arguing the US system is better than Canada's. Just calling out there are trade offs with single payer systems. If American's think they can move to a single payer system and keep all the bells and whistles they have now, they will be deeply disappointed.
And your 2nd link actually proves my point. The drug in the article is not covered in many Canadian provinces at all. The guy in the article is being denied the drug because it's not approved for his mutation. Most people with the correct mutation do get coverage for that drug (again, a new, state of the art drug).
Sure, but that's true in the US here, too.
No insurance? No med. ERs aren't gonna give you it.
Can't make your $6k bronze plan deductible? No med. Maybe you'll qualify for a patient assistance program from the drug company, maybe not.
> If American's think they can move to a single payer system and keep all the bells and whistles they have now, they will be deeply disappointed.
It's entirely possible to have a supplemental private health insurance system for the experimental or unapproved stuff. You can get private coverage for stuff like IVF in Australia, for example.
A lot of America's bells and whistles are already inaccessible to a large portion of the population.
> And your 2nd link actually proves my point. The drug in the article is not covered in many Canadian provinces at all. The guy in the article is being denied the drug because it's not approved for his mutation. Most people with the correct mutation do get coverage for that drug (again, a new, state of the art drug).
As the article mentions, the insurer approved their sibling with the same mutation for the same medication. Private insurance can be just as capricious as a single-payer's approval system.
Free primary and preventative care along with dental and vision, and have a government subsidized insurance program for hospital/long term illness coverage akin to the public university system (along with the in-state discounts).
And allow for a parallel private system to exist for those who want to pay more and get allegedly better treatment.
EDIT: This does appear to be inflation adjusted. Here’s a federal source which is definitely inflation adjusted showing funding increasing in real terms by 27% from 1995-2013. [2]
[1] - http://apps.urban.org/features/education-funding-trends/
[2] - https://nces.ed.gov/programs/digest/d16/tables/dt16_235.10.a...
[0] http://www.in2013dollars.com/1995-dollars-in-2015?amount=100
Many of the country's best schools are public, especially at the college-level.
If the government will not allow treatment and there’s no way to pay and you can’t leave the country, you’re finished.
If insurance will not allow treatment and there’s no way to pay and you can’t leave the country, you’re finished.
Side note: private health insurance, private healthcare facilities, and paying out of your own pocket are all possible in countries with socialized healthcare.
Alfie is going to die. He has no brain. He was being kept "alive" on life support. The hospital want to end this life support because it's in his best intersts to do so - there's no hope of treatment, and keeping him alive is likely to be keeping him in pain. The parents disagreed with this, and so it had to go to court.
This means there is legal representation for the hospital; for the parents; and independent representation for the child. This is because the child is a human and has rights and his best interests need to be kept in mind.
The parents have rejected the findings of the court, and have made many appeals. They've gone to appeal court several times, the supreme court several times, and ECHR[1] a couple of times.
All the courts agree: it's in Alfie's best interests to let him die, rather than rpolong his suffering when there's no hope of treatment.
Also, all the courts agree that Alfie's parents (and latterly his father) have been given terrible legal advice.
This is causing some consternation in US right-wing nutjobs.
Here are some, but not all, of the court hearings. I might have got the ordering wrong.
http://www.bailii.org/cgi-bin/format.cgi?doc=/ew/cases/EWHC/...
http://www.bailii.org/cgi-bin/format.cgi?doc=/ew/cases/EWHC/...
http://www.bailii.org/cgi-bin/format.cgi?doc=/ew/cases/EWCA/...
http://www.bailii.org/cgi-bin/format.cgi?doc=/ew/cases/EWHC/...
https://www.supremecourt.uk/docs/in-the-matter-of-alfie-evan...
http://www.bailii.org/cgi-bin/format.cgi?doc=/eu/cases/ECHR/...
http://www.bailii.org/cgi-bin/format.cgi?doc=/eu/cases/ECHR/...
An example of the terrible legal advice (from a non-lawyer too!)
---begin
On 12th April 2018 the father went to the hospital with some other people who included a foreign doctor and air ambulance staff. The father had a letter written to him by Mr Pavel Stroilov of the Christian Legal Centre which, we were told, is a campaigning organisation. In the letter Mr Stroilov, who we have been told is not a lawyer, purported to give the father legal advice. He said that it would be lawful for the father to remove Alfie from the hospital and take him to any other place he chose. The previous order made by Hayden J was said not to have circumvented "your parental rights".
The letter, which was disseminated on social media (presumably with the knowledge and consent of Mr Stroilov), stated that:
"as a matter of law it is your right to come to (the) hospital with a team of medical professionals with their own life-support equipment and move Alfie to such other place as you consider is best for him. You do not need any permission from (the) Hospital or the court to do so".
This letter was misleading to the extent of giving the father false advice. We have been told that it had the most regrettable consequences in that it led to a confrontation in which Alfie was involved. The Police had to be called. An application had to be made as a matter of urgency to Hayden J.
The letter gave false advice because the previous decisions made by the courts in this case have directly addressed whether the parents have the right to decide what should happen to Alfie. The clear answer which has been given is that the parents' wishes are not determinative. The court has also expressly decided that removing Alfie from the hospital as the parents wanted was "irreconcilable with (his) best interests" and that his treatment and care "shall" be given by this hospital. To act inconsistently with or contrary to the court's determination and order would be to act without lawful authority. This includes the hospital which would have been acting in breach of the court's order if they had permitted Alfie to be removed from the hospital.
All the doctors (even the Italian doctors) agree: Alfie Evans is going to die, and soon. What they're offering in Italy is exactly the same palliative end-of-life care that he'd get in the UK, but with the addition of a long painful trip.
Alfie Evans has had the benefit of world class medical treatment - in the US he'd have been killed by the insurance company a long time ago. He's also had the benefit of free legal representation to make sure his best interests (because in the UK and Europe the best interests of the child are what's important) are looked after.
Here's a ranty English lawyer: https://twitter.com/BarristerSecret/status/98919501104352870...
I don't even trust the market to create an efficient system.
I trust the market to be adjusted by the wealthy to further enrich themselves.
I also trust the government to be the one organized group of people that can restrain that market, to give the rest of us a chance.
There ARE a lot of alternatives to the current system. Canada, France, the Netherlands, and Singapore are good examples to look at--very different systems, all far more cost-effective than ours.
What most other countries are doing: Fund healthcare from tax money.
The middle class will anyway pay for the healthcare of those who can't pay for themselves. In other countries they pay in taxes, in the US they pay for it in their own higher medical bills.
This is a matter of an opinion of course. But most Europeans would opine that the American model is the unreasonable alternative.
People who self selected for free medical care didn't have much better health outcome than others who were not selected, except that they didn't go bankrupt.
So, the group that didn't get paid for didn't go to the ER, while the group that did get paid for went to the ER but didn't have better health outcomes than those that didn't. Surely that says something about the private, for profit institutions that run the ER business.
Then why do people in those same countries purchase additional insurance from the private sector?
> In other countries they pay in taxes, in the US they pay for it in their own higher medical bills.
Surely you have heard of Medicaid and Medicare before. Yes?
Same reason some people upgrade their coach-class airline tickets - they can afford a nicer, more personalized level of service.
And then, don't allow the for-profit to loan or grant or shift any resources over to the not-for-profit. In fact, ensure they're not owned by the same parent corporation or even the same shareholders.
Keep the logistics consolidated—everything flows through the for-profit's buyer—but then, have the for-profit rent its facilities and machinery, and provide its pre-acquired drugs and materials, to the not-for-profit at market price.
And have the for-profit and not-for-profit hire the same employees and split their shifts; or perhaps, have the for-profit hire them, with the option to volunteer as many hours as they wish to the not-for-profit. (This would lower the expenses of the not-for-profit considerably.)
In other words, leave the not-for-profit "twisting in the wind", where it's still running but nobody's paying for it, so it's just running at more and more of a loss each year. Try to minimize its costs—in fact, have people working for the not-for-profit entirely dedicated to trying to minimize its costs (successful strategies for which can be rolled back into the for-profit.)
But also, treat the not-for-profit as a thing which needs to raise money, rather than just making revenue. A thing like a University, which has entire departments dedicated to getting funding from its alumni. Maybe even work with other not-for-profit hospitals in a Public Advocacy Coalition to build a social norm that if one of these not-for-profit hospitals saved your life, and you went on to great [monetary] success, you should donate to that hospital (and it will, in turn, privilege your family while pretending not to, just like Universities do.)
A fun effect of this is that the not-for-profit will now be a large, visible advocate for cost-minimization in the for-profit's purchasing—since those costs will be passed on to them (so they'll be incentivized to lower them), but they can't just lower them by buying cheaper themselves (because they don't have their own purchasing/facilities management/IT/etc. departments), they'll instead have to figure out how the hospital as a whole can lower costs, in order for them to save any money.
Essentially, this is doing the same thing that creating municipal vote districts along income lines does: the rich voters and the poor voters each get their own voices in how the city should be run, and so the poor voters (through their representative) get the chance to argue against proposals that would benefit the rich voters but hurt them. Right now, hospitals don't have any such representative for their "poor voters."
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(Yes, I know that a lot of hospitals are already not-for-profits. They're still run on a model that tries to maximize revenue, though, because they need that money. If you split the unprofitable patients out, suddenly the for-profit hospital can lower its prices, while the not-for-profit is forced to lower its costs.)
Consider the aphorism "the squeaky wheel gets the grease." Why is this an aphorism? Because squeaky wheels are annoying. If the people who use the wheels have to hear them squeak, they'll soon oil them. So if you hear a squeaky wheel (for example, on a shopping cart), that's usually because the people with the oil don't ever have to get close enough to hear that squeak.
Proposals like Basic Income, or even welfare, basically translate to "greasing all the wheels on a regular schedule, whether you've heard them squeak or not"—i.e., fixing problems that aren't actually bothering you personally. It's nearly impossible to incentivize anyone to do that.
My proposal here is more in terms of "ensuring when manufacturing wheels that they will squeak as loudly as possible when they've begun failing." You want to solve the shopping-cart case, where the person with the oil isn't the person who has to use the cart. And the best way to do that is to ensure that the customers will be too irritated by the squeaking to actually use the carts; and therefore the carts will go disused; and therefore the customers will complain to the cashiers that there are no carts, and people will buy less than they would with a cart, and revenue will go down, and some stakeholder will notice, and gather information, and figure out that it's that all the carts are squeaking horribly, and so oil them.
Or, in other words, you want the squeak of "people not getting treated because they don't have the money" to be loud enough to actually make it all the way up to the hospital's CFO, where the squeaking will cause cost-cutting; and even further, to the city surrounding the hospital, where the squeaking will cause donating.
In fact, if you oil the carts regularly, you might not realize that your wheels are badly-made and are rusting prematurely; or that your parking lot needs a regular dust-blower-ing; or whatever else. Sensitive components—canaries in coal mines, or people with no money in poor health—show you where your system is weakest. If you eliminate them (by just providing UBI, or even just public healthcare), you eliminate the chance to observe where your system fails. In a country with more money than it knows what to do with, this is probably a sensible approach—it has fewer people suffer over the short term, after all, at the expense of a bloated, bureaucratic medical system. But if you're trying to figure out how to cut those costs, you need the squeaking.
Bawawahahaha. No. Non-profit is just a tax status that allows them not to pay income taxes or property taxes on enormous assets and enormous income.
2) Many shops in UK (especially London), run by Muslim or Seikh owners, have been feeding hungry people for years.
At this point socialized medicine could literally save US taxpayers money while also removing the need for health insurance.
What numbers are published can be haggled over in future laws.
But the requirement for some numbers to be published is a big win.
FWIW, the move to digital health records was basically realized through Medicare demanding it. Providers can't afford to go without Medicare payments; like Texas and California, so goes Medicare, so goes the market.
It's not even that. "Sticker price" is simply the opening of negotations, sam as with any big-ticket purchase like real estate and vehicles and school tuition, and to a lesser extent airfare and hotel rates.
As with any high-overhead business with room for high-marginal-profit on units, they simply seek to maximize total revenue or at least cover costs. They don't care which customers pay how much.
My routine healthcare is not a big-ticket purchase and should not be the kind of thing I need to negotiate over. The total package between hospitals and insurers is, but my transaction is not.
edit: forgot to add the link.
I just had $5k worth of bills from the birth of my last child (the amount wasn't surprising, pretty much exactly what the insurance estimated for standard pregnancy).
I called, credit card in hand, and asked if they have any discounts for paying on time. They gave me a 35% discount on the spot!
It still feels vaguely like insurance fraud because the $5k amount is what is going towards the deductibles...
medicare doesn't negotiate. they just pay a fixed cost up front.
Making up some numbers, my wife had already spent $3k on the OB-GYN which counts toward the deductible. The hospital billed us $7500. So $2k we pay to finish meeting the deductible and then 20% of the remaining $5500 is $1500, so our portion of the hospital bill is $3500.
If the insurance company knew we'd get a discount on our portion of the final bill, that calculation for how much of the bill we'd only have to pay 20% of would be different.
Right now we kinda just have to take people’s word for it.
This transparency is the first step needed to move us toward smarter consumption of care. I don’t see any worthwhile brands getting tarnished by pricing data.
If consumers see a hospital as expensive, they might choose a cheaper hospital that provides the same standard of care without the frills. This is the kind of decision making that will bring down care costs over time and I’m stoked to see this move.
The issue I see though is that all parties that have data are incentivized to keep it to themselves. Many "leading" hospitals actually don't have super great quality compared to other, less well known hospitals. So powerful, well known but low quality hospitals will lose if there's more transparency. They know this, and they're fighting it
Large EMRs will also lose if there is more interoperability. Right now the fact that Epic and Cerner "own" a hospitals data gives them a lot of power. If anyone wants data, they have to go not just through the hospital, but through the EMR duopoly.
Insurers don't want to publish their rates, because they'd face backlash from all around when people realize how much variability there is in how much they pay for the same procedure at different hospitals
I had a "pleasure" to actually dig for some service (online) and after a while I got frustrated by this exact thing - all prices are always hidden, you HAVE TO contact 'sales' department and even if they show some prices upfront there are sooo many hidden costs and obligatory services and taxes that it's virtually impossible to quickly compare services.
In contrast - in majority of the European countries (I think it's an EU thing) all companies are obliged to display complete, total price for customer with all taxes included - this makes life so much easier…
Not as much as you might think.
The biggest beneficiary of price opacity is, actually Medicare itself. Because prices are opaque, and because it's illegal to charge private insurers less than what you charge Medicare, and because Medicare has no legal mandate to reimburse COGS, Medicare is able to use the lack of price transparency to force providers to pass Medicare costs on to private insurers (which then gets passed on to privately-insured patients in the form of premiums).
A rather cynical - but wholly plausible - view of this news is that it's an attempt to undermine the long-term financial solvency of Medicare, by making it harder for them (in the long run) to pad their operating budget this way. Given that the press release heavily emphasizes the role of the current administration in making this change[0], and that the entire party has pretty consistently supported cutting funding for Medicare[2], it's a rather easy conclusion to come to.
[0] It's not exactly unusual to mention the President by name in a press release of this nature, but it's not exactly typical or standard practice either. Oftentimes, agencies will refer to themselves as if they were politically neutral and functioning somewhat independently of the executive branch[1], even though the leadership is obviously appointed by the executive.
[1] Because, to a large degree, they are - the people employed by these agencies have relatively low turnover, unlike the directors who are appointed fresh by each new administration.
[2] Not in their rhetoric, of course, but with their actions
When people talk about the free market and today's healthcare in the US I'm always like, "What are you even talking about?" You've got a situation where there is typically no competition and little or no information available to the consumer. Free market economics simply don't apply.
One of the reasons I like Kaiser is because the price for just about everything is posted. I know an CT scan of stomach area, with dye is $608. Every healthcare provider should be required by law to give you an estimate price on the spot. If it's too complicated because of multiple insurance providers and their contracts they should be forced to renegotiate in a way that make this possible. "It depends" or "we can't tell you until after we bill you" is not acceptable. Can you imagine any other market working that way? How much is this car? Can you imagine if the response was, "Well, it depends. We can't tell until after you agree to take possession. It's somewhere between $40 and $40,000. But it might actually be free if you submit form X, but you have to go back in time and submit it before you walked in the door and get it approved."
If the option was universal healthcare vs a free market system there would at least be a discussion. Instead it's universal healthcare vs the roll-of-the-dice healthcare system we have now.
It's not baffling if you look at the way the medical billing system actually works. In short, Medicare is able to use existing laws (the requirement that Medicare receive the lowest price, along with the lack of mandate to reimburse COGS) to force providers to use funds from privately-insured patients to cover the costs of treating Medicare patients. From a financial point of view, the biggest adversary of price transparency (for privately-insured patients) is Medicare itself.
In that light, it's not surprising that an administration which has been very clear it wants to defund Medicare (without actually admitting as much in those words) is establishing rules that will essentially restrict the effective operating budget that Medicare will work with, long-term.
If we don't go the single payer route, it seems one of the #1 things we could do is to help move "insurance" back to being actual insurance (i.e., we'll keep you from being bankrupted by your medical bills) rather than a system that highly subsidizes your regular medical care but then may not actually be there for you when the bills really pile up... If consumers had to actually shop for procedures (as opposed to knowing the out-of-pocket is $250 and who knows what happens beyond that), I think you'd start to see people screaming for transparency, and medical providers would have to get their acts together.
Only one of many problems, I know.
I'm pretty conservative and I'd love to see a solution to the healthcare marketplace that doesn't amount to nationalization, but at this point, the market is so distorted and fundamentally unworkable that even a nationalized healthcare industry would be preferable.
There is no definition that fits better than "FUBAR" [0]. The only solution is going to be tear down the industry that we have and build something more sustainable in its place, whether that new thing is a nationalized health system or just very serious regulations to ensure healthy and functioning competition and free-market ideals (Obamacare does the opposite of this, literally making it illegal to not pay a health insurer; good policy would make non-catastrophic medical coverage illegal). Whatever the answer is, there's going to be a lot of people who are unhappy about it, but we have to fix this.
That other conservatives are just slamming their heads into the sand and saying "free market" when it's impossible to know how much a given medical procedure will actually cost until 3-6 months after the fact is just utterly and fundamentally embarrassing for everyone. Pricing is the most fundamental element in a functioning market. You can't pretend to be making rational choices if you can't even find out the cost. The whole thing shows how very little anyone is paying attention to anything other than virtue signaling.
The government is a big bad powerful thing, but it exists for a reason, and reducing every argument down to "just let those nice men in the Hamptons handle it, they wouldn't be rich if they weren't real smart" gets really tiresome.
There's plenty of people that could afford higher deductibles than that (and would prefer the accompanying lower premiums), but not really the majority of people.
Cutting the basic benefits out of them wouldn't even really save that much money (because insurance negotiates reasonable prices for basic office visits...).
We need to stop looking at the individual level and "What can we eek out of people who don't qualify for Medicaid?", and look to the macro-scale effects. Insurance is the wrong model for routine services (indeed, insurance usually functions as a discount program rather than true insurance) and people shouldn't be able to sell it for that purpose due to the debilitating effects it has on the marketplace.
Docs and pharamacies should be up front about their real prices. Today, even people who are "posting prices" can't be up front about it because posted prices function as high anchors for insurance negotiations. This is why you can often get a massive "cash discount" if you call about a bill that you're going to self-pay. That's what they'd really like to charge you, but if they don't start out charging the sticker price they quoted the insurer, they're in big trouble.
For a market to work, there must be a real pricing dynamic where the consumer can be reasonably well informed about the actual total cost and vote with their feet. Hyperinflated 300% prices, necessitated by insurer demands for large discounts, don't count, they're still not real numbers. Markets simply cannot work without meaningful and accessible pricing information.
The medical system will remain a disaster until we can break this dynamic around pricing, and the only way to do that is to fundamentally change the way that medical insurance works, either by nationalizing insurance and/or medicine so that the government writes all the checks and price becomes only indirectly relevant to the public anyway, or by imposing law that mandates price transparency and seriously limits what "medical insurance" and "discount programs" can do, so that we don't immediately descend back into this.
IMO this is a textbook case of a market screaming for good regulation. Ideally we would identify the malicious actors (primarily insurers), develop rules and systems that minimize their ability to operate, and allow the free flow of commerce to handle everything else. "Nationalize it" is a clear power grab, but lacking any willingness to do anything else about such a breathtakingly large economic and humanitarian issue, even that would be better than "let's just keep crossing our fingers".
It's so sad that the level of conservative dialogue is not "let's find a good minimalist intervention that will get this market working again" but rather "Did someone say 'MURICA wasn't the best at something?!"
In America we are happy to burn a dollar as long as a rich person somewhere can make an extra penny.
As a nation we have no notion of public ethics and haven't for decades. We believe in every man for himself and rather than resignation we feel pride. Venerating not caring about our fellow man as if it was self reliance.
We believe in the dysfunction of the public sphere as an article of faith, implacable as gravity, instead of it being the result of our collective failure to build a system that works.
We feel pride in ourselves when we ought to feel shame for all of us.
But this doesn't answer the question: what is the revamping that would be done to solve the problem? I get that "We believe in the dysfunction of the public sphere as an article of faith" is true and the answer to my next question "okay cool, so why haven't we implemented that", but I'd first like to know what "that" is.
(not that you're on the hook for the time to educate me on a complex public policy issue)
The goal has to be making medicine work like everything else we buy, including the daily non-negotiables like food, water, clothing, and energy resources. There's no reason medicine shouldn't or can't work that way in the general case.
But as long as we make it about moving numbers around so that Group X is slightly less inconvenienced by this farce, we're playing their game. We need to be talking about how to break their stranglehold, and I don't think just "move it into the government so we can get installed as bureaucrats, who are even harder to get rid than executives!" is necessarily a great macro-scale response (though I continue to believe it's better than doing nothing).
I don't suggest taking anything from anyone who is actually involved in the thing here. The only people I want to take out of the equation are the pencil-pushers leeching gargantuan quantities of otherwise-useful time and money away from the public.
That so many people find it so difficult to conceive of routine medical care without an insurance carrier of some type is a testament to the work we have ahead of us.
https://www.amazon.com/dp/034580273X/ref=cm_sw_r_tw_dp_U_x_-...
The big issue, as you mention, is health insurance companies themselves. They aren't actual insurance companies—they are payers, like others in this thread have called out. Real insurance exists when unlikely but disastrous events occur, like a house fire or a car accident.
Payers act more like surrogates—they bargain and make purchasing decisions on behalf of users like us. This is the fundamental problem in healthcare because surrogates cannot make financial decisions as well as a free market can.
Goldhill’s proposal for changing the industry is to eliminate the role of surrogates and replace it with a version of a health savings account that everybody would be required to contribute into and carry indefinitely, and require everybody to have a very high deductible catastrophic insurance plan. For example, all healthcare payments under $30k would be paid for directly by the patient and come out of the savings account. When something truly big and expensive occurs in a patient’s health (e.g., a cancer diagnosis) is when catastrophic health insurance would kick in and cover it.
This would allow for patients to make active decisions about which type of care to choose, and would force providers to become more competitive to earn the business of actual customers.
We do this just fine with other usually-non-emergent necessities of life like food, clothing, and housing. We didn't need to nationalize land ownership or food distribution to create vibrant economies for these, despite the fact that people can't really just "choose not to buy them".
Things are that way in part because there is a controlled regulatory regime in there, not trying to nationalize everything but also acknowledging the duty to protect the market from bad actors. Food, clothing, and housing aren't perfect analogs because medicine is a professional service, but this suffices to show that necessities aren't necessarily exempt from market forces just by virtue of their non-optionality.
Medicine needs a middle ground between "nationalize it" and "ignore it", but in this case, if those are the only two options, "ignore it" is clearly the worse one.
My wife and kids had 0 medical emergencies last year and we still paid over $10k in doctor and dentist bills just from deductibles, copays, and coinsurance. That's after having nearly $1k per month deducted from my paychecks for insurance premiums, not to mention the part that my employer contributed on top of that. It makes me sick to add those figures up, so I'll just leave that as an exercise. You can bet that if there were any actual optionality here, we'd spend a few days trying to sort out the most efficient way to handle this stuff.
Let's also not forget that insurance imposes a significant amount of rationing too. Our policy only covered up to 40 "habilitative care" visits per year, despite the fact that every therapist and doctor we saw recommended about 3x that. These are relatively mild speech and occupational therapy visits -- 40 visits is combined, every speech and pt/ot visit counts against it. "You need insurance because you'll have to buy medical care or you'll die" doesn't always play out that way.
Frankly, no one wants to talk about chronic ailments. ADHD (the so-called fake disease) for example.
Nevermind that they are a real part of why premiums are likely as high as they are.
Nevermind that it is essentially a life-long tax for the patient.
Nevermind that the law deprives those who suffer from a case for which narcotic therapies work and CBT doesn't into profit slaves to drug manufacturer's and their 'attending' prescription writer.
They have a solution to the problem (that generally works out better for the supply chain than the patient)! How dare you suggest it isn't the best approach! What are you, some communist? /s
But alas, if we don't say it no one will listen.
So...
As the parent said...
"If it worked like normal insurance, people with chronic illnesses would still go bankrupt."
http://reason.com/archives/2017/10/25/this-one-weird-trick-c...
I presume you really mean 'residency slots' when you say doctors. In this case, the relevant administrative body is the ACGME... who sets the limits based on appropriations from Congress.
The trope of doctors restricting entry to enrich themselves does not explain reported physician shortages.
Never mind that Josef Mengele was a licensed physicians, or that the AMA was well established before the Tuskegee syphilis experiments occurred, also with work performed by licensed physicians.
Just that the bureaucracy has resulted in an industry that fails patients. Heart surgeons refuse difficult surgeries to juke the stats. Good for their mortality ratings (not that anybody could blame individuals doctors)[1], not so great for patients.
Even just the notion of specialties hurts the patient - it makes perfect sense that the deep knowledge involved means that an orthopedic doctor can't (and shouldn't!) treat issues that should be seen by a podiatrist. But at the end of the day, the patient is in chronic pain, and has such a low quality of life, that to them, the risks of street heroin are acceptable. This isn't a moral failing by the patient's, nor is it a lack of intelligence, this life being too much to bear otherwise, and if you've never considered suicide as an option, be grateful.
Dr. David Casarett's talk[2] takes a closer look at an alternate, but accepted medical practice, and gives some thoughts about how our medical bureaucrats have resulted in worse patient care.
[1] https://www.telegraph.co.uk/science/2016/06/03/one-in-three-... [2] https://www.ted.com/talks/david_casarett_a_doctor_s_case_for...
> Never mind that Josef Mengele was a licensed physicians, or that the AMA was well established before the Tuskegee syphilis experiments
The AMA has no role in licensing physicians, a task which is left to the states.
> Heart surgeons refuse difficult surgeries to juke[sic] the stats.
This is far more complicated than it seems. For example, consider that the sickest/most difficult patients are the most likely to die, irrespective of an intervention. At a certain point, the harm inherent to surgery outweighs any potential for benefit that the surgery might yield.
As a patient in that system (the NHS) I would prefer my surgeons not to make decisions based on trying to game the statistics. If I need heart surgery, I want whoever is competent and available. So if these stats block that, I'd rather we don't have the stats.
Frankly it's weird anyway because surgery is a team activity, not solo. Nothing serious is done by one bloke in a surgical gown, there's a team. I had a relatively minor operation and the named surgeon will have spent most of that operation _talking_ not operating. All the sewing and some of the cutting will be the nice younger doctors I met, a woman who'd been doing this a few years and was well on her way to being an actual surgeon, and a new bloke who seemed like he'd probably graduated just a couple of years ago. The old bloke with the paperwork saying he's allowed to cut people open is mostly there to watch over them both and step in if things go to shit. The woman is doing most of the work, showing the noob what she's doing and maybe overseeing while he stitches me back up at the end. There's some Eastern European doctor lady making sure I neither die nor wake up, and two or three nurses making sure everybody has what they need, and counting things to make sure nothing is left inside me that shouldn't be there. But if I'd died (very unlikely for minor surgery) it would count against my named surgeon and not the rest of the team.
http://articles.baltimoresun.com/1994-06-14/news/1994165047_...
For example, this guy was prescribing powerful meds with severe side effects.
http://www.chicagotribune.com/suburbs/daily-southtown/crime/...
But more to the point, almost everyone suffers harm because of the way our medical system is set up.
Maybe some ailments don't need 8 year degrees to cure. Just throwing out ideas here.
But anyhow, more transparency is almost always good. Particularly in the morass that is the American medical system. I keep wondering how ever let something so important get like this.
The AMA even explains this process: https://www.ama-assn.org/education/obtaining-medical-license
In healthcare you'd not only like to even out expenses over time, you'd also like to spread expenses over a group, else people with chronic conditions are still screwed.
You can argue that hospitals and ERs in particular are not a good place for checkups, but discouraging them is likely to be more costly (in $ and human lives) than not.
What I DO know from working in insurance is that lifetime medical costs are concentrated in the last 2 years of life (I worked on credit card insurance and life insurance).
That's where you could make huge costs savings (but is an ethical landmine, not to mention economic interests)
https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2017....
https://www.nihcm.org/categories/publications/the-concentrat...
It makes so much sense: If your father had to decide between a beer and you getting that wound checked, kids would die.
(For clarification, I'm all in for universal free healthcare, but comparisons need to be fair, and comparing the US to the nordics, is not fair)
https://www.kff.org/health-reform/fact-sheet/preventive-serv...
What you propose would work fine if humans were fully rational and not living paycheck to paycheck. Unfortunately that's not reality.
The law that got the nickname “Obamacare” is not the Accountable Care Act, it is the Patient Protection and Affordable Care Act.
More importantly it leads to less people dying of preventable matters. What you seem to be implying is that its a net negative to which I say citation needed.
It also catches things that require long expensive treatment early enough for them to be treated, rather than treatment be pointless, and, even if attempted, of shorter duration (on average) than if the conditions were found earlier, which is why preventive care doesn't seem to reduce aggregate costs.
The best way to reduce aggregate healthcare costs, if you have no other priorities, is to just make people less likely to seek care. No care = no costs.
Doing that could also drive up the price of oil changes such that they're no longer affordable without the use of insurance. If you could get an oil change for $50, then most people could afford it by paying for it outright. If that oil change now costs $500, then most people would have to go through insurance, and get the "discounted" price of $100 (which either has to be paid if the deductible has not been met, or you end up paying 10 to 30% of it).
Goods and services are allocated by price or by time. Take out the price component and assume that people will go to doctor more often, obtaining an appointment will take longer. How do time and hassle required to see a doctor disincentivize well visits?
That is, for any one particular patient who's found to have a disease down the road - say, cancer - it would have been cheaper for him if that problem had been found very early, so for his individual case the checkups and tests would have been a big savings.
But when you account for all the people that do not turn out to have the problem at all, and the cost of checkups and tests, and then especially the costs of the followups due to false positives that are a risk in every test, the overall cost of test and prevention is actually worse.
Firstly putting a bullet in the head of anyone with non trivial cancer would probably be a financial savings for the insurer but the real equation is the human/societal benefit of treatment vs costs to best make use of a finite resource.
A simple cost of treatment analysis even misses out on the income that a person would have earned had they not died and the money that could have been paid in taxes and used to fund more treatment.
Drilling down into just the cost of treatment your statement isn't even wrong its a category error like saying that adding 2 integers always yields a number greater than 42.
For any given test and set of circumstances under which it is administered there can be a cost benefit analysis.
Example if you spend a thousand dollars on each false positive result and save 10k for each and have a 1% false positive rate and test a million people with a 1 in a million true positive rate. You will find one true positive saving 10k unfortunately you will also find 10k false positives and waste 10 million dollars.
In actuality you wouldn't do this you would test people whose symptoms or circumstances suggest they are likely to have it.
It seems fantastic to suggest that preventative medicine is always financially negative when people who actually study health care say otherwise.
Mr. Gruber [yes, it's THAT Jonathan Gruber] found that when retirees in California began visiting their doctor less often and filling fewer prescriptions, overall medical spending fell. People did get sick more often, but treating their illnesses was still less costly than widespread basic care — in the form of doctors visits and drugs. ... As Dr. Mark R. Chassin, a former New York state health commissioner, says, preventive care “reduces costs, yes, for the individual who didn’t get sick.” [1]
You go on to state that the additional productivity of the person we saved also nets us additional savings. But the same article contradicts this notion as well:
The actual savings are also not as large as might at first seem. Even if you don’t develop diabetes, your lifetime medical costs won’t drop to zero. You might live longer and better and yet still ultimately run up almost as big a lifetime medical bill, because you’ll eventually have other problems. That would be an undeniably better outcome, but it wouldn’t produce a financial windfall for society.
You go on to suggest that medical professionals would not be wasting money on doing too many tests: "For any given test and set of circumstances under which it is administered there can be a cost benefit analysis."
That seems logical, but it's not how the real world works. People get emotional about the potential risks, and demand the tests even when there's not a clear indication. You might remember the hubbub a couple of years ago when it was suggested, based on historical evidence, that regular mammograms should be delayed a few years later than was currently the practice. But women's health advocacy groups raised such a hue and cry that the actual medical guidelines were not changed to follow the evidence.
[1] https://www.nytimes.com/2007/08/08/business/08leonhardt.html
This may be true in terms of outcomes, but it turns out not to be true in terms of aggregate costs.
(If you encourage smoking and discourage screenings and preventive care, you'll probably do a lot to reduce aggregate health costs, but at the expense of outcomes; the efficiencies you really want are ones that reduce cost while preserving outocomes, or improve outcomes without increasing costs. When outcomes and costs are in tension, though, desirability can be more ambiguous.)
The knock-on effect of there being fewer machines built keeps the price high. The first photocopier (the Xerox 914) cost the equivalent of $220,000 in 1965, yet there are very few businesses without a copier today because the price is so reasonable (5% of the 914's cost), and they do much much more.
You'd have even more people avoiding easily treatable conditions due to cost.
I’m not sure information is requisite in “free markets”; is it? I like the idea that a free market requires some information liquidity but I’m unfamiliar with any economic theories / philosophy on the subject.
Anyone here have some information that can be explored alongside that idea?
I wouldn’t think that’s the case, anyway. Because marketing/advertising/awareness is a cost with diminishing returns, meaning it’s be prohibitively expensive to inform everyone of your product in the market, much less make accessible ALL products in a category for comparison shopping for any customer at any given time (aside from a singularity event).
I do think markets require some information liquidity to be maintainable, and I generally understand free markets to be free of coercion.
This sounds more like an “transparent market” though I’m not sure that’s a defined concept.
Just about the ONLY assumption that holds true in healthcare is that firms maximize profits. And, in a twist of irony, the only healthcare provider to provide information on pricing is Kaiser Permanente—which is a non-profit. Yeah, they still do maximize profits, but not for shareholders. So you could make the argument that healthcare as a whole meets exactly zero of the assumptions necessary for any kind of free market model to apply.
>Pick up any text book and before you even get to supply and demand you will go through the "assumptions" that must be true in order for a free market to function.
You will go through the assumptions that must be true in order for a market to be in a state of perfect competition. Most econ books should be pretty good about this lanugage. 'Free market' is actually more about political philosophy than economics although it's usually cloaked in the language of normative economics.
They are usually listed as:
Perfect information
Perfect competition
Mobility of capital and labor
Firms maximize profits
Consumers maximize utility
A lot of people (most?) who champion free market economics have no idea what they are talking about. They could not pass the first quiz in an Econ 101 class.
In healthcare, at least in the decisions of consequence, you typically have no information and no choice.
Anyway, that’s all somewhat irrelevant. I asked a question wanting to know more about “free markets” as is commonly used in discussion, and not the theoretical concept which apparently does require complete information and is incompatible with the common / non-theoretical construct.
My curiosity remains, so I’ll ask if you know of any approachable resource that discusses the taxonomy of market models and their levers?
(In the past I have’nt found Amazon’s ranking of books to be useful as they’re written for entertainment, not exploration).
It's just like in Physics 101 you're dealing with point masses on a frictionless surface. Later on you learn abut friction and inertia, and still later you get into relativity.
We frequently start with that simplified view of the world, but there aren't any real professionals who believe that's the end of the story. Markets do exist, despite the fact that your assumptions don't hold true to varying degrees.
No, but information (specifically perfect information about cost and all benefits, to an infinite time horizon, of economic decisions among all market participants) is a (but not the only important) central assumption in the theory underpinning the conclusion that free markets are optimal in terms of economic efficiency.
You can have a free market where this isn't even approximately true, of course, but the farther it is from true—ceteris paribus—the weaker the argument for the desirability of free markets is.
That's debatable. In some markets (Veblen/Giffen goods, goods with a price elasticity that approaches zero, etc.) you could say that information doesn't matter because price is irrelevant, but I personally would say that you don't have a free market or any approximation of such without at least reasonable information. Which, you know, is up for interpretation.
Right now, lack of public understanding of healthcare quality and lack of transparency is a big weapon for providers. Providers have a lot of political clout, as hospitals are huge employers at local levels and thus have lots of local political influence, plus they are powerful on a national scale bc its a huge industry.
There could theoretically be a large scale political movement against hospitals, though it would probably have to be grassroots, as again, hospitals have lots of control over the political incumbency because hospitals employ so many people and are important to communities.
However, it is hard for grassroots movements to propose effective policy recommendations. Healthcare is complicated, and presenting simplistic solutions that sound good but probably won't work gets more grassroots support than complex solutions that may be more effective (i personally think that single payer is one of those solutions that sounds good but prob wont work, but i know thats controversial). In many cases, its probably possible for hospitals to push legislation that sounds like it is decreasing costs, but actually helps powerful hospitals make more money (one could argue that ACOs and ACA in general are an example of this). Making the issue worse is that hospitals control data, so they are able to cherry pick data that makes them look good and get public support based on these factors, but grassroots organizations cant access data to counter those claims
So hospitals have tons of political cover to protect their interests through 1) control of information and 2) influence on politicians through their roles as large employers
We like to talk about free markets, but we don't really want them, at least our elected representatives don't. This is the reason why Medicare is _legally prohibited_ from negotiating drug prices (something that blows the mind of pretty much everyone the first time they hear it).
For physician administered drugs, the gov't has said "we will pay an average of what everyone else pays". No negotiation, just defacto proclamation of what Medicare will pay.
For prescription drugs, Medicare pushes negotiation to private insurers who actually provide the coverage. They do negotiate with drug companies, often getting very steep discounts. Also, Medicare has said to drug companies "once a patient hit the donut hole, you need to give a 50% discount". Again, no negotiation, just a "if you want to do business with Medicare, deal with it".
So yes, they don't negotiate drug prices, they just tell the drug companies what they are willing to pay.
Of all such words, the word 'democracy' is possibly the most-abused.
Auto repair. Computer repair. Probably most kinds of repair. Even when prices are posted, there's always a ton of wiggle room, and by the time you find out the work is already done.
I walk in and sign a form that states I agree to pay diagnosis fee not to exceed ~$120. Diagnosis happens, I get an estimate of the work required to execute the repair. I can't recall a time when I paid anything other than precisely the amount of the quote offered ahead of time. Maybe it happens but it's vanishingly rare.
Best part is that the repair center will triage and rank the problems and often offer more than one treatment which will vary on endurance/cost/etc. Would that medicine could offer the same!
And the bill is usually honest. The pregnancy test for males isn't a joke, it really happened to a physician colleague of mine.
In most healthcare scenarios of consequence you have no such choice.
1) It's standard practice to proclaim one's love for free markets when one is trying to enter a market. "Competition is good!" (for me) But then as soon as one's company is entrenched in said market, one mysteriously starts doing everything possible to make it less free. "Competition is bad!" (for me) The one consistent part here is, of course, the "for me" part.
2) In most of the healthcare industry you are not the customer; your insurance company is. So the incentives are perverted accordingly. Higher prices for providers means more revenue for them, obviously; that part is straightforward. Higher prices paid by insurers, you would think, means it's harder for them, but just like any business, they adjust their prices (premiums, rates) accordingly, so they can pass costs on to the consumer and still make a profit. So higher prices from providers just means the insurer is essentially insuring a higher "volume" of claim dollars and collecting a higher volume of premiums; in other words they're doing more business and making proportionately more profit.
What's increasingly breaking the free market is provider consolidation. In many areas most of the small medical practices have been bought up by larger organizations. So those large providers control so much of the market that insurers have to pay whatever they charge. For example, in Northern California if an insurer (other than Kaiser Permanente) doesn't have Sutter Health in their network then their plans aren't viable.
I was livid when I couldn't find out how much it would cost for a medical procedure for my wife. All I got were excuses about how they couldn't do it. So many of us have high deductible insurance now. How can they not be setup to do this yet? How is it that we're not all demanding it?
Let's be clear: there's no real problem that couldn't possibly be solved here. All the other industries do it, medicine is no different. If unpredictable problems cause new expenses, then you can either disclaim those from upfront quotes and/or try to predict likely events that would cause additional charges.
In the end I signed and was never asked to return the item.
It's mandated in a sense because all Medicare data has to be sent to and aggregated by CMS and then reported on. So I think this already happens.
California also has some mandates about hospital "chargemaster" data, and the data is publicly available here: https://www.oshpd.ca.gov/chargemaster/
Cause people get in a huff about mandating things by law, complaining about "freedom".
I think a bigger issue is that during an emergency, even in the case where you are conscious and cogent, you will often have no ability to determine if you should get treatment at that hospital, or another.
I think it's utterly insane that life-critical procedures could result in someone being in massive debt (or bankrupted) through no fault of their own.
This insanity is one reason why when people ask "Would you be interested in working in the US?" my immediate answer is "hell no".
Even if employers were offering gold-plated top of the line insurance (doubtful), the insurers have so much wiggle room with bullshit about lifetime limits and whether they will cover X treatments, and whether specific hospitals are covered.
Is it so hard to provide a real-time cost? It might not be easy now, but we have the damn technology. System is broken. Mandate this, give them a deadline to implement. They have deep pockets, the engineers and tech exists, delivering it within 3 years should be mandated. Let me shop around cuz capitalism...
You want to cut healthcare costs? This is something 100% of congress can back, even with a hefty lobby against it. Cruz and Sanders could co-sponsor this for Christ-sake, thats how non-partisan this is.
Have you ever looked at the language specs for MUMPS? That's what a lot of medical software started out in, or is still written in. Compared to anything but Intercal, it's amazing that it works at all...
3 years indeed.
This is what people who offer advocacy services to the uninsured do. It's similar to getting comps on real estate, those people have access to billing systems to find out what insurers actually pay and negotiate based on that pricing.
I think that fundamentally (or almost fundamentally) clashes with transparency.
They won't. Having clear, sinple, unambiguous per-procedure price information widely available while quality information (including on induced downstream needs and costs) is less clear will produce strong downward pressure on quality, while also not controlling aggregate cost. That's a pretty clear pattern in human behavior that is often leveraged both as a competitive tactic and to increase total revenue.
Would be great if they were required to provide list, min insurer price, max, and median.
As a result, Medicare and Medicaid often pay more than private insurance. In part, that's because their ranges for negotiation are pegged to list prices. And so providers inflate those list prices. And nobody, except for a few clueless patients, actually pays list price.
Anyway, good for Medicare and Medicaid!
Pull requests for your local hospitals are welcomed!
This makes "shopping around" and being an informed consumer near impossible.
If this actually happens in a meaningful way, hospitals will have to be competitive on price, and I can easily see a 30% cost reduction across the industry just from that.
...which is why I'd be surprised if that actually happened. Such a big restructuring of such a politically powerful industry doesn't just happen in our system.
Does not mean "meaningless." And the purpose of shopping around is comparing between hospitals. List prices should be a good relative predictor for comparing cost.
When is the last time you dealt with any healthcare bills? This is almost universally untrue. Hospital A's list price for an MRI might be $1000, but your insurance has a deal with them where you only pay $100 out of pocket. Meanwhile Hospital B's list price for the same MRI is $500, but your insurance doesn't have a deal with them, so your OOP cost is $500. This is very common, and in many cases is impossible to know if it will happen until after you have had the procedure and are billed.
If you're checking with your insurer to find the price, then that makes the hospital's listed prices meaningless, which is the entire point of this comment chain.
In the perfect world, everyone would sit down with the hospital, look at the likely range of costs of a procedure, call the HMO/PPO to check how each outcome would be covered, and then repeat that process at several locations. But that is arduous and people don't have the time or patience.
Yes they do. Providers are already required to make their list prices publicly available, and insurance companies have it (they are already available to the general public as well, but they're probably going to be hard to find/understand for a layperson). Many insurance companies already have cost lookup tools specifically for this purpose. Posting the hospital's list price online like the article is talking about is purely for the consumption of the patient. It is not of use to the insurer.
>In the perfect world
In a perfect world, I'd contest that you wouldn't have to worry about healthcare costs at all, but I digress.
>everyone would sit down with the hospital, look at the likely range of costs of a procedure, call the HMO/PPO to check how each outcome would be covered
Except you already can do this even without looking at the list prices from a hospital. Your insurance can already tell you exactly how much you will be charged by any provider. They do not need these online 'list prices' to do so.
Every hospital charges more than the maximum reimbursable amount for the insurer. If they don't, that's because they've made a mistake - their goal is literally to set a bill that's high enough that it will generate a reimbursement for the maximum amount each time.
The problem is it's not a good predictor. I'm sure you've seen articles that say the cost of an MRI can vary between $500 and $5000. Those are the list prices.
For a given insurer, the contracted rate is probably pretty similar with the $500 rate being only marginally discounted and the $5000 rate heavily discounted.
And it will introduce price competition.
That's not how insurance works, though. You would pay 20% of your insurance's negotiated cost, not the list price. So you could still end up paying more at a hospital that has "lower prices", based on how well your insurance negotiates with them.
>And it will introduce price competition.
This is not universally a good thing.
Well first off, that's not a given. The article only mentions Medicare using price and electronic medical records as a way of 'rating' providers. I can't find anything similar about Medicare rating providers based on quality of care.
Second, look up the situation with Lasik eye clinics. Another user in this thread suggested it as a "great example of a highly functional healthcare market" driven by price competition. In reality, price competition in the Lasik market has caused eye clinics to operate more like car salesmen (complete with sales commissions, aggressive/pushy sales tactics, and deceptive marketing), and not like someone who actually has your best medical interests in mind.
I'm not saying that simply introducing price competition to hospitals will lead to something like that, but it's certainly an example of price competition not being a good thing.
The biggest problem with the US health care system is that it's decades behind every one of our counterparts in Europe, Australia/NZ, Japan, Canada, et. al.
People in other developed nation don't have to worry when they're sick. They know they can see a doctor and it either won't cost them anything, or it will always cost the same amount. If they lose their jobs, they don't have to worry about their health as well. People can chose to quit their jobs, or take long unpaid periods to work on their own projects, without having to worry about how they're going to pay for health care. In America, we're required to pay for private insurance, even if you leave the workforce.
There is a huge cognitive load when health is in the background of your mind. In America, we have to work. If you don't work, you don't get services; not until you're old enough to get Medicare. In other words, you don't get medical services until you're too old to be a working member of society; until the country bleeds you dry as a resource.
That is America.
Exactly. Everyone praising this is doing so because they think it's great that this will allow Americans to "shop around" when it comes to healthcare, but they seem to be missing the fact that even the very concept of "shopping around" for healthcare is absurd.
If you're having a heart attack, or just have a broken bone, or even if you just have a stomach ache, the last thing that you are going to want to have to spend time doing is "shopping around" before getting your problems fixed. Being able to shop around isn't something that should be praised, it's something that should be relentlessly mocked and is evidence of a failing healthcare system.
No it's not. A very large percentage of medical care is planned, not urgent. There is no reason why price comparison can't happen for those.
A great example of a highly functional healthcare market is vision correction laser surgery. Every time I look around some deal is being offered. Competition is what drove those prices down.
Can you do that with everything? Of course not. But you can do it with a lot of planned medical care.
And for those procedures, a hybrid system should suffice. All Americans, should, at minimum, be able to get urgent, surprise medical issues addressed in a way that doesn't completely destroy them financially.
Of course, nothing is black and white. Issues that could have been treated in a planned way become urgent if they're left to fester. Obamacare started shifting the incentives to make preventative measures more palatable, and healthcare cost growth has come down as a result. ACA is a /conservative/ set of policies. Even still, it elicits extreme reactions from loud people on the fringes.
> All Americans should, at minimum, be able to get routine and urgent, surprise medical issues addressed in a way that doesn't completely destroy them financially.
Elective procedures are obviously a thorny issue people will debate over where to draw the lines. But standard checkups, routine wellness procedures, and covering the unexpected ought to be the bare minimum—the healthcare floor of social decency beneath which we do not allow any member of society to fall without recognizing we are failing as a society.
The idea is that money shouldn't enter into the decision to have planned care at all. Let's say the price for a regular checkup goes from $200 to $100 (just an example). Okay but there are still people who will put off the checkup because of the cost. That shouldn't happen, people should just go to the doctor when they feel they need to, planned or unplanned.
>A great example of a highly functional healthcare market is vision correction laser surgery. Every time I look around some deal is being offered. Competition is what drove those prices down.
You mean LASIK? I mean besides the fact that you're falling for a markup-then-sale strategy there is a lot of contention around lasik surgeries - that they're misleadingly advertised, not that effective, bad side effects, etc. Heap a bunch of advertising on top that makes it hard for consumers to know the quality of what they're purchasing and you have basically all the hallmarks of bad un(der)regulated markets.
Money always enters the decision, even in a single payer system. Someone decides what will and won't be paid for. Your example of preventative care isn't a good one, since every US insurer had to cover it at no copay.
You mean LASIK?
Yes I do. And I mean the fact that it went from several thousand dollars in cost to under $1000 in pretty short time due to competition.
And of course consumers know what quality they are purchasing, any smart person would make the decision on more than just price.
I don't know about you, but I certainly don't think the 'marketplace' for procedures such as childbirths, biopsies, transplants, bone replacements, etc should look anything like the marketplace for Lasik does.
1: https://www.washingtonpost.com/archive/politics/2001/09/04/l...
2: https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedu...
3: https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedu...
4: https://www.ftc.gov/tips-advice/business-center/guidance/mar...
But if we want to go down that rabbit hole, a single payer system like the NHS isn't profit-driven like laser eye clinics are, so there's one way it differs. Doctors aren't incentivized to "sell" unnecessary surgeries.
More procedures, more $$$.
Which is yet more evidence of a failing healthcare system, and is certainly not reason to praise the concept of having to "shop around" just to get adequate and reasonably priced care.
However there are other incompetents that someone who is medically competent can not the less fall into. The doctor with poor human interaction skills makes the patient feel horribly before, during and after treatment. The doctor who takes "bribes" to prescribe a more expensive treatment when a cheaper alternative would work as well. Those are just a couple examples of how someone can be incompetent yet still not raise to the level of not being allowed to practice.
In any case it's less than 100%. And even if it were 100%, wouldn't transparency provide substantial, concrete benefits?
Really, I'm not sure how "some customers won't shop around" works as an argument against public knowledge of price and quality.
I figure "it can't hurt, there is a significant market failure, and price transparency can only help."
I'd like to hear someone knowledgeable provide a counterargument, though. Maybe it would be expensive or impossible to enumerate those costs. Maybe preferential ("discriminatory") pricing is really important to the smooth functioning of the system.
FTR, I think my original post did have several points that pertained to nonemergency care as well.
Right now, for many insurance plans, consumers of care are 100% price insensitive. If even, say, 5% of a market starts to take their business elsewhere out of concern for price, it starts to put more cost discipline onto the system, which encourages competition.
You can't suggest a huge change and then assume the world will stay the same post-change. It won't. What the health system needs is some incentive to control cost; today, it has very few.
http://www.politifact.com/truth-o-meter/statements/2013/oct/...
I've always been of the opinion that kind of information should be available next to the ballot box. I just have no idea how it should be presented.
Even the quickest of comprehensive summaries about a the ins and outs of your average healthcare plan would probably run at least 30 pages (and the actual bills run 100s of pages). Do you really expect to people to read that just before they vote?
Honestly, unless you are a hardcore healthcare wonk, reading the 1 page 'propaganda' summary is realistically all you can expect from people.
We have to slash at least $1 trillion in healthcare spending.
Everyone in the healthcare industry is going to be extremely upset about that. It will all come directly out of their pockets. That will include doctors and nurses, middle class people working in health insurance, biotech companies, medtech device makers, you name it.
As you bring the cost down, implementing broader socialized medicine than what the US already has (half of all Americans are getting some form of government healthcare coverage), becomes that much easier and cost effective. As costs stand today, there is no way the US can afford to implement the style of socialized medicine that Canada or Britain have - we're spending twice what they are per capita. The Democrats in California recently looked at implementing universal healthcare for the state, they immediately walked away from it because it's financially impossible at current costs.
As someone not from America, I want to say something positive.
Thank you America for inventing so many life saving drugs that people all around the world depend on.
In the US today, about 50% of the population has free or extremely low cost health care provided by the Government. The majority of poor people in the US now receive 100% free care via State-administered medicaid.
So what exactly does universal health care in the US look like? Medicaid/medicare for everyone? Based on the UK experience, we'd expect 20% of the US to still pay out of pocket for private insurance. Private insurance companies would also likely be free to discriminate on prior conditions because, after all, everyone has universal insurance as a backstop.
You risk creating a two-tier system of public-private insurance where healthy, wealthy people have access to concierge preventative care and very fast specialist referrals, while the chronically sick (uninsurable) and non-wealthy are stuck in a publicly run system with less preventative care and worse referral and wait times.
I'm not saying I have the answer - just raising some issues that are often lost in the debate over how to reform this market. Personally, since the medicaid expansion, I don't think insurance coverage is the problem any more. Now it's about quality and cost of care. And transparency and competition certainly seem like two reasonable ways to tackle cost.
>You risk creating a two-tier system of public-private insurance where healthy, wealthy people have access to concierge preventative care and very fast specialist referrals, while the chronically sick (uninsurable) and non-wealthy are stuck in a publicly run system with less preventative care and worse referral and wait times.
Sure, if that happens, fine let it happen. 0.1% of people might fall into the bracket of wealth that use private healthcare. Would you really hold up healthcare for 99.9% of people because of this?
You do not have the answer, but everyone else does. Go public. The benefits far outweigh any detraction.
I find the comparison country vs country to be valuable, but somewhat limited. The U.S. is unique in a lot of aspects.
For example in argentina(i know, not rich country but hear me out), that has public healthcare, healthcare spending per gdp has been cut in half in the last couple of decades: mostly because private healthcare ate up the market. Hybrid markets are a reasonable compromise.
The US is also not a free market of healthcare, it has the worst of both worlds: highly regulated, intrusive and punishing state, with proteccionism and quotas.
To this day I still believe the #1 healthcare policy issue is with the state's intervention. It is the FDA that makes pharma expensive, it is H1B quotas and medical licensing requirements that prevent foreign doctors to come to the US, it is Medicare that puts fee-for-service, it is the state that makes malpractice costly, etc etc.
You're conflating two things. A large portion of "cutting edge health science" research is funded publicly. The private funding tends to focus on reformulating existing drugs and other less-risky bets. The real game changers come out of moon-shots made possible by government funding.
https://www.npr.org/sections/health-shots/2015/01/13/3768013...
I dont know enough to confirm or refute, but government science in general is pretty inefficient: yes it does things that the private sector wouldnt do that are valuable, but it does a lot of other things poorly and expensively.
Not to mention that the very state makes researching drugs onerously expensive. It can take a billion dollars to get FDA approval, how is that reasonable.
It is unreasonable to have to prove drugs are safe before shipping them out to potentially millions of people? We must have very different definitions of reasonable.
You left out Medicaid.
Not in Germany, just to name one high income, developed country.
I don't know how a patient can be expected to make a decision in that situation -- either legally or economically.
I've had places laugh and hang up when I asked about pricing and paying cash, while others give me exact figures and a discount for cash. Maybe this law will at least start us down the path of pricing transparency.
By far, the most sensible system is to have a single-payer, universal healthcare system. Prices can be set nation-wide for drugs, our gov't can bargain and negotiate with providers, and most importantly: healthcare professionals will mostly not operate on a fee-for-service basis, which is a perverse incentive divorced from the Hippocratic oath.
Add to that the fact that you are likely ill. I think the biggest argument against healthcare-as-a-market is simply that patients can't be (expected to be) informed consumers.
The receptionist literally, and I am using this word correctly, LITERALLY laughed in my face when I asked how much the visit that had just ended would cost.
For me it's not about "shopping around" before I go to a hospital. Its having a transparent and up front bill for what services were rendered before I leave. It's preventing that shock unbelievable bill that shows up in the mail three months later, and giving the patient a chance to dispute fraudulent or excessive costs while they are still in the building.
Hospital billing needs to be open and transparent. It's the most manipulative and predatory industry on the planet. If only the goal was to help people, it seems like the companies that own hospitals only care about shareholders.
I always feel so helpless whenever I go as if my decisions are more or less made for me. Transparency will not only help me decide, but give me options that weren’t visible in the first place.
Hospitals and doctors must post their price list online.
Hospitals and doctors must disclose to each patient before any non-emergency service how much that service will cost. The disclosed cost must be consistent with the price list and must not depend on what insurance is involved.
Hospitals and doctors must not give any non-charitable discount to anyone that lowers the total amount that they charge below the listed price. (With the possible exception of Medicare.)
Hospitals and doctors must not attempt to collect more than the listed and disclosed price from any patient for any service.
In other words, if a doctor is willing to see a patient with some particular insurance plan for $100 (split between the insurer and patient however the insurer sees fit), then that doctor cannot bill a patient $300 for the same service becaues they have a different insurer.
Yes, a law like this would thoroughly invalidate the entire way that insurance contracts work right now in the US.
I'm hoping we reach consensus soon that healthcare isn't somehow "special". It's just an industry, with incumbent interests, fighting to earn as much profit as possible, just like any other industry.
I absolutely would love things to be transparent, but I think healthcare is more like fixing software bugs than delivering well-scoped features. It's very hard to estimate anything beyond the most basic, superficial issues.
Just to be totally clear, I want prices posted online. I'm just worried there would be asterisks next to everything and then they would be useless. Perhaps that's an opportunity for differentiation in hospitals: "broken bone - cast set: $X - all inclusive".
This does impose an annoyance cost on every little charge, which I think is a good thing. If a medical practice really wants to charge for every piece of gauze they use, then this should annoy the patient up front so the practice has an incentive to stop doing it.
The side effect of such a policy is that hospitals will then have huge incentives to perform the cheaper procedure. E.g. if the real price of C-section is higher than the real price of vaginal birth, but the effective price for both is mandated by the government, then hospitals will have too much pressure not to perform C-sections (even when they'd result in better outcomes for the patient).
A large number of hospital procedures are likely planned, and can therefore be subject to comparison shopping. Giving birth is an obvious one. But even for many fractures there is a day or two before the procedure, and you could transfer.
Maybe more importantly, public price information allows independent research into price disparities, and public shaming of the worst offenders. That’s data only insurance companies currently have access to.
If we start 'publicly shaming' hospitals for high prices, then that will encourage hospitals to aim for low prices. That of course sounds great on its face, but my concern is that this is going to encourage hospitals to achieve lower prices through cost cutting, (aka cutting corners, in the industry where corners need to be cut the least: healthcare).
Trying to rein in healthcare costs is great, but I fear that trying to do it by encouraging focus on narrow metrics like these could do more harm than good.
Also, these publicly-available prices will be almost meaningless to the average person, as they are just 'list prices' and won't match what insurance or any individual actually pays.
https://www.washingtonpost.com/news/wonk/wp/2015/01/21/a-kne...
> The report, which analyzed three years of BCBSA companies' claims data in 64 markets, found that the average price for a knee replacement surgery is $31,124. But that price, which doesn't reflect what the patient actually pays, can vary greatly within the same city. In Dallas, for example, a knee surgery will run anywhere between $16,772 and $61,585 depending on the hospital.
From TFA: It may still prove to be confusing to consumers, since standard rates are like list prices and don't reflect what insurers and government programs pay.
Just because your insurance doesn't cover something doesn't mean they should make more money. This is one of the root problems driving healthcare costs. No deals for government or insurance companies. Post prices. Standard procedures should end up with lower pricing due to competition.
Generally speaking, each hospital/practice/clinical lab has to negotiate with individual insurance companies to get reimbursed at a given rate minus "contractual adjustments" - this negotiation process is highly inefficient, given that each payer may do things differently (a contract with BCBS of NC may be different than one with Florida Blue), and smaller providers simply don't have the bandwidth or resources to have any leverage in this process.
The complexity of this ecosystem only hurts consumers and providers (and helps the payers, of course), and although many insurance entities call themselves "non-profit", I seriously question their motives.
It's almost reminiscent of the era leading up to the financial crisis of 2008, where complex derivatives, mortgage-backed securities, and other overly sophisticated financial instruments made those that worked in the industry fantastically wealthy, while the common people were left holding the bag when the stock market finally plummeted.
I hope we can find ways to simplify this system - the single payer system, for all of its flaws, seems like a step forward in the right direction.
The negotiations happen for 'in network' systems, and it's in the hospital's interests to be 'in network' for as many insurance companies as possible, as most people choose 'in network' care providers.
Secondly, if a provider doesn't negotiate with an insurance company, the insurance company would naturally reimburse a lot less. In the U.S., the lion's share of provider revenue comes from insurance companies instead of patient self-pay, so they have less leverage to negotiate here. Of course, a large hospital system could just say "screw you, we won't join your network" (in which case they have the upper hand, since people are more likely to pay insurance premiums for plans that include their current doctor/hospital).
This is great news and step zero on the long road to transparency in the voodoo that is USA medical billing.
What would be really awesome is if someone can get non-Medicare versions of these prices and somehow marry that with the co-pay / co-insurance of common insurance plans to give people an idea of what they'd be on the hook for. At the moment nothing short of going through with the medical service and then taking a time machine will get you the true answer. And even then they can retroactively change it!
Shameless self-promotion is encouraged in this type of reply so don't be shy!
In other words, along with covering everyone via the public system, Italy's private system is a better functioning market than the US system.
Apparently the hospitals have already been required to do this but now it will be online. Also this number will only give the upper bound of the cost since it is considerably negotiated down. What good does it do if they say mending a broken bone costs up to $20k when in reality it is somewhere between 0-$20k depending on insurance and other factors.
Last year I went to my dermatologist for a routine check up and they frooze 1 mole on my leg:
$ 600 for the visit
$ 600 for freezing the mole
Even if it was perfectly healthy, why not freeze it anyway?
And, unlike taxi laws, the laws on operating thingd that pretend to be legally-mandated emergency vehicles are going to be vigorously enforced.
Here's the healthcare plan we should have: https://medicareforall.dsausa.org/
Don't forget to account for the fact that Medicare's reimbursement rates are not self-sufficient - they're implicitly subsidized by private insurers. So it's actually much higher than that.
It doesn't really matter, if they're reimbursing below COGS (which they are). If the expected value of a set of numbers is negative, you can't make it positive by adding a bunch of other numbers which are also negative (even if they might be closer to zero, which in this case they oftentimes are not).
This has the incentive that private markets have incentives to do disease treatment and prevention before the patient goes to medicare, potentially offloading care onto the later stages.
I would surely like some formal study and analysis on this, i feel this is very theoretical.
As a provider, let's say 40% of your patients are on Medicare, and 60% are on private insurance. On average, you're losing money on a per-patient basis for 40% of your patient base, since Medicare's reimbursement rates are below COGS. You stay in the black by charging the remaining 60% enough to make up the difference.
Without the privately-insured patient base to subsidize the Medicare patients, the provider would go out of business immediately, because they wouldn't even have enough revenue to cover the direct, marginal costs of supplies for each treatment, let alone anything to pay for staff wages, office space, overhead, etc.
> I would surely like some formal study and analysis on this, i feel this is very theoretical.
This isn't theoretical at all. It's no secret that Medicare's reimbursement rates are below sustainable levels. Medicare itself admits as much. For providers that see a high enough percentage of Medicare patients that they can't effectively distribute the costs among their privately-insured patients (because there aren't enough of them), Medicare actually runs special stipend programs, where they provide you with extra money to stay afloat (separately from the regular reimbursements).
> Medicare does not reimburse below sustainable levels > On average, you're losing money on a per-patient basis for 40% of your patient basis..
I disagree with this conception of sustainable: at any point if you have two suppliers with price differenciation yes, one of them 'subsidizes' the other, but that doesnt make it so the latter doesnt bring revenue. If by law airlines could not sell coach anymore, they would all drastically go out of business, even though they dont make money on coach. Medicare does lower reimbursement but it only matters in so far they take the spot of a private insurer.
Furthermore, sustainable implies that there would be no providers at medicares rates but that is not true: there would be less because they pay less, but you would still have providers.
Second, accepting medicare is a hassle for providers but I assure you they dont do it out of charity. They give you infinite demand which means you can fill your non-private insurers slots with medicare and provide lots of revenue.
In most regions, Medicare reimburses rates that are less than COGS. If you have to pay $100 wholesale just for the supplies to perform a procedure, and you're only allowed to charge $93 for the procedure, you're going to go out of business very quickly.
Your assertion that "there would still be providers" is wrong, because unless Medicare dramatically raised its reimbursement rates[0], most providers would go out of business overnight. Even if it were true that there would still be providers, just fewer of them (which is not true), you're at best arguing for something which, in your own words, would exacerbate the current shortage of practicing clinicians, which would drive up prices for self-paying patients even further and dramatically lower the quality of care for the entire country.
> Second, accepting medicare is a hassle for providers but I assure you they dont do it out of charity. They give you infinite demand which means you can fill your non-private insurers slots with medicare and provide lots of revenue.
Medicare doesn't give you "infinite" demand. But furthermore, having more patients doesn't help you if you're literally losing money on a per-patient basis. You can't lose money on margin but "make it up in volume".
This is exactly why Medicare has to provide separate stipend programs to providers who aren't able to overcharge privately-insured patients and make up for their losses on Medicare patients that way.
[0] which is the entire point of the comment that began this whole thread - Medicare would have to dramatically raise its reimbursement rates if it covered all patients
As I explain below, Medicare reimburses providers rates that are below COGS. That's not a secret, and Medicare itself admits as much. It's not hard to see that, if Medicare reimburses rates that are below COGS, the only way providers can stay in business is by making up those losses with non-Medicare patients.
The patient pool of Medicare is actually not relevant to this entire conversation, because we're talking about what Medicare themselves reimburse for individual services, so we're already comparing like quantities. But if you really want to explore that line of reasoning, note that privately-managed Medicare plans (who have the same general patient population as Original Medicare) systematically outperform Medicare on the three top metrics: medical outcomes, cost, and patient satisfaction.
Insurance should be for the actual exceptional stuff. If we made prices transparent for basic care, then we may be able to have people pay for their own primary 'easy' care. This could lower the rate of more expensive illnesses as well as free money the insurance companies are using to pay for basic services to pay for the more life-saving, expensive stuff.
Article in The Atlantic back in 2009: https://www.theatlantic.com/magazine/archive/2009/09/how-ame...
My mother-in-law died of brain cancer over the course of about five days. We received a "Statement of Benefits". She received ~$130,000 of care. Medicare paid ~$30,000. That's bullshit. Per James Fallows' article, medical price transparency is CRITICAL. You can't improve something if you can't see it and can't measure it until after you experience it.
I'm an anti-Trump (and anti-Republican) Republican but I have to admit that, with this Medicare transparency action, sometimes this administration takes surprisingly sensible actions.
The situation is terribly regressive: people with the least money and the least likely to be able to afford healthcare and are therefore most likely to suffer high hospital costs. People with the most money get healthcare "insurance" and so get the lowest prices.
It is a tale of federally mandated wage control and specialized tax breaks. A quick google will show many articles outlining how we got here.
Why is car insurance not tied to employers? In general how much better does car insurance work than health? Are the prices not much more straightforward and is it easy to shop around? If you are treated poorly by your car insurance company, can you easily tell all your friends and change companies?
This is the real problem here. Most folks have no choice and no skin in the game, which leads to all these crazy stories about zero pricing information and no ability to change companies.
If the tax breaks simply got removed, and people had to actually pay directly for their insurance and could switch companies, the vast majority of these problems would go away.
Health insurance only works this way for the healthy. For the chronically ill, it's flat out cost reduction to have it and a profit loss for the insurer.
My insurance pays out more than I pay into it every year. I had one year it paid out ~$250k.
Unless we stop mandating care for the sick unable to pay for it, healthcare is socialized; it's just a matter of how efficiently socialized it is.
Insurance companies overcharge the healthy to make up for their losses with the chronically ill, and hospitals overcharge those who can pay to make up for their losses with those who can't.
Really just need to cut out the middle men.
Table 5 here shows a "weight" . That's the number of units of reimbursement a hospital gets for each particular diagnosis / procedure / whatever. (LOS is length of stay) (CC is complications) (MCC is major complications)
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Paymen...
Hospitals negotiate with CMS the number of dollars per unit of weight. Sometimes aggressively. It would be good to have that number of dollars posted publicly and explained. Does the hospital hate serving Medicare patients because they don't make enough?
1 - I'd imagine the price they will post is similar to an airline's full fare, refundable ticket price. The price actually paid is quite different and related to the negotiated rates with your insurer and your deductible.
2 - Hospital billing is often separated from physician billing. Does price transparency extend to all physician groups?
3 - Patients care about total out of pocket expense. How much is it going to cost me? Hospitals can't know this because they are not privy to your health plan structure/details - they only know their negotiated rates. Your health plan doesn't know it, because it hasn't received the full details of your treatment.
Call the facility, get a quote (they will probably have to do a bunch of work on their end), document quoted price (if I were to do this I would probably have the hospital email me a document), and don't pay more than the agreed upon price.
Receiving non-emergency medical care should be like shopping for cars, pizza, iPads, houses, etc. So, yeah, start doing that. Be the change you want to see.
Read an article that talked about insurance companies providing tools to consumers about pricing, turns out they don't use them because people are price conscience when it comes to their current healthcare needs. And my guess they're probably too price/time conscience when it comes to preventive care. Aka, they would need to be compensated to stop eating cheeseburgers.
You'll find they comply with this, just like California Prop 65.
They'll continue to give discounts just like Rockefeller gave rebates and subsidies.
https://www.theatlantic.com/magazine/archive/2009/09/how-ame...
And his book of course
Then we can trivially pick a plan independently of backroom deals that are impossible to evaluate ahead of time and easily pick the provider that provides the combination of service and price.
However, if a new hospital opens close-ish to an existing one, offers a temporary discount, then the two just keep an eye on each other's websites to maintain the status quo in pricing will offering "competition," now we have a duopoly.
Capitalism will find a way to keep screwing consumers.
If you do not like that this exposes publicly the capitalist nature of US health care, then I encourage you to support a universal/government health care option, rather than trying to prove this information isn't helpful.
Price transparency is great, but office visits are basically the only thing you can estimate well upfront (there's five CPT codes for the visit, 99211-99215 and it's easy to estimate which one will apply based on whether it's a new/existing patient and the level of history/examination you anticipate requiring). I will stand by my belief that the only way to "fix" healthcare in our country is going full single-payer so citizens don't have to worry about whether they can afford to get treated or not.
Having read horror stories about medical billing in the US I was prepared for a shock. However the bill was for something like £4.50... :-)
What will likely happen is that aggregators / bloggers / journalists will start comparing prices and write about the differences. People will see the articles. And in a moment of crisis, they'll potentially think about the ones they read about, remembering one hospital or another.
And even if they don't, the mere fact of comparison articles (and likely outrage from normal people in the comments sections, etc), will create competitive pressure driving prices closer together. At that point, people won't need to search for the specific price for a hospital because all will likely be similar.
If I needed some kind of elective or non-emergency procedure, they would be high on my list (along with medical tourism to foreign countries where procedures are also clearly priced, and even cheaper)
I've recently been having pretty good luck going to medical providers and offering cash (I have Kaiser insurance now, which I basically treat as emergency/catastrophic only, since they never cover any providers I'd want to see, so I basically end up paying cash.). I was able to get a dermatologist to go from $600+ to $95 because cash.
I ended up dropping dental insurance and just pay cash, even for a family of 4, it is cheaper, assuming the kids brush their teeth.
The thing that is really bizarre to me is that I've more than once seen people quite prices for non-emergency procedures in the US that are more expensive than taking a business class flight to London, checking into a high end hotel and getting treated at a top private hospital targeting mostly rich people... Of course it's less convenient than being treated near your home, but the difference can be significant.
This works okay if the patient is resident or is an EU citizen, and so is entitled to be treated by the public system (though it's arguably an effective subsidy of the private system by the public system), but I wouldn't have thought it'd be feasible for non-resident foreign citizens.
Many, like e.g. HCA International explicitly advertise to an international client base, and tout their large numbers of ICU beds as one of their features, so would rarely expect to need to transfer patients.
One thing that certainly does bring costs down in the UK is that the system is geared heavily towards maximizing utilization of resources by e.g. allowing the NHS trusts to take on private work, and allowing NHS doctors to take on work at private clinics, and allowing private clinics to rent NHS resources, so you may very well find that your treatment by a private healthcare company involves being operated in an NHS hospital by an NHS consultant on their spare time. But while they certainly then benefit from economies of scale, all of this happens on commercial terms - e.g. NHS trusts use profits from renting out capacity to offset parts of their running costs.
The biggest private providers do have their own operating theatres and ICU's, but they too tend to have NHS staff working part time or consulting and may still rent NHS resources where it makes sense.
The cost to visitors of NHS treatment is 1.5x the NHS rate. Some stuff is exempt.
Here's the official guidance: https://www.gov.uk/government/publications/guidance-on-overs...
https://www.gov.uk/government/publications/guidance-on-overs...
Are you kidding me? If a patient is in so much pain that they can't make rational decisions about their care or feel that their care is urgent enough that they don't have time to look at prices, they should probably be in the ER anyway. For the 95% of patients not in this situation, having tangible pricing will be beneficial. Furthermore, for patients in seriously debilitating conditions, many have caregivers that can look into procedure finances.
Which is better, a CT Scan for $1000 or one for $10,000?
You probably guessed the cheaper one, right? Thinking "all CT Scans are the same," right? I happen to know that's not remotely true, but it's easy to think that saving money on a test would make sense, right?
Okay, now which is better, open-heart surgery for $20,000 or $200,000?
That's a lot harder to answer, isn't it?
You need to know the outcomes of those procedures at that facility, compared to other facilities, to have any possible way to judge them.
Now, outcome data is probably not available for every single procedure.
If you need a heart transplant, and I know you need a heart transplant, you're in kind of a lousy position to negotiate, aren't you?
I don't buy some Defense tokens or insurance on some market. I pay taxes for National Defense.
Don't get me wrong, capitalism is awesome. And I worked in healthcare software for about 13 years. But applying capitalism to basic, necessary healthcare is no good.
Imagine saying, do you want a $300 used iPhone or a $600 used iPhone? Pick one. You don't have enough information to make the decision but at least you know the price difference.
How about ... both? Knowing "outcomes" AND pricing would allow me to made an educated decision. Lacking one, or the other? Not so much.
Forcing people to decide "For $5,000 more, I have a 2% greater 5-year survivability" is inhumane.
We can do better. Other countries have done better. Our healthcare is more expensive, and our outcomes are worse. Capitalism does not work in healthcare.
What do you think Sanofi is exactly? That's the giant French pharma corporation that sells drugs in a global healthcare market.
How about all the excellent German medtech device makers? They sell their products in a global healthcare market.
How about Switzerland, Germany, Japan? They all have regulated healthcare markets, and they're three of the best healthcare systems on earth.
If you're a radiologist in the EU, you're selling your skill in a market. If one country won't pay you what you want, you can try to go to another market and earn more.
If businesses want to produce goods and services that governments pay for, in order to provide healthcare to the citizens, that's great.