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Comment by BurningFrog | Hacker News Reader

One of the biggest problems with US health care is that it's usually impossible to find out what treatments will cost before having them.

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.

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Where as other high income/developed countries, citizens don't have to shop around because everyone is insured by the State and pays the same prices.

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.

> Where as other high income/developed countries, citizens don't have to shop around because everyone is insured by the State and pays the same prices.

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.

very concept of "shopping around" for healthcare is absurd

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 it's not purely a race to the bottom; as expected price levels are achieved, it also becomes possible to read signals in the price, so that medical practitioners who are willing to do extra work (reduce wait times, better followup, home visits, etc.) can charge more to compensate for that, rather than just doing the minimum amount of work necessary in order to get the fixed payment.

>No it's not. A very large percentage of medical care is planned, not urgent.

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.

I’d suggest a slight addition:

> 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.

>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.

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.

The idea is that money shouldn't enter into the decision to have planned care at all.

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.

Lasik eye surgery is a terrible example for you to pick for this. Lasik is notorious for being a market where laser clinics bought the machines when Lasik was a fad and were hoping demand would stay high, and are now having to resort to unscrupulous sales tactics to recoup their losses. Laser clinics give sales commission to their eye counselors as an incentive to get you to purchase Lasik even when you might not need it or it may not be best for you [1]. They have incentives to use deceptive marketing techniques to make you think that you need it and that it is affordable, even though the price you hear on the radio is almost never the actual price you will pay (they will tell you that the advertised price is only for some eyes, and that yours are more complicated and require more money). They will try to convince you that there are no side effects, despite an FDA study showing that 46% of people reported visual issues caused by Lasik, with 30% of all recipients stating that Lasik caused them to have chronic dry eye [2]. This is so commonplace that the FDA and FTC had to get involved to guide consumers about how to avoid these shady clinics and to tell these Lasik marketers to knock it off [3], [4].

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...

How does that differ under a single payer system where a doctor might do surgery that isn't needed. The problem of bad actors exists whether you have a market or not.

My comment wasn't meant to say anything about single payer systems. You used the Lasik surgery market as an example of a "highly functional medical market" and acted as if it is something to aspire to, when it clearly isn't. That's all I'm saying.

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.

They might not incentivized with the NHS (doctor's are salaried), but they sure as hell are in Canada with it's fee-for-service model.

More procedures, more $$$.

It's absurd, but as long as it's politically untenable to go all the way to something reasonable, things like this which will presumably be a lot easier to defend is still better than nothing - a huge proportion of medical needs are not emergency care, after all.

Completely disagree. Providers are not all the same. Some doctors are so incompetent they should not be allowed to practice, some are excellent. People should have full information on their providers, including costs, to be able to make informed choices.

>Some doctors are so incompetent they should not be allowed to practice

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.

You seem to be using the wrong (though obvious) definition of what it means to be incompetent. A doctor who is incompetent because of poor treatment is handled by the system.

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.

I'm not using the wrong definition. A doctor who is considered "incompetent" because they take "bribes" should certainly be terminated by the system. If they aren't, it is a failing system.

I put bribes in quotes for a reason. Outright bribes are handled by the system. However I'm implying any way to get around the rules without getting caught. Some are legal loopholes, some are illegal. The only point is by some way you got around the rules without getting caught.

That doesn't change my answer. If you have a system in which doctors carry out shady tactics and are able to "get around the rules without getting caught", and that system is so rife with such issues that you have to actively "shop around" to avoid them, then the system is failing.

This makes sense in theory, but the healthcare market isn't a great example of a free market. One example, especially for emergency care, you don't have many repeat customers (I realize there are exceptions). Word of mouth doesn't travel very far, even if people had time to examine reviews on Yelp. People aren't educated enough to understand if they received quality care or not anyway, beyond bike shedding (ie. bedside manner). If you receive poor care, you don't typically have options when it comes to getting a refund.

Emergency room costs are less than 10% of the total in the US. A popular, credible figure is 2%.

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.

Not an argument against, just an observation that it's unlikely to be part of a realistic solution to the problems we face in healthcare. Interesting point about emergency care costs. Do you have a source you could share?

Late reply, sorry, and an old third-hand source: http://www.politifact.com/truth-o-meter/statements/2013/oct/...

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.

Thanks for sharing. Looks like anywhere from 2-10% could be reasonable. Even if it's 2%, that's almost $50B a year. There isn't just one problem in healthcare; we'll need to solve multiple problems.

FTR, I think my original post did have several points that pertained to nonemergency care as well.

This analysis ignores the secondary effects of the mere ability to shop around.

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.

Emergency care for things like a heart attack or broken bone only account for 2% of healthcare spending. So your primary case for why "shopping around" is bad is mostly irrelevant. Nothing is stopping you from creating a not-for-profit healthcare co-op, getting participants to voluntarily turn over their healthcare decisions to you, and then demanding reduced prices from vendors. All I ask is that you don't force me to join it against my will.

http://www.politifact.com/truth-o-meter/statements/2013/oct/...

I never said anything about emergency care being my "primary case". My comment even specifically lists 2 instances of non-emergency care. Needing to shop around is an absurd concept for any medical care.

Please don't force me against my will to live by the whims of what you personally consider absurd in your own life. You are free to abdicate responsibility and choice to a third party all you like.

Your choice to live by an absurdly low standard of care is what forces the rest of us to suffer from a low standard of care as well (against our will). Your request to "don't force me against my will" is hypocritical.

And when you're dying on the sidewalk in front of the hospital, do you expect them to just let you die there and leave it to the county to dispose of the body? Like it or not it's unreasonable and inhumane to let capitalism condemn someone to a preventable death. Someone has to foot the bill for this. The only question is who and how. The naive answer is to let the hospital eat the loss but ultimately that just means that the rest of the patients pay it in increased costs. You can't sell yourself into slavery, you can't sell your organs, and you can't sign a contract to let the hospital ignore you dying on the sidewalk in front of the ER.

The total sum of all emergency care is less than 2% of healthcare spending in the US. And obviously the majority of that is going to be paid for by the patients, either directly or via insurance. The scenario you're talking about is a rounding error in healthcare spending costs. It certainly doesn't justify forcing people to accept what the likes of Donald Trump considers to be sufficient healthcare.

Could you please not do flamewars on Hacker News?

https://news.ycombinator.com/newsguidelines.html

Seems like the U.S. should adopt the Swiss system. It's much more effective than the current U.S. train wreck without quite so much political baggage as single-payer systems.

They tried taking a baby step in that direction with Obamacare. Government mandatory anything is a seriously hard sell in the US. I honestly think single payer is an easier sell at this point.

I would be curious as to how well public opinion correlates with legislation in regards to healthcare. The 'selling' of healthcare seems to be mostly propaganda, not a comprehensive description of the structures, inputs, and outputs of the healthcare system.

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.

I've always been of the opinion that kind of information should be available next to the ballot box.

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.

I completely agree, and no, it shouldn't be a prerequisite for voting. Using a mountain of indigestible information to assuage potential ignorance doesn't make much since... Like I said, I don't know how it should be presented.

Obamacare was an attempt in that direction, but for a lot of healthy people it made more sense to pay the relatively low penalty than get insurance. This breaks everything about it.

In many cases it made more sense to claim one of the sixteen or so reasons for exemption from the penalty than to even pay it...

The single most important thing for the US to do right now, is to considerably bring down the per capita spending on healthcare, by reducing the cost of everything in the system. It must be hammered down, belligerently.

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.

> That is America.

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.

I would like to thank America for being the world pharma profit center, as well. It is impossible to give away antibiotics for 30 pence a dosage if not for the American paying $50 per tablet.

Private insurance still exists in countries that have universal health care. In the UK, for example, a little over 10% of the population has private insurance.

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 are just muddying up a debate that should not be this hard. There are 2 countries in the world that do not have public healthcare; The US and Liberia. Whatever counterpoints there are to the public option, 196+ countries have already had those conversations and already solved the problems.

>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.

Beats what we have now, where there's a two-tier system, where healthy, wealthy people have concierge preventative care and very fast specialist referrals, and the non-wealthy are stuck in a privately run system with exorbiant fees and impossibly high medical bills.

Private health insurance for covered procedures is generally forbidden in Canada, to avoid creating exactly this sort of two-tiered system. Works great.

Rising costs of healthcare are also a big issue in other top-wealth countries, and for better or worse, the US also does cutting edge health science that other countries dont get close to.

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.

>for better or worse, the US also does cutting edge health science that other countries dont get close to.

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 think this conflates spending with results.

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 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.

If you don't work, you don't get services; not until you're old enough to get Medicare.

You left out Medicaid.

> everyone is insured by the State and pays the same prices.

Not in Germany, just to name one high income, developed country.

The article already states that these online prices will be meaningless to most people, as they are the 'list prices' that no insurance company or individual would actually end up paying. So it will still be nearly impossible to find out what a treatment will cost before having it.

>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.

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.

> 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.

Isn't it standard practice to find out which facilities/providers are in your network so you can judge this? I always check before we go somewhere new

Yes, but that is the only thing I check. If I have a choice between two in-network providers I don't even ask about price.

I mean, yea, you check with your insurer first? How could the hospital possibly have information about how much each insurer would cover considering there are literally hundreds? This seems like a "perfect is the enemy of good" situation

> I mean, yea, you check with your insurer first?

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.

The insurer doesn't know what each hospital charges. Posting costs online is just to make it more convenient to find the information.

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.

>The insurer doesn't know what each hospital charges.

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.

> The insurer doesn't know what each hospital charges. Posting costs online is just to make it more convenient to find the information.

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.

So at least you know what the maximum amount you have to pay, regardless what amount your insurance will pay.

List prices should be a good relative predictor for comparing cost.

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.

So at least I can compare the price, regardless what insurance I have.

Sure, predictions aren't always right. People should still check with the health insurance of where they should seek treatment. None of that doesn't makes list prices "meaningless"

It's not meaningless. Because you know if the procedure costs X, and your insurance covers 80%, you know you will only pay 0.2X at most. There will be no random charge for thousands of dollars for something trivial.

And it will introduce price competition.

>It's not meaningless. Because you know if the procedure costs X, and your insurance covers 80%, you know you will only pay 0.2X at most. There will be no random charge for thousands of dollars for something trivial.

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.

In what ways would price competition be worse than no price competition, given that other relevant information like quality of care is available as well?

> given that other relevant information like quality of care is available as well?

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.

At least you can see your worst case scenario.

I think this is the issue that should push us all toward a single-payer, government-backed system. The fact that we all (or our employers) pay a ridiculous amount for health insurance each month, PLUS end up paying out of pocket a high amount anyway as our health insurance really only kicks in once there is an extreme situation (emergency, chronic illness). And as a consumer I am stuck in the middle of it, with there being no competition but no recourse either.

> One of the biggest problems with US health care is that it's usually impossible to find out what treatments will cost before having them.

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.

You're presuming that consumers have the ability of easily making a switch to other healthcare centers. This is divorced from the demographics of healthcare in the USA, because the problem is that the sickest and oldest patients incur by far the most costs. Many of these individuals are unable to get to even their own hospital effectively, never mind doing market research and trying out different centers many more miles away. Simply put, there is far less ability for consumers to choose in healthcare, even if this step by Medicare is one small step in the right direction.

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.

Exactly. And it's pretty much standard practice for providers to expect you to just throw yourself at their (or your insurer's) mercy and only learn the price later. They don't even upper-bound the amount you might need to pay by default.

I don't know how a patient can be expected to make a decision in that situation -- either legally or economically.

> This makes "shopping around" and being an informed consumer near impossible.

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.

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