A bipartisan plan to end surprise ER bills | Hacker News Reader

A bipartisan plan to end surprise ER bills

vox.com

172 pointsjseliger151 comments

How about a law stating that a medical provider has to charge everyone the same price for the same service?

This would eliminate the many-to-many negotiation problem that contributes to absurdities like Duke University Hospital having 1,300 billing clerks for 900 beds (https://www.pbs.org/newshour/economy/why-does-health-care-co...). It would also make it much easier to estimate costs before going to a provider, because instead of having 1000 different prices, that service will have one price (albeit with some variability depending on what's actually done).

If you paired it with a law that mandated that hospitals publish their prices for services in a simple JSON format, such that companies could use it freely to create price comparison tools, suddenly you'd make it much easier for market forces to push prices down to sane levels. It's insane how difficult it is currently to figure out how much even routine and planned operations like delivering a child will cost, and as a result people don't bother to even try, so there's no incentive for hospitals to keep their list prices anywhere near the realm of sanity.

I mean, realistically, probably because the industry lobbyists don’t care for the idea. It is completely obvious as a (partial) solution, and isn’t even really anti-market, so should be acceptable to all sides of the POLITICAL spectrum. But the industry wouldn’t like it very much.

The industry isn't going to like anything that works.

So, ban or severely restrict lobbying and corporate donations.

I mean, it’s not like this is some absurd pie-in-the-sky idea; most developed democracies restrict both.

So everyone pays Medicaid prices? Medicare prices?

If a doctor accepts the Medicare price, then they'd be obligated to charge everyone else the same price. Or they're free to charge more, and not accept Medicare patients (or the patient would be responsible for the amount over the coverage). This would be easy to look up ahead of time, since their prices would be public and easily accessible via a variety of price comparison tools, and it would be easy for tools to let you filter by whether your insurance covered the amount charged by that provider for that service.

You make it sound so easy. People on Medicare vote.

I never said it would be easy politically. Healthcare is a morass with a huge number of entrenched and entangled interests. And the dark side of reducing its absurd costs is that much of the reason for the high price is a bunch of pretty unnecessary high paying jobs involved that largely exist to deal with the system's complexity. And while most people can cheer for lower healthcare cost, they might have a harder time cheering for putting all the people out of work.

Worse, it's an industry that employs lots of people in every locality. So it's politically very difficult to tackle.

I don't think this would be that terrible for Medicare patients, though. Doctors who were fully covered by Medicare would make it known far and wide, and those who didn't but have large numbers of Medicare patients would see large drops in their patient load.

Medicare pricing is currently only possible because healthcare providers can cross-subsidize Medicare patients via raising prices on other patient pools. It's not going to work.

Maybe we pencil in a Medicare exemption then. But one service one price cuts out a lot of inefficiency and allows actual price shopping, making the system more efficient; everyone wins (on average).

Keep in mind that 25-30% of current medical spending goes to administrative overhead, much of which is billing related. If that was eliminated or severely simplified, that would mean significantly more money for a given amount billed.

It's extremely bloated in other ways too. This isn't a streamlined system with nothing to cut. So I think it's a bit premature to say Medicare pricing is only possible because they're allowed to gouge others, there are many other levers.

It's layers of markups and artificial scarcity stacked one on top of the other. Hospital associations that lock up their turf, and have geographic monopolies. Electronic medical record companies that create proprietary and incompatible standards. Medical device manufacturers that use regulatory capture at the FDA to ensure they have exclusive production rights. The American Medical Association restricting the supply of doctors and nurses, to keep their wages high.

Pharmaceutical manufacturers making slight tweaks to existing drugs to extend their patents only to cease all production on the old generics... causing even simple things like insulin to be outrageously priced.

Since insurance plans shield consumers from the costs, they have little or no incentive to price shop. So nobody notices these layers of markups, they just notice the big insurance premiums and assume it is all evil insurance companies charging too much when that is just the tip of the iceberg.

Ehhh, not quite.

Medicare reimbursement on a knee replacement is about $12,500.

In the UK, the average price of a private knee replacement is £11,434.

Those aren't exactly super duper far off from each other and in need of $45,000 price tags (avg US cost of knee replacement) to offset.

It's low enough in the UK, that if I lived in the US and found myself needing to pay privately for something non-urgent, I'd probably fly to the UK or elsewhere to do it. There are in fact several private London hospitals that market themselves to foreign patients.

The doctor (and most other) salaries in the UK are much lower however.

If that is true, it just highlights how broken US healthcare pricing is, if even hospitals or hospital groups are unable to negotiate good enough supplier pricing to be able to make that work.

For some perspective of this: The US government in recent years have often paid more per US citizen for all of Medicare and Medicaid than UK citizens pay for the NHS (1).

The difference being that that per citizen cost in the UK provides universal coverage. Per eligible person, while Medicare is quite cheap by US standards, it's incredibly expensive by the standards of most other developed countries... So US tax payers pay more for healthcare than UK taxpayers before most of you even get any cover yourself.

You might expect it to be higher than the UK given difference in salaries etc., but the per eligible person costs in Norway, Switzerland and Luxembourg, the three most expensive countries in the world for healthcare outside of the US, largely driven by high salaries, are lower than the Medicare per eligible person costs (2), and lower than the combined Medicare/Medicaid per eligible person costs for Norway and Luxembourg and just barely higher for Switzerland. But Medicare cover is also far more limited.

So how in the world can it cost so much more?

(1) https://www.theguardian.com/society/ng-interactive/2016/feb/... - UK cost per person in 2014/2015: 2069 GBP. 2069 GBP is ca. $2695 per person today. Medicare in 2017: $702 billion according to https://www.kff.org/medicare/issue-brief/the-facts-on-medica... Medicaid in 2016: $533 billion according to https://www.kff.org/medicaid/state-indicator/total-medicaid-... US population ca. 327m, gives $3770 per person.

If looking at just Medicare you come out a bit lower at $2167, but of course that includes cover for far fewer people, only about 55 million, for costs per patient more comparable to the NHS of more than $12,700. The per-patient cost of Medicaid and Medicare combined is more than $9500/year.

(2) https://en.wikipedia.org/wiki/List_of_countries_by_total_hea...

> or the patient would be responsible for the amount over the coverage

Medicare's current terms don't allow that. If you accept Medicare and charge more than 15% over the Medicare price, you stop being eligible for reimbursement by Medicare.

Those terms could be changed, of course. But then it's worth asking why that limitation is in place now.

Good question. But yeah, seems like a relatively minor change compared to what I'm proposing. I'm sure it wouldn't play well politically, though.

While were at it lets require health insurance be required to bill as a percentage of income.

Or maybe, the state determines a fee schedule, each doctor is paid the same amount for each procedure completed by the state, then the state bills everyone as a percentage of their income, via taxes? And everyone's covered. And there's no pre-existing conditions. Or co-pays. Or deductibles. Or out of pocket maximums. If only there were examples to draw from ;)

If only "pay for service" wasn't a recognized problem that we're currently trying to solve itself. It's almost as if when doctors are paid per procedure, they do a bunch of unnecessary procedures.

The idea that healthcare can be centrally managed comes from people assuming it's way simpler than it is.

Here's a good place to start. You know that demand in the US for a transparent fee schedule so people know what things cost at hospitals? Here's the list of every service administered in Ontario and exactly how much it costs: http://www.health.gov.on.ca/en/pro/programs/ohip/sob/

Those are in Canadian dollars by the way; yes, a specialist consult costs the province $100 (and you, $0).

It's hard to hear that you're trying to pre-solve cost problems you don't know you'll have if you were to switch to central management when the US is currently the most expensive healthcare system per capita by a lot (like, double), and is ranked 36th by the WHO. Far less expensive systems per capita are ranked dramatically higher even though they have a fixed fee schedule. Sure, there's room to improve, but maybe knock out the low-hanging fruit first.

Further, if that's too distasteful, there's other ways to make this work; the Swiss system forbids private insurers from making profit on the basic administration of healthcare, and caps individuals out of pocket expenses. I'm sure the insurers would find a way under such constraints.

The ACA also demands insurers pay 85% of revenue in health care costs and caps out of pocket expenses...

Heh much of the citizenry of the US is a bit allergic to the idea of fully socialized medicine. We like options.

You can have a private insurance system on top of a tax-subsidized public one that provides a baseline.

Or we could try a public option, for starters. I bet that would drive prices down significantly already, simply by virtue of being large enough to negotiate them down.

> It's insane how difficult it is currently to figure out how much even routine and planned operations like delivering a child will cost, and as a result people don't bother to even try

In my real-life experience, that is false. When my wife was pregnant we asked the doctor if we could pay upfront. She said yes, gave us a price, and explained what that would cover. We paid her; the delivery was at the hospital, and everything went well.

Was the doctor's quoted price the same as the all-in price? In our case, the OB's bill was something like 10% of the final total, which was close to 6 figures, despite being bog standard.

Your total seems to be one to two orders of magnitude greater than what we paid. We fully prepaid, and there were no complications. However, I wasn't talking about cost but replying to the assertion that one could not forecast costs.

I replied to, "It's insane how difficult it is currently to figure out how much even routine and planned operations like delivering a child will cost, and as a result people don't bother to even try". Your post seemed to refute that as well.

How about everyone gets to bill through the hospital instead of every person who tangentially heard of you one way or another sending you their own bill. If the hospital is in-network, they bill based on in-network rates, and all those "providers" can take up their bill with the hospital (who at least knows they're there, unlike the patient).

This seems like a reasonable solution. It's basically how we handle telecom and utility billing.

Hell, it’s how we handle restaurant billing.

let's talk about the tip again?

If it is mandatory, it is not a tip. My old boss told me how he was at a dinner with our Australian overlords (long story) and they said nobody will leave any tip.

If a tip is mandatory, it is a service charge. I don't go to the extreme of never tipping but I usually do not tip if the bill has an itemized service charge.

Services that are "out of network" are not optional.

(warning: may make you angry) https://www.nytimes.com/2014/09/21/us/drive-by-doctoring-sur... (2014)

archive fo: https://archive.fo/TBmrO

screenshot https://screenshotscdn.firefoxusercontent.com/images/adb3850...

When there is an itemized service charge, tipping is rarely expected. It is an option, but not expected.

Yet there always seems to be a space for it, or a step to skip. Sure makes it seem expected when it's not simply leaving bills on the table before you leave.

If it fixes all other medical billing, I am OK with doctors office is asking me for an optional tip based on how good I think the service is.

That would be LIGHTYEARS easier to understand than what currently exists.

Friendly reminder, those things are optional, and not human rights.

Being provided healthcare is a “human right”? Sounds more like forced labor to me.

That's absurd. Nobody in any OECD country where healthcare is a human right is required by law to practice medicine. People do it as a public service, because they care. No doctor in Canada has a whip behind them as they apply bandaids. In fact, it's absurdly difficult to get into medical school in Canada, but people do it anyways because it's a mid-six-figure good job. That people who are sick are entitled to healthcare via voluntary labor is in violation of nobody's rights and you know it.

Not even Canada's furthest-right-wing parties advocate privatizing healthcare. They don't even talk about it. Because Canadians know that fully private healthcare is a shit system.

Healthcare as a right is your freedom to pursue your life regardless of the circumstances of your birth. It's the ultimate freedom - the freedom from worry, from illness, from bankruptcy. Freedom to pursue your own business or being an independent contractor without fear of death.

Your "slavery with extra steps" argument is long dead. Maybe read this? From 2009. [1]

[1] https://www.pri.org/stories/2009-10-15/canadian-health-care-...

It's forced labor in that the state takes the proceeds of some of your labor in order to pay those doctors to treat others. I.e. Taxes. No one is saying that doctors are put into work-camps or threatened into working.

Oh, I see - so are you suggesting the interstate system, the fire department, the post office, the public school system, the water pipes, electricity, gas, medicare, medicaid, the army, every regulatory body, and so on are all forced labor? If so, great, count me in. It feels like an entirely arbitrary place to draw the line to say you support public education and the fire department but not public health. If you support neither, well, the dark ages are that way. Literally because the power grid is socialized.

Either way, nobody's forced to work. Neither you, nor your doctor.

If we don't work, we starve. Yes, every living being is 'forced to work'. The gun may be held by an opressive government, or nature itself, but work is as omnipresent as death and taxes.

I have read that hospitals actually tell providers to not be in network so they can make more money.

I've never hears of anything like this, where can I learn more?

I don't know about his allegation, but if you are seen at an in-network hospital by an out-of-network doctor, you pay out-of-network. Even if you were unconscious, anesthetized, etc.

Right, I'm moreso curious about the validity of the conspiracy theory.

How about the state gets a bill for everyone and the risk is distributed over the population minimizing the cost and improving efficiency? This happens by maximizing the risk pool size and eliminating waste from marketing and executive compensation (and the claims denial department). This happens to also incentivize the state to ensure everyone gets the preventative care they need, and line up incentives re: legislation (for instance around cigarettes and alcohol). Then we can call it “what every other civilized country does.”

How do you then provide higher-quality but more expensive healthcare to those who can afford it?

It's pretty simple: https://www.nuffieldhealth.com/ https://www.bupa.co.uk/

But then you can’t have “everyone is charged the same” which some posters were suggesting... basically all I’m saying is that “just public” is barely better than “just private” - ideally you’d have a reasonable mix (with, of course, full transparency of prices, ratings, quality control etc.)

How is it barely better than 'just private'? WHO rankings show that not to be true (the US is 36th at $7500 per capita spend, Canada's single-payer system is 30th at $3600 per capita spend, the UK's 'single-payer' system is 18th, Spain's single-payer system is 7th). The reality is that if you're attempting to minimize illness and suffering, doing that at a larger scale is always strictly better than restricting it to those who are lucky enough to be able to pay. You can of course optimize further but single payer is strictly better than private cover. Two-tier is another valid solution.

I don't know about Canada's and Spain's system, but UK's (where I live) definitely isn't "single-payer" - there does exist private insurance, it allows you to "skip the line", get better diagnosis and probably also better treatment.

The "just public" system doesn't work for similar reasons as communism doesn't work. (1) Lack of incentives and (2) corruption. A paid-for healthcare encourages innovation (you can sell expensive new treatment to rich people who want to live longer, when the technology is mature it is then distributed to the masses), and prevents corruption - e.g. in Slovenia, which is "almost public" (i.e. the private healthcare system is severely limited by the government), there is rampant corruption - if rich/powerful people can't "jump the lines" by paying more, they will (try to) jump the lines by utilizing other forms of power (threats, favors, gifts, ...).

It's easy to shit on US/Switzerland, but keep in mind that their "expensive" healthcare systems also fund a huge amount of farmacy research that then "trickles down" to other countries.

You provide the same high-quality healthcare to everyone because nobody is better than anyone else on account of wealth. Wealthy people don't suddenly need different healthcare when they make money.

Why not also provide the same high-quality cars, housing, jobs etc to everyone?

Hint: communism doesn't work.

Also, the reality is you have to prioritize. A public health-care system has a limited amount of money (by definition) and needs to spend it in a carefully balanced way. E.g. you'd rather operate/save a kid than a 90 year old person. Another example is, governments "advise" citizens to do preventative exams based on cost-efficiency, not on "best quality healthcare" - it's simply unrealistic to perform a mammography on 50% of the older than 25 population every year. But if someone wants to do that, and can pay for the costs themselves, why would I, you or the government limit their freedom?

The system described above, as applied specifically for healthcare, works wonderfully for most in countries that use it - significantly better than in US, anyway. That alone is already a reasonable answer to your "why?".

But also, there's no reason why you can't have private insurers providing better options on top of a public system. In fact, most countries do exactly that.

Care in the US is quite good, but the billing is the most opaque thing imaginable. I went in for a skin biopsy and got a bill from 3 different people. Why? I don't take my car to the shop and get a bill from 3 other shops in town. Ridiculous. I really think the onus should be on the provider to issue a single bill and provide up front pricing.

I received a bill 9 months after a procedure. After I had already received a dozen other bills for various other services pretty much immediately and paid immediately. My nuanced argument was "you waited 9 months, fuck off". I never heard anything more about that one.

That sounds more like a scam. Is there any way to verify the bill is legitimate?

It definitely was legitimate.

100% agreed here-- on a HDHP (the only option from my employer) and recently had a diagnostic procedure done at an ambulatory surgical facility. Paid the surgical facility up front; later got a separate bill for two separate additional fees from the doctor and from the anesthesiologist (billed together because they're part of the same group, fortunately).

And there was no way for me to tell how much any of this would cost me up front, while I was scheduling the procedure. Would it have been cheaper to have it done elsewhere? I dunno; no way to tell.

> "Care in the US is quite good"

Well, now there's a classic example of survivorship bias. Care in the US is good when you can get it, but on average? On average care is quite bad. When you bring in the millions of people with no health insurance into the averages then the picture looks quite a lot less rosy. Things are so bad that there is a multi-decade differential in life expectancy between the top 20% and the bottom 20%. That is absolutely unconscionable.

It's a decent start, but it doesn't really do a whole lot for "transparency", it simply caps the charges against some completely unknown and somewhat arbitrary number.

The important point for patients is that those charges - capped or not - would no longer be directly billed; instead the insurance companies would be responsible for paying them.

Hopefully the insurance companies would demand some transparency.

At least when it comes to ERs transparency isn’t exactly useful. Most people don’t have time to go shopping around between them, all transparency does this let you know you’re being billed $1700 for a Band-Aid instead of billing code B736.21.

This clearly isn’t a fix to the problems of the healthcare industry, but it certainly sounds like a nice step up.

While I understand the logistics behind it, the idea that you can go to a place, pay your bill, then have eight different people bill you for the same service just feels like an absolute scam.

Yes, one was the doctor, one was the lab, one was the hospital etc. and they may work for different companies and even in different buildings it’s just that they all HAPPENED to be in that one building that one day if that one time.

But you don’t go to a restaurant and get separate bills from the establishment and the waiter and the cook and the group which buys ingredients.

“We couldn’t have told you how much that Caesar salad would have cost, it depends on complex negotiations with your dietitian. Had it been at least 30 days since your last consumption of Californian arugula?”

> At least when it comes to ERs transparency isn’t exactly useful. Most people don’t have time to go shopping around between them, all transparency does this let you know you’re being billed $1700 for a Band-Aid instead of billing code B736.21.

Exactly!

I link to an answer I wrote about this here: https://news.ycombinator.com/item?id=18108870

Direct link: https://www.quora.com/Would-a-completely-free-market-healthc...

Insurance companies do have negotiated prices with all their network providers for all applicable billing codes. And insurers do often provide those numbers to their plan members, at least partially. The trouble is that you can't always know in advance which billing code a provider will actually submit on the claim, and some providers are out of network without negotiated prices.

>The trouble is that you can't always know in advance which billing code a provider will actually submit on the claim,

That seems like the billing system itself is conceptually faulty. Like a supermarket where the same gallon of milk costs different prices depending on which shelf you took it off of.

For a given customer, the "gallon of milk" costs the same regardless of which shelf it comes from. But if you come in to buy milk and end up buying champagne instead the price will be different.

Billing amounts are calculated based on specific unique procedure and modifier codes. The coding is typically done by trained coders using the doctor's notes as a reference, and the coders select the most expensive codes that they can legally justify. Many doctors aren't even aware of their billing rates for various procedures. In some cases the doctor won't know which specific procedures will be needed until she gets into it and sees what's going on, at which point it's too late for price estimates.

Payers (insurers) are trying to fix the billing system by moving away from the fee-for-service model and toward value-based care (payment for meeting care quality goals) or various forms of capitation (flat payment per patient per year regardless of which procedures are needed).

It is essentially a "don't be a complete dick" statistical cap. Whenever you hear somebody complaining about excessive regulations remember all of the other cases that resulted against past antisocial behavior like that.

Radiologist and anesthesiologists are the vultures of the healthcare industry - they are often out of network and they hide behind the scenes at hospitals and outpatient surgery centers.

The anesthesiologist for a family member's out patient tonsillectomy was the sole out of network component in the procedure. When they remonstrated that we should have known, I responded that maybe we should have checked if the orderly, the valet, et cetera was in-network.

I remember one doctor carping that the highest paid doctor at UCSF is a radiologist who works 9-5 and never deals with any patients face to face.

Tip: Never use a hospitals radiology services if you can help it.

I have not read through the entire article, so don't know if what I'll state is covered, however, I have experienced something similar with Kaiser, though not with ER, but with regular Doctor's visits. They just send me a surprise from time to time, and the latest one is $175.00 for a visit. This is, literally, something that just keeps happening. Somebody on their end messes up, or somebody does some sort of funny business, and patients get unforeseen bills. I wish somebody would investigate them and force them to get their act together. I mean it's convenient that they have all facilities in one place, but they are really expensive and their billing practices are inconsistent.

In Australia ED is free, paid for by state governments. We spend ~10% of GDP on healthcare, the US spends 18%. We have a private system, but it has to compete with free, and that's stiff competition.

Excellent! This is action.

Not the best action (more below) but anything else is wildly better than the situation we have in the current U.S. Healthcare system

Change needs to happen to the U.S. Healthcare system so that surprise billings just stop. This change is not going to happen on its own without people driving change.

The issue at hand is that Healthcare costs in the U.S. are all over the place.

Same place, same doctor, same procedure on the same person on the same day can yield massively different invoices depending on whether the person is insured, where they work, what kind of insurance they carry!

Hospitals wield a lot more power than you and I would guess.

An example: https://www.publicintegrity.org/2015/06/15/17474/profit-hosp...

As a person who's extremely passionate about driving change in the U.S. Healthcare system, I communicate a lot with people who have fallen on hard times due to an enormous medical bill.

Here are two scenarios for you:

https://www.quora.com/Recently-my-husband-visited-the-ER-in-...

https://www.quora.com/Why-did-the-doctor-charge-me-3600-hr-t...

When people ask me what I think is "wrong" with the health care in the USA, my answer surprises them:

Nothing is wrong with the health care in the USA. It is one of the very best in the world for those who can afford it.

The issue is that one should not have to look unexpectedly to a life completely ruined because they suddenly fell sick or got into an accident - they should be able to pick up their lives when they need to do it the most and go on from there.

My hypothesis is that a system where everyone pays the same rate regardless of whether they are insured or not would head us off to a much better direction.

I invite your feedback on:

https://www.quora.com/Would-a-completely-free-market-healthc...

https://www.quora.com/In-the-US-the-majority-of-people-under...

Two things are the core problems IMO. Defacto price controls and cartel like business processes.

Feedback I have is health insurance should work like other insurance where if there is a dispute the claimant has defacto sue the insurance company. They can't just turn around and bill insured if the insurance denies.

> So far, things have turned out fine — I’ve only been billed a $150 copayment for my ER trip...

Copayment should be eliminated too. Paying for an insurance I want to be sure that if something happens to me I don't have to worry about anything, even about having spare $150.

Copayments are essential to keep bored and lonely people from going to the doctor every day for nothing in particular.

AFAIK, only the UK has a zero copayment system among the government run health care systems.

In the Czech Republic copay is optional (depends on the insurance company and the plan, not really widespread, the majority of people don't have copay) and nobody seems to be misusing this. You can also just buy insurance that is going to cover almost everything (and with no copay) for reasonable money without even having a job (if you actually have a job the insurance costs you and the employer a fixed percent of your salary). Some times the laws change (just to get changed back some years after) and compulsory copay gets introduced but it always is just ~$1 (which would be enough to repel bored grannies and homeless alcoholics that just want to hang out if there actually were any, but in fact there don't seem to be any actually misusing hospitals). Hospitals don't look and feel as fancy and cozy as they do in the USA and a stationary patients' diet is a disaster from the dietary value point of view but in every other aspect everything works amazing.

So it sounds like the Czech Republic has some kind of private health insurance system?

All (AFAIK) the health insurance companies in the Czech Republic are private (public actually, but not state-owned) corporations that are regulated heavily but in a very reasonable client-oriented and a little bit socialistic way. Every person is legally obliged to have a paid health insurance but the coverage is the same while the cost is a fixed percent of their income to be paid on monthly basis so poor people pay less and get the same service. People that don't have legal regular local income (e.g. foreign students) must buy insurance approximately the same way tourists do when traveling abroad (everybody else can also go and do this and it's as easy as buying a cellphone subscription, that's almost a free market).

Germany doesn't have copayments either for doctor vists.

Canada only has user fees for dental. (They're thinking about it for doctor's, but haven't done it yet.) The annoyance of having to go somewhere (interrupt their day, take off work, etc) has so far been sufficient of a deterrent.

Hungary. There was a mandatory 1 USD (yes, seriously, it was exactly just a token amount) copayment [called visitation fee] a ~10 years ago, and a huge political campaign ensued to get rid of it. Sadly it was successful, because populism.

Exactly the same thing in the Czech Republic. But I wouldn't say "sadly" as the $1 visitation fee was introduced and removed a number of times and it didn't change anything.

It was a godsend in Hungary. Waiting times dropped, accountability skyrocketed.

Thanks god. I hate this so much

As a German who had to take US-americans to the ER twice, once in Germany, once on Curacao, my observation can be summarized as "WTF?".

In both cases the patient initially refused treatment out of fear to receive a high bill. Both bills ended up being about 50 USD (a few stitches in the first case, lab analysis to confirm it were kidney stones in the second case).

In the first case, the patient's spouse told me not to worry, it ain't too bad. But she would stay with him to make sure he does not fall unconscious ("uhm.. ok...."; I got a taxi to pick them up for a trip to the ER); in the second case I ate my dinner while watching the guy scream in pain - being a doctor's child helps with that .. he finally agreed to let me take him to the ER.

Dear US-americans doctors, you lost me. Where again was the exit ethics took during your education?

The doctors don’t create the bills, or even really influence billing. The billing issues are caused by hospital administrators who are mostly MBAs or Policy masters, and they’re negotiating with MBAs in insurance companies.

Do you think that the doctors or hotel administrators have more power?

Who's richer?

Doctors typically don’t work for hospitals. Their services are billed separately.

The AMA isn't even just complicit. It is pretty nearly a cause. There's plenty of blame to go around and doctors are not passive participants in the process.

I'm seconding scarejumba's position here. Doctor's are enormously powerful and effectively unionized through the AMA. They can influence both the operations of hospitals and the American government itself.

Like any aristocratic guild that provides a necessary societal function however, they as a block choose to profit from it.

This is not every doctor or even every ER doctor. But it's important not to let doctors as a class off the hook.

Why would you intentionally lower your income rate, particularly after racking up $500k in tuition? Doctors have no incentive to lower bill rates as long as they're pocketing a percentage.

It's unfortunately probably the case that these things have been feeding into each other. Some doctors charge more -> college's can justify higher tuition because people think doctors now make more -> now new doctors NEED to charge more to tuition debt and to get the benefits they were sold on. Rinse and repeat.

Similar experience, went to the ER with a friend in Taipei who had a busted lip and no coverage. Paid $20USD for the visit, prescription for antibiotics and the antibiotics filled on the spot.

They recently socialized their for-profit system.

I also paid out of pocket for a specialist visit in Canada last year, grand total $60CAD.

My girlfriend had an eye problem when we were in Germany. Went to the eye doctor and paid 25 Euro cash including an antibiotic.

I’m not completely sold on socialized medicine —but in the US we definitely have a problem. Congress, or the admin should at least threaten “socialization” and get them to shape up, and follow thru if they don’t.

Perh a two-tiered system one basic for all citizens and another which could cover more advanced procedures along with elective choices of medicine, however, still reasonably affordable by most working people.

That is how most socialized medicine works. At least in Norway and Switzerland. Just because you have government guaranteed service doesn't mean it is illegal to sell more/better service. Perhaps shorter waiting lines, nicer hospital or better healing. You just have to try a bit harder to be worth it to people.

Most Canadian provinces significantly restrict or outright ban private healthcare for stuff that's covered by the public system. Since Canada is the closest example to US, and the one most people turn to first, that unfortunate quirk is given undue prominence in the healthcare debate here.

Stop applying duct tape to a ridiculous system. Its time to offer a public option like every other country in the OECD. That’s how you solve this. This is sheer stupidity all the way down. How are so few of you mad as hell getting the worst deal in the OECD? I’m mad for you.

It’s like watching someone hit themselves in the face with bare knuckles, stop and say you know what this needs? Boxing gloves, then it won’t hurt as much. Like, you’re right, it won’t hurt as much, but why are you doing this to yourself?

Either this is a free market and we allow the market to sort this out, allowing people to die and go broke in the process, or we say this is a public good that deserves a public solution. A whack-a-mole based patchwork of legal impositions on the market is not a solution to anything. It just encourages the captains of the insurance industry to find the next loophole to exploit (or go out and create them by lobbying) to ensure profits keep going up quarter over quarter, until they’re whacked back down again. Then in 6-18 months were right back where we started.

We used to have a free market and it sucked. So they took the worst part of it and slapped a national insurance program over it and that's Medicare. And now 50 years later the rest of the market sucks.

> The policy proposal, which you can read here, essentially bars out-of-network doctors from billing patients directly for their care. Instead, they would have to seek payment from the insurance plan. This would mean that in the cases above, the out-of-network doctors couldn’t send those big bills to the patients, who’d be all set after paying their emergency room copays.

I do love "sensible policy changes" that work by extracting money from physicians to cover patient bills rather than actually fixing the systemic dysfunction.

If you're the surgeon to hand, you don't get to refuse to do emergency surgery. You have to take care of that patient, ethically and legally. Oh, turns out they're out of network, and their insurer isn't obligated to give you a dime? Awesome, free surgery!

Here's a sensible solution: when it comes to emergency-based care, insurers must accept all comers as in-network. There's no such thing as "out of network" emergency-related care.

But hey, insurers have powerful leverage and a near-monopoly. What're the odds we'd take a slice off their profit margin?

People should demand an end to private insurers. Makes zero send to have middle men who profit off denying care.

The balance sheets of public insuers would also benefit from denying care.

And if your government denies care, there is no higher authority to keep them in check.

Voters?

I'm not entirely sold on the idea of people voting in their self interest anymore.

idk about you but i have a zero premium plan with $2300 max out of pocket for in-network services. all i want is a foolproof way to ensure all my providers are in-network.

How can such a plan exist? Or am I missing something?

You are missing the fact that its basically his employer self insuring, as a form of unpaid compensation. The only thing the insurer is doing is acting as a billing agent.

It’s not self-insurance, necessarily. When OP says “zero premium” they mean (even if they don’t know it) that their employer is paying 100% of their premium.

What they said, I worked for an outfit with a similar plan (lower max. out of pocket, though). They were self-insured, though, and the latest year I have data for, it was about $20K/year for health coverage.

Also worth noting that self-funded plans will have their premiums set based on the plan's actual claims experience, which means employers with a sicker risk pool will pay more. This also encourages discrimination against older or unhealthy/disabled workers, since they statistically cost more. (This is illegal, but it happens all the time and is hard to prove.)

Well, when I was working there, employee premiums where exactly 0, company picking up the entire tab, but I am quite sure that this stuff does happen.

The employer picking up 100% of the premiums (which, in a self-funded plan like this, are paid into the plan trust) just makes this kind of stuff even more likely. If an employee or employee's covered spouse or dependent has health issues requiring $XXX,XXX/year of treatment, getting rid of the employee will directly save the company $XXX,XXX/year. Quite a powerful incentive for scumbags, even if it's completely immoral and illegal (ERISA 510).

Of course. Since the company actually does have some decency (being privately held helps, too) eventually they just decided, as I hear, to simply convert to a (still generous) regular insurance plan.

Granted, the other reason was that because of Pajamacare, health plans that are "too good" get taxed excessively.

How much does that plan actually cost? Your W-2 should include the value of the employer's subsidy.

You're still paying for inflated healthcare costs either way; in a competitive labor market (not always the case but certainly is in SV), reduced benefit costs would be expected to increase cash compensation.

> How much does that plan actually cost? Your W-2 should include the value of the employer's subsidy.

idk honestly, but i would be interested to find out. this is my first year working at this particular form so i will need to wait for my first w-2.

> You're still paying for inflated healthcare costs either way; in a competitive labor market (not always the case but certainly is in SV), reduced benefit costs would be expected to increase cash compensation.

sure, but the employer doesn't pay any tax on this type of benefit, whereas we would both face additional taxes if they simply paid me more.

all i'm pushing back on is the original statement that "people should demand an end to private insurers". people who don't get insurance through their employer and/or can't afford it themselves should probably oppose private insurance. software engineers, who already tend to have company insurance and be in high tax brackets, are pretty unlikely to benefit from any efficiency gains from a national health service. people like this can be wiped out by surprise out-of-network fees quite easily, so it is rational to focus on that aspect.

> sure, but the employer doesn't pay any tax on this type of benefit, whereas we would both face additional taxes if they simply paid me more.

That argument seems like the equivalent of wasting money just for a tax deduction. You are right in a way though: if a single-payer plan is financed through progressive taxation or a payroll tax with no or a sufficiently high cap, higher earners will end up paying more than under the current system while lower earners will pay less.

> all i'm pushing back on is the original statement that "people should demand an end to private insurers". people who don't get insurance through their employer and/or can't afford it themselves should probably oppose private insurance.

Unless you get sick, are unable to work as a result, exhaust FMLA (if available), and can't get coverage through a spouse or parent (if under 26). Then hopefully you've got the savings or disability insurance to pay for COBRA (under which you have to pay the full premium your employer is currently paying) and/or Marketplace insurance in the interim, or you're stuck with Medicaid. Even worse, most Marketplace plans have narrow networks, so you may find that you're not able to keep some of your doctors -- particularly the specialists you're likely to need for an extended illness. Medicaid is even worse, because the reimbursement rates are so low.

And hopefully none of that happens to a loved one, who may not be in the relatively good position you are.

And that's ignoring the moral argument in favor of, well, not allowing people to die in a supposedly first-world country because they can't afford healthcare.

Yeah me too with no such thing as out of pocket maximum for all services, because they’re all in network, because I live in Canada.

Ask your Representative and Senators to sign on to HR 676 (https://www.congress.gov/bill/115th-congress/house-bill/676) and S 1804 (https://www.congress.gov/bill/115th-congress/senate-bill/180...), if they haven't already.

My concern is the patients, not the doctors; it's hard for me to see them as victims in the U.S. The awful health care system is their creation to a significant degree, and one which many of them protect. They get paid very well, often via absurd billing practices, running up bills on unnecessary treatment, pushing drugs in which they have a financial interest, etc. If I understand correctly, they restrict the number of doctors to a degree that it denies availability to people who need it, AFAICT to constrain supply and drive up their incomes. That they have to give back a little - something people in every walk of life have to do - is not high on my list of concerns.

I didn’t create the system, I was born into it. By the time I was old enough to vote it was far too established for radical changes to be easy to make.

From what I’ve read/seen the system seems to be almost entirely a creation of unintended consequences of Congress, businesses, and well-meaning insurance companies. Sure there are bad actors but I don’t think they created the system, They only take it vantage of what was created (again, possibly unintentionally) by others.

Demand change.

You think I and tens of millions of voters DON’T?

> unintended consequences of Congress, businesses, and well-meaning insurance companies

They invest a large amount in very smart people predicting the consequences and then in lobbying (and bribing) politicians, and in supporting public information campaigns, to pass the laws that provide their desired consequences. For them to portray themselves as innocent and naive, if they do, would be cynical and absurd. It always seems to work out they make a lot of money, but probably unintentionally.

Now they do because it’s a huge business. But as the foundations of our system were being setup I don’t think that was really the case. With the possible exception of the AMA fighting nationalized healthcare.

There doesn’t seem to have been a large investigation into the consequences of allowing healthcare coverage to be given to employees without counting as salary. That was one of the core sins.

> But as the foundations of our system were being setup I don’t think that was really the case.

Why do you think that? Is there something I could read? Certainly lobbying and financial incentives to politicians have existed forever.

The number of doctors is primarily limited by the amount of federal government funding for residency slots.

Hospitals have billions of dollars of net income...they could very easily invest in residency slots.

Would the AMA have some influence on that?

Only to the extent that they can lobby Congress like anyone else. I don't think the AMA has done any lobbying lately against expanding residency funding.

"Here's a sensible solution: when it comes to emergency-based care, insurers must accept all comers as in-network. There's no such thing as "out of network" emergency-related care."

I actually agree. And to make this work insurers should stop negotiating individual rates with providers and instead providers should have a set price they charge no matter who pays. It's nuts that if you don't have insurance you pay 30k but with insurance suddenly the provider is OK with 7.5k.

Yes!

I hinted about it here: https://news.ycombinator.com/item?id=18108839

More details here: https://news.ycombinator.com/item?id=18108870

Please don't just link to other comments, it makes for disjointed and difficult reading.

>insurers should stop negotiating individual rates with providers and instead providers should have a set price they charge no matter who pays

It's not that simple, unfortunately. For one thing, Medicare reimburse at rates that are significantly below market prices [0][1]. Medicaid pays even less on average, and Medicaid reimbursement rates vary significantly from state to state [2]. Care providers need to make up for this by charging a higher rate to those who have private insurance or pay cash.

The obvious retort to the above is that providers could charge a single, higher rate for everyone except Medicare and Medicaid. But if you prevent providers from offering reduced rates to insurers that include them in their networks, insurers will have an incentive to make their networks narrower, charging higher out-of-network deductibles and copays for a larger proportion of providers. Eliminating provider networks entirely isn't a good option, since they're one of the only mechanisms keeping costs in check to begin with: insurers can remove providers from their networks if they become too expensive (or if the quality of care declines), pushing policyholders to cheaper (and/or higher-quality) providers.

To extend your example, say that instead of charging a 30k out-of-network rate and a 7.5k in-network rate for a particular insurer, a provider charges 15k for everyone. Are all insurers required to pay for the procedure at 15k (subject to deductibles and copays paid by policyholders)? If so, what's to stop the provider from charging 30k next year? And if not, what incentive do insurers have to pay for it?

[0] https://www.cbo.gov/system/files/115th-congress-2017-2018/wo...

[1] https://www.aaos.org/AAOSNow/2017/Oct/Cover/cover01/

[2] https://www.texmed.org/June16Journal/

Since normal rules of supply and demand don't apply to many essential healthcare services (demand is essentially infinite when the alternative is death or serious disability), it's questionable whether a "market" price even exists in the normal economic sense.

> I do love "sensible policy changes" that work by extracting money from physicians to cover patient bills rather than actually fixing the systemic dysfunction.

The article says insurers are required to pay:

> The doctors would instead have to work with patients’ insurance, which would pay the greater of the following two amounts: > > * The median in-network rate negotiated by health plans > * 125 percent of the average amount paid to similar providers in the same geographic area

That seems more than reasonable to me. They will get greater than market rate, if you define "market rate" as rates negotiated between insurers and doctors and not whatever nonsense they can get away with charging when the patient does not have pricing information and often isn't in a position to make a decision anyway.

> Here's a sensible solution: when it comes to emergency-based care, insurers must accept all comers as in-network. There's no such thing as "out of network" emergency-related care.

They are already required to pay for out-of-network emergency care even if the plan ordinarily doesn't cover out-of-network services at all, but they are only required to pay the usual and customary rates for those services, not the inflated nonsense bills (unless it's a state-regulated plan where state law requires the insurer to pay the inflated bills).

The reason doctors are in-network is the because they agreed to a discounted rate.

If you forced insurance companies to accept all-comers, you’ve just drastically increased the cost of ER care.

My preference would be for the hospitals to hold the bag.

> My preference would be for the hospitals to hold the bag.

Fair enough.

How about everyone needing to pay the same rate regardless of whether they are insured or not: https://www.quora.com/Would-a-completely-free-market-healthc...

A hospital holding the bag we could quickly go out of business. You would HAVE to implement some sort of backstop against that at the same time.

The hospitals are the ones giving privileged to these out of network physicians who work in their hospitals.

They could hire them with the agreement that they accept the insurer’s in-network rate.

Or end up with almost no staff until it’s all sorted out.

I assume it wouldnt be “no staff” considering it’s a rare occurrence when a physician is out of network.

And i’m not talking about situations where the entire hospital is out of network. It’s when the patient does their homework and the doctor and facility are in network and then some random doc shows up who is out of network and the patient gets screwed.

Change needs to happen to the U.S. Healthcare system so that these incidents just stop. This change is not going to happen on its own without people driving change.

So you and I agree that change is needed, and action is necesary but what should be the course of action?

> Here's a sensible solution: when it comes to emergency-based care, insurers must accept all comers as in-network. There's no such thing as "out of network" emergency-related care.

Ah. I see you have good intentions but what you are saying is "Hospitals should be allowed to get paid whatever they charge and insurance companies should pay it"

Do you see the problem?

An example: https://www.publicintegrity.org/2015/06/15/17474/profit-hosp...

As a person who's extremely passionate about driving change in the U.S. Healthcare system, I communicate a lot with people who have falled on hard times due to a medical bill.

Here are two scenarios for you:

https://www.quora.com/Recently-my-husband-visited-the-ER-in-... https://www.quora.com/Why-did-the-doctor-charge-me-3600-hr-t...

When people ask me what I think is "wrong" with the health care in the USA, my answer surprises them:

Nothing is wrong with the health care in the USA. It is one of the very best in the world for those who can afford it.

I invite your feedback on:

https://www.quora.com/Would-a-completely-free-market-healthc...

https://www.quora.com/In-the-US-the-majority-of-people-under...

Non-Americans may not realize: In America, going to the ER, it's possible and often happens that someone can be billed any random, unlimited amount for 10 seconds of interaction: $3,150 for "consultation." Yes. Heck, you don't even need to be seen to be billed. As soon as they collect personal information, despite not being seen, they can and do still try to bill you randomly regardless. One ER in the Bay Area has a security guard whose job it is to collect Social Security or tax identifiers from people before they can speak to anyone in the hospital.

Fuck the "bipartisan plan". M4A now.

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