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Comment by tfha | Hacker News Reader

If you want to fix medicine, increase transparency. Earlier this summer, I had white spots on my throat and needed to go get checked for strep.

I called around, and finally settled on a facility that told me they could check for strep for just $59. I go in, get my throat culture, then get my bill.

"Well yeah, the throat culture was only $59. But the nurse had to do it and it's $120 to see a nurse. Also, the doctor has to check in before any operation is performed, and that's $200. After all other fees, your total bill is $400".

There's no way that should be legal. I was quoted $60.

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The lack of transparency is due to perverse incentives in the healthcare system stemming from overly complex legislation.

As a country, the US hasn't decided whether healthcare is a fundamental right or privilege. As a result, we constantly make political decisions that straddle the line without ever really going one way.

The biggest culprit is the "fee-for-service" model of reimbursement, where healthcare providers (physicians) are reimbursed based on the quantity of care rather than patient outcomes. Each procedure has a code (CPT) that is used to bill insurance. Billing for each of these codes is completely arbitrary and up to provider/payer negotiations. The fee-for-service model is a clear example of a perverse incentive.

Who reimburses the fee-for-service model? Either the government (Medicare/Medicaid isn't even entirely government-run, as many states rely on a for-profit Medicare Administrative Contractor) or private health insurance companies. The perverse incentives can now be seen from both the provider's side and the payer's side: hospitals and physicians negotiate to get the best reimbursement rates that they can. And of course, because these insurance companies want to make money, they make it "difficult" for providers to get paid for each procedure and will find any reasonable way to deny the claim from going through. Because of this, providers artificially raise the amount charged to the payers as high as they think they can get away with in the hopes that insurance will pay up.

Meanwhile, patients suffer greatly as there's no transparency.

You are way off base. The original WSJ article has links to other articles detailing how hospitals merge themselves into a monopoly that has to be accepted by the insurer. The hospital sets the prices. They also go into how these large hospital systems gobble up doctors offices and use the same leverage to increase prices and tack exhoribiant fees--just like the experience of the person you are replying to.

Not off base at all. Their description of the perverse incentives was very accurate.

I had worked as an engineer and was closely aligned to the fraud division for one of the larger insurers some time ago.

I mean, you are both pointing out things that exist, are happening, and are problematic.

I cannot divulge my sources, so take it for what it is, but in talking with people at the top of several very large private insurers (as far back as 2016) they were sick of how providers weren't healing people and bleeding them out.

I've seen evidence (firsthand) that value based care can work, but it's hard to get provider networks on board when they are the ones who aren't getting paid when readmission rates are too high.

Insurers are part of the racket. At least that's how it feels from a consumer point of view.

Insurers essentially get a cut of the overall revenue, so they perversely win the more overall is spent.

> The biggest culprit is the "fee-for-service" model of reimbursement, where healthcare providers (physicians) are reimbursed based on the quantity of care rather than patient outcomes.

Charge a hospital based on patient outcomes? How would that work?

Say getting a base ammount per problem fixed or identified to some standard say $20k for solving severe stomach ulcers with bonuses for things like not having any longterm damage, minimal patient suffering and such. It doesn't matter if they use cheap antibiotics or surgery or how many screening tests were performed in that hypothetical.

Granted there would be major devils in the details especially if it causes "underwater" patients.

Except not every patient can be fixed. Doctors would be incentivized not to take on really sick patients or those with mystery illnesses.

That's exactly what would happen. In a university hospital setting it's the most experienced physician that takes on the most difficult cases.

Automobile mechanics are required to provide a written estimate in advance. I don't see why health care should be any different.

Before anyone objects with "but what about emergencies!" note that emergency care is a single-digit percentage of total health expenditures.

>>Before anyone objects with "but what about emergencies!" note that emergency care is a single-digit percentage of total health expenditures.

That is true, but emergency care disproportionately results in bankruptcies compared to other forms of care.

I imagine this is directly related to the inflated costs of emergency care. A dose of ibuprofen (two tablets) costing in the $40+ range?

Well they have to pay for storage and for that very well paid employee to pass you the pills.

Moderate sarcasm.

But really that’s a deeper issue with insurance causing most of that. If you don’t have insurance, most hospitals will severely discount the costs that you are originally charged if you just work with them. It shows those prices are bullshit to begin with.

Even if they are willing to give you a discount if you don’t have insurance, those ibuprofen pills are still going to be charged 10x or 100x over their cost. Health industry knows nobody can shop around and get quotes and regulators are unwilling to protect patients. It’s no wonder we are in the mess we are in.

My locality has a ballot initiative up this year that would put a % cap on what hospitals can charge over their costs, and boy oh boy are the industry mouthpieces out in force to oppose it! They are having a field day with patients’ wallets, they know it, and they don’t want it to end.

It's like being given a potentially ancient, bit-rotten code base and asked to refactor the shit out of it for a fixed price. And you can't know that upfront.

It might take a day. It may take a decade. It may take you the customer to change your entire approach.

This is not feasible. You can not disregard hidden defects and the cost of fixing them unless you do not really want reliabilty. If you do not want it, then don't complain.

In IT this requested lack of reliability is accepted. In healthcare and auto repair it is barred by law.

EDIT: i hate autocorrection.

GP suggested a written estimate, not a quote.

GP was booking an appointment for a routine procedure which has a known scope, effort, and bill of materials. There is nothing in this procedure that even remotely resembles refactoring a legacy codebase.

It's not the same. The nurse, the doctor was not a surprise. Bet you given 20 cases of people coming to check for strep, chances are their bills would have been around $400 too not $60. So they should use that amount.

> i hate autocorrection. No you don't, or you'd turn it off. I'm sure there's a metaphor in there somewhere.

All of those fees are completely predictable. Sure if the doctor noticed a problem, they could then offer advice/treatment and the new price.

This idea that medicine is different than other fields is crazy.

The example above is essentially an estimate of the cost of parts (the strep throat test). The cost of a sick patient visit is known and could have been easily included in the estimate.

One current problem is that even if you have insurance, and seek emergency care at a hospital that is part of the network covered by your plan, you still often end up with a huge surprise bill.

>Vox's database shows that patients are especially vulnerable to these surprise bills when out-of-network doctors work at in-network hospitals.

“It does happen quite a lot in the emergency room,” says Christopher Garmon, an assistant professor at the University of Missouri Kansas City.

Garmon published a study last year that found as many as one in five emergency room visits led to a surprise bill from an out-of-network provider involved in the care.

https://www.vox.com/2018/5/23/17353284/emergency-room-doctor...

Anecdata: had to take spouse to ER earlier this year. She had a reasonably run-of-the-mill cold, but the cough had irritated her throat enough that everything she attempted to eat was triggering her gag reflex. She was getting pretty feeble from lack of food (and throwing what little she could get down back up).

Insurance is through her work, so I had to coax her through logging in to her account so that I could try to find an in-network ER list.

After spending ~30 minutes grumbling at the website over the complete lack of anything resembling clarity, I had a list of 3 hospitals that appeared to be in-network (and a sinking feeling that this could easily cost thousands of dollars). Set off around 2am. Arrived at first. 5+hour wait. Went to the next, no wait. They didn't manage to do much aside from giving a few tests that came up negative, administered fluids, gave her a steroid shot, and did a blood panel.

Her blood panel had one abnormal result that the doctor was willing to admit her for observation over (and had admitted people in the pass for less), but the doctor also noted that the parameter can vary a lot person to person; some people would be fine at that level. I had a sinking feeling in my stomach and decided it would be better to take her home to keep an eye on her than risk financial ruin. I think we were there 2-3 hours.

When the bill came months later, it was $2600 because the doctor was out of network.

We had a baby 4 months ago. We still get surprise bills from things we don’t even know about. Some of them could be scams but I have very little idea on how to even verify. Calls get stuck on automated helpdesk.

For all technological advancements in US, the healthcare system is quite backwards. It’s not a new problem. Tons of countries do it well “Canada, Australia, Sweden ...”

The US political and healthcare system refused to accept other models since there is sooooo much money to be made at the expense of “some-other” people dying and going bankrupt.

House insurance, car insurance, all other forms of insurance are transparent, US healthcare is the most “mafia-like money extortion” system.

> emergency care is a single-digit percentage of total health expenditures.

How does that contrast with "care provided by emergency departments?"

> "but what about emergencies!" note that emergency care is a single-digit percentage of total health expenditures.

Right, as soon as the patient is admitted, it's a cardiothoracic surgery issue, or an oncology issue, or a high-risk obstetrics issue, or a critical care issue, or a neurosurgery issue, or a nephrology issue, or a general surgery issue, or an in-patient psych issue, or an ENT issue, or an opthalmology issue, or a geriatrics issue, etc.

It’s hilarious that people suggest that doctors should provide written estimates in advance, on a site full of programmers where the accepted wisdom is that its impossible for them to provide accurate estimates for the work they do.

Here's a relevant quote from a nice article [1]:

""" When you are estimating tasks that are done over and over, you can look to your historical execution time for insights. We average chopping X logs per hour.

If I hand you a Rubik's Cube and ask you to tell me how long it will take you to solve it...what is your answer going to be? If you've done it before you might have an idea. Maybe you just kept plugging away until you finally solved it? Maybe you've watched one of those videos about how to solve a Rubik's Cube, have practiced it and are confident that you could do it in 3 minutes flat? Maybe you have no idea?

Complexity and experience will dictate your answers, but then those estimates still only reflect your perception of the task...not everyone else on your team.

At best those numbers are a guess.

Every step in a software project is solving problems. You don't know how long it will take to solve the problem. You don't know how many new problems you might run into along the way. Can the new problems be solved by you or do they need to be solved by other people? """

[1]: https://www.brightball.com/articles/reality-driven-developme...

There's a big difference between not being able to provide an exact estimate because of unforeseen events[1] and not providing an estimate that includes services that are being provided to pretty much everyone visiting the health care provider for the given condition. I mean the nurse and the doctor costs quoted above are not "unforeseen".

[1] If you're going to try to say that what is "unforeseen" is relative it's not that relative, you can get an independent committee of doctors and provide a percentage based on their experience how much often that event is expected in that situation

Doctors, like auto mechanics, repeat the same tasks over and over and have a pretty good idea what something will cost. Like with automobiles, there are sometimes surprises, and those can require a new estimate to be signed off on.

Software development is inherently nonrepetitive and therefore unpredictable.

Healthcare is much closer to auto repair than software development.

> Healthcare is much closer to auto repair than software development.

O'boy. What doctor do you go to?

Healthcare is much closer to auto repair than software development.

Sure, on a car that's running that you can't turn off, with parts you can't replace, a maintenance history you can't see, and an ECU that actively misrepresents what's going on.

Hey now that sounds a lot like our '81 Vanagon!

Haha, if anything, software should be the most predictable. Most software just provides some screens to enter and view data. How difficult can it be to predict that? I would rate healthcare much more difficult to predict.

Most software just provides some screens to enter and view data.

That is a dangerously naive view of software. Even apps that look like simple CRUD end up riddled with specialized business logic. Apps which truly are a few screens of simple CRUD end up as spreadsheets or Microsoft Access. We've gotten pretty good at not reinventing wheels.

Say what you will about the challenge of it, doctoring is fundamentally procedural and repetitive. Patients don't really show up with whole new undiscovered diseases anymore.

Doctors shouldn't even have to do it. The treatment center should be able to do it. For example:

  Rolled ankle
    100% [of patients get charged]: Office visit: $50
    58%: X-rays: $55 - $95
    22%: boot/cast: $240
    3%: surgery: ??
    <1%: other: ??

This would't work for all symptoms, but it would work for a lot. But no treatment center does this.

Doctors and the health care industry have better lobbyists than auto mechanics.

Too expensive to fix an auto issue. Oh well, let’s just dump the car and get another one.

Too expensive to fix healthcare issue. You’ll probably die or make it worse if you don’t fix it. “How much is your life worth to you?”

You can get a ton more random money by holding people’s lives over them. That is in summary the US healthcare system. Full of middlemen squeezing every penny they can out of you because they can.

Whoever campaigns for a transparent healthcare system, I’m voting for them.

Our broken healthcare system kills more people than all terrorist attacks and natural disasters combined because people can’t afford to pay the bill mafia.

That’s just a very sad state of affairs.

Singapore does this really well. A hospital is mandated by law to provide you financial counselling - it’s like a predictive charge sheet of what you will be charged when you’re admitted to the hospital. It’s unreasonable to expect 100% accuracy, they give you an estimate based on everything they know. if circumstances change, they are required to provide you an updated financial counsel sheet.

Yes sir, we can replace your spark plugs for only $4.00 each.

It costs $75 to pull the car into the garage, the lift fee is $105, it's $21 to open the hood, $64 to unplug the wires from the old plugs, $64 to plug the wires into the new plugs, then there's $18 to close the hood (gravity assist discount), and another $75 to put the car back in the parking lot.

Don't worry, changing your plugs is only $16.

Never once in 20 years of automobile ownership has a mechanic tried a stunt like that on me.

Precisely. Yet it is completely normal in American medicine. And worse, the actual patients are rarely aware of the total amount billed or paid because their insurance company handles it.

If they didn't itemize, you would complain that all you see is a bill for $1000, at $500/hour.

You would be asking what goes into that hourly rate.

Try to open auto shop (it is painful but doable) and hospital. I bet issue lies in that difference.

I take it you have never been to a mechanic?

Because every single one I've been to also includes labor cost in the estimate.

I'm here at work, on break after taking orders for automotive work, and quoting prices... The only thing not included in the quote is the tax.

Think parent is simply illustrating what the medical case might look like in a garage. I'd say point is made.

My (motorcycle) mechanic quotes me based on the parts and the amount of time required to do the repair. So she'll say "A new set of tires is $130, and the shop labor is $110 an hour. If you only bring in the wheels, then labor is just $50." I'm not sure what magical force is causing my mechanic to behave this way. It could be personal preference, some kind of regulatory requirement, pressure from competing shops, etc. Whatever that force is, it doesn't seem to exist in the american sickness and treatment system.

Somewhat ironically, mechanics seem to be generally considered one of the least trustworthy forms of business. I wonder why the medical profession hasn't seemed to earn a similar reputation. Maybe they will but they just haven't gotten there yet.

I'm starting to feel the same way about medical professions. Example: I go to my dentist...and as I'm sitting in the chair, hygienist tells me she's going to put on fluoride and xrays as part of routine. Alright, no problem, I have preventative coverage.

Turns out it cost $30 for flurodie and $60 for xrays. Fluoride is only covered in kids, and xrays every 2 years. I call up dentist office and you know what they tell me? They don't provide treatment based on insurance coverage.

Right...they provide treatment based on how much money they can rip you off on. Fluoride for adults is new. We have fluoride in the water and in the toothpaste.. I don't recall having it in the past and my Google search tells me where's a debate on whether it's even beneficial. I only see that it benefits the dentist's pockets.

Similar experience for me as well. Went in to get a chipped tooth looked at before it got worse. Less than 5 min exam by the doc, and an assistant. Hygienist had to look at something... Bill for $400. How the hell is this crap legal??

"Don't worry about it, my insurance will cover it"

Don't forget the nurse mechanics needed to transport the vehicle to the right location and the anesthesiologist mechanic to monitor the vehicle's electrical system, and the surgeon mechanic to do the procedure. And they'll also charge you fees for the tools they use.

Are you suggesting that you'd have surgery without a nurse, surgeon, or anesthesiologist? And that you shouldn't expect to have to pay for equipment used in your surgery?1

The point of the original post that the parent responded to was the fact that they got an estimate of cost for treatment that just included the cost of the strep throat test and none of the other associated costs.

The parent post expanded on that point by trying to list all the other charges for a common car service in the style that would be similar to what one would see if they were admitted to the hospital for an procedure. He then reiterated the point that the cost estimate only included the cost of parts (the 4 spark plugs).

I just expanded on that by listing the other labor related charges for the procedure that still wouldn't be included in the estimate.

In terms of car repair, you just have to know about the hourly rate of the shop and the number of hours they state a particular repair will take. In a hospital setting, you have no idea how many people will interact with you and what their charges will be (which appear to be unrelated to how much time they actually spent with your case).

If I suspect strep, I make a same-day appointment with my family doctor, show my government issued health card, get swabbed and have a result in a few minutes. I then smile at the receptionist and walk out; there is no bill for seeing your doctor or having tests run.

If I need antibiotics, my employer provided insurance covers the full cost and I pay a fixed $10 or so fee to the pharmacy.

You live a few hundred km south of me I bet, and in every way except this our world is very similar.. but you guys have far deeper problems then just transparency. Your entire view of healthcare is wrong.

And just a reminder the US doesn’t even spend much less taxpayer money than Canada and other Western countries. The US taxpayer spends about 8-9% of GDP on healthcare, and gets this result. Other countries spend the same and get a free universal healthcare system.

For other reasons, I don't have a family doctor. All the doctors my insurance will pay for require making appointments >9 months in advance, and I fly so much with work that I can't commit to that type of lead time. Twice I've missed appointments, and both times instead of letting me reschedule the practice informed me that I was no longer allowed with them, and that missing an appointment is considered a big offense.

One day I'll figure it out but at 24 years old it's not a huge deal to me.

It is just insane to me that you have a medical issue and you're calling around for quotes. I know we have had this conversation to death for decades now but it just makes me so angry.

Why?

The most efficient provider should get his or her business. That way we can treat more people for strep and increase human welfare.

Probably because if we had universal healthcare, you wouldn't have to call any because you would get the same service for free.

How would the universe provide healthcare?

https://en.m.wikipedia.org/wiki/Universal_health_care

It's true that you wouldn't have to call around, because you wouldn't have to compare the cost of out-of-pocket providers. It's not true that you wouldn't have to pay. You would pay through taxes, or someone else would pay through taxes. And you would pay in terms of the waiting time, which becomes an alternative form of payment in public systems.

Interesting that everyone makes this argument for things that aren't already covered by taxes. No one sits and argues that you do have to pay for the interstate system in a discussion about the cost of using it as the turnpike.

No one thinks that no end user cost (what people usually mean when they say free) <> no money spent.

Isn't the interstate system frequently blocked and the roads not really good, the speed limit low, construction way too expensive and slow, etc? I wouldn't really want to have that in my healthcare system...

My point: Let's stop comparing healthcare to road construction/maintenance. It's human lives. It works differently.

I wasn't comparing healthcare to roads. I was commenting about how silly people sound when they say "it isn't free, taxes fund it".

Also, speed limits can be comparable to turnpike's, the interstates are rarely "blocked" unless you mean congested, which is a different issue and one that more road at that location would actually make worse. Construction costs are comparable to turnpike construction and maintenance costs and are slow because, unlike a turnpike it's most visible and most delaying in areas like cities where you can't move cars to a shoulder, something that isn't an issue for turnpikes..

>interstate frequently blocked

By whom? Traffic is just an argument for mass transit

>roads not really good

That’s an argument for more government not less. They’re fine where I live.

>speed limit low

It’s reasonable in cities and towns

>construction expensive and slow

Also high quality

You already have a beurocracy in “your” health care system. It’s just a private one and not a public one. The difference is cost involved in administrative overhead deciding who gets care and for what.

A nation needs a good health care system and a good road system to afford productive workers.

Both systems when implemented poorly cause human death and disability.

> By whom? Traffic is just an argument for mass transit

Huh? I don't see any argument at all. The fact is that it is, right now, blocked.

> That’s an argument for more government not less. They’re fine where I live.

Yeah, sure - I live in the Czech Republic, a place where we have more government and the worst roads you will ever see in a first world country.

It's definitely not an argument for "more government" - actually it's not an argument for either because you've provided zero arguments. Why it'd be better than it is now?

> Also high quality

The highways are definitely not high quality, it's just good enough. Visit Germany sometimes. Construction time has almost no relevance to quality, btw (if we don't talk about extremes).

> It’s reasonable in cities and towns

We are talking about interstates.

> You already have a beurocracy in “your” health care system. It’s just a private one and not a public one.

Yeah, I know. Again, what's your point? You stated facts that are well known by everyone interested in this topic. There are very clear advantages to a free market and there are very clear disadvantages of a public solution (and of course the contrary).

Have you ever thought about the fact that only people in the USA actually want a public system? Maybe a private system could work well if implemented correctly (see Switzerland, a country with one of the best healthcare in the world - that is private) - government is not a universal and definitely not always the best solution.

> The difference is cost involved in administrative overhead deciding who gets care and for what.

Is that the only difference, really? How much experience exactly do you have with public systems? Are you sure you have a complete picture? I have lived in several ones over my whole life. I prefer the US system.

BTW is there really a difference? You know the same thing needs to happen in a public system as not everyone is eligible for everything? How does it compare to waiting for 4 months until a doctor is available (in non-urgent cases)? How does it compare to generally substantially lower quality of care (not medical, but care - as in quality of food in hospitals, whether they treat you respectfully, whether you need to sleep on a hallway because all rooms are packed with 5+ people...)?

Do you know that only the most basic (we call it "medically necessary") treatments are paid and everything else needs to be paid out of pocket in full as there is no possibility to insure yourself for upper level of care (actually it's illegal)?

> Both systems when implemented poorly cause human death and disability.

Exactly. So let's stop with "hurr durr we need full government intervention" and let's focus on what's wrong, why it happened and how to fix it ASAP - and you're not going to fix anything ASAP if your way is to rebuild the whole thing and nationalize/bankrupt (or both, as is common with governments doing business) huge companies.

The USA system needs change, however I'm pretty sure that such dramatic change would leave the country in ruins (or more likely in a lot of dead bodies) simply because it's extremely hard to run such system even if you've been doing it and continuously improving it and gaining experience for the last 70 years and your country is 20x smaller - and there is no country in the world where a public system would have substantially better results than the US one.

You shouldn't even need to call around, prices for routine procedures like checking for strep should be clearly posted. The bill shouldn't change if you're insured or uninsured, just the payer changes.

There's obviously some variation here, and for that an hourly rate makes sense.

Health care should be more like car repair: go in for a quote, then pay when you decide on a provider. Obviously emergencies are different, but things like strep or broken bones are pretty common, so they should have a set price.

The most efficient provider should get his or her business.

That's an assertion, not an argument supported by observations. In the European countries the government sets prices for procedures, and it works well, life expectancy there isn't lower than it is in the US.

Life expectancy is not a simple proxy for quality of health care. Exercise, diet, happiness, genetics, disaster propensity, and many cultural factors have an impact on life expectancy.

Compare specifically to the UK then - we get no exercise, have awful diets, are miserable, have a more inbred version of US genetics, fucking love self-inflicted disasters apparently, and are culturally mostly indistinguishable from the US. And yet, despite the fact that we spend a fraction of what you spend on healthcare, have a couple more years' life expectancy.

And by almost any measure we are no better than and frequently behind other western democracies in healthcare.

European countries are free riders on the American healthcare system.

Americans pay out the nose for drug prescriptions, which fund the vast majority of research and development budgets, which then benefit all people, worldwide.

I think this is very self-serving propaganda by the American healthcare system. And even if it's true let's fix this by charging less in the US and see what happens to the rest of the world. .

As a European, I agree.

Come on, the big companies are multinationals, and not all of them do all research stateside. Novartis are Swiss, GSK are British, Merck KGA are German, Novo Nordisk are Danish, Takeda are Japanese &c pp. The Yanks overpay terribly for healthcare, that's true.

It doesn't matter where they do research, it matters where they sell their drugs.

And all of those countries make more revenue selling to the US than they do any other country by a long shot.

Of course they do. But that's not the fault of the other countries, its because US politicians allow the pharmaceutical and health care industry to get away with it. The fix is not to force others to pay the same high price for life saving medication; the solution is to bring the costs down for all. But in the US we allow corporations and lobbyists to control the narrative and people actually think its ok to force someone to choose between being able to afford their medication or food.

While I probably agree with your thesis, you have not actually addressed GP's assertion that the US subsidizes Drug Research. There is no question that we pay more for drugs than others. There is also no question that it is better for the consumer if we have cheaper drugs.

What you haven't answered is whether the research can be supported without the American market subsidizing of that research.

It is in fact, expensive to develop new drugs and something has to pay for that development.

>>European countries are free riders on the American healthcare system.

Citation needed.

Americans pay out the nose for all medical care, not just drugs. So I doubt your assertion really holds water.

If the world wants and needs better drugs, there are other ways to fund research. If we give a damn, we can find such solutions.

>The most efficient provider should get his or her business.

Given that the US has this system and US healthcare is multiples more expensive with worse or similar outcomes in essentially every field, I suggest we can put that theory to rest now.

What about Switzerland though?

(definitely not defending the US system)

There must be some additional variable. Be nice to know what it is.

> Given that the US has this system

The US does not have this system.

The grand parent describes this exact process. Why would we think he was lying?

No lying is necessary, misinformation is common. People generally don't know how much the healthcare industry is regulated and how exactly.

The most efficient provider, however, might not be the best provider. If you have cancer, you want to get the best treatment and survive. But hey, this other guy might be able to do it cheaper!

Just as big a problem as the opacity in pricing, is the opacity in figuring out who the best providers even are. There's no Yelp for healthcare because powerful groups won't let it exist.

What's the alternative? Everyone charges the same price? Who sets this price?

Calling around and shopping is what people do on practically every other service or good they buy now.

And on every other service you will get something that at least resembles a straight answer.

My guess is that this is where healthcare is headed in the US. If things stay on the current trajectory, the govt is simply going to step in set prices.

In terms of how they would be set, Medicare already spends a ton of time created a system of DRG codes for every condition along with a set payment (adjusted by COL and other things).

Of course Medicare rates are sometimes less than the cost to provide the care. But I see us just getting to the point that the govt will just say “tough shit”.

Do you call around and shop for different fire departments? Seems weird that such a basic need would be treated this way.

Fire departments are analogous to ambulance response — these services are entirely based on geographic location and, similarly to insurance, need to be arranged in advance by a municipality or county, or an out-of-district annual payment. Most healthcare is not summoned this way although there are an increasing number of medical practices that charge a subscription in exchange for quick access to the office and remote consultations.

If you think you're angry now you should try actually calling around for quotes. My experience is that most places you call won't even try to give you a straight answer!

>It is just insane to me that you have a medical issue and you're calling around for quotes.

You dont call around for quotes of $100+ services?

Why?

Because you should be able to show up, get your treatment and go home without paying a dime, like in most developed countries.

That sounds unsustainable and bad capitalism.

Free services mean a few people will overuse and abuse.

So you are saying poor people should just die I guess. Them and their kids.

Indeed, ever since I realized I could get medical care without paying for it I've been going out and getting cancer a couple times a week.

Eventually seeking out excessive medical care will be considered a mental illness and it’s practioners hospitalized

"Drug seeking behavior" extended to antibiotics and chemotherapy lol

> That sounds unsustainable

It is perfectly sustainable if you have a population that isn't ideologically opposed to taxes. You can fix that with education.

> and bad capitalism.

Good capitalism or bad capitalism, who cares? This sounds like a pointless ideological concern, again.

> Free services mean a few people will overuse and abuse.

It seems spiteful to me to deny universal healthcare to the majority because a minority might abuse it.

Countries with universal health care spend less on health care. It’s empirically proven to be cheaper.

I was diagnosed with Oropharyngeal Cancer 39 days ago. Keeping up with the appointments alone has been bad enough. I am not sure how I would deal with this if I had to shop around for the best deal.

-I went to urgent care for some swelling on my neck that escalated quickly. 45 minutes later I was getting a MRI. This was on a Friday. They called and said it was cancer.

-Monday I was seen by a ear nose throat doctor. Yes, cancer indeed.

-Tuesday I saw a oncologist.

-At this point I decided to move to Portland since my sister lives up here. So the oncologist referred me to another ENT doctor in Portland.

-About a week later I saw a dentist and radiologist on the same day. Everyone agreed that due to the bad shape my teeth are/were in and the location of the cancer my teeth need to come out.

-A few days later another oncologist

-All my teeth removed (this has been rough)

-Tomorrow a "simulation" and PET scan to see if the cancer has spread

-Tuesday is something called a swallowing test

-Wednesday is a check up with the oral surgeon

-Friday is some intake thing for the feeding tube and a meeting with the nutritionist.

-Next Monday feeding tube installed.

-Next Tuesday another check-up with the G.I doctor.

-Next Wednesday radiation and chemo start.

So yeah.. I have no clue how much this shit is costing and I don't really care since I have Medicare. I just wish everyone had the same luxury.

Godspeed brother, I wish you the best. You'll be in my thoughts

Welcome to the [Cancer] club noone wants to join. Good luck w/ your treatment.

I hope you don’t mind, but praying for you and your treatment going forward.

Fight the good fight, internet stranger. Don't give up. Good luck.

We live in a boring dystopia https://twitter.com/visakanv/status/990570131238473728

Calling for quotes is how buyers (patients) force prices down in the long run.

For example, I got a quote this summer for an outpatient MRI that was 20% the cost of a hospital MRI, faster, and would accomplish the same thing. Now I tell everyone I know about this. If enough people do this, the hospital will not be as free to increase the cost and might even lower it (or at least start providing quotes!)

This price-shopping process is slowed by all the shenanigans that keep prices and services provided confusing, and demand to improve this is hampered by insistence that patients are never in a state of mind to shop for the best healthcare provider. It’s simply untrue—and there are workarounds in the worst cases like healthcare POAs and family members donating time.

It’s worth noting that Kaiser does this. They post a fee schedule for just about every routine procedure in every region they operate in. There is no abiguity about what an MRI costs.

Transparency won’t fix healthcare in the US, but it is a starting point. Hell, it’s fundamental to simple free market economics. It’s silly to say we have a free market healthcare system when there is virtually no cost information about goods and services until after purchase.

And Kaiser has 7 minute primary care appointments, and a high rate of physician burnout.

Do you think that's because they post their prices?

Its because of their pricing structure as a vertically integrated system.

That's pretty frustrating. I had a related experience where I needed antibiotics. As it was the weekend, I just went to a local walk in clinic. The person in front of me did not have insurance and his cost to see the doctor was $90. I had insurance and my out of pocket was initially $45, a couple weeks later I got the remainder of my bill for using out of network: $135. So in total I was charged double the individual without insurance plus the cost of my medication.

It seems that a major driver of insurance and medical costs is that doctors are allowed to charge different pricing for the same service. In this case, paying a monthly fee for insurance ended up costing me more.

That sucks. The CVS Minute Clinic will quote you $99-129 for a strep throat visit, which includes the culture and the script if you actually have it. Nurse practitioners are, I think, the future of primary care.

This stuff is all bad, but it's useful to remember that primary care is actually a small fraction of the overall price of health care. Where we're really spending the money is on long-term and end-of-life care.

> Nurse practitioners are, I think, the future of primary care.

Agreed. When I visit my PCP, I normally meet with a NP. I’ve been quite happy with the quality of care received.

> Where we're really spending the money is on long-term and end-of-life care.

With the boomers entering the end-of-life phase of their lives it will be interesting to see if we will be able to change culturally and realize the huge sums of money spent with little benefit to the economy. I’m struggling with this myself currently as my parents are aging (quickly). They don’t have unlimited savings to spend on health care. While I have ample resources, I’m not convinced shelling out $1MM is worth it for them to live with a marginal quality of life for just a couple of years. Just writing that makes me feel like a terrible person but I try to think rationally and without emotions.

Edit to add: I’m genuinely curious about your thoughts on this, @tptacek. I’ve always respected and appreciated your opinion here on HN.

Our unwillingness, on a national level (and perhaps on a civilizational level, though I don't know very much about other countries) to speak plainly about this issue, and address it directly, is one of the most fundamental problems in all of healthcare.

My veterinarian charges around $60 for office visits. A surgery with general anesthetic might be $1000. It's about 10x cheaper than a human doctor, maybe 100x if you go to a random emergency room. Veterinary medicine involve all the same steps as for a human patient. I can usually get appointments the same day too. It's a totally free market, where vets compete on price and service.

Same with medical procedures in the US that aren’t covered by insurance - cosmetic surgery, LASIK surgery, etc.

The free market works pretty dam well for those.

This is something I've been advocating for in California. Basically the equivalent to the auto repair law that guarantees that the repair is done to the quote or they tell you it will cost more and you have the right to take their quote elsewhere[1].

[1] If the technician later determines that it will take additional work and will cost more to fix your car than the original estimate, someone from the shop must contact you, describe the additional work and cost, and get your permission to proceed. -- https://www.bar.ca.gov/Consumer/Auto_Repair_Guide.html

Imagine a system where you go to the GP, and just make a walk-in appointment. You sit for ten to fifteen minutes, see your GP. They check you over, direct you to go see the nurse, who checks your throat. Then afterwards, the GP tells you that they'll phone you later on with the results.

You walk back past the reception desk, ask what the bill was, and they either say "that'll be $40 which you can claim back by taking the receipt around the corner to Medicare", or they'll say "Oh nothing to pay, it's all bulk billed".

You walk out having either spent nothing, or spent a few bucks which you get back after a five minute walk up the road.

That was my recent experience.

At least you got a quote...I've been told by providers that they only accept insurance patients (no up front cash), and they can't tell you till they bill you...Not sure why this is the only industry like that.

You don't go to a restaurant and get the pricing after you eat. Heck when you go to a buffet you don't get billed based on how many plates you get.

I work at a small community hospital about 225 beds. They have 9 VPs, 44 directors, and 44 assistant directors. This in addition to the Medical Staff Supervisors. Seems a bit much... no.

Sounds like rampant title inflation at the very least.

Friends taking care of friends... can you feel the love ;)

Any time you try to define what your insurance will cover, all you can get is s nkn binding estimate, yet most places have you sign an agreement to pay in full based on that estimate, even if the estimate is wrong.

What happens if you insist on paying only the $59 that you were quoted?

They send it to a ruthless collections company and ruin your credit.

That sounds like an entirely separate uniquely American problem. Don't you have laws that prevent disputed bills from affecting credit scores?

Edit: and wouldn't this lead to lawsuits against medical practitioners for extortion if it can be proved that they make a habit of doing this to patients?

No, because it is just an estimate. Every medical estimate in the US will include language that explains services other than those in the estimate may be provided, and you'll be responsible for paying for them. The provider is under no legal obligation to only perform the estimated services.

Also, in America, doctors will always have you sign an agreement before they see you and before the price is known, that essentially says, “you agree to be responsible for paying any amount the doctor asks for, without any limit.”

How is this legal? I mean, you can just straight up make it illegal. There's no fundamental law that says you have to allow such predatory practices.

There's a reason why health insurance companies do the amount of lobbying they do.

Surely goes to collections

The real issue is not a big percentage of the population care about the prices. A good chunk of them are covered by employer based insurance or government medicine. Only the poor and unemployed care about it and unfortunately they don’t have the gravity to change things in the US. Only the wealthy and entities able to fund a 301c can influence things. Point is I do t know what asking around for prices is going to do. By definition if you are asking around you don’t matter to the politicians.

Transparency is good and all, but there is anther way. In most advanced economies professional bureaucracy figures out the costs. Ordinary folks focus on getting healthy, not on costs.

> In most advanced economies professional bureaucracy figures out the costs.

This works terribly for most advanced economies, Britain and Canada in particular.

As a Canadian living in the USA, I can say that it works less terribly than the American alternative.

Not if you have cancer.

https://www.ctvnews.ca/health/health-care-wait-times-hit-20-...

Again, I have lived there, and the numbers seem on the upper end of plausible for non-essential surgery like breast reduction, but extremely bogus for anything important. A day or two was normal for routine treatments.

The official government figures, where about half of patients get care within 24 hours, and about 90% within 48, are much more in line with my experience.

I know someone personally who had to wait months to see somebody. He said screw it and came to the states for care instead (dual citizenship). He was able to see a specialist immediately and found out he was grossly misdiagnosed.

And I know people in the USA who have gone to Canada or India for medical tourism because they could not get good care at an affordable price in the USA. But these are anecdotes.

When you look at the stats aggregated by OECD, Canada is indeed among the worst public health services in the developed world, but it still provides better care to the median earner than the US health system, at half the aggregated cost per capita.

Never once have I heard of an American going to Canada for medical tourism. I live on the Ontario/NY border and have my whole life.

I'm sorely disappointed in your arguments so far. Your stats support your point and are legitimate but mine are not. Typical liberal nonsense.

I agree, my stats are in line with what I and my family have experienced, and yours are not.

Combine that with multiple agencies such as Health Canada and OECD which have measured wait times an order of magnitude lower than you cited, I am not sure what else to say.

The governments stats basically have to be kept. Running the system requires all of the necessary data to already be collected for other purposes, and their stats are drawn from that.

The stats you provide are collected by an institute looking to further their ideology. They come from a far smaller data pool,and their collection method seems rather suspect. For example, they're asking the actual practitioner rather than anyone involved in scheduling.

> The stats you provide are collected by an institute looking to further their ideology.

Proof?

> The governments stats basically have to be kept. Running the system requires all of the necessary data to already be collected for other purposes, and their stats are drawn from that.

You trust a government entity to accurately report data that's not in it's best interest? When has that ever happened?

> You trust a government entity to accurately report data that's not in it's best interest? When has that ever happened?

Can you explain what your criteria would be for a trustworthy source?

>Proof?

That's essentially the definition of a think tank. This one was founded by a libertarian and considered by many to be libertarian. Certainly cause to question their stats, and I didn't like what I saw.

>You trust a government entity to accurately report data that's not in it's best interest? When has that ever happened?

This is probably enough for you to question their stats, but you've done nothing to show they are wrong.

He has data you have an anecdote. Guess which one is worth more?

And why is his data more legitimate than my data? And don't bring up the so called "bias" because of factors unrelated to the study. Every study has bias, including the numbers ori_b is touting.

Because one does not measure the quality of health care by the amount of time spent waiting for non-critical treatments such as hip replacements or breast reduction surgery, which is the only thing that your numbers are vaguely consistent with across about 10 different sources I've looked at by this point.

I challenge you to find a second source that is both consistent with your article, and breaks down the waiting times by type of treatment, including treatments that do not need follow ups with specialists.

> Because one does not measure the quality of health care by the amount of time spent waiting for non-critical treatments such as hip replacements

Why not?

Most people are in serious pain and have their mobility severely compromised while they wait - I know from personal experience.

Just search for it on Google, you'll find dozens of news articles.

The Fraser institute, which published this study, has a right wing bias and is funded by the Koch Brothers. It seeks to displace the public system in Canada with private healthcare modelled after the US. While they claim independence and give their research away freely, one should be aware of their interests.

Proof?

https://www.cbc.ca/news/world/koch-brothers-dark-money-repub...

https://www.vancouverobserver.com/politics/charitable-fraser...

Neither of those links are proof that the study is invalid. So, once again, proof?

Read again. The original posters claim was that the study was funded by foreign money that pushes an agenda, not that it was invalid.

As to the invalidity:

The fact that I have never waited for more than a couple of days for treatment in over 25 years, and neither had anyone I know (with 2 exceptions, both of which were for elective surgery like breast reduction surgery) does imply that, at best, their median measurement is measuring a specific niche, rather than general treatment.

Combine that with the fact that multiple agencies have measures wait times as being an order of magnitude lower than your source, and yes, I do think your numbers are invalid.

> The original posters claim was that the study was funded by foreign money that pushes an agenda, not that it was invalid.

Nobody's stupid enough to believe that one doesn't imply the other.

If you believe one implies the other, then evidence of the funding should be sufficient as evidence of invalidity. If you don't believe one implies the other, then your question about the funding was answered, and you are moving goalposts.

Which question was that? Stop putting words in my mouth. You've repeatedly argue in bad faith, made bad assumptions and attributed statements to me that I did not make.

Here's the initial post:

> The Fraser institute, which published this study, has a right wing bias and is funded by the Koch Brothers. It seeks to displace the public system in Canada with private healthcare modelled after the US. While they claim independence and give their research away freely, one should be aware of their interests.

You requested "proof". Given that the only quantifiable claims which could possibly be proven is that they are funded by the Koch brothers, and would like to replace the public system with a private one, I assumed you were asking for proof of that.

Now, if you were not asking for proof of that, can you quote the section of the above you did want proof of?

The brass fucking neck of you saying I'm not arguing in good faith when you produce a trainwreck of a thread like this.

The fact you think Britain has a single NHS doesn't inspire confidence in your level of knowledge, but let's hear it: why is the system so poor in the UK?

> The fact you think Britain has a single NHS doesn't inspire confidence in your level of knowledge

Can you point me to where I say that? You've just killed any potential discussion by arguing in bad faith. Why should I listen to anything you have to say on the subject now that I know your intentions are hostile and that you're not open to debate?

Your inability to provide any examples has been noted.

Alternatively, socialize the costs. I've never bothered to figure out what going to the doctor would cost me, because it's so cheap here. I don't understand how it's economical to have a workforce with poor health care.

Or you know, do both! Socialize the costs, but unevenly, then inflate the costs, spread them across as many middlemen as possible, and charge left and right!

Why would you pay?

$400 for a strep test is highway robbery.

> There's no way that should be legal. I was quoted $60.

Well, part of the problem is that the state now assumes that consumers are not qualified to take care of themselves, and that the only people who are qualified are state-approved high-demand professionals. Oddly enough, opioid overdoses were not higher when you could just buy the stuff over the counter; but people have forgotten that people used to be responsible for their own well-being, and are convinced that they should not be trusted to defer to experts when they see fit.

Some things should simply be left to Our Betters.

After the Alfie Evans circus I'm inclined to agree. You need to be properly trained to be able to recognize what is in the best interest of the patient and that that is the only thing that matters.

It’s bizarre that “capitalism” is frequently blamed for the moral atrocity that is the American medical industry when really it’s one of the most clear cut examples of a state-mandated cartel

I'd be a great business man to if people were legally required to purchase my product.

That is just absurd. We accept that kings will naturally strive to uphold their power, that feudal lords will protect their privileges, and so on. But somehow, some seemingly dogmatic people firmly believe that despite the entire incentive structure pointing in that direction, genuine agents of capitalism are not furthering their own interests through the means of state power.

Citizens United is one such example.

Of course they are. But that is not capitalism. You can't blame the free market for people "furthering their own interests through the means of state power" when the very existence of state power is antithetical to free markets. The "free" in "free market" refers specifically to the absence of legitimized and systematic aggression, of which state power is the foremost example.

This is a completely and utterly ahistorical redefinition together with selective reasoning. The theological fantasy where capitalism is freed from its state component would not differ either with regards to these incentives, the state would just be replaced by "private-property lords" which you'd stamp as legitimate and welcome the voluntary toil of the propertyless masses.

If you're going to use private and/or archaic definitions for common terms, please say so up front so we can avoid wasting our time. The term capitalism in common use today means a political and economic system which favors private ownership of the means of production, with strong implications of "laisse-faire" and "free market" policies. It is not a synonym for plutocracy, the vesting of political power in those possessing wealth. To the extent that owners of capital are effective in turning the power of the state to their own benefit, to intervene in the market on their behalf, what you have is a plutocracy, not capitalism.

Unsurprisingly, you did not address the point I made. The surgical separation of private-property, political power, and plutocracy that you're making is a fantasy in which they're somehow not deeply intertwined and interdependent from start to finish.

Also do yourself a favour and never assume that your US libertarian bubble definition is the de facto standard around the globe. Europe has a long and dark history of the kind of (neo-)feudalism that you're peddling, it's not hard to spot.

I'm very suspicious of that factoid, given that limiting Paracetamol purchase size was very effective at reducing overdoses in the UK.

Also, the US has seen a recent huge rise in opioid overdoses ...

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