What I learned from reading a thousand emergency room bills
vox.com
vox.com
I have yet to hear a coherent explanation for how anyone can reasonably expect for price discovery to even pretend to function in a market where the consumers can't even guess the prices until after they've already purchased and frequently couldn't reasonably be expected to refuse service even if they did believe it was overpriced.
You do actually, by where you choose to live and also by the services as detailed in [1].
I think there's merit to investigating public health care. That line stops for me in eliminating private care.
1] https://www.theatlantic.com/technology/archive/2018/11/kim-k...
So that's what they call "Taking care of an elderly relative" these days!
Family networks are probably the number one reason. Child/elder care, food/housing/etc. sharing and a lot more are all major factors that by definition do not show up in economic reports.
And that's before people's "psychological conditioning" (which some people refer to as "being part of a family") is considered.
I, too, have moved around a lot - across the US three times, overseas and back once, with smaller cross-state moves in between. And it has worked out for me. I am also not married, have no kids, am not very close to my family, have a high degree of risk tolerance and high attraction to novelty, and seem to need a smaller community of folks in my life than many others.
I'm also well aware that I am an abnormally-unattached person. Most people have significantly more difficulty uprooting and moving somewhere else. Writing that off as conditioning that interferes with economic concerns not only fails to recognize very real economic aspects that don't show up a bank account, but also fails to recognize that humans value things other than money.
And if it doesn't survive, good! Industries don't have an inherent right to keep existing if they don't fill some useful function. Refusing to implement an otherwise desirable social program because it might cause an existing industry to become obsolete is far and away the most anti-capitalist argument I see self avowed capitalists make.
This is the same issue with toll roads vs. public roads. Imagine there are two similar roads leading from A to B, one a toll road and the other public. The toll road charges drivers $1 per 100 miles. The public road is free to use but costs every driver $5 per 100 miles in taxes. Which one do you think drivers will take? The more expensive public road, of course—because they're already paying for it, whereas the toll road would be an additional expense.
Imagine your hypothetical were reversed. Imagine we already had a network toll roads priced at an average of $5/100 miles, and that we had a plan to build and maintain public roads at an expected cost of $1/100 miles. There might be plenty of good reasons not to prefer the more efficient public plan, but the fact that it would put toll road vendors out of business isn't one of them.
Capitalists don't mindlessly prefer private things just because they're private. We like them because they tend to self-optimize for efficiency more effectively than a centrally managed system can. Usually. There are a whole thread's worth of reasons to believe health care is one of the exceptions, both in theory and in practice. If that's the case, then refusing to implement a superior public system solely because it would decimate the inferior private one is just another flavor of the same anticompetitive protectionist bullshit that makes tarrifs and professional licensing and restrictive zoning and a dozen other types of cronyism distasteful.
I have no particular sympathy for any private provider that can't compete with other private providers in the market. However, from my point of view private and public providers aren't in the same market, or even providing the same product: one is simply selling access to roads, or health care, while the other is giving these things away bundled with the dubious "service" of compelling other people to pay the bill. To me that bundled "service" is of immense negative value, and the existence of the public system is driving the providers of the unalloyed product I actually do want out of the market. So, from my point of view, the fact that the public plan would put the toll road vendors out of business and thus leave me with no decent travel options that don't involve externalizing the cost onto others is actually a good reason to oppose the public plan. (There are others: While I don't want to participate in this externalization process as an unwilling beneficiary on moral grounds, I'd also prefer not to become one of its victims.)
Of course, if there exists a way to build and maintain a road at a cost of $1 per 100 miles, there is no particular reason why that cost couldn't be payed through tolls instead of taxes, thus giving us the best of both worlds. There are basically only two ways which public services can manage to cut costs compared to a private provider. One is by externalizing the cost of the service onto non-users, and the other is by being exempt from regulations which private providers would be forced to follow (or, equivalently, having the regulations tailored to suit the public service by sympathetic legislators).
> Capitalists don't mindlessly prefer private things just because they're private.
Whereas libertarians such as myself do prefer private things simply because they're private, which is to say: because they don't involve the use of force. Which is not to say that there aren't practical reasons to prefer private systems as well—just that, to me, any system which involves force is automatically more costly than any voluntary system, which makes these other reasons more-or-less irrelevant.
The wealthy with their ability to influence politics will lobby to undermine/weaken the public system to save their tax dollars.
You are better off with one system so that everyone is entitled to the same level of care. We do this with fire/police, same applies to health.
Another way of looking at it is we don't have private firehalls. I'd argue healthcare is the same.
Interestingly we are moving towards having private security forces, enabling some to be more safe than others. I don't agree with that either. So, maybe it's a philosophical difference, I feel strongly that for basic rights (e.g. health, safety) we should all be treated equal, and money should not grant me special treatment.
I haven't seen a proposal yet that would eliminate private care (or even supplementary private insurance).
Certainly it is true, I agree, that emergency hospitals and ambulances are public-option only.
My original statement might have been more accurate had I said "fully eliminate private care and private insurance".
Certainly with medicare for all both of those would be drastically reduced. With the medicaid buy-in they would both be moderately reduced.
I still think private care and private insurance will exist under both models, but like you said, they may be different in terms of what they cover.
Hence there are VERY few private clinics in Canada except for services where the govt realized it was in their benefit to allow it (MRIs).
Has anyone proposed that? If not, I'm not sure why you mentioned it.
Anyway, I suppose I can see the benefit to private doctors, but if private emergency response services for individuals are popular, then something is fucked, as your link demonstrates. Not saying they should be banned, but they shouldn't have to exist in a properly-run society.
What serious single payer proposals have been put forward that would eliminate private-pay, private insurance, or private care?
I've never seen one.
In fact, almost all "single payer" health systems that exist in other countries have private care and private insurance options. For example, such options are available in both the UK with the NHS and in Canada.
I've never once spoken with an advocate of single payer who wants to eliminate private pay, private insurance, or private care.
I am also an advocate of single payer, and I wouldn't advocate eliminating any of those things.
Both Medicare for all and Medicare buy in plans wouldn't eliminate private health insurance.
Private health insurance would still exist under both plans as supplemental coverage that people could buy that would cover things that were not covered by medicare.
The markets would be potentially reduced (drastically with medicare for all, moderately with a generally available medicare buy-in), but it's totally false to say they would be eliminated under those plans.
I'm sure there are plenty of things to dislike about Sanders or anyone else whose political leanings tend toward things like publicly-funded healthcare coverage, it should be possible to come up with a few of them without blatant misrepresentation
Plus the whole point is to eliminate dealing with the adminsitrative burden of claims and billing. IF you just add another insurance, you just make it worse.
In the case that Medicare is expanded and is optional, medicare will have the following fair challenges: it has to compete with other private insurances, which means is has to pay as much, and any administrative cost dissipates, in fact it gets worse, as providers still have to do multiple billing. If it has to charge ,it will also have to turn away patients. It it doesnt charge, everyone will have medicare, and private insurance will not provide services that medicare gives for free or without restriction.
Up to this point, "single payer" has not provided a single cost reduction means.
That's absolutely not true.
https://www.congress.gov/bill/115th-congress/senate-bill/180...
If I understood this text correctly, this will be:
An optional insurance plan (SEC. 105) An insurance that gets tax benefits (SEC. 701) An insurance that has incredibly perverse utilization incentives (SEC. 202)
I would be quite on board on this plan if it weren't funded with special taxation, and it gave itself no promise of benefit for being the state, not because I think its a good one, but because it will confirm its a terrible one.
Said another way: Should I then also move when I want to find a better price on milk?
Believe it or not there are people who move into cities because of better fire departments, police departments, etc.
> You do actually, by where you choose to live
That's wrong on so many different levels:
1) The emergency service provider is unlikely to tell you how much anything costs in reality ahead of time.
2) Not all emergency services providers offer the best price for all services, or are even equipped offer all services.
3) Many medical emergencies are completely unexpected, you have no idea what kinds of services you'll actually need in an emergency.
4) You're not really talking about "where you choose to live," but rather "where you choose to be at all times." Do you really have a choice of ER if you have to stay within a couple miles of it at all times to make sure you'd always be taken there in an emergency?
5) etc.
In the past, fire companies would show up and demand payment before putting out fires. If a payment couldn't be made, the company might negotiate the purchase of the burning property at a steep discount.
Later, insurance companies hired brigades to only put out fires on insured properties. Fire companies might have fought or sabotaged one another in order to win the right to put out a fire and get paid for it.
While it isn't perfect, and it's often underfunded, I definitely prefer the system we have now.
However the policy of negotiating for property at bargain basement prices while there was a fire next door was very notably one of the ways that Marcus Licinius Crassus (a political ally of Julius Caesar) enriched his fortune.
Supposedly Crassus, the richest Roman of his day, made rather a lot of money like this.
The same as a concert promoter hiring off-duty cops.
https://www.latimes.com/local/lanow/la-me-ln-private-firefig...
Essentially, the state (or region) contracts a company to deliver ambulance services. The contracts usually last a few years and are limited to a region.
Furthermore, the company that wins the contract (usually lowest bidder) is held accountable is too many responses are too slow, etc.. usually with hefty fines.
I guess you can call it privatization, but it's more of a regulated monopoly. Ultimately, these things outsources uncertainty from the state to the private sector. I'm not convinced it's always a good idea, since companies can just factor the cost of fines into the contract... Granted if there is competition, it can drive the prices down a LOT.
However Healthcare in the US isn't a regulated monopoly like that.
I think it was this one
I'll argue whatever PG&E problems are they don't rise at all to the level of healthcare. And their problems are due to poor regulation and the US's current terrible management culture.
This works in Denmark because of Denmark, but it's still a system that has obvious weakness.
[1]: https://en.wikipedia.org/wiki/Corruption_Perceptions_Index
Usually credited to Marcus Licinius Crassus, who had a fire brigade for just that purpose. Contemporary of Julius Caesar.
There are analogies (with smaller consequences) in private tow truck operation.
(I certainly prefer publicly funded fire service)
This creates the perverse incentive to demand an outrageous price so they can get an property for cheap. Next step would be setting fires to buy even more property.
Now, if two crews showed up and bid against each other, things start to get interesting.
It also means it might be that nobody shows up, because it's a holiday, so nobody was on duty.
Well surely public services are more incentivized to display this behavior
https://en.wikipedia.org/wiki/Broad_Street_Riot
Here is a comedian's take on it in podcast form: https://thedollop.net/wp/episode-138-dollop/
Sabotage and physical fights broke out between fire companies while fires burned. That's a pretty gritty situation.
Allowing fire sales gives way to perverse incentives, like the profitability of arson and predatory pricing of fire fighting fees such that certain portion of victims will always have to sell their property at a discount.
But suppose that you have an honorable firefighting department run by an honorable man. Why could he not have set up a private firefighting company instead, doing pro bono work when required? Given the honorable behavior of his company, why would consumers not want to prefer him for insurance than shady competition, which may be cheaper but is also more likely to screw you over when you most need them?
Government-run agencies can be good or bad; private companies can be good or bad. There is no silver bullet and much depends on the prevailing culture. But government can use the threat of force to compel you to pay for their services. If a private company attempts the same, we would call it an organized crime group.
In some parts of the world, insured properties were marked with metal plaques (generically termed "Fire Insurance Marks" [1]) bearing the insurer's symbol/logo. This enabled the insurer's firefighting service to verify that they should protect the building. I've occasionally seen them on old buildings here in the UK. One I remember was a stylised representation of the sun, denoting The Sun Fire Office - which was founded in the 1700s and still exists as RSA Group plc.
If this is true, the system is completely broken.
If it's not true, then the system is completely broken, but in a different way.
Of course, it's absurd that all 3 out of 4 paths require you to take extra, often really painful steps (collection + bankruptcy, maintaining insurance, or long drawn-out negotiation) just to pay a reasonable price for something that is 100% non-optional and most countries provide for much-closer-to-free. But that's kinda what happens when the system is broken
So my 15 minutes $600 allergy appointment that insurance refused to cover (after covering the same damn appointments for 12 years) is that high because of others, or so I keep hearing...
Then there's another problem: who defines what is considered "cosmetic"? Most insurance companies currently don't cover e.g. facial feminization surgeries for transgender women, even though they're considered medically necessary by WPATH, a document drafted largely by insurance companies [0].
[0]: https://www.wpath.org/media/cms/Documents/SOC%20v7/SOC%20V7_..., p. 58
What state? In Washington (and many, though definitely not all), ambulance prices are regulated, for this reason. When I worked private ambulance a couple of years ago it was $680 + $8/mi.
Worse, the police aren't going to arrest people who pay them.
The "free market" (in a libertarian sense) does not permit the initiation of force against people who have not resorted to force themselves. If that is a significant restriction on your police department's activities then there is something seriously wrong with your police department.
> Worse, the police aren't going to arrest people who pay them.
If they aren't willing to arrest anyone who pays them then no one will bother to pay them. Resolving disputes between two paying customers is part of their job description, and they won't retain customers if they're seen as biased or corrupt.
There are private police forces, we call them the "mafia", and people pay them for "protection". Sure, they're corrupt, but with no government funded police, whatcha going to do about it?
If the suspect is eventually convicted (of something at least as serious as kidnapping) then that conviction retroactively justifies the arrest.
If the suspect is never convicted then arresting them is little better than kidnapping. If the police at least had a reasonable belief that the person they arrested would be convicted then it falls under the heading of accidental harm rather than negligence or malicious intent, which shields them from retribution, but that doesn't avoid the need to pay restitution to make their victim whole.
In short: Be sure you're arresting the right person, and don't do anything to them in the process which you'd find difficult to set right.
Enforcing laws is the point of government, and a free market requires enforcement of laws. This is why countries with a non-functioning government are an anathema to business, not a paradise.
[0] https://en.wikipedia.org/wiki/Kensington_and_Chelsea_(UK_Par...
[1] https://www.theguardian.com/public-leaders-network/2018/feb/...
Which is to say don't propose something until you understand the unintended side effects. You can get your desired result but while making everything worse. (this paragraph applies to everything in politics)
I think the American experiment in trying to provide market health care has demonstrated that you can, in fact, have a 'free' market for healthcare, while making almost everything about that healthcare worse.
Your vision benefits enjoy similar tax breaks, but I've yet to see an optometrist try to bill someone without benefits $800 for a vision exam, or $4,000 for a pair of glasses.
Its not the tax break. It's something else.
Vision doesn't work that way because enough people don't have basic vision care that they won't stand for the complexity.
I'll contend (though of course there is no way to prove this) that if we hadn't had the advantage to company provided insurance the complex billing wouldn't have developed in the first place.
No reason we can't have something similar that in US health care as far as I'm aware, at least for the happy path where the patient is lucid and in a reasonable state of mind up front. But then again, why do we have to worry about this when plenty of countries have a basically-zero-fee system in place?
Nobody advocating for free market healthcare is expecting people to shop around in emergencies. People are expected to shop around for good insurance plans which will cover emergency situations to their satisfaction. That is why many free market healthcare supporters also support removing the incentives for employer-provided insurance plans:
- remove the tax exemption for employer-provided insurance
- add a tax exemption for individual/family insurance, including a rebate for the amount of money payroll (social security and medicare) taxes would affect the amount of money available for that insurance
This way, people don't lose their insurance when they lose their job, and people have more insurance options. This would also likely have a beneficial affect on insurance competition.
Acquiring insurance does nothing to ensure that the facility you visit will accept that insurance.
Further, even if the facility you visit does accept the insurance, that's no guarantee that all doctors within that facility accept that insurance.
Even further, there's no guarantee you'll be conscious to validate that you go to a facility that accepts your insurance.
The insurance system needs to be fundamentally repaired before it can be used to support a "free market" healthcare system.
Does acquiring a credit card ensure that businesses will accept it? When you select your insurance plan, check who accepts it. Problem solved.
* Not inform me they don't accept my credit card
* Provide the goods and/or render the services
* Charge my 10 times the standard price for those goods and/or services because my card was not accepted?
No sane person would agree that this would be an acceptable regime for credit cards. Yet it's the world we live in with health insurance.
A "free market" is only effective with price transparency and discovery mechanisms. This is not possible in the current healthcare and insurance system as it exists today.
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Aside from that, you failed to even engage or address the following points from my earlier comment.
> Further, even if the facility you visit does accept the insurance, that's no guarantee that all doctors within that facility accept that insurance.
> Even further, there's no guarantee you'll be conscious to validate that you go to a facility that accepts your insurance.
I think both of those points address and rebut your "check who accepts it" argument. Do you have any response to those?
When my car is damaged in an accident, I take it wherever I want to have it repaired. I don't have to think about whether the shop is "in network" or not. My insurance pays for the cost of the repair, up to the limits of my coverage. Simple.
Among people who support "free market healthcare", who specifically is seriously pushing a plan like this? It is not something I've seen before.
In a true free market you would have more choices: most emergencies are close to home so you are likely to know which hospital is a good deal.
Of course there are still the emergency while on vacation, and the sudden collapse where a bystander brings you somewhere which are harder to handle. Though if there really was a free market there is incentive to handle those well - if only because the system is designed for the majority of cases where they have to handle it well or you would have gone elsewhere.
What you are describing are in fact the freest parts of the health insurance market.
Employers, quite rationally and of their own free will, choose to offer health insurance as a benefit because it attracts and retains talent better than other similarly priced incentives. The fact that you're hesitant to take a leave reveals that it's working.
Insurance companies, quite rationally and of their own free will, choose to offer steep discounts to purchasers who buy for a large group of people instead of just one or two. It reduces their marketing costs and gets them a better balance between sick and healthy clients.
You, quite rationally and of your own free will, choose to both accept your employer's offer of discounted insurance and to remain at your position longer than you would otherwise prefer to maintain that insurance coverage. In fact, the only thing you foresee changing the status quo and allowing you to retire at all is when you become entitled to benefits from the state in the form of Medicare.
Nothing in the phrase "free market" implies the resulting equilibrium won't conspire to limit an individual consumer's choices.
Every other developed country manages to provide equivalent care for a fraction of the price. So much for the free market optimizing for better outcomes, eh?
Sorry, it's because of tax breaks, not pure rational free market. All the rest of what you describe are unintended consequences of that non-free-market tax break that seems like such a good idea on the surface.
This is false. Offering insurance as compensation started during WWII when wages were frozen by the government. Employers found other ways of attracting workers.
There is also the fact that employer-provided insurance is almost entirely untaxed. A dollar in direct employer insurance is essentially a dollar directly to healthcare spending. If it goes through to the employee, that's reduced to at most $0.70 due to payroll taxes, and often much lower. This provides and incentive for both employers and employees to prefer employer-provided insurance.
Compared to these, the effects you described are negligible.
Absolutely true, and those regulations haven't been in effect for the better part of a century now.
If you want to argue that long-discontinued government programs can entrench systems that continue to produce market distortions today then I'm happy to agree with you, but that's the exact stated rationale for the broad suite of civil rights regulations that in my experience most libertarians oppose on economic freedom grounds. I don't think you get to have it both ways.
> There is also the fact that employer-provided insurance is almost entirely untaxed.
Again, true. But I think you're drastically underestimating how beneficial it is to an insurer to cover groups of mostly healthy people (i.e. a company's entire labor force) instead of groups of mostly sick people (i.e. those most motivated to acquire private health insurance).
In order for the market for healthcare to be truly free, in the sense you're describing, medical professionals would need to be willing to consistently refuse service to people who can't pay, which is frequently in violation of their professional ethics. Since that (entirely private and voluntary) market distortion isn't going away any time soon, insurers who can find other mechanisms to incentivize relatively healthy people to contribute to the risk pool can provide the same coverage at a lower cost per person.
That means that, tax incentive or no, insuring a broad cross section of mostly healthy people as a group is always going to be cheaper than insuring them individually. And the more healthy people can be incentivized to sign up, the cheaper it becomes for all participants, which gives whoever is making decisions on behalf of the group an incentive to encourage as much of their potential pool to participate as they can. The taxes reinforce this system, but it would still be self-perpetuating without them.
Prove it. You are making the positive claim. You have the burden of proof.
Your claim is the opposite. You can prove it by showing that employer provided insurance started growing before the given government involvement.
I doubt that evidence exists.
My claim is that, once established, the resulting equilibrium is economically stable. Your claim, as I understand it, is that it's not.
Given that the price controls that we agree created the current status quo were replaced by significantly less coercive tax incentives decades ago and to the best of my knowledge the industry hasn't attempted to realign away from employer-provided insurance since then, I don't see a reason to privilege your hypothesis over mine.
Is this the magic phrase that means "free market" to you? Because the word "free" is in it?
We could say that the USSR, quite rationally and of its own free will, sent millions to the gulags and forced labor camps to create widgets. Cute, right? Hey, they did it quite rationally (after all, the labor is way cheaper when you're using prison camps) and of their own free will, therefore it's the free market!
The US governent does create incentives which change the optimal behavior of rational actors in the health insurance market, but those actors still have very broad latitude to respond to those incentives as they see fit. That's not perfect economic freedom, but it's a lot closer to it than the systems most other countries use. It also gets noticeably worse results on a broad variety of metrics than the systems most other countries use. Make of that what you will.
What is worse is that poorer people in the individual market can’t even get a tax break for buying health insurance (not until it becomes 10 percent of their income and they decide to itemize). In contrast, employers buy health insurance for their employees tax free. This literally screws poor people in service jobs by making them actually pay much more for health insurance (even including what the employer would pay).
Also, I doubt that the average family has $12,0000 of medical bills a year, and would be better off paying out of pocket except for that fact that bills can be randomly expensive.
The thing I'd be very wary of is things like "50% coinsurance after deductible" which I think translates to "this is catastrophic coverage, you're responsible for all 'regular' medical expenses and we'll cover things like hospitalization."
None of the selection is easy, even for professionals (https://armandalegshow.com/4-why-you-and-i-will-likely-pick-... but all of the shows are interesting). Still, if you're in one of the states that allows a little longer to get on an Exchange plan and you need one, do so.
Edit: another worthwhile read about the decision tree for selecting a plan if you're in a state that runs its own Exchange (like California where you have until mid-January): https://www.balloon-juice.com/2018/10/18/going-through-my-ch...
In the US model healthcare is a profit center which allow those who can afford to get help and those who can't various sub-optimal variations of help.
In the ex. Scandinavian model healthcare is a cost center and there is a set budget each year which the providers need to function within. This means that prioritization needs to happen and various illnesses and procedures are limited to x amount a year.
Healthcare is a wicked problem cause it's a good thing that it's a profit center in the sense that it provides budgets to do more research and it's a a bad thing because it makes it unreasonable expensive to to not have healthcare.
In the scandinavian model it's a good thing that everyone gets treated (more or less) the same but a bad thing that they don't have as much capital to work with invest in new machines and that there are budgets which limit how much the government will spend on various procedures.
Personally I would like the system to be so that you pay to get normal check-ups, there is no limit to how many doctors are allowed in different parts of the healtcare sector and no one goes bankrupt from getting seriously ill.
That would at least help with some sort of a balance I think.
Of course the problem is that the US is such a big country with huge immigration and scandinavian countries arent so it's always hard to compare.
> Of course the problem is that the US is such a big country with huge immigration and scandinavian countries arent so it's always hard to compare.
US Population: 325 million
US Immigration: 1.5 million (2016)
EU Population: 512 million
EU Immigration: 2 million (2016)
(taken from top Google results)
It's fairly accurate to say that, compared to the US, the whole of EU has a "Scandinavian" model of health-care (ie, states guarantee good health-care services to everyone).
(8+ state for the past 21 years, those 8 states having population of 291 million today)
source wikipedia
That's not what I said at all. I was explaining how the US system is very different than the Scandinavian system. That's all. You can't compare them at all.
Whatever racist undertone you heard there was your doing not mine.
That may not be what you meant to do and that categorization may not be fair, but it's one of many possible trigger phrases.
And given i dont actually give you any other reason to think i am racist its pretty absurd that you decide to make that interpretation of what i say but unfortunately its becoming more and more the norm. Try asking me what i mean next time instead of just throwing words around accusing people you dont know anything about for being racist.
Why would illegal immigration have any impact on healthcare, unless you were implying that they were a drain on the system (which is an assertion needing to be backed up by facts)?
There is a world of difference between a small homogenous group of countries where everyone pays more or less the same taxes their whole life and where immigration is fairly limited and then a country like the US where people arrive often later in life after they grew up other places and before they start paying taxes to the system.
Healthcare budgets are built up over decades not just year over year. It's based on people when they are young and don't cost too much for the system pays to the system so that when they grow older they are offset by younger generations again.
11 million people who live partly outside the system even when they pay taxes is a big number and since they live concentrated in around 20 metropolitan areas almost half of them in 3 states that make them an actual issue on top of the other things as they are not just distributed across the entire country.
In what universe it's racist to point out that illegal immigrants adds to the complexity of why the US can't have the scandinavian model is beyond me. You are the only one making illegal immigration a matter of race for some absurd reason.
Of course, most people/companies can't be bothered with this, since the government health care is good enough, but paying for private healthcare is definitely a non-theoretical option.
I really don't understand why it being a big country would make things difficult. Any sane person would adjust the needs dependent on state and smaller. Norway's population is about the same as Indiana's, but is more sparsely populated - so some of the same problems as the western states. The benefit of the US being large would be that there are more pools to draw money from. And there are just as many opportunities to save money.
For example, Norway will send a nurse to one's home up to 6 times a day. For free. Even if you live on a cabin on an island or on a mountain. Why? Simply because it is still cheaper than a nursing home, overall. And as a bonus, folks tend to live longer and be happier with life.
As far as immigration goes, it is impossible to compare. But: Not every immigrant gets free healthcare. I get the state healthcare because my immigration status is family immigration - my spouse is Norwegian. If I were here for a job, however, I'd have to pay for health insurance. Of course, they'll still treat someone that pays cash and still treat emergencies. I don't really see how this would be an issue in the US either so long as the laws were set up correctly.
I'll further add that I think the healthcare is a bit different if folks are coming from an EU country - there are agreements in place about health care and things like that. Again, I don't see why this wouldn't be the case in the states.
I think it depends on the job. If you work for a foreign company and are temporarily in Norway (e.g., spending a quarter at the Olso branch from your HQ elsewhere), you're on the hook for your own insurance: https://helsenorge.no/bo-i-utlandet/posted-workers-outside-t...
If you immigrate to Norway for a job, you're covered like everyone else: https://helsenorge.no/foreigners-in-norway/employee-from-a-c...
Healthcare systems like the scandinavian are established over decades as the young needs to pay for the old until they get old themselves and have to get covered by the young.
This kind of system is more or less impossible in the US and it would be extremely expensive.
That doesn't mean the current system in the US is any good, it's horrible to say the least. But the scandinavian dream isn't possible in the US and I have yet to see anyone showing any actual proposal that would work given the setup with federal and state and what they can decide.
That's literally how Social Security works, and the fact that more guest workers pay payroll taxes into the system than are eligible to collect benefits from it actually makes it slightly cheaper than it would otherwise be.
I'm American. The first one is easy enough to consider. I can drive to Sweden in the same or less time than it would have taken me to get out of Indiana. I know it is big. I just don't see how that is an excuse. It isn't like you can't customize health care to a geographic area so it serves the needs of the people best. There are multiple ways to do that.
And that bit about immigration? That's propaganda 101 in school. Trust me, I'm aware. I fail to see how that is an issue. Most folks in the US aren't new immigrants: They are at least 2nd to 3rd generation. Even if I take the higher numbers I saw - around 25% - most folks are still just Americans. I don't really see how that affects anything. Don't most folks still want healthcare? Do immigrants avoid health care? Don't most of these families have at least one working adult paying into the tax system?
And of course it would be expensive - the current system is expensive. But it isn't efficient now, and that can easily be changed. Just because you haven't seen a proposal you'd be happy with doesn't mean it can't work. Most of the proposals I've seen in the US are more focused on preserving health insurance companies instead of focusing on getting health care ot everyone.
Homogenous and small.
These countries are homogenous which also means politically. You will be hard pressed to find any real fundamental political differences between parties in the scandinavian countries.
They are all on the left side of Sanders.
Furthermore, it matters quite a lot that you are dealing with a fairly limited population who all suffers from more or less the same issues because they genetically are alike.
And again keep in mind the Scandinavian countries have budgets which means that you can't always get the treatment you want/need even if you had the money.
Again I am not saying the US system is good it's obviously not.
But a single-payer system in the US just isn't realistic or attractive for that matter.
The problem in the US is the price, but that price is held up artifically not because of the market. So we need to remove the things that make the price go up that hight. That IMO would be a much better approach than trying to mimick scandinavian countries as great as they are for their population (but definitely not without it's problems)
And again keep in mind the Scandinavian countries have budgets which means that you can't always get the treatment you want/need even if you had the money.
I don't know where you get this sort of information. I will never not be able to afford my medication. I broke my arm and got immediate, affordable treatment and had paid time off work even though my job was seasonal. In the US, with insurance, I would have struggled, not only with hospital bills, but with work. If you have an issue that they cannot treat in the country, you can travel outside of the country for treatment. Even if you are poor and have no money - the state does that. There are private hospitals and clinics around - if you have money, you can use them. They aren't always that much more expensive and the waiting period for non-emergency stuff is less.
The bottom line is that you are against a single payer system. That's fine, be honest, but please make sure your actual facts are facts instead of things people hear.
It sounds like you don't want to see the problem which makes it hard to have any discussion.
The size is a problem given that you would need to be able to offer consistent care across the nation this is exactly the kind of problems that single payer systems deal with. They are an actual problem in the scandinavian countries and these countries are small. Federal is federal.
I am not against a single-payer system. I grew up with one as I am Danish so I want a single-payer system. Especially as I have been having 2 melanomas and might likely get more and live in the US. I just wont work here and I won't be able to get the kind of care that I get now.
I know both systems pretty well that's where I get that information from I been living in both and experienced both.
I don't think "free market healthcare" is oxymoronic though. It does not seem to me impossible (logically...maybe it's impossible politically) to remove the current incentives that prohibit price discovery and/or enact laws and regulations that incentivize it.
I wonder if private urgent care businesses could offer free rides from emergency rooms to other facilities? There might well be laws against this. However, the existence of such services might give people a degree of choice they don't currently have.
A few years back, I was in the position of seeking emergency room/urgent care services for my girlfriend at the time in North San Jose. It was not a pleasant experience, to the point where we just decided to simply give up. On the other hand, I did the same for my girlfriend at the time in Houston, and found the whole experience to be relatively smooth.
For example, suppose you wanted to start a hospital that offered price transparency, like the Surgery Center of Oklahoma does. (1)
In thirty-five states and the District of Columbia, you'd first have to acquire a certificate-of-need (CON) from the state healthcare regulators.
In order to get certificate of need, you must prove that the community “needs” the new or expanded service, and existing providers are invited to challenge your application.
Existing hospitals typically don't want new competitors taking away their patients, so they vigorously fight to prevent new CON's from being issued.
For example, Dr. Mark Monteferrante wanted to buy a second MRI machine for his radiology practice in 2003. But it took five years and more than $175,000 in fees to get the certificate. (2)
And conlaws are just one example of perverse effects of state intervention into the healthcare market, from state laws restricting insurance competition, to severe restrictions on new entrants to the medical labor market, to drug monopolies.
(1) https://surgerycenterok.com/pricing/
(2) https://www.modernhealthcare.com/article/20160123/MAGAZINE/3...
Furthermore when the alternative is death or debilitation, the price a "consumer" is willing to pay is effectively everything they possess and can borrow. That is both a massive distortion and non-optimal for the economy as a whole.
There are certainly regulatory inefficiencies and other inefficiencies in healthcare markets, but a truly "free market" in healthcare not morally justifiable.
There is no economic system that can deliver all of the health care to everyone who wants it.
Fundamentally, health care resources are limited: doctors, beds, MRI machines, etc.
Desire for health care is much less limited.
The question is not whether to give everyone what they want, but instead how to imperfectly ration what we have.
I'm currently living in an european country that has a national health service that supposedly ticks all the socialist talking points, including free (in theory) access to emergency care, but not only is the service largely inoperational with year-long waiting periods for surgeries, including cancer treatments, but also has a disgruntle workforce who systematically complains they are underpaid and overworked.
The situation is so appalingly bad that the national health service even routes patients to private hospitals and clinics, ending up paying a hefty bill for the services they were supposed to provide in-house but are largely unable to provide.
If he had the same disease in US, he would die much earlier than he did, I'm 100% certain of it, because quite simply there is no way he could afford the treatment or the premiums that americans are paying for their healthcare. Even when he was sick enough that he couldn't work anymore, he was still 100% covered and didn't have to pay anything for anything ever.
My point is - there are people in our countries who are probably dying because they have to wait months to be seen by someone. True. But there are also people in US who are dying because they cannot afford the treatment they need. I feel like this is far worse than the first situation - after all, we only have a finite number of doctors, a finite amount of hospitals, and limited capacity to add more(for reasons other than financial too). But US is the richest country in the world - and its citizens die because they cannot afford cancer drugs? That's abhorrent.
If your dad was over 65, he would be on Medicare. If he was younger than 65 and impoverished (income between 0 - ~150% of poverty level) he would be on Medicaid or another state plan for low income people. If he's above 150% of poverty level he probably has health insurance available at work or thru ACA. In fact is legally obligated to.
https://www.snopes.com/fact-check/shane-patrick-boyle-died-a...
Medical expenses, unlike credit card debt or student loans, can still be discharged through bankruptcy. For lower income elderly folks, that coupled with low paying job opportunities usually leads to disaster.
We are overspending on the quality of health care we get today. Further there is a lot of fear mongering about socialized medicine.
I've experienced medicine in both the UK and the US. I can tell you, there isn't a difference in quality. Further, when I got a cold and went in, wait time wasn't 6 hours or whatever other BS people claim. Wait time was ~10 minutes. In fact, the time to see a doctor in the US is almost always longer. Why? Because half the time you have to fill out forms and provide proof of insurance and a whole host of other information for them before they will put you on the waiting list.
What did I have to fill out to see a doc in the UK? A card that had my name and current address. Even that, they told me, was optional.
Cheaper medicine for less money is a reality. The only people that lose with socialized medicine are admin and insurance. Everyone else in the nation wins.
In Japan the first time I went to a doctor it was for stomach pain. He gave me on ultrasound and declared I had hepatitis. My personel department at my company decided to take me to another doctor. Had to weight 2.5 hours in a room with around 250 other sick people. Was finally told I had food poisoning.
I am not defending the USA system but both the UK system and the Japanese system have issues as well. I've spent the most time in the Japanese system. What I like is it's easy to see a doctor and relatively cheap. Prices are apparently set by the government. Conversely a large percentage of Japanese doctors are quacks and would be unqualified to practice in the USA. It's a common topic of conversation for foreigners here to tell their horror stories of all the crazy experiences they've had with doctors here. Also, top doctors, or rather surgeons are known to require bribes in the $XXXX-$XXXXX range beyond the decided on fees.
The decision to go to a doctor is a financial one in the US, sometimes superceding a health one. Our life expectancy is dropping as well. It’s a broken system and adding more of what is broken about it won’t work, if the goal is for society to be healthy.
Ultrasound? That is absurd.
I can't speak for UK/US/Japan but in India situation is quite similar. Opaque pricing along with quacks (or maybe genuine doctors) out to milk as much as they can, especially if they know that you have insurance.
A colleague of mine who had stomach pain was told that he had to get his appendix removed. When he refused the doctor actually threatened him with a write-up to ensure that he doesn't receive any insurance money. After the company got involved he was moved to another hospital, only to be told that he had stomach gas.
I think the best part is not having the mental burden of potentially going bankrupt afterwards...
That's the thing I don't understand: they pay more in tax, and they pay more in insurance, and they don't get universal coverage and have worse outcomes across a range of measures.
I have never had a problem getting a appointment to see my GP.
Starting with the fact that employers pick insurance plans for their employees, eliminating enormous market power: and this happens because the government doesn't tax the money that is spent on insurance plans.
My experience was very different. In January-February this year I had to visit (unfortunately) both the Emergency Room in NYC and the A&E in London. While the quality of the medical equipment in London matches the one in NYC, the understaffing is much more severe. In neither place was my wait time only 10 minutes, but in NYC I had to wait for about 1 hour (including paperwork), while in London for about 6 hours.
I talked with other people in London about my experience that the medical system is severely understaffed, and all agreed. On the plus side, I did not have to pay anything in the UK (they didn't even care that I was not a UK resident). In the US I had to pay north of $1000, despite having insurance.
I recently moved to a new state and I’m trying to get set up with a new primary care provider. I’ve been trying to get an appointment for six months, but they keep bumping my appointment back. Did I mention that I had to settle for a nurse because none of the doctors in my area are accepting new patients?
That is because NHS spending is being slashed viciously. Obviously, if socialised medicine is being dismantled, it can't be expected to work all that well anymore.
Different A&E departments have different problems. The NHS is the largest employer in Europe, and it's reductive to say "all London hospitals are understaffed". They are not. Part of the problem is seasonal and even daily shifts in A&E visits, you can't staff for the worst case all the time. And January/Feb is known to be a busy couple of months.
Presumably they too need healthcare, so even they win, in the long run.
In reality most healthy individuals want a limited amount of care, sick individuals want the least amount of care required to return them to health - and there are fundamental limits on the amount of care that can be provided to those who are beyond the help of current technology.
As such you would expect a finite level of demand from the economy as a whole if everyone was allowed as much healthcare as they desired. Any attempt at rationing care will both reduce efficiency, and constrain supply - driving up prices. The most market oriented system would leave supply unconstrained and provide universal and automatic coverage allowing more suppliers to enter the market until supply outstrips demand and "prices" naturally fall.
I got a cold yesterday with a crazy bad sore throat, I thought of maybe popping into the doctor. But it turns out to be just a regular cold. My mother would have 100% gone to the doctor. The clinics here in Canada are chock full of kids with the flu and people coming in 'because'. Maybe that's beneficial due to the risk 'it could be something bad'. Or maybe the economics don't make sense i.e. for really mundane things it's better to just stay home and take Tylenol.
But the demand is super high. Once people cross 50, there are always problems. Always something. And it's all expensive.
I would assume it's detrimental because it results in doctors' waiting rooms full of people with colds (making it a dangerous place for anyone who is immunosupressed and really needs to see the doctor).
Assuming the average doctor’s visit is 15 minutes and the average person goes to the doctor every month. That’s only 1 GP per 640 people. After that point they might send you to a specialist some fraction of the time, but it’s still finite.
Consider dental insurance is ~15$ a month and most people go to the dentist twice a year. That’s about what GP side of heathcare costs. It’s the care after that point from people with actual issues that gets expensive. Yet, without the vast overhead of insurance you cut the costs of providing actual heath in half. Which more than covers the costs from people that are currently turned away.
PS: And yes billing is ~50% of current US costs when you include Doctor time dealing with paperwork. Remember the entire insurance industry and their profit is pure added cost, but so is the medical billing people inside each provider.
Say, medical necessity and probable benefit?
We're a long way from those particular decision criteria, presently.
I don't see the connection between posting prices and pricing people out of the market.
Granted, this ignores the human trait to increase consumption when removed from directly paying all associated costs (e.g., my behavior at Golden Corral)
There exist entities who are willing to provide soup kitchen services below operating costs in perpetuity (i.e. charitably, for free). The price for services is kept artificially low ($0) by constant infusions of capital from outside the market (charitable donations), which prevents for-profit vendors who don't receive constant cash infusions from being able to compete on a level playing field. The resulting market is thereby warped by the distorting influence from non-market forces, preventing it from operating efficiently. It's not "free", in the technical sense.
This isn't necessarily a bad thing, to be clear. The charitable funding system may well provide better aggregate social outcomes than a free market would for any number of reasons, not the least of which being that one of the freedoms that "free market" implies is the freedom for vendors to decide that some of their potential customers are more trouble than they're worth to serve.
In situation one wouldn't the advantage go to the non-profit motivated supplier and in situation 2) doesn't it ultimately benefit the customer with lower prices?
Socialized healthcare has its own "immoral" trade-offs. We essentially reduce per capita quality in favor of all-inclusive coverage. Proponents of free-market healthcare would argue that the inefficient allocation of resources inherent to socialization is immoral. Libertarians would argue that forcing money from one person to give to another for medical care is immoral. It's not really a question of morality, more of preferred philosophy and practicality. Framing it around morality makes the other side seem abhorrent and the situation difficult to find common ground.
That's a false dichotomy; there are many mixed systems where the government provides a baseline level of care with private insurance providing additional services or benefits (eg: government covers a shared hospital room, private insurance covers a private room).
>Libertarians would argue that forcing money from one person to give to another for medical care is immoral
True libertarians also argue that all taxation is theft (if they're purists anyway), making road construction immoral.
> Framing it around morality makes the other side seem abhorrent and the situation difficult to find common ground.
A "free market" in healthcare requires us to condemn people to death or debilitating injury when they cannot afford care. Unlike nearly every other area, this one literally involves life and death so I believe it must meet a different standard than other activity (economic or otherwise).
No, it doesn't make road construction immoral in the eyes of libertarians. It makes taking money from other people, by force, in order to build a road, immoral. People are totally free to build roads privately and pay for it themselves, and even band together to build these roads.
(Part of where the standard libertarian argument falls apart, in my eyes, is that government in many ways really is just a scaled up version of "people banding together to build a road". There are there are legitimate moral/philosophical questions around opt-in vs. opt-out though).
There is a significant qualitative difference in that "people banding together to build a road" is an entirely voluntary activity, whereas government is nothing of the kind. It's not merely a matter of "opt-in vs. opt-out". Even in an opt-out system one can choose not to participate without penalty, but if you inform a government that you're choosing to "opt out" they won't just leave you alone to live as you please. They draw their arbitrary lines on a map and consider everything within those lines to fall under their control. Even if you move halfway around the world and renounce your citizenship, and in doing so cut off all ties to everyone and everything you once knew, you may find that they still claim a share of your income to pay for that road you'll never be able to use.
The "scaled-up" version of "people banding together to build a road" is a co-op or corporation. Such an organization does not have the power to tax or to impose regulations on anyone who doesn't explicitly and voluntarily agree to them.
> True libertarians also argue that all taxation is theft (if
> they're purists anyway), making road construction immoral.
There are many kinds of libertarianism, and the American-style extreme capitalist libertarianism is not the only one, and probably one of the most irrational forms of libertarianism.
Personally, I feel providing essential care to everybody equally does the most to free people from oppression and extortion by those who wield power over them at a time when they're vulnerable.
This is also true with food. What keeps the price down is competition, not price controls.
But such true emergency response seems like actually a very minor part of all medical care. It would be better for people to have private emergency arrangements through their insurance - but, of course, this is not always viable (if you are bleeding out in a car accident, there is no time to figure out which hospital you have a deal with), so that is one area where the state should probably be involved.
A well working competitive market doesn't charge the maximum consumers can bear. It charges cost of service plus a profit margin.
Someone is morbidly obese. They will die and are already debilitated. The cost of having their life back is eating less. Many are not willing to pay that price.
Basically economics talk for how the second best solution might not be close to the best solution (i.e. there are local maxima).
A perfectly free market might be theoretically best, but socialised healthcare might be better than a badly regulated private system.
But what the US has now is neither. And many of the most pervasive problems it has now are very much attributable to current regulations and laws.
For pricing, Hospitals/Insurance Co.'s are unwilling to absorb the cost of the statistical chances that something goes wrong or extra labor/things are needed during healthcare. That's why the patient-facing price could be anything and you get an itemized bill.
The only way to get slow-moving and predictable patient-facing prices is to get the hospitals/insurance to absorb these costs.
But as others say, healthcare is the most regulated industry in the USA. It’s the opposite of a free market.
It’s actually a great example why regulations often suck.
And I'm not saying a hospital or a cafe ought to be at all similar. That's not the point. The point is how odd it is to pretend that health care is a "free market" in the current state as some rhetorical device to associate these surprise fees with free markets.
At a cafe, you don't get charged for using a stirrer or spoon or napkins. A cafe doesn't charge you for sitting on a stool. Free market health care would operate in the same way, if it existed. You get charged for your operation, they don't add in fees for specific items that you needed that would reasonably be expected as part of the process (a Tylenol pill, using a tissue, the gloves your surgeon wore). And again, I'm not suggesting this is how it ought to be, but let's not be disingenuous and pretend that absurd, opaque prices are somehow a result of a free market.
Any particular reason you think that?
Cafes sell standardized products--if we order the same small latte, we get the same thing and pay the same price. If you "require" something different, you pay a different price. Almond milk, for example, is $0.50 extra, near me. Flavored syrups cost a quarter.
Medicine is a lot less one-size-fits-all. Your fractured arm could be harder to repair than mine and thus takes longer or requires more supplies (and those aren't cheap--bone screws can run $40+/each). Maybe a diagnostic test is inconclusive and needs a more expensive follow-up. You can't really know how some of this is going to go beforehand. I suppose some places could offer a prix fixe option, based on their expected cost + a safety margin. I bet many wouldn't though, because the variance can be huge.
We agree to service and pay even if it would bankrupt us because at least we'd still be alive.
When a person is mandated to purchase insurance that is not a free market.
When insurance companies have monopolies in an entire state and it’s illegal to purchase insurance from another state, that is not a free market.
When hospitals are partly state funded, tax-free organizations, that is not a free market.
When hospitals are required to treat patients regardless of their ability to pay, that is not a free market.
When medical bills are paid by Medicaid, that is not a free market.
Healthcare in the United States is anything but a free market. Down vote me, if it makes you feel better, but it will not change this fact.
Hospitals are for-profit entities that will optimize debt-collection and bargaining power over patients. They will start taking payment upfront as well as influencing patients to choose financing options that are in the best interest of the hospital and not the patient themselves.
It's hard not to feel like the whole system is rotten.
Call the hospital and demand it be removed from your bill. That's what others[1] (including myself) have done and the fraudulent charge was eventually removed.
The absurd part is that you would even need to do this. How many people don't understand you can fight healthcare charges and get them removed? How many have the free time that it takes to call the billing department over and over?
The whole health insurance system is trash and needs to be replaced.
The surgeon's assistant was the out of network provider and he was also part of a different practice, so it was his practice billing department that would not budge because they deemed their costs as reasonable and "already discounted".
They can't. That's the problem - there's little you can do to stop it from happening, even if you're aware of this sort of billing problem and try to take steps to prevent it.
https://www.npr.org/sections/health-shots/2018/08/27/6408918...
> Surprise bills occur when a patient goes to a hospital in his insurance network but receives treatment from a doctor who does not participate in the network, resulting in a direct bill to the patient. They can also occur in cases like Calver's, where insurers will pay for needed emergency care at the closest hospital — even if it is out of network — but the hospital and the insurer may not agree on a reasonable price. The hospital then demands that patients pay the difference, in a practice called balance billing.
https://www.npr.org/sections/health-shots/2015/02/17/3869088...
> The surgeon's office later told her that he belonged to two different medical groups. One was in Morgan's husband's health plan network, the other wasn't.
I got this one, it was mindblowing. For ER work, they'd bill through one practice, for scheduled appointments, another.
I got balance billed for $11k. My father, who worked in employee benefits for over 30 years, couldn't even figure out what was up at first. Then they filed to send me to collections because I kept refusing to pay (note, I'm in California and this billing is illegal for life-threatening emergency visits matching the situation I was in). Finally, the insurance company stepped in and covered me, but we were only able to achieve this because my family knew people personally at the insurer.
All kinds of messed up.
So they jack up everyone else's bills in the hopes that enough people will pay that they'll make a profit.
Insurance companies will usually push back, so (sometimes partially) uninsured people with decent credit hit with huge charges.
No. That’s the justification given so that people get angry at the wrong thing.
Hospitals charge this because they CAN. They are doing what businesses do and that is maximizing their profit.
Don’t get angry at the uninsured get angry at the politicians for enabling a broken system.
Including all the non-profit hospitals? What's their motivation?
"Non-profit" doesn't mean "can't make a profit".
Rarely paid for with reimbursement revenues.
> giant endowments
Definitely not paid for with reimbursement revenues.
> amenities for staff
Try cutting these, and see how quickly 1199 SEIU comes down on you.
> raising administrator salaries "to retain premium talent", etc.
Even if you assumed that there were no relationship between the wages paid and the quality of work performed (there is), these are nowhere near big enough to account for the difference. They're also not that far out of line with other countries, either: 25% in the US, compared to 20% in the Netherlands, for example.
But more so than that: they're SG&A expenses, which are further down the balance sheet than the reimbursement revenues. And yet, hospitals actually lose money on the top line for Medicare patients (who represent about 40% of the market). That's the real reason reimbursement rates are raised for private insurers - the private insurers are required (by law) to pay more, and they need to subsidize the sub-COGS reimbursements from the public insurers (Medicare, and to a lesser extent Medicaid).
So no, none of the things you listed actually explain the reason hospitals charge private insurers the rates they do.
Non-profit simply means any surplus of revenue is spent. So, the more revenue generated by a non-profit's paying customers means they get to funnel that to their core mission (likely research, possibly those that can't pay, or cynically more salary for those running the show).
Hospitals make very low profit margins; hospitals have been hemorrhaging money and either being bought out by hospital systems or insurers, or even shutting their doors entirely.
In any case, it's not uninsured patients that cost the hospital money; there aren't enough of them to make a difference at most hospitals. The patients that cost hospitals money are Medicare patients, because Medicare reimburses rates that are below COGS, and private insurers are required by law to reimburse more.
In other words, yes, it's the politicians that enable a broken system, but no, it's not the uninsured patients who are at fault, and it's not "profit-maximizing businesses" that are at fault either. Hospitals don't want this convoluted billing system any more than patients do, but it's literally forced on them as a result of accepting Medicare patients.
Given that this is going on, why not just switch to a single payer system and spread this out over a much larger population rather than each hospital trying to insure against it?
You can't get months worth of chemo or physical therapy or dermatological consults or whatnot at an ER.
What percentage of hospital budgets is lost to this?
If it's anything less then 95%, I don't see how the assistance of an out-of-network nurse could possibly cost $5,000.
How many patiens are uninsured? 10%? 20%?
This still does not explain how the hospital can bill $5k for one hour of a nurse that may be making herself $50 per hour at most.
This is actually only a half truth. Emergency rooms are required to treat patients who need emergency care. They don't need to fix all ailments. If you have cancer they can turn you away, but if your organs are failing as the result of cancer they have to treat you. If you need a heart surgery they can turn you away, but if you're having a heart attack they need to treat you. For the most part, treatment is pretty much just making sure you're stable and can leave the hospital without immediately dying. This only applies to emergency rooms as well. Where you go to get surgeries is usually not the same place you go to treat an emergency condition. It might be affiliated with the same hospital, and might be attached to the emergency room, but it isn't itself an emergency room.
I got burned by this in California a decade ago. A dentist charged me $4,500 to fix a broken tooth (panic!) and fill in a cavity on a Sunday.
Had I known then what it might have cost I'd have simply flown back to Europe in the next flight ($600-800 at the time) and get the same thing done for under $100-200 with a full refund from my local social security.
Adding insult to injury I had a very expensive international health insurance policy owing to my traveling around the world back then. And they didn't cover dental with my plan. I knew they wouldn't. But it was still mind boggling to me in that I never expected a casual procedure that would have cost me €150 at most anywhere in Europe - most of which would have gotten refunded at that - to cost me a whopping $4,500 in the US.
You only find out just how badly it works when you need it the most.
Do dentists in Europe work on Sunday? In my experience the grocery stores aren't even open...
Emergency dental care is provided in the US as well. Filling a cavity is not considered an emergency.
Actually it wasn't - went from nothing to blinding pain as if someone threw a switch. I'd have 10-15 minutes of agony then it turned off for the same time and it repeated at that frequency all of the Saturday until a GP came out on the Saturday evening and gave me painkillers and told me to go to the emergency dental clinic the next day.
It was right in the middle of my 3 years exams at University - which was a bit of bad timing!
The US isn't a monolith. The majority of the population very much wants meaningful health coverage, but thanks to Supreme Court decisions like Citizens United, corporations are entitled to free political expression under the first Amendment, so they can give unlimited amounts of money to political candidates. This allows uberwealthy individuals to form corporations for the explicit purpose of installing anti-taxation cronies into legislatures at both the state and national level.
Our political process is very corrupt, and it's taken a national emergency (Trump's Presidency) to wake people up. The 2018 midterms demonstrated that far more citizens are paying attention and plan on voting, so hopefully the US goes single payer soon, but it's going to be a brutal political fight.
Bernie who was the most vocal about changes was taken out by Hillary, but no one batted an eye. No one really wants change to the healthcare and pharma industry as it will hurt the entire ecosystem (especially advertising $).
This second aspect has never been addressed on a national level, or barely at all.
At the state level, if you think of them as their own countries some do have very accessible programs. Some even having universal healthcare in that state.
So the US is complicated.
And then there is the distrust of how people of other cultures in our country would use a subsidy if it isnt clear that they have the same ethics and motives. This exacerbates many political issues.
Because disinformation campaigns have pushed people to vote against their interests.
Otherwise underpaid, overworked surgical residents leave either due to truly catastrophic burnout, mental illness, family emergency or pregnancy.
They are replaced by moonlighters, because the economics of the surgery are that the nurses and other unionized employees get mandatory breaks, so the seemingly 1-2 hour delay waiting for a different resident to be free balloons into a multi-staff scheduling fiasco. We could amortize all those costs into "surgery minutes" which are paid whether or not the literal room is in use or whatever.
It's a math problem if by saving surgery minutes, the hospital saves real economic money for itself, the patient or the state, so I'm not sure if that is or is not the case in your particular case.
What's interesting isn't that there's legislation one way or another, or that you feel like you got a raw deal. The legislation isn't going to change what it says it will, because it will still make sense to hire moonlighters. And motivated people like you will still somehow still wind up paying the cost.
The real test of your merit is whether or not you think in the grand scheme of things, this is fair. Are you frustrated that there may have been a pregnant resident, and that's why there's a moonlighter in the operating room?
What does justice look like there? Cut you a check for thousands of dollars? That never happens. Retribution on residents who might get pregnant? That's what happens.
Your situation is shitty. I know in most movies, books and the press, the doctor is usually the antagonist. We live in a world that resents their disproportionately immigrant backgrounds, disproportionately even gender balance compared to other professions, and most of all their pay, despite their hard work. How do you feel?
Source: https://www.nyacep.org/practice-resources-2/resources/practi...
I don't have a problem with ER care being more expensive -- that isn't necessarily unreasonable when you are getting care in an expensive facility open 24x7, fitted out with equipment to handle any possible medical emergency, and staffed with highly educated people who make a lot of money. But it is unfair to have no idea what costs you are facing and whether any of those costs are out of network on your insurance.
My wife is a doctor, and at this point, I think single-payer is the least bad option.
Can you help me understand why if everyone is paying for everyone's healthcare in a socialize system - how that reforms the transparency and stops the abuses?
I actually agree w/ overhead limits, but you also need other efficiency metrics to keep the anti-optimization in check. Or, personally I think we should go to some form of universal healthcare and wipe out private health insurance as it's currently constituted.
Why wouldn't insurers argue for better prices now?
Even in our own VA system, their negotiated prices are lower for drugs than the Medicare part D program, barred from negotiating (and with large pieces managed by private companies).
I think your skepticism should primarily be directed to wondering if private systems can ever negotiate a fair price in healthcare products and services.
The rest of the OECD has universal healthcare, but not necessarily fully public healthcare (the model vary considerably.)
Which just means that there are lots of good proven models that the US could adopt.
https://ourworldindata.org/the-link-between-life-expectancy-...
The most recent life expectancy numbers are the hardest to interpret, the US has the only three-year-running negative life expectancy growth in the first world nations - but some argue we should separate healthcare from the suicide numbers that are a big contributors. I don't know that I agree with that as there is a fuzzy line between healthcare and social care efforts.
Age-adjusted all-cause death rate is the better stat for measuring life-saving outcomes.
Child mortality is certainly a useful stat for its purpose, though.
Are there sources of that stat over time and between nations that you would recommend?
http://apps.who.int/gho/data/view.main.1360?lang=en
It probably still supports the point you are trying to make, I just get grumpy about statistic selection.
The proposed alternative is to give tremendous power to an organization with less conflicted responsibilities.
I think "only (any large organization) can negotiate a better price" is a little misleading on the surface. On a macro level it should, in theory, be true, and should already be happening with private insurers; when I've looked at my own EOBs, they consistently will list a service, a coding, a billed price, an "allowed" price that is always much less than the billed price, and the amount paid (which predictably matches the "allowed" price). And yeah, when we're watching politicians pontificate, we end up having strong opinions about the total price of healthcare and its effect on the economy.
That said, does anyone _really_ make personal healthcare decisions based on the macro effect on the economy? I personally doubt it.
I posit that the vast majority of US citizens and residents wouldn't care if the annual healthcare spend changed by US$200 million, but any individual American cares A WHOLE LOT if you bill them personally for US$100,000 and their insurance doesn't cover it (or much of it).
It seems to me that a much better approach to this entire conversation is "let's drastically reduce the number of Americans forced into bankruptcy because they or their dependent got sick". My own inclination is that that'll require government intervention, because the incentives for a for-profit insurance company are to pay out as little as possible, but I'm open to anything that addresses that problem.
In a larger system, we get lower prices via several mechanisms: - Preventative care replacing ER care due to universal coverage - Larger risk pool lowers per-participant costs - Single payer has more leverage and depth of time/knowledge to regulate/negotiate with individual hospitals
The reality of a competitive landscape, hand of market, etc, that just didn't happen.
That one entity can unilaterally refuse to do business with abusive vendors. They can negotiate for lower prices. They can notice and investigate discrepancies in pricing between similar cases. They are in a position to judge which types of care are and are not cost effective and can refuse to cover the latter.
So that explains why having an insurance company helps, but it doesn't explain why a private insurance company can't perform the same role. For that, we have to introspect a little into how insurance firms work.
An insurance company is, in essence, a mechanism for transferring funds from lucky people to unlucky ones. If your car gets totaled then, in essence, a bunch of other people with working vehicles have all volunteered to chip in a couple of bucks toward buying you a new one. The insurer is mostly facilitating the transfer and skimming just enough off in the process to cover their administrative costs.
The private insurance market works well enough for most types of property because the volunteers can't predict in advance whether they're going to be lucky or not and because there's a realistic upper bound on how much money the unlucky ones will need to be made whole. Neither of these assumptions are true for healthcare. Many people were born into pre-crashed cars, to stretch the metaphor, and at least for the foreseeable future it's not possible to decide to replace a body instead of attempting to repair it.
So we need* some non-market mechanism to incentivize or compel insurance companies to cover the already unlucky: people with pre-existing conditions. But that introduces a new problem. The lucky people are being asked to volunteer to chip in more, and at least some of them will stop volunteering. That causes the prices to go up even more, which causes a few more volunteers to leave, which causes the prices to go up again, and so on. Pretty soon there's no volunteers left to transfer funds from.
So we also need* some non-market mechanism to incentivize or compel healthy people to contribute to our insurance system. And with those two requirements (needs to cover everyone and everyone needs to contribute) we are left with a problem space that the State is really the only entity with the ability to implement a solution. It doesn't have to be socialized medicine, per se, but it does basically have to be big government of one stripe or another.
\* Yes, we do technically have the option of compelling innocent people to suffer and die from otherwise treatable diseases that they're not wealthy enough to afford to cover out of their own pocket. If you're aware of that fact and comfortable with it then okay, but please do understand that it is the societal tradeoff that we would have to make to avoid some sort of serious state involvement in provisioning medical care.
That doesn't always work out as well as you might think. A number of years back Medicare told hospitals they'd no longer pay for UTI treatment, unless the provider could prove that the patient had the UTI when they were admitted. This made sense, because hospital-acquired UTI is a big thing.
The thing is, what hospitals had to do to defend against this was to test everybody being admitted to prove that they already had the UTI. So from Medicare's point of view they were saving, but from a broader perspective they were pushing unnecessary costs (unnecessary tests) onto providers which increased the total amount being spent on healthcare.
It's also worth pointing that what you're describing is an illusion of efficiency arising from Medicare implicitly pushing costs off onto non-Medicare patients. That wouldn't be able to happen if there weren't any non-Medicare patients.
Having worked for companies that do government contract work (DoD, in particular), this line of reasoning always makes me laugh.
I am now firmly in the single payer camp. Medicare for All, I guess. To the insurance companies and medical billing industry, and even doctors, I say: "Sorry, not sorry, when this train comes through try to remember you did it to yourself."
Less than half; US healthcare spending was around 8.5% GDP public, 8.8% GDP private in 2016.
https://www.healthsystemtracker.org/chart-collection/health-...
Even if we take the value to be 50%, my point stands -- the gov't is already heavily involved in funding healthcare in this country. Implementing single payer at this point would simplify quite a lot of bureaucracy.
So if everybody was covered by Medicare, either the providers would be going bankrupt left and right, or the Medicare reimbursements would have to rise - i.e., the price to the government would increase, and the only thing to do about that is to pass it on to the taxpayers.
It's a common misconceptions that Medicare is more efficient than commercial insurance, because on paper it looks that way. But in fact they're hiding their administrative expenses by forcing the providers to do much of their bookkeeping. (Source: my wife used to manage the department in the hospital that did that Medicare financial stuff)
Kaiser, who has a plausible claim to expertise in this field, puts the overhead cost of Medicare at 2%. The raw number is more like 1.4% but Medicare does get to piggyback a lot of the administrative workload on Social Security so perhaps that is why Kaiser's number is higher.
Insurance industry advocates, who are incentivized to provide the lowest number that can be defended, put private insurance overhead at 17%.
The rest of your suggestion -- that Medicare doesn't even pay for the actual cost of service -- is hard to really reason about accurately. Prices and costs are so completely distorted now that I am very skeptical of anybody's estimates of 'actual value.' Things will change dramatically if we eliminate the insurance industry and medical billing field.
Having just experienced first world level healthcare in another country and paying for it out of pocket at 1/20th or less of what it runs in the US, I am certain we are getting shafted.
It's important to note that this industry is a complete bullshit industry with complete bullshit jobs. Their only job is to say no, to stop money from going out of the insurance companies, in any way possible. That is their entire purpose.
Your medical insurance money props up this industry. Every person working in this industry and receiving a salary, and every person owning shares of companies in this industry receiving profits, are taking money that should have been spent on producing healthcare for themselves.
So however many billions of dollars of revenue this industry makes, we would instantly save most of it by getting rid of this industry.
This is exactly what I'm talking about. I'm sure that number is accurate, if you're looking at Medicare's books. I'm telling you that when you look at the way Medicare forces the industry to handle their charges, it makes the industry much less efficient, both in terms of administering the provision of care to Medicare's "customers" as well as more generally across how the industry handles its accounting in general.
Every hospital (and skilled nursing facility) has a small team of people whose job is to compile the statistics that Medicare demands, and report it annually in what's called "The Medicare Cost Report". Add up 1 or 2 or 5 FTEs across every hospital and SNF facility in the country, Medicare's claimed efficiency is quickly turned upside down. There is some work that providers have to do for other payers, but its scale doesn't approach the order of magnitude of what Medicare forces. This isn't a matter of opinion (like my wife's); this is absolutely factual and objective.
It gets even worse than that. Because the care paid for by Medicare together with that of Medicaid (which is a separate program, but rides on Medicare's coattails for a lot of its reporting mechanics) dwarfs any private payer, hospital information systems (at least the parts that deal with finance) are structured around the way statistics need to handled for Medicare. That squeezes out the ability to do any more traditional cost accounting. This is the reason that the fee for a given service varies so wildly from hospital to hospital: because they're not doing normal cost accounting (but instead tracking Medicare statistics) the don't actually have a good idea of what any given thing costs, so their fee schedules are all over the place. (I'm generalizing here, there are hospitals that do it better, but my anecdata from hospitals we've had close association with show that this problem is quite widespread.)
We are, but not by insurance companies. Their profit margins are thin. The issue is hospitals.
Sarah Kliffs idea to reduce the cost of hospitals is price controls: for the government to tell them they cant choose a price, and to ban them from accepting other insurance.
I propose the other thought experiment: why doesnt medicare just compete in the market with other insurance plans: it charges X and provides the service. If its truly more efficient it will beat all the rest.
Eventually, as this started to be more widely known the Conservative government "fixed" it. Not by paying nurses more, not by lowering the immigration income requirement to match what they pay skilled workers like nurses, but by specifically exempting nurses.
Sorry wasn't awake enough when I first wrote this.
If not, what do you think is currently happening to those people who need mental health care or routine surgery in a non-single-payer system?
I've never had to wait for an elective procedure because I can choose to privately pay for care on a schedule more convenient to me. I have private health cover which tries to compete on this basis.
But if I had any emergency needs, then I'd be treated immediately at any hospital by the public system, which I pay into with taxes. And the waiting list for those elective procedures, if I couldn't afford private care, is a priority list - based on need.
The idea that shortages don't exist in the US is absurd - sure they do, you can't afford critical care then you just don't get it. The US waiting list is infinite.
You'd think they'd be a bit more invested in the process of healing, but I haven't found much evidence of that. I hope I'm horribly wrong here.
Personally, I don't think doctors are the answer. I used to really like the idea of high-deductible. But eventually, I just came around to the idea that only the gov't can fix it (with lots of tradeoffs in that fix, obviously).
I think they could, but more people would need to be in them and try to do what you did. It needs to be enough people to eliminate the problem where insurance companies like the system being too complex because then you use them instead of paying for it our of pocket.
Insurance companies clearly have nothing to worry about. I might be able to put in extra effort to negotiate my costs down by paying out of pocket, but then it would not count towards my deductible or out of pocket maximum. Even with HDHP, I am still clearly incentivized to just pay whatever the insurance company thinks I should.
It's a great racket to be in, really. They can negotiate the pricing in advance so that they appear to be useful in making my costs lower, while not actually incurring any costs other than paperwork. They hold all the cards and they have captured the regulatory authorities.
Correct me if I'm wrong, but Medicare-for-All is just public insurance. It's not a state take over of all private hospitals.
But instead of negotiating a price with you, the hospital will be negotiating with the state. Hospitals can still compete on prices and likely the state will grant contracts for non-urgent services to the cheapest provider..
Modulo, whatever level of free choice is left and what capacity is available, etc..
Disclaimer: In full support of single payer/government managed healthcare
It's not like there is any competition right now? You can't even get a price quote for elective surgery.
Also I wouldn't be so sure that your children don't have significant leverage over you, hehe :) (They probably don't realize how much leverage they have)
It's practically impossible to make an informed economic decision about truly emergency medical care without heavy regulation. It's not uncommon to be literally unconscious while all the care decisions for you are being made by others.
See this article for an example: some uninsured woman had a brain hemorrhage and woke up with $357,000 in medical bills:
https://www.nytimes.com/2017/03/29/magazine/those-indecipher...
https://www.campussafetymagazine.com/tag/hospital_shootings/
I guess you can go look for the motivation, most shootings probably isn't financially motivated thought.
Both my kids were born early. The medical bills for both totaled (with hospital stays for babies and mom) north of 100k each, the second WAY north.
Both involved situations that were "emergency" type situations. We couldn't shop around, we couldn't even sign anything. We trusted the hospitals and doctors and went from there. Fortunately I had good insurance, if for some reason I had to pay it would have been a huge financal burden for years and years.
And let's say I did have time to think about it? What then? I'm not a doctor, this isn't shopping for a car... I don't feel like I could possibly know enough about emergency baby birthing, surgery, etc to know... "Gosh honey when the baby's heart rate starts to slow unexpectedly, I think we should save a few bucks".
Here take this bill that will bankrupt for the rest of your life.
The big problem is that every other modern country has this shit sorted out. They don’t bring crippling debt because you got a minor surgery.
In US, we are literally murdering people because they are too afraid of what it will cost.
Literally one of those words is not being used correctly.
Having children is a pretty basic part of being human. And the costs are such that even millionaires are going to feel it. When basically nobody can afford to participate in reproduction, something is going to go sideways.
With my "good" insurance, I still ended up with a multi-thousand dollar deductible. Which I thought was problematic until I started hearing about people who have high deductible plans that only make you pay 20% after hitting your deductible.
For a 100K bill, 20% is still absurd and especially after you've already paid $2-10K out of pocket.
The patient sees a $10k bill, pays a $300 deductible, and only $2k ever actually materializes in the exchange between doctor/insurance. And afaict, this is the expected operation.
Of course, when you're uninsured, the numbers stop making any sense, because they fail to go through the convoluted process that reduces it. You just get the $10k bill and thats the end of story. But for the insured, a $10k bill is not $10k exchanged.
I think the same culture exists with doctors/insurance. It's not that they're skilled enough or have enough power to negotiate down 50%... doctors are putting numbers up expecting to be reduced to 50%.
And then us poor saps get slapped with these absurd numbers and thank the gods we had insurance... but no one involved ever really expected to pay that number. And ofc, without insurance, you're like an american trying to shop in india -- no idea how to play the game, trying to negotiate in the american fashion with 120%/80% when the other guy started with 300%, and don't have the information to realize that initial $20 offer negotiated down to $18 isn't even close to what an indian would have managed (probably $5).
And its not like he's going to correct you when you fail to negotiate properly.
If I'm not mistaken, those plans also have an Out-of-Pocket Maximum. So you pay 100% up to your deductible, then some fraction of the cost above that until you hit the OOP max.
Say again? Unconscious people don't have the agency to make price competition work, regulation or no.
You need to be conscious to comparison shop. You also need lots of time to do so, time you don't have when you're having a heart attack or bleeding out from a severe injury. Regulation isn't the problem here, it's the lack of the right kind of it.
The app and insurance profile should also allow you put in guidance on what is allowed if you're brought in unconscious. Some may not want to be resuscitated.
There are a few procedures where a layperson could probably make meaningful decisions. How much anesthesia do you want for a procedure: cheap but uncomfortable, or pricy and painless? Should a specialist go all out to minimize scarring, or are you fine with a mark on your arm.
But for most other things, would you actually be comfortable analyzing the risks, costs, and benefits of treatments on your own? Diagnostic tests too? You're really going to say "I hear what you're saying about a possible stroke. Still, I think the CT is overpriced--and don't even get me started on the MRI—so I'll either pay for a regular old x-ray or we can just see how this numb face/slurred speech thing plays out...."
Also, how is this going to work for malpractice? The first person who opts out of the "expensive" stuff and doesn't make a full recovery is going to raise merry hell. "I KNOW I SAID NOT TO DO IT, BUT YOU EXPLAINED IT BADLY. If only I had known..."
https://duckduckgo.com/?q=Switzerland+compulsory+health+insu...
gives this as the first hit:
https://www.ch.ch/en/basic-health-insurance-services/
There is also this from a non-Swiss point of view:
https://www.expatica.com/ch/healthcare/healthcare-basics/hea...
Since the insurance companies are the middle man, the cost structures become less directly correlated between patient behavior. Demand is inelastic, particularly because insurance smooths it out. The hopsital needs so much money, so why not inflate the price of advil over here, even though it doesn't directly correlate to their costs.
Semi-tinfoil-hat conspiracy incoming: I think doctors and hospitals actually want government funded medical care, and are doing some of this to speed that up. Think about it. No more dealing with 100 different insurance companies or sometimes trying to bill uninsured patients: just develop expertise in handling one single government agency, and rake in essentially as much money as you care to have.
I hadn't thought of it this way before, but that's exactly what Raytheon, Northrup Gruman, and Lockheed Martin do. Hmm.
Reminds me of this really good article. TLDR: Man tried to call a number of hospitals to find out how much childbirth is going to cost him and received no answers.
https://www.vox.com/2016/5/5/11591592/birth-cost-hospital-bi...
The hospital can totally give a realistic, projected price: It can know what the probability of a complicated birth will be, and it is also able to amortize that over all the uncomplicated births.
There's no sane public-policy reason it should be structured like a reverse slot machine: you pull the lever, get a fixed prize, then find out how much you'll pay for it.
Unforeseen complications are not exclusive to the healthcare industry. Imagine if you were trying to build a house, but had no idea how much it would cost. "Realistically, no construction company will give out a price; they don't know what unexpected complications may arise."
Something needs to happen here. Either healthcare is socialized (my strong preference), or the industry needs to implement some type of price transparency.
Not to mention, your analogy to construction works is a good one - but perhaps not in the way you intended. Plenty of construction projects run into complications and experience cost overruns. The only situation in which I can see hospitals giving out prices is in the same context as construction projects. Non-binding estimates that are projections based on prior assumptions, which will change if unexpected situations occur.
In fact the best analogy I've come across is with car mechanics. Fixing a person is like fixing a car. The shop can charge a set rate for labor, and will provide an invoice for parts. In that sense, price is perfect transparent. But even the best mechanics can't predict with certainty what it'll take to fix a car without seeing it first. Who knows when they'll pop open the hood expecting to do a standard operation only to find that the car is messed up way harder than was originally predicted.
As the GP noted, if you don't even know the order of magnitude to expect, the cost will always be a concern. The upper bound on the price is in the trillions, after all.
> If we start making hospitals list prices beforehand, then they're going to have to raise the base price for an uncomplicated birth in order to subsidize those that do experience complications.
This function is currently performed by insurance companies; a frequent criticism is that insurance should limit itself to true emergency situations, but when any routine operation can balloon in price unexpectedly, it's not irrational to want its purchase mediated through the insurance provider.
Prices negotiated with insurance companies are negotiated under conditions very different from an uninsured patient. For example, risk of non-payment is drastically higher among the uninsured. This had to be offset by charging a higher rate so those losses are made up on patients that do pay. If you offer to pay for medical procedures in cash and immediately then you can usually negotiate the price down to a fraction of the list cost.
They can?
Vox's reporting over the past couple years has suggested quite the opposite—that past prices are not easy to find, and that even when they are, your price can drastically vary from someone else's even for the same service. That's why they started this "submit your emergency room bills" project.
That's not quite enough scope control for all services.
It says "Additional charges are made if you require critical care. If your baby requires transitional or specialist care, this is free if they are entitled to NHS care and is chargeable if they are not."
It's a little harder to do that with humans since they aren't going to pause an operation, keep the incision open, and tell the spouse "We found an unexpected tumor, so let's wait an hour while we generate a new quote and you can decide if you want to pay it".
But that should be part of the quote "Unexpected events can cause us to exceed the quote", and then they should have to document why it was unexpected.
It's inescapable, in that providing a description of the problem that is precise enough to generate a perfectly accurate estimate is very close to actually just being the solution. As you do the work, the estimated time to do the work approaches the time already spent doing it.
But a lot of customers want essentially the same thing--probably a glorified CRUD app with pretty management dashboards, and a workflow that exactly parallels the all-paper workflow first designed in 1965. If you do that sort of thing often enough, eventually you get a feel for how much it costs, even with the variation across customers.
Medicine has a great advantage over software in that decades of hyper-detailed hospital billing--set up in an effort to maximize the yield of patient cash-ectomies in the face of insurer pushback--can now be subjected to statistical analysis. All those diagnosis and billing codes can be plugged back in to the billing databases to discover the median cost for the care to treat a particular ailment. It isn't so hard to then say that I am willing to pay the median actual cost, plus an X% margin for the hospital, even if the actual cost is less, provided that the hospital also eats the difference if the cost is actually more. On average, if everyone did this, the hospital still makes enough money to stay in business.
Some diagnoses in particular, such as the one every woman on the planet is likely to get an average of 2 times during her lifetime, probably while between the ages of 16 and 50, are particularly amenable to cost averaging. If you can't quote the cost of a hospital childbirth to a patient with months of lead time, including the possibility of emergency surgery, you deserve what happens to you when every actuary can crank out an answer using a pocket calculator within 15 minutes of being asked to do so. You know how much it costs. You just don't want to say, because that takes away your leverage to charge more.
But ethically, the care provider should probably not have that leverage, because if they haggle, people can die. If you cure a disease that affects 3 people in 100000, we can talk about the size of your bonus. But if you (the hospital) are on your 3rd laparoscopic gallbladder removal in the same week, and still don't know how much it costs, I want the power to set the price taken away from you.
In other words, UHC is a step to lower costs, but it will still be more expensive than a good free/mixed market solution.
The price-opacity may be a product of regulation, but the prices themselves are free market capitalism working as intended. For another example of the same, consider the recent reporting on collusion between generic drug companies[1]. When you can't refuse to buy the product, the vendor has a ton of power to set prices as they wish.
[1] https://www.wsj.com/articles/generic-drug-makers-shares-drop...
https://www.vox.com/policy-and-politics/2018/7/31/17629526/m...
Reminds me of the brief hospital visit I had in Paraguay where I needed to have a friend or relative always with me because the hospital didn't stock anything. If ibuprofen, bandages, syringes, antibiotics, etc were needed, the hospital staff would tell me and I would have my friend or relative run across the street to buy the necessary supplies from one of the pharmacies so the doctor or nurse could treat me.
Cheap hospital bill, cheap pharmacy bill, pain in the butt for my friends and relatives.
I charge clients similarly. I overbid projects that I don't really want to do. If you want me to setup Wordpress for you, I'll charge you out the nose. Granted, you get to accept my fees before I ever send you a bill. It's not a perfect analogy.
> This is all due to the key fee I’ve been investigating this year: the ER facility fee. This is the fee that ERs charge for walking in the door and seeking care, something akin to a cover charge at a bar.
This seems absolutely reasonable to me, I wish I could charge a 'fill my email with RFPs' type fees. Walking into a waiting room, signing in and waiting is not nothing. You and your symptoms get evaluated and triaged. That takes expertise and know-how. The prices vary wildly because different hospitals experience different levels of demand, I imagine.
One can always forgo setting up WordPress, which is not always the case with healthcare.
Conversely if someone told me to setup Wordpress and that I could only charge $50, I'd change industries in a heartbeat.
In theory maybe. Usually I would say these things are not exactly top priority and you are not getting your money's worth in the premium there. At best, of your list, you're paying for the instant availability, but what about the times where it's not instantly available? You're not paying for a guarantee of it.
Hospitals aren't telling their patients, "We're not really the right institution to give you ibuprofen. We can do it if you really want us to, but it'll be incredibly expensive. You can just go buy some at the store for like ten cents." In fact, I bet that even if you have the presence of mind to decline their ibuprofen because you'd rather get your own, they'll strenuously argue against it, or even start treating you as not following medical orders.
In any case, it would be a lot more palatable if they'd charge marginal costs for marginal items, and charge overhead separately. It may well cost them something on the order of $60 to give someone ibuprofen, on average, but it does not cost them $60 more to give one more person ibuprofen. It would be more honest to charge two cents for the pill, and separately charge your fair share of the cost of the staff that obtains, vets, distributes, and administers that pill along with everything else you're getting.
I agree with you - it would be really interesting to see honest and transparent itemized bills, with separate items for overhead. I wonder if people would have the same problem with high bills in that case. Probably wouldn't like the total any more, but maybe it'd be easier to understand.
It's hard to argue the 600x markup is there to cover overhead when they literally have a facility charge there to cover overhead.
You also have separate line items for each of the things you mentioned -- doctors, nurses, staff, etc. You are paying for that expertise, often many times over, in addition to a $60 pill that retails for $0.10 at the local Walgreens (who also manages to make sure that it's not expired).
Most hospitals in the US are non-profits. You can go look at their financial statements yourself. They're not exactly raking in the dough. Running a hospital is enormously expensive, and if somebody comes in needing $1 million worth of care, then you're required by law to give it even if they can't pay.
That money has to come from somewhere. That's why Ibuprofen is $60.
The % of people who are uninsured has halved in the last decade, and this hasn't changed a thing for insurance billing.
I agree with you 1000%. Highball the bill to the insurance company - fight with them - send the leftovers to the patient. That is totally unfair.
It's kind of like going to a mechanic and getting a bill of $200 for a single headlamp bulb, and another $300 for labor. Then the mechanic arguing that the $200 for the bulb includes the mechanic's expertise, knowing which bulb to buy, etc. Umm...no. All that is included in labor costs.
>This seems absolutely reasonable to me, I wish I could charge a 'fill my email with RFPs' type fees.
Do you not think that fee should encompass doctor's expertise, instead of sprinkling that over cost of materials?
My initial reaction when I read the piece was in agreement. I think it makes sense for ERs to have a facility fee. However, it doesn't explain how one hospital's facility fee can be, say, double that of another. Is it that one hospital is using Hue lightbulbs compared to the other?
A $5751 bill which is almost entirely a facility fee is ridiculous.
I would imagine a facility fee should be relatively fixed - it is the cost to maintain the facility and has nothing to do with a given patient's medical condition. As such, it is trivial for a hospital to publicize the fee and provide transparency.
In general, I think all the items they bill for are reasonable. The amounts, though? Not at all. When you start looking at the variation in how much is charged for the same items across different hospitals (or even within), there is no good model that can provide an explanation.
The market also doesn’t expect you to accept payment terms much worse than NET30.
And a hundred other ways that healthcare is a tricky business. If we want to fix price transparency, we need to fix all that too.
Insurance companies generally get “most favored nation” clauses so that they all pay the same price as each other. EOBs show the list price for a service, and the much smaller amount actually paid. The people who really get the short end of the stick are uninsured: they only see the list price and maybe an offer to negotiate.
> I charge clients similarly. I overbid projects that I don't really want to do. If you want me to setup Wordpress for you, I'll charge you out the nose. Granted, you get to accept my fees before I ever send you a bill. It's not a perfect analogy.
A more apt analogy might be you installing a Wordpress plugin that costs $10 for a client, then sending them a bill that looks like this:
$1,000 - Install fee
$1,000 - Plugin license
=========
$2,000 - Total
Then, when the client complains that you sold them a $10 plugin for $1,000, you say "Yeah, well, you weren't just paying for the plugin, you were paying for my time to install it" even though you had an additional charge for the time you spent installing it.
If we can find a way to bring market forces to bear, it will pressure healthcare organizations to reorganize themselves to provide services in a more affordable way. And before anyone gets sanctimonious about putting money over quality care, consider the actual harmful effects of these crazy bills on people's lives. I used to do title work, and I became familiar with a pattern of people quietly paying their mortgage on their house for a couple decades, no liens, and then all of a sudden a lien from a hospital bill shows up. And then everything starts to crumble, other liens accrue, and I'm doing the title search for the foreclosure. A family just got moved from middle class to living in poverty. Our healthcare system is becoming a vehicle to impoverish people.
I think the problem (also outlined in other comments) is that there are no market forces in the US health services market. There is no pressure to provide less expensive services, no pressure to reorganize, and no reason not to do what is being done now: build a non-transparent system where people get charged arbitrary amounts and prices are not known beforehand.
Health care that is not time critical should not work like the fire department. In fact, emergency rooms, once they diagnose something as not being an emergency should be able to say, "sorry, this isn't the right place for this, go to a doctors office."
With non-emergency care we should all be able to get price quotes up front, we should be completely aware of our choices and the be able to shop around. We could maybe outsource that to health care clubs like Aetna and UHC if we choose to (knowing that we are getting less choice and that we'll have to deal with those bureaucracies as a trade-off), but there shouldn't be any tax breaks or employee incentives for using those health clubs.
I recently had surgery to have my vision corrected with no "insurance" (or health care club) involved and it was so nice. I shopped around, the doctors all competed for my business and treated me like royalty, there was absolutely no confusion over price, there were financing options available, the technology was cutting edge (or I could have chosen to go less cutting edge and paid less), it was incredibly refreshing. I'd love if most of my health care could be like that.
No one in their right mind is going to decide that the going rate for chemotherapy is a little steep right now so they're going to sit with the cancer for a year or two and see if the prices come down.
B) I'm not going to wake up in the morning to discover that my expected annual food costs have suddenly increased by four or five orders of magnitude. There is no budget-conscious version of a lot of non-emergency, but still lifesaving, medical care.
B) that's because food is a free market
B) Let me rephrase. I'm not going to wake up one day to find that my required daily calorie intake has increased by multiple orders of magnitude. There are very few household budgets that could reasonably be expected to absorb such a shock, no matter how efficiently the market for those calories functions.
B) Again, yes, we need health insurance for rare surprises just like we get fire insurance, auto collision insurance, etc. in case of those rare occurrences. We do not need insurance for medical treatments that everyone gets. We just need to plan ahead financially for those, just like we do for food, clothing, housing, etc. Preparing ahead of time for known expenses is not insurance. If everyone's house burned down a few times each year fire insurance would not work, you would instead just factor that in to the cost of living.
As far as I can tell the main difference between the socialized food insurance we already have and the socialized medical insurance I'd like us to have is that subsistence level food costs are uniformly low for everyone whereas subsistence level medical costs vary wildly from person to person.
That seems like an important number to know.
- Emergency room wait: $0.10 for lights
- OTC eyedrops (4 drops): $0.20
- Triage by on-duty nurse: $100 (@ $300/hr)
- Consult by on-duty physician: $220 (@ $600/hr)
- Late-night convenience fee: $100 (between 7pm and 7am)
etc. I made up all the numbers, I have no idea how healthcare professionals calculate their hourly rate.
Except that in this case, the market is paying before being told the cost. So, what is enforcing the upper limit on price in this type of bizarro market?
How can markets function without price-transparency?
Does every other human have the right to extraordinarily expensive, often unproven cancer treatments only available at research institutions in the United States? Are we willing to start making cost based decisions on who should die (i.e. should we really be spending hundreds of thousands of dollars keeping those above 90 alive for age related illnesses?)
Everyone will want everything free, but for this to work you have to make uncomfortable decisions. If you put nothing into the system, how much should you get out? Should others with more resources then be able to then buy private insurance for access to better care even though that sounds "unfair"?
Everyone always glosses over these fun questions when they talk about universal health-care systems.
1. Your first point about "unproven cancer treatment" has an overly narrow focus on the edge of medical research. These cases are yes something that needs to be addressed, but they are far from the norm of normal medical care.
2. I've never heard anyone ask for anything free related to healthcare. There is very little truly free care in the US. The conversation here is about price transparency and what is considered reasonable.
As a European living in the US I find it mind-boggling that the richest country in the world does not consider universal healthcare to be a fundamental right of its citizens.
-youth of today
I don't see why that same thing couldn't apply for healthcare. 1. ERs should publish prices in a public database. If a price is not published for an item/procedure, the customer can pay the lowest price she/he can find for the same procedure from an other provider. 2. The same price must be charged from everyone (regardless of insurance).
Even if only a small fraction of people shop around it might push down the prices. Even if the above is too naive, I am sure someone smarter can come up with a less naive version of it.
this would bring a lot of sanity into the system.
One difference is that the ambulance service charges for residents, and usually it is reasonable priced (but not cheap) but if it turns out you need a helicopter the bill can be quite large! But insurance covers it. For most professionals insurance is very cheap because of the tax saving you get.
There is just no way that any perceived marginal improvement in the quality of care on an individual basis warrants an off chance of maybe being bankrupted. I can't say I've ever found the quality of care of be poor or unacceptable. It's always been available and served me well.
I kind of liken it to being forced to drive an $80,000 BMW as opposed to being provided with a reasonable Toyota that does the job.
The economic experiment has been tried and the US is on the wrong side of it.
I'm aware however, with the rescue helicopters there can sometimes be complications because at the end of the day, someone needs to pay - but as an accident, everything's covered under ACC anyways. (and: http://www.police.govt.nz/faq/if-i-get-lost-and-need-search-...)
I have lived here for 9 years and although have paid my insurance diligently i always get anxiety at going to the doctor's office.
Doctors (GP) visit typically costs me around $40-50NZD, thats likely on the high side, Children are free / fully subsidised.
A&E visit would be $50-100NZD
Most all injury related medical costs are covered or subsidised by ACC.
Specialists Appts typically cost ~$200 per visit
Private health insurance, while in no way "required", is still offered by the bigger employers and will see better outcomes for elective and non-urgent surgery and is priced in the hundreds of dollars per year for "basic" coverage if you wish to purchase as an individual.
Edit: clarified coverage for visitors
Is this why my local hospitals are advertising their ER wait times? The arbitrary profit from arbitrary "in the door" fees?
I once fainted during a comedy show because the comedian was talking about his wife almost dying in surgery in graphic detail and I got nauseous and fainted. I woke up outside the comedy club up against a wall with an ambulance there. They basically took my blood pressure and gave me a bottle of water then asked if I wanted to go to the hospital. I declined. I still received a $3000 emergency services bill later... Apparently they checked my ID/insurance when I passed out and somehow I ended up with a bill even though I declined service.
In contrast, I once hit my head on a train in France and had a huge gash that needed stitches. I took a taxi to an ER, got seen within 20 minutes, left the ER within 90 minutes, then had a $50 Euro bill.
The contrast between "socialized" healthcare in Europe vs privatized healthcare in the US is shocking. We receive far, far, far worse quality and fewer services despite paying a lot more. We're in the worst of all situations.
As for high drug prices like the $60 ibuprofen, you are mainly paying for it to be delivered to you by a nurse.
ER's have an average profitability of 7.8%. Higher than Walmart but lower than Apple. So if they became non-profit in some way, they could cut that percentage of costs. That's some, but still very expensive.
https://www.beckershospitalreview.com/finance/7-things-to-kn...
There will be a line-item for the ibuprofen itself, there will then (generally) be a separate line item for staff time spent helping you, and there will almost always be another line item for the facility fee.
The nurse's overhead is theoretically included in those latter two line items, so shouldn't _also_ be charged in the ibuprofen line item.
Now, there are logistical concerns that will make the ibuprofen marginally more expensive at an ER than at a clinic, but definitely not $60.
I accept the logic of high drug prices including staffing costs when those staffings costs aren't included in other line items. In most hospital bills, it seems, those staffing costs are already included.
One big issue though are that lobbyists who wanted to keep prices high - to squeeze in as much profit as they can out of these. Drugs, Antibiotics, Procedures, Medical Professionals. I know it would be far-fetched to standardize and at least provide some level of transparency across all facets of operation in this field, but that would be a good start.
Analyze the data, and find ways where things can be improved incrementally.
Sounds crazy, right?
It worked well for my family and I during the many years I spent in Italy, which has health care costs that are something like half of what they are in the US in terms of GDP.
Although I seemed to have noticed a lot of increase as well in terms of pricing and services.
There's just really no cure for an appetite of greed.
Despite knowing a lot about how it works after being in the industry for several years, I don't think I'd have the stomach to take a stab at a startup in this field myself. I've already had to deal with it over the years as an systems engineer and I'm pretty sick of it.
Also, if you're planning to do business with the big companies in this field, at least from the standpoint of my company, they really drag their feet with signing any business deals with you, and just about every company doesn't really want to pay you to do anything. We've had multiple companies back out of contracts (or act like they're going to sign once things are negotiated, then don't), even after we've done significant development (in one case building a whole system for them) and not pay us for our work, and then have the gall to ask us for parts of the code afterwards.
The only reason we did that work also, is because there are some crazy hard deadlines with open enrollment and the process drags so much that by the time everything is signed the software basically already has to be complete immediately upon signing if we wanted their business or else it would miss the open enrollment window (or pre-open enrollment, or whatever else hard deadline they had).
Also, the industry has been upended and thrown into chaos with Obamacare, and if the Republicans ever succeed in repealing/replacing it, then it will probably be thrown into chaos again. This creates an opportunity for startups that can move much quicker than these behemoth companies can move in reaction to these things, but it also means that you could be building a business on top of quicksand, and might have to make significant and expensive changes yourself in a few years if it changes underneath your feet as well.
How are you going to get it? Even Google has huge regulatory issues around touching health care data. Medical records are some of the most highly regulated pieces of information around. A startup would have to have very deep pockets (or a few lawyers as founders) to have any chance IMO.
But it does.
I recently got my wisdom teeth pulled out in Germany, and without my asking, the doctor sent me a pack of 12 Ibuprofen and billed me 24 euro, i.e. €2/pill. I didn't want them because I had 500 of the same at home, which I bought for 25 euro — i.e. €0.05/pill. That's a markup of 40x.
These insurance companies and hospital groups are pure evil. Absolutely disgusted with what a backwards ass country America is.
Is it possible the fairly new walk-in clinics could help?
Could there be a big red sign on the ED door saying, "Hey we are very expensive and if your condition isn't serious you will wait a long time! Consider using the walk-in clinic at 123 Main Street."
No amount of analysis of the details is going to fix those things.
The American system is largely a joke where doctors rather collect their co-pays and write prescriptions.
Even a dot-plot chart from different peoples experience with different practices and needs would be a great improvement to the “it depends” of today
This article is BS. I didn't read it, it would be a waste of time.
Like literally, have some government body write a table:
1 pill of 400 mg paracetamol ............ $0.50
1 pill of 800 mg paracetamol ............ $0.60
prescribing medicine (once per day) ..... $4.32
base fee for an ER visit .............. $200.00
5 minutes of work by an ER physician ... $27.43
It's not going to happen because "omg socialism", but this is literally how other countries handle it. Possibly with a multiplier that the hospital/doctor can apply within certain limits. If you really need to, maybe even allow deviating from it as long as the patient is conscious, in a position to make that choice (i.e. not emergency care), is explicitly informed that this is above the "official" rate, is informed about the rate, and signs off on it beforehand.
And I'd like to point out that this sort of regulation isn't unprecedented in the US either. Taxi prices are regulated this way in many areas. Apparently, transportation is more important and less suitable to be left to a free market than healthcare...
The "long wait times" that Canadians sometimes complain about actually address this problem within public healthcare. If you come into the ER for a non-emergency, fine, but prepare to wait 4-6 hours. Every emergency case coming in the door will get placement ahead of you.
Some provinces (e.g. Ontario) address this with phone triage hotlines that help you make a decision about whether to go to the ER, a walk-in clinic, or wait for a doctor's appointment.
(Source: my wife worked at a rural hospital on the border in a neighboring state.)
You'd be giving up genetic testing, numerous advances in wound care, a number of advanced antibiotics, leaps in transplant technology, and a whole slew of joint-replacement innovations. Plus cancer treatments, and of course, AIDS therapies. Massive impacts, right?
And if today is better than 1970, 1970 was better than 1950, and 1950 better than 1920, and....
Right?
Not so fast.
New York City have been tracking mortality rates since 1800, and there's a chart I love to pass around in these discussions, with the charming cocktail-party friendly title of "The Conquest of Pestilence in New York City ... as shown by the death rate as recorded in the official records of the Department of Health and Mental Hygiene".
The 20th century has seen a host of medical advances: antibiotics, vaccines, transplants, tailored drugs, implants. High-cost, yes, but huge impacts.
No, not really.
https://1.bp.blogspot.com/-uTWEATUzgxk/TXQoTibILtI/AAAAAAAAA...
The turning point in the chart -- where the increase in mortality as New York as it grew from a town of 60,515 (1800) to a city of 813,669 (1860), was the formation of the Department of Public Health itself, in 1866. Peak mortality hit 50/1,000 in the 1830s, 180s, and 1860s, with a sustained average above 35/1,000, and marked volatility as the city was rocked by epidemics. By the 1890s, it had fallen to 20, and 1920, about 12. The pre-WWII low was actually in 1939-40, at just over 10, and mortality rose through the early 1970s. There has been a further decline, to about 7.5, since 1990.
Analysis elsewhere suggests that this is almost wholly attributable to increased longevity among minority populations -- nonwhites generally, black women, and especially black men. My suspicion (though I've not researched in depth) is that this is largely attributable to increased access to medical care, either through improved socioeconomic status and access to the commercial healthcare market, or through public health programmes. There is little if any evidence that the gains come from medical technology itself.
This is a topic that's been much studied. Robert J. Gordon's epic assessment of US economic progress, The Rise and Fall of American Growth (2016) looks hard at medical advances, particularly since 1970, and finds them largely absent. Victor Fuchs, healthcare economist (heavily cited by Gordon) has found published similar results for the past few decades.
A personal anecdote is a close friend who'd died of an obscure cancer in the early 1990s. The (brutal) treatments they'd undergone were essentially unchanged since the early 1970s, or even 1960s, as I read the literature, and have changed little in the ensuing nearly three decades. Given that one of the questions and agonies we faced at the time was "what if some miracle cure emerges, or we weren't doing enough", this failure-to-advance is in some ways a bit of validation: we really try to do everything we could, and applied the best available knowledge, and no, even now, the outcome is virtually unchanged: four out of five patients with that diagnosis die within five years, often less.
(Other friends have survived their, mostly other, cancer diagnoses. And of the cancer-friends we'd made, some are still alive, others have died, in cases of complications from treatment, including blood- and tissue-donation related infections such as hepatitis. Life is not fair.)
Real healthcare improvement, as with so many other quality-of-life improvements, comes not from heroic measures, but by assuring adequate access. And the market is a terrible mechanism for assuring such adequacy.