Hospital prices are about to go public in the U.S. | Hacker News Reader

Hospital prices are about to go public in the U.S.

ajc.com

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Pro tip: I was a neurosurgical anesthesiologist at the University of Virginia Health Sciences Center for twelve years (1983-1995). Every now and then I'd get a call from our billing office that they'd received a letter from a patient I'd cared for who was too poor to pay what our department had billed (usually many thousands of dollars: I had NO IDEA what our charges were, BTW, nor did any of my colleagues in the department). Every time that happened, I'd go over to the billing office and — without bothering to read the letter — tell our billing chief to waive all anesthesia-related charges. In other words, by my initialing a form we had, their balance due us was 0. Try it, you never know, it might work for you.

If you are a patient in this situation, there are advocates who can help you. One thing to try is to ask the billing department if they will "accept assignment". What that means is that instead of billing you their fake rate, they would instead bill you as if you were an insurer.

IMO, it is incredibly unethical and dishonest for these medical corporations to charge different fees depending on who you are. Prices should be transparent, and should be the same for everyone.

Some may argue that an organization representing a large pool of people should be able to achieve economy of scale and a better price. This seems false to me, as in reality there is only one pool of people and care provider provide care to that one pool. Its time to kick the middlemen out.

I've done that. Except I didn't know the words "accept assignment". I basically just said that I'd pay whatever they'd charge if I had insurance. So they could either accept that, or let it go to collection. And if they let it go to collection, I argued, they'd probably get less than the insurance price that I'd pay them.

And I got an adjusted bill.

God this a thousand times. How in the /fuck/ have we allowed our medical system to come to this?

I get the negotiation side of things. I get that the leverage insurance companies have is the culprit. But at the end of the day, hospitals just upcharge so they have the upper hand in negotiation. There’s no reason that individuals who choose not to go the insurance route are artificially charge X times what insurance companies are. There’s no excuse.

Charge them the cost of the procedures with whatever markup is reasonable for the hospital to stay in business. It shouldn’t be any other way.

When you remove the middlemen, what will you replace them with?

Tiny bits of software.

What's the purpose of the software?

Middlemen are not indispensable - they need to justify their existence not others to justify their absence. The whole point of cutting out the middlemen is to force them to go from a parasitic role to offer some sort of actual utility for their price.

If the middlemen have something of value to offer they have little to fear - just someone to buy gasoline by the tanker for instance keeps gas station middle-men safe because they provide both a workable connection between logistics of the very large production and consumer scale amounts - in addition to the distribution.

My experience is that hospitals have switched to a zero tolerance policy around this in the last few years. They'd rather make no concessions and sell bad debt for pennies on the dollar than set a precedent that there are alternative channels of payment. The one lifeline they give you is an interest free loan. From an economic standpoint, I'm sure this optimizes revenue. From a humanitarian standpoint, it's disturbing. I'm not arguing healthcare should be free or discounted, but when you receive a $500 bill because the on-call ambulance wasn't in network (though the others are in-network and would have cost you $50) it is hard to justify zero tolerance. We have a gold plan and I can't count the times we've been subject to loophole fees like this.

Caveat: All hospitals not managed identically.

I'm sure there's a lot of varying billing policy, hospital to hospital. And varying ability to financially write off care.

As a gut guess, I'd expect rural hospitals to be the worst about this and suburban the best.

I'm sure this is true. We've (unfortunately) now experienced this at 4 different hospital systems. The customer service is alarmingly similar.

Hospital: "Call your insurance company and ask for a break" Insurance Company: "Call the hospital and ask for a break"

Also, 2/4 of these hospitals had outsourced their billing which means they can't even make decisions on behalf of the hospital (and have a disincentive to write anything off). Seems like a structural way of avoiding writedowns.

Was going to ask about outsourcing. I don't know the market on provider billing, but I'd assume there are some companies that manage a number of facilities.

And wow, does that search bring up a lot of astroturf: https://www.google.com/search?q=list+of+medical+billing+comp...

Thank you for doing that. As somebody who has recently received a discount from their dentist on an emergency procedure, I can't begin to tell you how much we as patients appreciate these acts of consideration and kindness. Even if we can't fix the larger, systemic problems in healthcare right now, these individual acts of kindness can really make a big difference in somebody's life.

Doctors don't know the prices, and neither do the customers (not without doing a lot of homework that can't be done during emergencies). Even when you know the list prices, the actual prices your insurance negotiates are almost certainly different, so asking for list prices isn't enough.

Basically, in the U.S. the healthcare system is not exactly a free market as pricing signals are unclear, and most consumers have no idea how or inclination to price shop as they have been trained for decades to not bother. The problem is now not just a matter of how insurance is structured, but cultural.

My wife owns and operates a private medical practice (she's an audiologist), and it's insane the way she has to do billing and accounts receivable.

When a patient asks about prices she quotes them her standard price for the necessary services and calls their insurance company to confirm that the patient is covered and check what kind of copay the patient needs to pay. Assuming the patient is satisfied with the results of that call she provides the services, bills the patient for their copay, and files a claim with their insurance company.

Several months later (and no real way to predict when), the insurance company will provide an "offer" for probably somewhere around 60% of the quoted price (though this varies dramatically as well). She can accept the offer, in which case she's inevitably required by the terms to eat the difference instead of attempting to collect the balance from the patient. Or she can reject it and attempt to collect from the patient, in which case they will likely be very confused and angry as to why their insurance isn't being accepted, despite her explicitly confirming that it would be covered before they purchased her services.

To be clear, none of this is negotiated or agreed upon in any meaningful sense. She doesn't have any special relationship with any insurance provider. Instead, the providers use their massive power differential to dictate terms. She wouldn't be able to stay in business if she didn't accept at least some insurance, but they'd be quite happy to never write her another check.

She knows what her price schedule for everything is, but it doesn't end up mattering that much since she doesn't know when or how much she'll ultimately be reimbursed except in an extremely broad aggregate sense. The worst part is that she has to dramatically overprice her services so that she can ultimately get adequately reimbursed to keep the lights on, which just ends up hurting the patients who don't have insurance.

In a world of pre-1990s, high-deductible, 80/20 insurance, this would happen less as the insurance company might not do the 800lb gorilla thing until the patient maxes their deductibles, and high deductibles give the consumer a strong incentive to negotiate directly with the provider.

It's insane more people haven't realized this. All you need to do to fix our healthcare system is bring transparency to prices and have insurance actually be insurance again instead of health plans. I have multiple anecdotes from my own life where I didn't care about the cost of something due to my insurance paying for it (and in some instances not being able to be informed of the price beforehand). When you have a whole country like that it's easy to see how things have gotten to this point.

The only downside is I don't see how it would fly politically...which is a big downside.

The counterexample is Medicare and Medicaid, which (CMS particularly) are exhaustively transparent (to provider and patient alike) regarding what they cover, pricing schedules, etc. Having architected revenue cycle platforms, I can say that Medicare was almost ridiculously easy to work compared to private carriers.

It should be sustainable for patients to directly pay for the provider for the services directly for most medical care.

Yes, but that would require lower costs (prices). That we could get if pricing were more transparent. I believe that will require moving back to high-deductible 80/20 style insurance.

This was my experience when my partner received treatment and the insurance company refused to cover the anesthesia charges (they claimed anesthesia was optional for the procedure and thus wasn't covered). The anesthesiologist's office was surprised that it wasn't covered and waived the charges.

It was the only bright spot in a prolonged battle with the insurance company and the hospital.

Optional anesthesia may be a new trend. Restraints and a bite belt are cheaper, but the hospital would figure out a way to milk that too.

Bite belt sanitation fee: $300

Another big tip: if you need an X-Ray or any kind of exam done, don't do it in a hospital. Go to a clinic (if applicable of course) that specializes in those kind of exams and is covered by your insurance company if you can, it will cost a lot less usually. You can usually call your primary and ask them what clinics or labs they recommend. You'd be surprised what a huge difference that makes.

After we establish transparent pricing across the board, we're going to have to deal with the reality that some folks seek care without having any ability to pay for services.

Yes, we will, and that will hopefully lead to a more important conversation about what the priorities of a society's medical system should really be, or how a society should prioritize funding medical services if you want to take a different approach.

Some folks need care without having the ability to pay.

by my initialing a form we had, their balance due us was 0

That is very nice of you. I hope others like you in positions of power do the same!

As I recall, every fellow attending did exactly what I did whenever they received a letter like that. It happened so infrequently, and our department billed so many tens of millions of dollars/year, it wasn't even a ripple in the pond.

it wasn't even a ripple in the pond.

True, but it did make a difference to those people you helped! so yeah, kudos to you.

I'm up voting your comment, people on this site can be ridiculous.

After thinking about this, I realized he probably didn't do the job for free. Even though "anesthesia" is broken out as a line item on the bill from the hospital, it's not what the anesthesiologist gets paid. It's probably not a passed-through charge like it appears to be.

We were on salary, not paid by the case.

Like our elected officials for example

I would prefer not resorting to begging.

I was in a hospital in Singapore recently, and the prices for doctor consultation fees, staying in a room, and even certain tests were listed right at the front of the emergency room desk.

After the patient I was with was stabilized, the nurse confirmed with us verbally what the rough cost should be for the rest of what the doctor prescribed, and asked if we wished to proceed. We could have said no and gone elsewhere if we wanted, since the patient at least was relatively stable and we knew what was wrong.

I want this experience to be the norm in the USA.

Where I live you know the cost before you go to the doctor since you will only pay a symbolic sum of 30 USD even if the visit ends up with something like a life long cancer treatment. If you need medicine you will pay at most 120 USD per year regardless of the costs.

The idea that your access to healthcare should be linked to your own or your parents financial is crazy.

I agree in principal to an extent - however economics need to be tied to the end product somewhat. Otherwise many people would opt for $100k healthcare cost (at the expense of the public) to extend their life for a few more months, this is not reasonable. Resources are finite - therefore we need appropriate allocation.

In the end I agree that a basic safety net is necessary and serves a greater good - providing things like normal checkups, preventative services, and acute trauma care is reasonable. However $200k for a second heart surgery for someone who hasn't taken heed of earlier exercise or diet advice by a practitioner should not be supported.

Serious question: Do you live a perfect life? Do you exercise daily? Do you never eat processed meat (linked to cancer)? Do you never drink soda (linked to metabolic syndrome)? Do you not smoke? Do you not drink any alcohol (linked to cancer)? Do you live close to your work so as to minimize the time spent in a car (car accidents are a major cause of preventable death)? Are you not overweight, even a little? And so on.

Do you think that someone who follows all but one of those rules still deserves healthcare? All but two? What's the moral difference between someone who smokes and someone who hasn't taken heed of diet/exercise advice after getting heart surgery? Where do you draw the line?

It's easy to say, "I don't want to pay for the healthcare of some hypothetical 'slob'". But make it real, consider what this actually means, and I think it's not something most of us want.

None of us is perfect. I'm sure that even olympic athletes occasionally eat bacon. Let he who is without sin cast the first stone, right?

> Do you think that someone who follows all but one of those rules still deserves healthcare? All but two? What's the moral difference between someone who smokes and someone who hasn't taken heed of diet/exercise advice after getting heart surgery?

Yes. Yes.

Moral difference no idea, but neither one should expect to have society foot the entire bill for their bad habits.

> Where do you draw the line?

Probably around morbid obesity that's unrelated to genetic/chronic issues.

> Let he who is without sin cast the first stone, right?

By setting an unreasonable standard and saying no one under it has the ability to cast judgment is extremely anti-intellectual. If 2 people were telling you about health habits and one of them was an olympic athlete (who occasionally ate bacon), and the other was a random overweight person from the street, whose advice would you give more weight to?

If you ask the public to subsidize your personal expenses, the public inherently has the right to set reasonable limits on that subsidy. If you want to be free from those limits, it's your responsibility to pay your own way.

No I don't live a perfect life, I try to do better when afforded the opportunity - but that's besides the point. You're right - I over extended the scope with my initial statement. An in no way do I think the individual without sin is the one who should be making the call either.

However, I think if we gather a pool of public funds there needs to be a priority system or some feedback loop or liability included (back to finite resources being at stake).

Those things like sugar may come with a tax so that respective procedures are funded by it. Likewise for driving, insurance is required. For diet and exercise, maybe you can get an income tax credit for following certain things.

Not perfect, but I think we can get better then a simple pool that's support for everything and anything.

> However $200k for a second heart surgery for someone who hasn't taken heed of earlier exercise or diet advice by a practitioner should not be supported.

I disagree that failing to adhere to a certain diet should be punishable by death.

> Where I live you know the cost before you go to the doctor since you will only pay a symbolic sum of 30 USD even if the visit ends up with something like a life long cancer treatment. If you need medicine you will pay at most 120 USD per year regardless of the costs.

Then the problem is you have no pricing mechanism for determining how much the provider should actually be paid. If you offer less than what people value the service at, you'll get shortages (or, in this context, waiting lists and less life-saving medical R&D). If you offer too much, you're overpaying (see also US government contractors).

Governments in Europe apparently solve the "paying too much" problem by systematically underpaying, but that doesn't work if everybody does it. The US can't subsidize your medical R&D if they're doing the same thing.

> The idea that your access to healthcare should be linked to your own or your parents financial is crazy.

I've never understood why people have this idea about healthcare but not even more immediate necessities like food and housing. It's not as if the solution you're proposing is even analogous to the solutions we use for the poor there (i.e. free clinics akin to homeless shelters and soup kitchens). If the problem is that free clinics are poorly funded, why isn't the solution to fund them better rather than nationalizing the entire healthcare system?

> I've never understood why people have this idea about healthcare but not even more immediate necessities like food and housing.

Hmm but I have the same view for food and housing. Where I live if your mother doesn't have allow money to buy proper food the government will contribute (both for food and housing).

The difference is that the government doesn't take over all farms, restaurants and grocery stores and require you to get your food from them even for everyone who can afford it themselves.

With the difference that a long-cancer treatment might cost hundreds of thousands of dollars in the US and simply bankrupt the hospital.

Its easier to eat up cost if its a lot lower and has caps. The US has no apetite for those level of restrictions.

Not sure if you are joking but the hospitals are paid by the government for the provided services (via tax money). Obviously a life long cancer treatment will cost much more than 30 USD.

If the government has a final say, then it has to restrict supply to keep costs down. It cant say yes to everything.

That's similar to my experience in Thailand. Everyone in my family has had one or more hospital stays for illness, surgery or injury. Prices for common procedures are posted. After initial evaluation there is a discussion about what the estimated total cost will be.

I would never again want to have medical treatment in the USA.

We could have said no and gone elsewhere if we wanted, since the patient at least was relatively stable and we knew what was wrong.

Next question, if the patient did go elsewhere, would they get to keep all the test results/would the hospital share the test results with the new facility? Or would the new place have to rerun all those tests?

> would they get to keep all the test results

Huh, is that a thing in the US? I understand the old hospital might not automatically giving them to you or the new one rerunning them anyway for practical reasons. But if you've payed for the tests, I'd expect you to own the results...

I believe so. We specifically asked if we could take our results with us, although I didn’t specifically ask what would happen if we rejected further treatment. I think it would have been fine, though, and likely they would have charged us at least a small amount (maybe around $100 USD).

Would you prefer the Singaporean norm (clearly posted prices) to the Canadian/European one (free at the point of use)?

There is no single "European" model.

True. In fact it is worth noting that a large portion of the ACA/Obamacare model was based upon Swiss healthcare (specifically the individual mandate in particular) due to its heavy private market presence.

First line in Wikipedia (https://en.wikipedia.org/wiki/Healthcare_in_Switzerland) There are no free state-provided health services, but private health insurance is compulsory for all persons residing in Switzerland (within three months of taking up residence or being born in the country).

The difference being their version of the individual mandate was not struck down or watered down to becoming a 'penalty'. Instead it was like what we do with auto insurance.

Neither is it "free", at least not in Germany. It gets charged to your insurer.

Personally, yes. Like many posters here I am an Engineer not in the medical field, so take my opinion with a grain (read: mound) of salt.

Most "free" healthcare systems have either (1) horrible quality of service or (2) impossibly long waits unless your life is in danger or close to it. The latter is a systemic issue I've noticed in that healthcare, regardless of pricing or structure, does not aim to foster optimal health, but merely to prevent mortality - so if you go with a 'minor' issue such as recurring headaches or chronic fatigue, it will be dismissed entirely.

I don't have the right answer here and am all for people having affordable options from 'free, wait 3 months' to '20K, full service now', but once again, personally speaking, I'm not rich enough for 'free' things. I'd rather pay and know exactly what (and in this case, much more importantly, when) I'm getting. And from what I've noticed, my personal beliefs that people should strive for optimal health rather than mere preservation of life, is a popular opinion deemed 'unrealistic' by experts.

As a soon-to-be Canadian who has only experienced the US and Canadian systems, up here the quality of service isn't horrible and the waits for service tend to be shorter than they are in the US - but they are based on need rather than wealth. So someone in discomfort but no danger will end up waiting longer in Canada then if they were rich and lived in the US, but my relative with cancer was seen to promptly due to a high chance of complications if surgery had been delayed.

So I'm not sure what constitutes "most free healthcare systems" but Canada is apparently different from "most"

If you are rich and live in Canada, you can cross the border and pay out of pocket to receive treatment in the United States. I wouldn’t be surprised if Taiwan (the only other country with a Canada-style one-tier single-payer system) has a similar relationship with Singapore. Britain also has the ability to pay out of pocket for private practice care as an alternative to the NHS.

Re: quality vs wait period trade off.

We generally call this the 'Iron Triangle' in healthcare policy/management. You basically get a pick at most two out of (1) access, (2) quality, (3) cost.

As to your general sentiment healthcare is a bit 'one size fits all' when in terms of insurance/reimbursement solutions. Note that the needs of the aforementioned triangle are weighted differently based on acuity of care. More generalized simple/low acuity care we are happy to get low cost and ready access as our best solutions (e.g. minute clinics, online/virtual care/telemedicine for getting a vaccine or pinkeye/localized infection without complication).

Meanwhile ER representing the other spectrum we instead have greater need for higher quality and access. You must get to an ER ASAP and get stabilized.

Chronic care quality solutions with long term cost-effectiveness are what are needed. Access to a specialist for longer term condition management (or episode or care like a cancer diagnosis).

Similarly more procedures are becoming outpatient, or recovery at home, or at dialysis centers, or at skilled nursing facilities ... you get the point.

I argue the problem is that the insurers have not adequately fragmented the insurance market/reimbursement model. Healthcare is changing in how it is delivered and insurers are not keeping up with it when it comes to modeling their payouts. For example why does being in-network matter for low cost care at outpatient facilities? The added 'negotiation' of being in a specific network doesn't add much value. One size fits all doesn't work with the modern spectrum of care.

What are prices like? I suspect they are much lower than the equivalents in the U.S. Thesis: transparent pricing tends to keep prices down.

Playing the devil's advocate for a sec here. But If you paid out of pocket and later got reimbursed by the insurance company, I think, you would have to deal with the insurance company later. The system in the US is quite different and although broken it can be fixed by just fairer price comparison mandated by law.

The only way that will work is if the insurance companies have to pay the posted prices, which I advocate as well.

It is if you're a pet. This is exactly how my veterinary visits go.

For someone who worked on price transparency in 2013 - I was personally affected with surprise billing - and spent long hours working on a price discovery / transparency tool called pricepain.com, this (first step of an) anti cartel measure brings tears of joy. While it won’t solve all issues at once, shining some light into the medical billing mess can only be a good thing, allow market forces to enter the picture somewhat. It’s rather sad, that it didn’t come from the industry itself - but I guess that speaks volumes already. Florida faced a dilemma with their incredibly broken public school system many decades ago and was stuck in a political gridlock as no party agreed on any measure the other would propose to improve the situation. Finally, the only item both parties did agree on, was to grade schools. Just a single simple letter, a search for more light. The result of a little bit more transparency caused a chain reaction of consequences leading to higher quality of service overall. I hope that similarly this move will spark a quality/performance re-orientation and help create more Surgery Centers of Oklahoma. It’s high time.

Something I worry about, and that maybe you can help shed some light on, is what the ramifications of such a move would be.

You mentioned the grading of schools leading to higher quality. Do we know if any metric suffered as a result? One guess I have is that teachers started teaching for the test rather than for the foundation.

Take that same question and apply it back to the issue of hospital cost. If there's more transparency, the obvious conclusion is that there will be increased competition and an overall lowering of costs for patients. Does that come at the cost of quality of care? My gut says no, but my brain says that hospital administrators are incredibly talented at cutting costs. Maybe we have other safeguards such as HCAHPS to prevent the worsening of quality.

And as my own comment on this situation - how does this move fit into the insurance realm? My understanding is that hospitals will display the overinflated prices, but not the individual insurance negotiated prices. So how does this increased 'transparency' help?

> You mentioned the grading of schools leading to higher quality. Do we know if any metric suffered as a result?

We don't know. Something might have suffered but if you're not measuring a metric, you can't really know anything about it. That was the reality of the educational system--very little measurement of anything--and hence the baseline of agreement (not just in Florida but in many states) was simply: let's start measuring.

> One guess I have is that teachers started teaching for the test rather than for the foundation.

This is a good guess, and some teachers and parents definitely agree with you. But the reality is that (again) unless you are carefully measuring a metric, you don't know what is really happening. Collecting a few anecdotes and opinions does not necessarily result in good data.

It's also possible that in the absence of performance metrics, some teachers managed their work to maximize throughput and minimize complaints--by passing students through to the next grade whether or not they were ready. This is also supported by anecdotes, like colleges and employers reporting a decline in student readiness.

I suspect that with teachers teaching to a test, it improves bad teachers and holds good teachers back a little.

It accomplishes little. The tests are a subset of the things the students should have been learning anyway. The idea was that by measuring performance teaching could be improved where needed. The actual result was that the "help" given to classes with bad scores has been to overtrain some tiny neural nets to respond to very specific stimuli without teaching them anything beyond the specifically measured behavior. Even the students that pass often haven't mastered the material. They just can take the test. We opted to replace accountability with process and reaped the usual results.

Either way, the result is that the students learn to take the test well and might not learn much if anything else.

...and Florida still is a bad place to get a public education.

This won't help consumers. The prices (both charges and what Medicare pays) are already effectively public: https://data.cms.gov/Medicare-Physician-Supplier/Medicare-Pr...

The problem, as some other comments point out, is that they're way too complicated. The link I posted, for example, is just the provider charges. A hospital visit typically has a facility claim and at least one provider claim. Depending on the type of service received and the agreement between insurance and facility, the facility fees can be billed a variety of ways (diagnosis related groups, ambulatory payment classifications, or HCPCS). Each provider that sees you or performs labs, x-rays, etc can bill separately, and each could have a separate or no contract with your insurance. The latter is how surprise 'out of network' bills happen.

It's a total mess and hopelessly complex for the average consumer.

I shared this experience before on HN, but I once cut my leg quite severely playing ice hockey. Ended up at the ER dripping blood everywhere. I went to the desk and asked if they took my insurance. Said I was only interested in treatment if my insurance would cover it. I was assured it was fine.

Naturally the doctor assigned to me did not take my insurance...

I got out of the out-of-network billing after hours of phone calls and lots of unkind words. But man was it just a terrible experience. And with insurance coming from work, it’s not like I could change providers. And with one hospital close to my house I didn’t have lots of options in an emergency. Nor would I expect any other hospital to treat me differently.

My dad is a nurse and I grew up wandering hospitals. He complained as far back as the 80s that insurance was killing medicine. I didn’t understand it as a kid, but I see more what he was getting at as an adult.

Just out of curiosity: have you tried calling your insurance to ask them where you should go?

I haven't either, and have generally gone by your route of asking the hospital whether it will be insured, but I'd imagine calling insurance (if a feasible option?) would provide a lower rate of error.

The patient shouldn't have to call the insurance provider to see where it is accepted. This is adding to the problem. Do you have insurance, yes or no? Should be a good he only question not add-ons like, what provider, etc. It's stupid as hell that certain doctors are in network at a hospital while others are out of network, at the same damn facility. Ask me how I know this. American Healthcare insurance and billing is beyond messed up and needs to be fixed.

> The patient shouldn't have to call the insurance provider to see where it is accepted

But this is actually the one that provides the service. You dont call the music band to ask about the prices ticketek charges. You should and can ask about the price without insurance and you might get an answer (though you wont like it).

See other comments in this thread about where that question gets you. My experience has not been any different. IE, the answer ranges from "I can't tell you until the procedure is done", to exorbitant quotes. Of course I don't like those answers, who does?

The collecting system is way too complicated for a provider to know. Nobody can reasonable assure you of that, the same way an accountant cant assure you you are compliant on all IRS codes, or even a doctor can assure you you will be healthy if you do a treatment.

But think what happens when you have a patient with insurance, bleeding right in front of you: would you turn them away because of this lack of assurance? its an unreasonable ask of a human being.

Insurance copmanies are the Ticketek of the health industry: they take the bad rep for the ones reaping the benefits.

As I noted below ($25 vs. $1400 for my sore shoulder), the range of ways providers can "code" what they charge you for is not sane. And how my inpatient bill in a different situation reached ~$45,000 was clearly because the hospital knew how to pad the bill.

And in fact I'd say medical coding is a boarder line predatory practice. There are a number of companies that specialize in padding / inflating medical codes against insurance companies for hospitals (or fighting them etc). It is just another inefficiency in the current system costing everyone more money.

A friend's brother owned a construction and landscape company. One of their key philosophies was "You have to know how to write a bill." A wide range of equipment types, each with different hourly rates, can be used on any one job. Different procedures can be used. Figuring out the combinations that create the greatest "defensible" profit was a widely acknowledged goal of most companies in the space. I am also aware of training companies that do something similar.

It's a common business mindset, unfortunately.

> It's a total mess and hopelessly complex for the average consumer.

Sounds like something the people on this forum can help improve.

Sounds like something the people on this forum can help improve.

A lot of the problems average consumers face are political/social and not technical (technical problems associated with these issues were solved decades ago). For example, it takes 10 days for my bank to send funds from U.S to my home country. Why 10 days? I have no idea. What I do know is 10 days is extremely unreasonable at the end of 2018.

I filled a form and put "none" for "any visible marks like scars, tattoo etc?" question, because I honestly have none. The form got rejected, now I have to "creatively" answer this question.

When my dad was in the hospital, I got so many bills - I had a lot of trouble looking through those and locating errors (we were charged extra and the only way to find those was to painstakingly go through the bills line by line). I had no energy or interest to do it (when my dad was in the ICU) - every single thing was complex, needlessly so, and was frustrating to the point of tears.

And then comes insurance - ever tried post processing a claim? Wouldn't wish it on my enemy.

There are hundreds and hundreds of examples like these - hospitals, courts/police, banks (even the private ones), airports, any government office in general ... it seems as if they relish in wasting average person's time and money. No amount of software/ML/AI etc can fix these, until the mindset is changed for good.

A large group of people owe their careers and salaries to these inefficiencies, they won't give it up without a serious fight. For example, filing taxes in US - there is no way H&R block, turbo tax etc will go down without a fight, it is just not in their interest to have a simpler tax code.

It makes me depressed to have to fill out some form with information the government already has just to do my taxes. Just send me my return and I can dispute it if I don't like the result.

I guess there is political pressure to make the process as annoying as possible, and not just from tax services corporations.

It's not a technological problem but a political one: the obfuscatory pricing is deliberate.

Maybe you could have "fighting hospital billing as a service", but that's definitely going to need a chunk of human labour on top of whatever AI assistance you apply.

I agree that the problem is political.

While it might be nice in the short term to see some technological approaches to address the mess, the solution is ALSO political, NOT technological.

Making the information public, however obfuscated, will enable journalists and activists to systematically expose this problem for what it is and that's the first step towards fixing it.

The next thing that will happen is that many more people will be able to win massive lawsuits which is the only recourse the healthcare/insurance industrial complex understands.

Is there any way this could be represented via interactive graph? We were able to tame much complex stuff than deliberate obfuscation by people not aware what tech can do.

I guess there is not enough incentive ($$) to solve this problem.

The $$ is being made by the hospitals

See https://www.vox.com/health-care/2018/12/18/18134825/emergenc... to start digging into the mess

But technology can help patients unite against hospitals... Just like Yelp crowdsources the restaurant experience, or Glassdoor crowdsources salaries,and anotherss could collect crowdsourced medical bills and predict prices for procedures.

So, somehow technology can help educate ~300 million people about insurance, procedure costs, payments, and also provide medical education to those 300 million people so that they can wrap their head around the necessary medical lingo?

In a way it's like if Apple was advertising the price of its individual electronic components rather than the all-in price.

It's far worse than that. It's like if Apple didn't have a price for an iPhone, but instead at the register it scanned the package and looked at which factories each part came from and which assembly-line workers in those factories worked on those specific parts, and which mines the minerals came from, etc. and then charged a different line item for every one of those factors.

Sure, the average cost is $1000. But yours might be $5000.

> It's a total mess and hopelessly complex for the average consumer.

But not for insurance companies; it's in their interest to compare hospitals and get the best care for the lowest price.

I for one hope this will trigger competition. On the other hand, it'll probably end up shafting the personnel instead of the ridiculous profit margins.

The idea of effective competition in emergency services has always struck me as fanciful.

The benefit that competition provides to incentivize lower prices and better services is a consumer's ability to easily deny someone their business and go elsewhere.

What would this look like here?

Would one be in the back of an ambulance doing price shopping on a tablet as they are fighting some terrible injury?

Perhaps tie in different billing departments in a conference call as they bid over who will do the critically urgent surgery as the patient slides in and out of consciousness?

Maybe decide to have a heart attack during a winter sale special or reach into their dresser to get a coupon out as they collapse to the floor?

Or would someone be placed on a transportable life support system as they get ferried across a city deal hunting by having different procedures at different institutions, expecting them to talk to each other and string together piecemeal lab results for a coherent diagnosis?

Maybe someone would do the work beforehand, search all the popular ailments and their procedures and then do price shopping in good health and prepare an execution plan if they fall ill?

Maybe there's a non-absurd example, but I honestly can't think of it. The competition mechanism seems to be a completely unrealistic application.

Even if you limit competition among hospitals to non-emergency procedures, it would still be enormously beneficial.

But even with emergency procedures I think you could still have effective competition based on outcomes and price. Here's an article suggesting that in some cases a poor quality hospital will triple your chance of death compared to a good hospital [0]. With more data, I could imagine a study that says, "Hospital B is so much worse for treating heart attacks than Hospital A that it is equivalent to delaying treatment by 20-25 minutes". Paramedics treating a heart attack victim would therefore have a fairly simple calculation: What is the difference between estimated time taken to reach Hospital A and estimated time taken to reach Hospital B? If more than 25 minutes you choose hospital B, if less than 20 minutes you choose Hospital A, and if between 20 and 25 minutes you choose whichever hospital historically charges the least for heart attack treatment.

[0] http://www.nytimes.com/2016/12/14/business/hospitals-death-r...

Ambulance staff are incentivized by pretty nurses and free food/snacks. Ask any paramedic in a city with enough choice of hospitals and they'll tell you.

What is the best answer to the "emergency care competition" that you've found?

And what proportion of medical spending is on emergency vs. not?

Even in non-emergency care, perfect competition requires perfect knowledge (the consumer to know medical knowledge), perfect information (knowing the exact quality of care from all competitors beforehand), rational buyers (having no preexisting biases based on irrational cognition), no barriers to entry or exit (ie, being able to switch hospitals mid stream), no network effect (the previous state...eg who does the lab work, shouldn't have an outsize influence on the subsequent, eg who does the diagnosis... See dollar auction for an extreme example https://en.m.wikipedia.org/wiki/Dollar_auction) and a variety of other fairly unachievable factors which do not apply here.

It's not a good model to structure the allocation in this particular instance, too many conditions are nearly impossible to satisfy. It's not a sensible way to design this market.

>>What is the best answer to the "emergency care competition" that you've found?

Pay what the insurance or medicare pays, plus a capped xx% because they got a volume discount. By law hospitals have to stabilize you, can't let you die, money or no money. (I know they have been cases of trying to dump patients but...)

So you saved me, but how did you come up with the $455,000 bill? We entered into a contract without prices, so the prices should be customary. 5-10X what insurance pays isn't fair.

I'm not sure this is the case. Since medical insurance companies are heavily regulated on margins, their primary way of making money is investing the "pool" that's used to pay out claims. The size of this pool is determined by actuaries, so it can't be increased arbitrarily. But it grows in two ways: more patients, or more required reserve per-patient. In this way, insurance companies actually benefit from higher hospital prices.

Health insurance has ridicolous margins? Whats your source?

I'd be happier to see regulated business practices. While I agree that the prices are a problem, I've felt more pain from bills that keep coming in for more than a year after a major event. And when I go to complain, they say that someone made a mistake, the insurance took a long time to respond, or some other excuse. Give me a final bill with all charges within 30 days, then 30 more days to resolve any issues with that bill, and then let the billing end so we can move on with our financial lives without wondering if one more bill is going to show up next week, tied to my credit record.

One thing that troubles me, is the hospital near me does the same thing, but "consoladates the bill". This literally is just a never ending fee that increases and they never list for what.

Every single month I call and they give me the run-around. After 6 months of this, I have yet to pay the full bill until they mail me an itemized list and without fail it's wrong. I contact them, they remove two or three charges, I ask them to mail me the updated one. They do, then next month I receive a bill for those proceedures they removed the last time.

Its to the point every month my bill now goes from $0 to ~$800, then back to $0 by the end of the month. Unfortunately, they now called and threaten the ~$800 "over due bill" to collection's. Luckily, I've recorded and documented everything, so I got it removed (again).

However, I'm just waiting for this to go to collection's at some point, even though I owe zero at the end of every month. I'm 90% sure this is a bug in their system, but I can't seem to get around it.

Having worked for a medical billing office, I hate to say it, but this is the norm. The billing office is often not officially the hospital or medical practice. Although we got all the records, we never really interacted and it was just files on a computer. I used to do write-offs, which was basically taking $10m a day and just clicking "don't need to pay". Usually it was dead people, poor, etc. At least that part of the job seemed somewhat nice.

I currently use hospital billing as an example when explaining the halting problem. You’re never sure if you’ve paid off an incident or if another bill will show up in a few months...

Before we were married my wife had an MRI. Having not met her deductible they sent her a bill for 1.5k. Not ideal but we were able to afford it and paid the bill. 364 days later we received another bill for roughly the same. We thought there was an error. After months of back and forth, even after they had told us for 2months that “they took care of it and we would not be charged” we ended up having to pay another $500. This whole process was beyond infuriating.

The other bill apparently came from the Dr who read the MRI. The fun part was we were never contacted by that Dr about the results. She eventually left the hospital and she canceled our follow up appointment.

The part I love is when the insurance company points the fingers at the clinic, and clinic points fingers at insurance for how long the whole thing takes, meanwhile I get sent to collections.

/now I pay a few dollars (no matter if I owe something or if they owe me) near the end of the 90 days those two companies have to figure out how much I owe so I don't have to deal with collections.

Think that a provider gets that billing cycle as well. Every patient that has insurance means the provider needs to collect from 2 different agencies: through the credit card in a copay and through the insurance, that fights the price.

I've heard of why the insurance companies usually take a while, something to do with HIPAA and some insurance companies being bought out, so now they have to forward information back and forth, all whilst remaining compliant. At least something along those lines is what someone from HR at my company (not related to the medical industry) was telling us one time. I wasn't able to find a good article on it though sadly.

It is regulations that have given us the current obtuse system.

When you give agency to someone so they can "fix the problem" you inevitably create a means for wealthy special interests to grasp control.

My guess is that eventually the govt will step in and start regulating prices if providers don’t.

One interesting idea (not well thought out at all) would say that all prices need to be +\- 50% of what Medicare pays.

Medicare pays $20,000 for stent placement? Great! You can charge whatever you want up to $30,000.

A lot of effort goes into setting Medicare rates (and they are based on self reported costs across the country), so forcing providers to be in the ballpark of those might help.

It wouldn’t solve the issue, but it would eliminate those ridiculous “why do you charge $10,000 for an MRI when the clinic down the street charges $1,000?”.

> all prices need to be +\- 50% of what Medicare pays.

This is actually close to what happens with private insurers- they negotiate with a hospital to pay n-times what Medicare pays for some set of treatments.

So why does Medicare pay the least? Because they have the most patients covered of any insurance network in the US. That's a hell of a bargaining factor. More patients = cheaper prices.

The logical conclusion is to then have Medicare for all. That'll regulate all prices to be exactly what Medicare pays!

That still doesn't explain how prices of medical services in many other countries turn out several order of magnitudes smaller than commonly encountered prices in the US.

I've discussed this before, but I think there's quite a bit of funny money in hospital bills -- a 10k bill rarely actually materializes in 10k transferred across all parties involved.

Doctors bill $10k to your insurance, the insurance decides its too much, lawyers are on-hire to negotiate and take a 30% cut of the outcome, and finally 2k is paid out; the absurd bill naturally accounts for the absurd process, and I don't think anyone except the consumer ever expects 10k to really be 10k. And ofc, the insured consumer only ever pays $500 of it from his deductible.

This was basically Shkreli's defense as well -- the insured patient doesn't pay anything close to the bill given; and I'm pretty sure, neither does the insurance. If you want to raise the price be $10, you add $1000 to the bill.

This type of billing practice causes a mess of winners and losers, essentially unless your insurer has good pricing with wherever you end up getting treatment (often not a choice you get to make in an emergency), you can end up holding the bag for the cash price, usually half of the $10k number you mention. Quite ridiculous when other insurers are paying less than half that price, smells of a scam.

I'd be curious to know how much of that is caused by malpractice insurance. I mean if hospitals were overcharging so much, then surely we should see lines of rolls royce in the hospital parking lot. Doctors are well paid in the US but they are typically not rich.

HDHPs are becoming extremely common. A $500 deductible would be amazing. Deductibles in the thousands of dollars are more common - mine is on the higher end, $6600, while still costing more than 20k a year.

Are the prices that Medicare pay orders of magnitude different? ISTR that Medicare and the VA both pay about $10k per patient per year, which I think is comparable with the NHS. No sources as this is half-remembered.

People on Medicare are over 65 and people in the VA have been in the military. Both of those groups of people are going to have much higher medical needs than the general population.

NHS spending is £2892 per person/year, that's quite a bit lower.

We would also need to know the average number of visits per patient before this data means anything otherwise it's just data without context or meaning.

US health spending in aggregate is between 2-3% more than comparable European countries. Life expectancy is several years lower.

Because doctors in the US can easily make $300k+.

No. Medicare pays the least because the don’t negotiate. They just set prices. As a hospital/doctor you can choose to accept Medicare patients or not. Most providers lose money on Medicare patients, or so the like to say.

What do they mean by "lose money"?

Even if I turn up at a private hospital here in Norway, I pay nowhere near what you would pay in the US. Which tells me that either hospitals are run extremely inefficiently in the US (orders of magnitude worse than here) or there are layers of pretty substantial profit margins.

I may be a bit peculiar, but I think a healthcare sector that is set up to mainly benefit execs and shareholders is a bit immoral.

Medicare reimbursements are below cost of care.

If all insurance lowered to Medicare reimbursements, you will reduce supply.

Wouldn’t it make more sense to properly separate private and public? If hospitals can be either Medicare-only or no-Medicare (using Medicare as the name of a future broad/universal system much larger than Medicare/aid is today) then hospitals would chose to be Medicare in proportion to how many are covered. If everyone (including those who chose a private insurance) pays a full insurance premium for the public system on their taxes, the private insurers’ patient lists would shrink very quickly, and so would the number of hospitals that could survive by providing treatment to those patients. So looking from outside it looks like “hospital prices” is just another one of the problems that would be solved by a tax funded public universal healthcare insurance?

Example (Sweden): I pay a full public insurance through taxes, and I have a private insurance via my employer that lets me cut some waiting times for certain procedures from 90 to 14 days. It’s an expensive way for my employer to make sure I’d be back to work quicker than I would otherwise be. Obviously, this is a luxury few use or need so the number of hospitals that provide this care is extremely limited (a few percent).

If you have public hospitals that are tax funded and private hospitals, you will see that private hospitals will only provide profitable services (cardian, neuro, etc) and give all loss patients to public hospitals (psychiatry, managed care, etc). Public hospitals will have a unreasonable burden of high-cost patients.

Some insurers benchmark Medicare rates for some procedures. It certainly isn’t the majority of rates, those tend to be percent of charges.

And no, Medicare doesn’t have the lowest rates (Medicaid does). The rates aren’t low due to negotiation (hah!), it’s the gov’t basically saying “here is what we pay, take it or leave it”.

Except republicans and bush passed a law a decade ago saying the government can't negotiate drug prices for Medicare. It's beyond stupid and the main reason you see so many niche drugs go up 50x in price overnight lately. The companies have figured out they can exploit that law this way.

So if you eliminated medicare and put all those patients into private insurance, they would all lower prices?

If you look at healthcare vs GDP, the US is way above the line compared to comparable countries. https://www.healthsystemtracker.org/chart-collection/health-...

I think scaling the average costs from other countries accounting for GDP would be a good way to set the rates.

If you look at the actual household income in various countries, as opposed to the GDP, which doesn't always track household income as well for many OECD countries, it turns out that the US has pretty much the healthcare consumption expected for its average household income: https://randomcriticalanalysis.com/2018/11/19/why-everything.... Based on this analysis, I think the primary issue with US healthcare is the fact that people, especially with bad insurance, can be wiped out due to medical debt. On the other hand, even countries that have tried to control their healthcare costs have generally failed to make much impact.

In all OECD countries, unfortunately, healthcare spending doesn't seem to be especially correlated with increased lifespace.

I'm not so sure average household income would be all that useful when income inequality is high. You would have to slice and dice those numbers a bit more to make them even vaguely representative of reality.

Besides, you have to factor in living costs.

I've looked into living cost a few times when considering working in the Bay Area and I realized that while my income would easily double, my living costs would increase a more than just a factor of two. I would have to accept a lower standard of living than I enjoy now.

I think the only way to really deal with healthcare cost is to look at whether or not we think it is a good idea that there is a huge profit margin. For patient outcomes and for society as a whole.

> On the other hand, even countries that have tried to control their healthcare costs have generally failed to make much impact.

Because healthcare is an ever expanding, ever innovating industry with infinite scope. For countries with universal healthcare this is painfully obvious. What once was a service in the 1950s to perform what now would be considered very rudimentary procedures and proscribe < 1% of contemporary drugs, now do space age procedures as if routine and treatment plans that took decades of international cooperation to develop.

> In all OECD countries, unfortunately, healthcare spending doesn't seem to be especially correlated with increased lifespace.

Diseases of plenty now represent greater harm in most of the developed world than do ailments of scarcity.

Please stop using average. Median is a much better measure.

It’s really not in this context. The median household vis-a-vis income isn’t necessarily the median household vis-a-vis health consumption. More generally, health spending is massively subsidized by society writ large. Society’s willingness and capacity to pay is much better indicated by average income than the income of the median household (never mind issues pertaining to measurement of the income distribution within countries!). Furthermore, the vast majority of health expenditures in most high-income countries are spent on a small fraction of the population in any given year (those that are very sick, badly injured, etc.)

Median and average are not good representations of a distribution.

Average can be the median or the mean. Usually the government reports median when they say average.

That's an interesting measure - wouldn't it be biased by the fact that household income in the US is "artificially" inflated compared to other countries, because healthcare costs need to be paid from income?

First, we can assess the degree to which the US is unusual by inspecting the scatter plot. If US household income was somehow unusually inflated by health spending, then it its residual should be much larger than it is (especially in better models that incorporate some of the non-linearity observed in other countries).

Second, just where is this extra income supposed to come from? More likely households bear almost all of the incidence of this spending, meaning each dollar spent on health means approximately one dollar less available to households to use elsewhere. This is certainly what the literature on employer health insurance benefits tends to suggest.

Third, the timing of this is all wrong. It’s clear the arrow of causation goes overwhelmingly from income to health spending because changes in health spending clearly follow changes in income. Over the past few decades it takes an average of about 2-3 years for changes income to be fully reflected in changes in health spending due to the large role played by 3rd party payers, employers, etc (the current year elasticity is about 0.2 whereas the long-term elasticity is north of 1.6).

~RCA

The graph is already adjusted for PPP, so this difference in income should be largely mitigated, shouldn't it? Thus the US still spends about double of other countries.

One challenge is the mix of spending is actually quite different even adjusting for GDP!

Adjusted for GDP, US spending on inpatient procedures is somewhat inline. However, spending for outpatient procedures is way higher. Americans just have a lot more outpatient stuff done than other countries.[1]

[1] McKinsey analysis of US healthcare spending; search my history for actual link or google it!

Honestly, how do people become so easily convinced that price controls would work in healthcare when they don't work anywhere else?

Inventing a fancy index is not a replacement for "price fixing". And price fixing does not work. You reduce supply.

This could also be due to people in the US simply seeking more care than in other countries.

Even if that was true it doesn't necessarily map. Preventative medicine is known to reduce costs considerably for one. Paradoxically healthcare can be expensive because people aren't getting enough care.

FWIW, this isn't what I observe.

What’s the logic in that? If the cost is socialised surely you’d expect more people to seek care than if they were paying?

What’s the logic in that?

Am I going to get a quad bypass just because it is cheaper?

People seek care because they need it. The kind of care that people use more because it is cheaper/available is maintenance care (which reduces overall costs because things are often treated before they become critical).

The first time I heard “I am feeling sick / cut my hand / need stitches but I cannot afford to go to the doctor” was in the US, and it left me dumbfounded - I have lived in a few places, and that’s a US only thing.

Also, I could understand some of George Carlin’s jokes (e.g. “dirty doctor” one) until I had lived in the US.

I think I didn’t make my point clearly. The post I replied to was suggesting that Americans seek care more than others and that’s why costs are higher. I didn’t think that likely, and argue that direct exposure to the cost would lead to people seeking care less often.

Utilization increases with decrease in cost.

In argentina I remember calling a doctor home to check up on a cold. This would be unreasonably expensive in the US for very little healthservice in exchange.

I think there's a balance to be found. Here in France people will go to the doctor for a common cold, and immediately load up on unnecessary medicine at the pharmacy. I'm sure that if they were asked to pay even 5E out of their pocket it would significantly reduce the shortage of GPs and the lower costs.

“I have cancer and I went to the doctor and they gave me painkillers” is a non-US/EU thing.

I think it’s cultural; strong families/communities seem correlated with not wanting to be a burden on that family/community when your time comes. Individualism, as in the US, seems more correlated with trying to stay alive/healthy at any cost.

Please. You cannot be serious. Are you really saying that pricing in the US healthcare system is so broken that the only way to set prices is to take other countries prices and convert them?

It would certainly be a good start.

In fact, the US could improve a lot of basic services if it looked at what other developed countries (OECD) are delivering, and for how much, and made those targets for the next lets say ~10 years.

After those 10 years of bringing the US more into line with the best countries in the world, it should strive to do even better.

Or, alternatively, the US can keep falling further behind.

This applies to quite a lot. Banking, legal, infrastructure, political systems etc.

It amazes me how the US is still arguing how archaic districting laws should work, how to have elections with integrity or manage without paper checks or fax machines.

I realize there are politicsl/historical and cultural differences but there is a combination of exceptionalism (“the US is so special we can’t just look at France and imitate”) and resignation (“yeah we want that but we cant have that because it would never work because X”) surrounding each of these discussions. The US is pushing boundaries in so many areas but when it comes to evolving society in a way that requires broad agreements, there isn’t much to report on

“The US” is not a entity unless you’re saying we should convert to a single payor system, then set prices based on rest of world pricing.

I can tell from first hand experience. Healthcare companies, set prices by market. Specifically, by what price that market will sustain. It just so happens that the US can sustain the highest prices. You know being unregulated and rich af and all.

This is how all industries/companies set prices btw. What you’re saying, It’s kind of like saying, I want New York City to base real estate prices off median home prices in the Midwest because as a buyer I like those prices better.

From the point of view of people from other countries: Yes. Your pricing is fucked up.

That sounds like an awesome idea if you completely ignore all the important things about healthcare differences across countries.

In fact, it sounds like a great way to make things worse!

This is one of those nice ideas that has some pretty serious hidden costs. You’d struggle to compare healthcare in the US to other countries, because the quality of healthcare available (talking about availability, not accessibility) in the US is generally superior to other countries. So you could end up simply eroding the quality of care in the US. Another thing people tend not to talk about when discussing healthcare in the US is how much the US contributes to medical research and innovation. No other nation on earth even comes close. If you adjust the system so much that you remove the incentive to carry out that research, then the quality of care in literally the entire world would suffer.

I disagree about quality/availability. In Japan, Taiwan, Mainland China, Thailand; I’ve had amazing health care for the fraction of the price. Shit, a full cancer check only cost me 90 dollars in Japan. Getting my eyes fully checked for retinal tears cost me nothing due to national insurance in China.

In some cases, maybe the US has better care. But the cost of that is just way too damn high.

Yes, medical research in the US is superior, but that shouldn’t be at the cost of peoples’ lives.

The US health care is optimised for the the p99, top 1% of the population who can afford anything. The other countries you mentioned optimise for the p50, the average person.

In the developed world, the price of routine checkups are not what people would generally be referring to when discussing _quality_ of healthcare. Generally speaking, the US has the best facilities, technology, expertise and pharmaceuticals available. Which is why people come from all over the world for procedures that simply aren’t available elsewhere. Again, I’m not talking about the problems with accessibility, merely talking about available treatments.

Reducing investment in medical research will absolutely come at the cost of people’s lives. More people’s infact, as anybody will die from a terminal illness that doesn’t have a treatment. As an example the US market constitutes something life 70% of _global_ pharmaceutical profits.

In my experience, Russia had a decent healthcare system in the Soviet era. Care was (obviously, I guess) pretty much free. Most physicians were female. And most of them were apparently driven by moral conviction.

The US was rather a shock for me. Costs were mind-boggling, and most physicians struck me as jerks. At least, the male ones did, and they predominated. Nurses, on the other hand, generally seemed OK.

Somehow the US healthcare system seems to attract jerks for physicians, and they seem to be mostly in it for the money. Not all of them, obviously. But enough to set the standard.

I have no clue how that happened. Or how to reverse it.

Edit: Some might ask why being "in it for the money" is bad. I mean, that's what "free enterprise" is about, isn't it? But think about it. Is it OK for priests/minster/rabbis to be "in it for the money"? Or politicians? I hope not. And then, why physicians?

This is anecdotal. To counter, my family have had very good overall experience with physicians in the US. Moreover, my college friends who went on to become physicians are all people I'd happily take my own family to see.

One of the problems with care in the US are clinics that treat Drs (and NPs and PAs) essentially as billing machines, and don't allow them any time to build any rapport or relationship with patients. Depending on your insurance coverage, your location, and your needs, your experience will vary wildly.

Yes, it's just my experience.

For what it's worth, my experience teaching premeds was also not so great :) That's also anecdotal. But colleagues had similar complaints.

Also:

> And we fail to recognize that what we really have is a distribution problem. Parts of this country have lots of doctors, perhaps too many. ... A result is that many rural areas, and less popular cities, experience more of a doctor shortage than others.

> The other distribution issue is in specialization. When it comes to generalists, we ranked 24th of 28 countries in doctors per 1,000 people. Specialists are a different story. There, we were 11th. This is an important fact about the American health care system. We sometimes hear that we have too many specialists and too few generalists. That’s not necessarily the case. We have an average number of specialists compared with other advanced countries, and even shortages in some specialties. It’s the ratio of specialists to generalists that’s the problem. When you compare the percentage of physicians who are generalists with those who are specialists, the United States beats only Greece among developed economies.

> Here, financial drivers play a role. Doctors who choose to specialize can make much more money, millions more dollars over a career, than primary care physicians.

https://www.nytimes.com/2016/11/08/upshot/a-doctor-shortage-...

Also see https://www.politico.com/agenda/story/2017/10/25/doctors-sal...

Medical research in the US comes out to something like $500/year per capita. It’s doesn't come anywhere close to accounting for the cost differences between the US and other first-world countries.

I didn’t say research alone did. I said that when you compare investment in research, as well as the quality of care, you’d expect the cost of healthcare in the US to be higher. As much higher as they are? I don’t think so. But if you want to fix the accessibility issues without impacting innovation and quality of care, then you’re going to need a solution slightly more thought out than hamfisted price fixing.

> as well as the quality of care, you’d expect the cost of healthcare in the US to be higher

If the quality of care is so amazing I'd expect Americans to have longer life expectancy, and they don't.

You're implying that both the quality of care and the amount of medical research done is a result of the profits of the medical companies. I'm not sure that this is the case.

Profit is the only thing that drives investment in care and research. You’re asserting that you can reduce profits via price fixing and still deliver the same outcomes in both care and research.

Profit is the only thing that drives investment in care and research

This is manifestly untrue in so many domains, including medicine. Most research is heavily government funded, particularly pure research, and most academics are not interested in profit. The only orgs motivated by profit (drug companies, insurance companies) are the ones who push this misconception, because they profit from it. As one example, the UK runs large trials comstantly to improve care, without a profit motive.

Nobody has to postulate that price fixing (as you call it), or single payer healthcare without insurers works better, because the rest of the developed world outside the US uses that system and delivers very similar outcomes for radically lower cost. The facts are clear.

Whose profit?

If you refer to the professionals’ compensations that’s correct, but not that useful as it applies to all of the adult working population.

If you’re referring to the capital accumulation of investments in healthcare companies, you’re off the mark, as there are several examples that falsify your statement, even in the US

I disagree from personal experience. Location of where you are in the US matters. I'm in Montreal right now and the mental healthcare here is superior than what I experienced in the US in Michigan (majority of my life). I would even go as far to write the mental healthcare in USA, which I received ruined my life. If only I had the pleasure of what is available in Canada for my whole life.

The further toward the poles you go, the more mental healthcare is needed, so it makes sense they would have the experience and infrastructure! (Completely serious.)

This isn't necessarily the case with my situation. There was only one hospital for where I lived in Marquette, Michigan. My mental healthcare was pertaining to gender dysphoria and not depression which I think you're associating with longer winters. Anyway place I grew up was filled with religious nuts to make things short. They forcibly prescribed me with antipsychotics while ignoring my right & modern medical approach of gender dysphoria. Montreal is a large city compared to that place and is progressive like California. So basically where you're located when it comes to social structure is huge.

I think I might have heard this at some point in the past.

Anyway, I found a reference to support your claim:

Also consistent with the conclusions of Torrey1 and Saha et al,2 our analyses shown in table 3 found a strong tendency for prevalence to increase with latitude.[1]

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2669590/

The Indians have better cardiac surgery outcomes. I don't care about anything but outcomes. It's no surprise, though. Their guy has done 150 surgeries in the last year. This guy has done maybe 40. No good. If things are so much better here, why are outcomes not as good? IMR, MMR, even with companies that have comparable or stronger definitions.

The evidence is constantly against US healthcare except for experimental or rare treatments. The doctors aren't any worse, surely.

At the top end, this will be true. Surely, a well-trained surgeon is a well-trained surgeon and mechanically they should all have roughly equivalent skills. The difference lies in experiential knowledge: knowing what to do whilst in a surgery, based on practical experience and seeing similar patients. We've interviewed four of the top pediatric cardiology centers in the past two months, searching for the best treatment option for our daughter, and only 1 of them has a research focus in the needed area, accompanied by a specific treatment protocol and specifically trained staff. That's not because the other hospitals are "worse". It's a result of our daughter's need being extremely rare, with very low demand. Even the above-mentioned hospital only sees ~1 patient per month (compared to maybe 1 per year or fewer at the other hospitals).

I 100% agree: experience is key ... but so is a clinic's/hospital's internal investment in any given speciality. And if it's a teaching/research hospital, so then is publishing by its clinical experts.

The specter of price controls.

They dont work, simply because if you limit payment then hospitals will stop doing the procedure, will fight against doing them, and will engage in high cost cutting to provide them. Please remember that about 60%+ plus of hospitals are non-profits: they only bask in the profits for their own salaries, but don't have the profit-based mentality usually accussed of.

You might want them to do that, but I doubt the market will agree with you on that one.

> My guess is that eventually the govt will step in and start regulating prices if providers don’t.

There will be a heavy pushback from industry about how that’s socialism, delivered via Fox News and other conservative outlets.

Well that is socialism. (As is our conflation of insurance and charity.) Being a form of price control, it also happens to not work very well.

EDIT: and if anyone can explain why forcing doctors and hospitals to provide their services at a loss, is not socialism, then feel free to reply; as that will be assuredly more enlightening than a simple downvote.

I didn't downvote you, but I'll take a stab at this!

> Well that is socialism

As indeed is provision of roads, fire trucks, police, military and so on. For some reason, people rarely call those out

> Being a form of price control, it also happens to not work very well

I think there's a strong strong case that it works very well in every rich country, because they're all doing it to some degree?

> forcing doctors and hospitals to provide their services at a loss

This assume they're not currently making super-normal profit, which I'm far from convinced by.

>As indeed is provision of roads, fire trucks, police, military and so on. For some reason, people rarely call those out

Personally I would call out. But hey, so what if I did? As you rightly pointed out most people are convinced that they need the govt in their _many_ aspects of their lives. I'm outnumbered by people who think, that they can decide what is good for me as an individual.

Why put a minimum? Why not just the cap part?

I actually stiffed a doctor once because he refused to give a price up front and when I got the bill it was outlandish. I also made a huge scene in the intake/waiting room about this. I was leaving the United States at the time so I didn't really care about my credit record.

To be slightly more honest: he wasn't the doctor assigned to me on intake, he was another doctor from another hospital across the street as a consultant IMHO trying to get onto my case so he could bill me.

Had new insurance and a sore shoulder. Was billed ~$1,400 for a physical therapist to examine it ("evaluation"). No treatment. Very little covered by insurance.

The next day had a chiropractor treat it and shoulder was fine. $25 with coupon. Funny part is, as it was new insurance, I spent over 30 minutes with insurance rep in advance on phone going over options and trying to get an idea of likely costs.

When I had a heart problem and no insurance, we called providers all over town (Minneapolis) to try to get prices in advance. Most would only give estimates over a wide range. Some flat out said it was there policy to not give estimates. Eventually found a cardiologist who worked basically free ($30 plus donation). I bought a Kardio to record my own ECG so I can have more data to improve my communication with cardiologists, who are (understandably) a bit alarmist about what can go wrong and tend to err on the side of (expensive) caution without sufficient data.

Feels like a broken system.

So you have insurance but it doesn't cover stuff when you are actually ill? Does your insurance policy actually spell stuff out so that you can predict what will or won't be covered?

Note: I'm from the UK and find the stories about US healthcare insurance grimly fascinating....

Not just health insurance, but healthcare is crazy too.

Spent a total of 36 hours on the phone with the hospital to figure out how much something would cost because I knew I had to pay out of pocket. And they weren't even right when they finally gave me a number.

Had a doctor remove a cotton ball from my ear in the hallway. Charged me 2.4k for that. Didn't have insurance either.

My wife's friend delivered her own baby in the hallway and they still sent her a bill for delivery.

My wife had her gall bladder removed, supposedly the most common surgery. Surgeon charged 25k, hospital charged 65k, anesthesiologist charged 3k, and a doctor that talked to her for 25 seconds charged 1.5k. Insurance and the hospital argued over the bill for almost a year, during which time the hospital kept sending me payment due notices.

No one in this industry has my sympathy.

I couldn’t even get the billing codes for a routine ultrasound. And no one will ever respond to you in writing for anything.

Welcome to the US.

I'm currently fighting insurance because they won't cover a GI tract test without "proof" from another test first.

OK that's understandable. You don't want random people asking for tests all the time, but the Dr already saw me, and gave me meds to fix the issue that would give the insurance company "proof." There's just new complications now.

So I get to wait until everything comes back in full force. Last time I couldn't work for a few weeks, but hey at least they're saving a few hundred at most now....

This is still a better experience than the issues I had with my jaw. The jaw issues are the only pain in my life that was bad enough I blacked out twice from it. But insurance won't cover that because they think it's a dental issue, dental won't cover it because it's the jaw.

The only treatment for the jaw I got was because a jaw specialist lied on the insurance papers. He said he wrote down headpains, not jaw issues. He said he learned that telling insurance companies the truth is not what gets them to cover their clients.

/sidenote that jaw pain is second to none. It runs circles around any migraines (the dark room, no sound kind) I've ever had. Never knew there was such pain before.

On the phone in advance, was given some hint of what could go wrong.

Basically, it depends on how the provider "codes" the treatment. You can contest the code, i.e. say you should have been billed for something other than what they are calling it. There is apparently a very wide range of things similar visits could be coded as.

The majority of medical related bankruptcies in the USA are from people with insurance.

https://www.thebalance.com/medical-bankruptcy-statistics-415...

The differences in the prices you mentioned are astronomical...

I'm already getting angry here to be charged $50 instead of $25 when the doctor "touches" you during some basic evaluation. But at least they tell you about any massive amounts coming up before any treatment happens.

It's not sane. With insurance, was hospitalized for a heart condition. ~$45,000. Found no problem in testing, so they kept ordering more tests, sending in more cardiologists. Kept hearing "I know you've said this several times already, but please repeat for me...". Each time I repeated the story to a different doctor there was a large bill. Clearly the hospital new how to pad the bill.

I eventually left "against doctor's advice" though there was a doctor there that agreed with me leaving. Pursued lower cost versions of remaining tests recommended on outpatient basis.

The funny part that time was there was a "patient billing advocate" in the hospital, who was magically never available over the three days I was there despite repeated efforts by us each day.

"With insurance, was hospitalized for a heart condition. ~$45,000"

Please tell me you didn't have to pay the ~$45,000 personally?

We had to pay our ~$8,000 deductible, everything above that was covered. We paid by negotiating a one lump sum payment and got 25% off. Had a relative with more cash flow make the payment all at once then paid them in installments. Was told by a doctor later that they only get paid 75% of what they bill by the insurance company, and that considering that, the 25% discount made sense. Tried for a 30% discount but 25% was the best we could do. I pre-negotiated 25%, then had the relative with more experience in negotiating close the deal and try for 30%.

There was a substantial upside. The cardiac event happened early in the year, and everything covered by insurance for the rest of the year was 100% free. We were able to pursue some things we probably wouldn't have otherwise. Simple things like having more cough syrup on hand became a no-brainer as cost of visit and prescription was guaranteed to be $0

I wouldn't compare a chiropractor to a physical therapist, but $1400 for a sore shoulder? Was this in the ER?

No. Set up the PT evaluation through regular channels, showed up at scheduled time, etc.

They aren't directly comparable, but I wanted to point out treatment vs. evaluation costs experienced. Chiropractor was evaluation and treatment, PT was evaluation only.

I had to assume there was some kind of error, but contesting didn't help. Probably could have contested harder/smarter, but decided instead not to pay. This provider does not turn non-payers over to collections (no credit impact), and does not refuse later service to non-payers. This was the only item I refused to pay via this provider over years going through them.

most doctors in the US actually do not know about the prices of treatments as it changes based on insurance administrator/insurer, and then what the patient pays also have huge variability based on insurance administrator/insurer.

Most doctors in the US actually do know how pricing works.

95% of the time if ask a doctor the cost of a procedure they have more idea what the cash price is, not to mention whatever my copay will be calculated to be based on my insurance and its agreements with the service providers.

That's not what parent said. Sure, they arguably "know how pricing works". Their staff (or at least, their data systems) know about each patient's insurance. And hopefully, what physician services it covers. But I doubt that physicians themselves know that stuff. It's not what they focus on.

In my experience, staff generally know how to code referrals for lab work and specialists so patients' insurance will cover it. But sometimes they screw up. So for example, I've been prescribed a testosterone supplement. But insurance won't cover testing for blood testosterone, level unless they use the right diagnostic code. Also for prostate-specific antigen checking. They have to code "enlarged prostate" in order to have it covered. There's another code for routine testing, but it isn't enough.

They know in generalities how it works, but I doubt that most doctors in a hospital setting can tell you how much a particular procedure will cost you.

Even my dentist in a private practice often doesn't know "Well, we'll bill this to the insurance company, but they might not cover it all so we'll have to bill you"

They know how it works but not the exact price of an aspirin. They can't exactly tell you to go to the pharmacy out of your hospital bed to get a $2 bottle vs a $50 pill from them.

Is it not reasonable for them to ask, if they don't know? Also should they not have a general ballpark idea? I'm British and would expect Drs to be aware of costs before advising treatment (ruling out cheaper to rule out things etc).

No, because it will be different for every patient (for the same treatment) and will fluctuate widely from year to year. Also there is a general ethical sense of recommending the best treatment and dealing with cost as an afterthought.

I get why they might not be able to tell you how much you'll pay because of your specific insurer, but why would the overall price of the treatment change with it? That seems bizarre.

The doctor has no clue how the nurse (or assistant that handles billing) will bill the interaction, as they'll often optimize billings to extract the most money possible from your insurer.

Its scummy and fraudulent, but issuing a large bill to an insurer, then getting a much smaller check back is how medical billing works here in the USA. Having your insurance pay for a trip to the ER after a car accident would be $7k for them, or $84k for your car insurance, hence why one should carry a car insurance policy with good driver/passenger injury coverage :P

The cost for the provider is the same, but what the insurance pays is in someone elses hands. If you wished not to abide by the insurance, just pay out of pocket.

Insurance should really be only high deductible plans, so the patient really looks into pricing for his general care/periodic care.

One thing I advocate is fixed pricing. It's great to put prices online, but as long as insurance companies and such get to make deals there will be no real transparency or competition. The one downside I see to enforcing the prices is that it would ruin this ability to offer a break to people who need it.

On the other hand, with enforce posted prices those prices would come down to levels similar to what insurance companies pay so the sticker shock to those uninsured would be significantly lower. Still, there will always be those in need.

It's a good goal, but this is a very complex system.

For example, if published prices were brought down to slightly-above-insurance rates, fewer people would buy insurance.

Consequently, insurers would have less bargaining power, further erroding their price advantage (and financial solvency).

As an end result, absent regulatory mandate, non-high deductible plans would cease to be market viable.

Providers, insurers, and patients are in a zero-sum competition for the same dollars.

The ultimate question is -- do we want the US medical system to look like the US air travel system?

On the whole, it seems like it would be better than what we've got. But I think we could do better (specifically: smooth boom/bust cycles, increase healthy competition)

> For example, if published prices were brought down to slightly-above-insurance rates, fewer people would buy insurance.

Would they? I don't buy insurance so my doctor visits are only $20 - I buy insurance so that if something catastrophic happens to me, I'm not on the hook for hundreds of thousands of dollars.

Even if the cost of (e.g., brain surgery, emergency appendectomy, resetting shattered bones) was the same as what insurance pays, I still wouldn't be able to afford it.

I would hazard to say that both of us aren't in the demographic where $20 matters.

But for a lot of people, $20 vs $250 is the difference between going to a doctor and not.

Separate from that there's the catastrophic vs no coverage argument. If you're struggling to make rent at the end of the month, it's probably a smarter personal bet not to buy insurance.

But patients without at least catastrophic are corrosive to our medical system, and what the ACA mandate was targeting.

Personally, I think the ACA mandate for a catastrophic policy, with preventative care included, and direct cash subsidies to people at the poverty line (to cover routine care) is the best solution.

I'd expect the ACA designers considered this, and only broadened the mandate requirements as a horse trade to insurers for assuming the risk of offering marketplace plans.

Yea this is exactly why I only ever get high deductible insurance.

IF you do fixed pricing in medicine, then as a provider you want to turn away care from expensive patients. They become huge money sinks, so you have to do everything in your power to turn them away.

That's the way it works in Maryland; medical providers are only allowed to have one rate card.

Presumably, this is based on ICD10 codes... but there can be 30 different services tied to a code. You still won't know what code is being charged until after the service is rendered, and if it's rack rate you won't know the actual rate your insurance will be charged, until THEY tell you... because that is proprietary information (just like the reason why your treatment was denied coverage).

Imagine you have diabetes and want to know which provider or insurance company will give you better endocrinology rates... it's the best case treatment knowledge scenario, but you can't figure anything out without knowing the secret negotiated rates for each possible coverage pair.

>Presumably, this is based on ICD10 codes... but there can be 30 different services tied to a code. You still won't know what code is being charged until after the service is rendered,

This is not the case in CA. Chargemasters have already been public since 2011, and they list everything the hospital will charge for.

Are people really billed based on diagnostic codes? If true, it’s not what ICD-10 was designed for.

Patient A can recover from the same procedure for the same diagnosis much quicker and with fewer interventions than Patient B. Would insureco get billed the same for both?

They aren't. Prices are based on the HCPCS codes (CPT for clinical charges). For example, a 99213 is a return office visit.

Providers often enter ICD-10 codes (required by Epic) and do not know HCPCS or CPT... so how could they tell you what you will be charged? There isn't a way (that even educators know of to get those codes or the pricing)... the prices are handled by billing, which is a separate department and you can't reach them by phone. They will call you back (within 30days), but they do not leave messages.

Clinic and hospital in the heart of silicon valley.

This is a start but will be useless unless how these published prices are arrived at are regulated so they can’t be gamed behind discounts, copays, deductions, insurer discounts, tacked on items, etc. It’ll be like buying a mattress and trying to do price shopping.

The published prices will need to have a readily useful and predictable meaning and interpretation.

Exactly. As it is, everytime we end up with a sizable bill I call and ask for a discount, and right away they tend to give a 10% pay in full discount. I've seen this through different providers and insurance plans. I would have never thought about it until someone suggested it to me.

Hah, yeah, I even pad my product prices so that when I run a sale, I still get my profit.

The next logical step is to require written estimates in advance, just like the auto repair industry.

The reason you can get a written estimate is because there’s a big book the service writer flips to, “hmm, front swing arm bushings on a ‘12 Corolla: 2 hours. Front end alignment: 0.75 hours...” Worst case is, I get the acetylene torch out for those rusted-to-hell front end bolts, but it’ll take me about what the book says, usually less. Well, worst case is a bunch more front end parts are shot, waste of money to do just bushings, and customer doesn’t want to spend the money (after the requisite phone call). Bolt ‘er back together still broken, and send them on their way.

You figure out how to apply that same scenario to cardiac surgery, and you can have your written estimates.

Doctoring really isn't all that different in principle. The actuaries have these books and already do estimate these costs. And the overwhelming vast number of procedures are consistently predictable.

There's a couple ways of managing unforeseen issues, the simplest of which is to pad the total with a comfortable risk margin. Or allow extra billing for emergencies, but publish rates on how often they "miss" their estimates like restaurant health codes.

Right now they're not even trying.

That only works for non-urgent care and when estimates are cheap enough to encourage shopping around. Although even free estimates cost you time.

Most health care is non urgent.

To underline this, the amount of money spent on emergency care (the kind where you might not have the opportunity to get an estimate) is in the single digit percentages, and may be as low as 2%.

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

Could you explain a little further? Most industries are able to provide quotes, why shouldn’t healthcare facilities?

Those industries probably bake the cost of estimating quotes into the manpower cost already. Hospital bills would ostensibly be even higher simply to provide quotes.

But I believe his core point was up front. When your arm is off, you're not going to ask for, or even reject, a quote.

I would anticipate though that once quotes are known, and posted to glassdoor-like services, one could develop an app where you point to your arm, select "it's fallen off" and then you are provided the cheapest hospitals for your issue and their ratings.

and require the same price for lone customers as what is negociated with insurances.

and then strangle the parasitic insurance companies that are paid handsomely by the consumer to build pointless bureaucracy and safeguard their market position

Considering the patients have no idea what is going on and therefore no way to tell if what they are being sold by medical care providers is appropriate or not, insurance (who also have doctors reviewing the cases) is actually the only entity that is auditing the work of the medical providers to make sure they’re following the proper procedure and prevent overcharging.

Is this right though? Surely buying 20k knee joint replacements should earn a discount? Just setting it such that it wasn’t taking the piss would seem a vast improvement.

How does prepaying for treatment help with costs at all? Either you _can_ forecast accurately how many knee replacements you are going to do in which case prepaying won’t help you plan better — or you “prebill” for knee replacements and then incentivize doctors to push people into knee replacements to maximize their payouts ...

Economies of scale - if you don’t pass on the saving the money is going to someone. I guess you’re picking the providers (hospital and medical companies) and I’m picking the patient.

s/the auto repair/every other/

Just in time for end of year tax donations, and on a related note, I’m a big fan of RIP medical debt. They buy up medical debt for pennies on the dollar, then forgive it.

It’s too late to prevent credit score dings, but at least it gets rid of collectors for someone.

By law, when debt is sold to collectors, the person that owes the debt should have the option to pay the price offered to the collector. In the current system, hospitals are just paying shady crooks to borderline-illegally hassle people.

This is almost completely meaningless unless it's paired with some serious help in figuring out the total cost of a visit.

Every service that offers this sort of price transparency I've seen so far lists the prices for single insurance billing codes at a time. A lay person isn't going to understand the total cost of the visit from that, because there's no way to figure out which billing codes are going to be make up everything that's been billed for different types of visits.

An average price also means absolutely nothing, if the variance is significant or the medical care depends on circumstances and can, as an example, vary from a single day hospitalization to a 2 week hospitalization.

While this is positive progress, I would really appreciate more effort put on actually reducing the prices themselves.

I guess the more expensive hospitals could see patients choose less expensive hospitals, and forcing them to lower their prices, but I'm not too optimistic of that happening in any meaningful way.

"A lay person isn't going to understand the total cost of the visit from that, because there's no way to figure out which billing codes are going to be make up everything that's been billed for different types of visits."

Another problem is, for many, you won't even know what your ailment and treatments will be until after.

>Another problem is, for many, you won't even know what your ailment and treatments will be until after.

Progress is progress, even if it's not perfect. Many people get diagnosed and treated on separate visits, and many more have long-term illnesses that they know relatively well. Soon there will be a proliferation of guides for common long-term illnesses like diabetes, detailing what billing codes you can expect. Eventually, I hope to be able to put a condition (say, pregnancy) along with some personal information into a computer, and get out the flow matrix telling me the probabilities of all possible futures and the costs of each. That's a long way off, but this is the first step.

When medical costs are being discussed, the relatively rare situation of being rushed in to a hospital unconscious for doctors to do a series of completely unpredictable procedures on you tends to get focused on almost exclusively. In reality, a huge fraction of medical expenses go to (comparatively) predictable things like cancer treatments, where an operation will be scheduled out two weeks in advance. Even a day's notice would be enough time for price selection to happen, if all you had to do was look at a list of providers, prices and success rates.

that problem sounds like a market opportunity

it's that or deadweight loss

How about transparency of medical records - i.e. if I provide some credentials, can I definitively get a copy of my medical history so that I can easily take it with me to another country/hospital?

By definitively I mean within some federal regulation or system that doesn't depend on an employee at a particular hospital getting around to it on their coffee break.

You certainly can under HIPAA, and I’ve done this several times without unreasonable delay. If you’ve had issues, I’m sure the “sternly worded letter from a lawyer” approach would get the gears turning.

Thanks! Are they all interconnected, so that if I use a service like https://www.medicare.gov/manage-your-health/medicares-blue-b... I will get the collected records from different doctor visits at different hospitals?

They are not all interconnected. Most providers have some sort of connectivity to a regional health information exchange network, but there are a lot of gaps and interoperability problems.

Blue Button 2.0 is helpful but currently it only gives authorized providers access to your Medicare claims (if you're a Medicare beneficiary), which have limited clinical value. Getting a copy of your full chart requires going through other channels.

Coral Health (in ios and play stores) lets you do this already for lots of hospitals.

I take issue with this headline. Hospital prices are already, by law, public in the US. The new rule makes it required to post them online, whereas previously you might have to call/email the hospital to get the price list rather than looking at their website.

This is an important distinction, IMO, because I have seen people saying that this is an important step because "insurance/patients can now negotiate easier with a set price list". The issue with this is that, like mentioned above, the public has already had access to these price lists, so this new rule changes nothing in that regard.

The new rule might make it easier for insurance companies or those collecting pricing information to scrape the price data from the hospitals' websites, which is a good thing, but overall I think this new rule is being overblown in terms of the actual impact it will have.

If the only access you have to a price list is through a private comms channel, what guarantee do you have that you are receiving the same prices and service for a given price as someone else?

If the prices were available through a centralized third party (government health agency or similar) then sure, it's not much of a difference, but if the only way before was by directly contacting the hospitals, then it being available online is a big difference in the actual "public" nature of the information.

Also, calling or writing snail mail to multiple individual hospitals for price lists is a barrier in 2018 that not only dissuades, but is possibly physically not viable for affected people.

In my opinion, being posted online is rightfully the baseline for information to be considered "publicly available" (but probably not sufficient) today.

My heuristic is if you can't find out a piece of information by visiting a public library within 5-10 minutes, it's not public information.

There's nothing in this ruling that requires the price list, even online, to fit within your heuristic.

The hospital could choose to place the price list at a url of blahblahhospital dot com / 3424kjfksm34. And to get that URL, you have to call the hospital and ask for it. There is nothing in the rule going into effect on Jan 1 that says they have to plaster the price list on their front page or on Google.

For that matter, they still could give separate price lists to different parties, as long as said price lists are 'online' (eg price list for you is at our_prices dot html, whereas someone else's price list is at our_other_prices dot html).

And, beyond all of this, is the fact that even if you do get access to the price list, it is meaningless to you as a patient. The article discusses this. As a patient, if you want to know an actual realistic estimate of your costs, the only way to get that is to call/go into the hospital and ask, or to go through your insurance company estimator, both of which are already available and aren't changed by this new ruling.

Your points are all legitimate and ones I agree with, but I just don't think this new HHS rule does anything to meaningfully address them.

Not really at this scale. I work for a health care non profit. Medicare has set prices they will pay and the consumer can get estimates for some general procedures but nothing like this. We are going from price estimates for many procedures to a twenty thousand CSV list published online.

One way we could wheedle useful information out of this is how the published prices relate to other providers, especially if there are huge discrepancies.

Telling me an average MRI has an average list price of $1000 at provider A tells me nothing. But if provider B says theirs is $10,000? That could be pointing to something important.

I think that one is a key point. Regardless of the insurance carrier-negotiated discounts, this kind of transparency should make people say "wth?"

Especially as people start working and thinking of how to provide 1:1 comparisons between providers. That's the next step but we need the data first.

The ability to “shop around” for cheaper care sounds fantastic. But could that system actually work for healthcare? Is there anything intrinsic to healthcare that limits the ability of a free market in that arena (morally, economically, etc.)?

>Is there anything intrinsic to healthcare that limits the ability of a free market

Oh, lots (the biggest fundamental failing being that a person will generally pay anything to not die or be in pain -- its why extortion and robbery can never lead to an efficient market). But examining costs doesn't mean we have to apply a market-based approach to controlling those costs.

I was curious at what determines medical prices after recent stay in hospital, my bill was bizarre and it seemed that different hospitals charge substantially different amounts. So I wrote a medical pricing app to explore hospital bills and medicare reimbursement

I still don't understand why pricing so different throughout the country, but at least there is a pretty app to visualize it

https://itunes.apple.com/us/app/u-s-medical-prices/id1376580...

Should be extended to require: * Prices _actually_ paid vs. list price for procedures * All-in prices for the ten most common/expensive procedures (e.g. all associated costs of a heart surgery).

Now if we could just get some kind of all payer system in place. so everyone pays the lowest prices offered. but I guess its a start. The problem is there's not enough competition and not enough schools and we don't allow doctors from other countries to test to become a US doctor. with out basically starting over.

https://innovation.cms.gov/initiatives/Maryland-All-Payer-Mo...

Some anecdotes related in the comments are scary. I'm wondering, how is the situation for a software engineer working in a big company (say GAFA in silicon valley). Suppose you broke a leg skiing, and need surgery and various medical exams. How much are you expected to pay? what's the administrative overhead? same question for dental care.

completely depends on your insurance plan...something like this will definitely be covered, but how much you will pay depends on your deductible, how much you’ve already contributed to your deductible, what copay or coinsurance you need to pay once you meet it, and your out of pocket max (max you will pay for anything in a given year)

I have supplemental “accident insurance” since I’m relatively young and healthy and the biggest reason why I’d end up in the ER is due to a physical accident. With this insurance it covers more of what I would pay in this situation than my insurance would alone.

How much I would pay is depend on insurance plan. How much is payable can be stated. Even insurance needs to publish their payouts for each of published data of hospitals.

Also if someone out of network walks into the room.

Yeah that’s a big one. Also if you have an emergency and go to a in network facility your doctor might be out of network. Most decent insurance plans do say that in emergencies they treat in network and out of network care equally, but definitely not all plans work like that.

It's hard to believe how little progress has been made with medical billing.

My last standard annual physical was billed at $2.6k, had 30+ line items, and despite being covered my insurance left me with an out-of-pocket of $200+.

I guess I'll take this as a win, albeit small.

fyi, Medicare made their reimbursement data available some time ago, including billed vs reimbursed.

https://www.cms.gov/Research-Statistics-Data-and-Systems/Sta...

CEDARS-SINAI MEDICAL CENTER in CA billed on average $2.8 mil for one heart transplant (nearly 50 performed) while Tufts Medical only billed $586k on average for similar number of procedures.

They were reimbursed $345k and $280k per procedure respectively.

Insurance companies should follow suit.

I like to see when title mentions the country. National news websites typically don't include the name of the country, which is a definite inconvenience on global communities like hn and some subreddits

Can anyone recommend some resources to read up on the US healthcare system? I am looking to spend a good week studying the subject so I can have a more informed opinion on the subject.

To have a truly informed opinion, I recommend The economics of Healthcare class on Coursera.

Its only a couple of hours to understand why pricing is so complicated in the US, and why the problems people focus on are usually the wrong ones.

Thanks.

EMR, Health Information Exchanges, teams of analysts organizing standards for information exchange, and mandates for upgrades should have set the stage for transparency beyond published fictional information by providers.

Would someone please comment about these projects? The affordable care act gave more than a billion dollars away for people to work on the exact same, redundant projects in regions across the United States. Did these initiatives reach production and are they running today?

Yes EMRs have been widely deployed, and the majority of providers are now connected to some sort of HIE. This has helped to improve care quality slightly by reducing medical errors and preventing the need for duplicate procedures. However it hasn't had much impact on billing or insurance issues; those will have to be addressed separately.

Medical Records and Practice Management are often two separate pieces of software, with only the latter one dealing with billing and insurance.

I work for a startup with two people and the other guy can't pay a real salary or benefits. So I can't really afford to live in nice areas of the US or really even afford the health insurance and medication for just me even after subsidies. If I needed to visit a hospital in the US without insurance, I know I would be bankrupt.

So my solution is until business starts making money I am going to continue to live in Mexico and get Mexican health insurance.

This is honestly something I look forward to witnessing. Currently it's hard to find detailed financial information for how much a person with whatever diseases ends up being covered per year with costs. I think transparency about coverage is necessary for people being unfairly handled by providers based on their condition being minuscule compared to another disease with a larger population that has better coverage because more advocacy.

There is a similarly useless drug price list. What is needed is crowd sourced discount pricing of the insurance companies, per hospital. Leaks would be welcomed.

It's funny that co-pay I am paying for a service in the USA is comparable to a full private treatment with the same quality in Poland, where I grew up.

It can be difficult for a patient to determine quality of care.

And difficult to compare country against country.

Poland is similar to USA in cardiovascular care, but much worse in cancer : https://en.m.wikipedia.org/wiki/List_of_countries_by_quality...

I'm curious about the quality of that source actually.

Based on the pdf linked from the OECD page [0] it looks like they're measuring the reported incidents of cancer based on medical records.

The medical records for the US may be skewed because they only cover the well-off (after all, the poor can't afford healthcare), while in other countries, like Poland, everyone rich and poor receives care and are included in the statistic.

Also, the numbers on wikipedia are stale, but they don't seem to have changed that much on the OEDC website. The ux is garbage so I didn't click around that much.

[0]: https://www.oecd.org/els/health-systems/Definitions-of-Healt...

List price $72,588.00

Insurance co pays $5600

OK, maybe I am exaggerating a bit but this is useless. Someone brought unconscious to the hospital should pay reasonable and common fees when they leave the hospital, not whatever the hospital dreams up. What the insurance companies pay the hospital for the procedure, maybe with a 20% increase should be it for everyone.

Sadly, I've seen worse billed/reimbursement ratio in reality.

I wonder if the prices listed will be shown in a manner that is legible by the average citizen or if they will be so convoluted that no one will be able to make sense of them.

Reading the article it seems as this will be the case. Hopefully that changes down the road.

Has there been any precedent of patients saying to the hospital at the start of a visit "I agree to pay 1.5x the medicare reimbursement rate and no more, if you don't agree to this I will go to the next hospital"?

Ah, always a surprise to entrenched businesses when freer markets are introduced.

Now this is the way it should be:

https://surgerycenterok.com/pricing/

These prices seem reasonable, even though the cost is in the thousands of dollars.

The question is what happens when you try to get your insurance company to pay this quoted price.

Why the hell would you allow automatic playing video ads that crash the mobile browser? What a shitty site

It’s funny how long it took me to figure out the rule, is being pushed through by Trump’s HHS appointee.

Some of the only info I could find on him by name is how much of “a distaster” he would be published around the time he was appointed.

I’m getting real sick of what constitutes professional journalism. I don’t like Trump, but when accomplishments are effectively hidden, and all speculation is unabashedly negative - there is a problem.

Its about damn time

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