A Common Blood Test Can Cost $11 or Almost $1k
nytimes.com
nytimes.com
An anecdote I like to share with friends back home is related to a routine blood test that she has every few months. The price the provider bills varies significantly, but one time they billed $2900. Our insurance paid them $27 like they usually do and the remainder was written off.
Imagine being sick, having no insurance, maybe no job, and receiving that bill in the mail with absolutely no way for you to know that they would probably accept over 100x less than billed. I can understand why medical expenses are the #1 cause of bankruptcy in this country.
EDIT: One more interesting detail from the podcast and the book it's based on: Those deals between PBMs and pharma companies are secret. Not even the insurance companies know the details of what's in there.
It's also fun to point out that typically this is everyone involved in a consumer getting their drug: * the consumer * the consumer's employer who selects the insurance * the insurance * a PBM who get a Pharma benefit plan for the insurance * the Pharma company that manufactures the drug * the pharmacy you actually buy the drugs. On top of that the actual payment apparently happens often months after you received the drug.
Edit2: Clarifying "PBM"
[1]http://www.econtalk.org/robin-feldman-on-drugs-money-and-sec...
Of course the vending machine was full of junk food, and the contract was with the same company that controlled the pharmacy. These people need to be put out of business.
In some cases pharma co.'s created their own PBMs.
There is a long and storied history of litigation on American drug pricing. If you want to understand the Rube Goldberg machine, I recommend searching the keywords "Average Wholesale Price" or "AWP".
In terms of consumer protection, some states are better than others. Maine was a leader in this area. However it looks like the pharma industry has prevailed.
https://www.policymed.com/2011/06/maine-set-to-repeal-unfair...
If you are desperate and your life is at risk, they can literally strip you naked - just see how many unscrupulous people become rich during wars.
When you are in a medical emergency, and you need a treatment right there and right then - no time to shop around - why should an unregulated, shareholder value maximising business, not extract from you as much as you can afford?
In a free market, you'd also have choice via competition to drive that price down. Right now, hospitals can literally veto their competition by claiming "there isn't enough demand to justify another hospital in this area". So bing, no new hospital, no competition.
And of course, this assumes your provider is out to screw you at every turn. This turns out to not be the case for obvious reasons; your provider still wants your business in the future. In the case of a single hospital/provider (a la regulation) they've got your business no matter what.
Competition is a key force in markets, and regulation in the medical industry provides huge barriers to competition.
Not really though. Like, if I am having a heart attack the correct answer to "Which hospital do I go to?" is always going to be "The closest one equipped to handle it". Well technically the one I get can to the fastest that can handle it but you see my point.
This kind of choice via competition would work for things like optometrists and GPs (assuming you live in an area with more than one general practice) but just plain doesn't for emergencies.
An because it's so obvious, people will want to be prepared for it. By having insurance (real insurance, not the bizarre "health insurance" construct we have today), or subscribing to some service like you do for when you car breaks down etc.
I'm not sure what exactly would happen, but I'm certain it won't be that people will just never think about this until they all, one by one, have a medical emergency and have to unexpectedly pick a hospital on the spot.
Because if hospital B isn't my choice but I'm closer to it when the emergency happens I am going to hospital B
But that is not at all what I'm asking about. You clearly didn't read the post I commented on.
If my basement is flooding and I sound rich and dumb to the plumber I call, I might get quoted triple the price of one of his regular customers, sure.
But there won't be a Plumbing Benefit Manager company as a middle man that has a "negotiated special hourly $800 rate" with the plumber so I don't have to pay the "official $9340 rate".
That sort of complex plunder reeks of regulation to me. I can't imagine how it arises. Which is why I asked.
Gouging related to temporary situations is a laughable comparison.
The comparison isn't laughable at all.
Send out a flier in the Sunday newspaper and the margins on medicine will reduce to as close to zero as possible just like food.
I worked for a time in pharma and believe me direct to consumer was seen as a boon to profit margins, not a constraint.
Public transparent pricing that will drive consumers to pick and choose their health care providers would do great things for the ridiculous situation we are in.
But I never see ads for cheap drugs.
So I think you're talking about different things.
I'm sure this analysis[0] has plenty of critique waiting to pounce, but it's something to consider.
[0] https://www.peoplespolicyproject.org/2019/04/08/us-workers-a...
A less nuanced explanation is to agree that in an unregulated market, this type of excessive rent seeking would not exist. The old and sick would simply die in the streets. (Actually that's not quite fair since in an unregulated market we wouldn't have streets.)
Obamacare alone added 20,000 pages of regulations.
https://open.live.bbc.co.uk/mediaselector/6/redir/version/2....
This kind of discrepancy makes these debates somewhat pointless as different sides talk past one another.
There are many reasons - high quality of medical staff, top notch equipment, just a good place to be. Also, Suisse is long term perceived as creme de la creme in many aspects of life, so this fits the overall picture, be it real or some wishful thinking (mostly real though).
In Utah I've gotten further, but usually if they knock off 20% I've had a good day. It's insanity. The market is completely messed up.
It’s a stupid game about who is the biggest bully. Not many people have the nerves for this.
I read somewhere that’s how to fix your credit rating, wonder if it’s also good for s discount ;)
Also interesting, e.g. what happens if you lose your job, decide to go indie or until you find another job... In other words, how safe you feel? (compared to living in Australia with their universal healthcare)
Unless your employer pays a portion for you, expect to spend $4,000 to $8,000 per year per person on health insurance premiums, depending on your age, plus up to $3,000 or so on out of pocket costs assuming you need medical care.
It’s just your lifetime’s, up to 65 or whenever Medicare (taxpayer funded care) kicks in, health costs amortized over your whole life and then discounted for age since younger people don’t need as much healthcare.
In America, the voters want doctors and hospitals and drug makers to provide everyone, no matter how destitute, with services and medicine. But the voters also don’t want any to pay any additional taxes, so this is all a work around to that.
Poor people and old people get subsidized by Medicaid and Medicare (taxpayers) and they pay less or nothing at all, so the providers go after everyone else (middle class) for as much as they can. The bigger employers who have negotiating power can do well for themselves, but the smaller employers/individuals on healthcare.gov get screwed because they don’t have enough negotiating power to prevent getting taken for all they have.
Everyone assumes if youre dirt poor you get Medicaid. But at least for some states as I’ve found out that’s far from true. In Florida for example (we have a poor friend there who is sick) non disabled adults do not ever qualify even if they earn zero dollars.
https://www.benefits.gov/benefit/1625
> To qualify for this benefit, you must:
> Be over the age of 64; or > Be pregnant or have a child 18 or under; or > Be blind or disabled; or > Have a child, parent, or spouse in your household who is blind or disabled
By suggesting my friend needs proper motivation do you mean she should get pregnant so as to qualify?
Re avoiding treating people with chronic conditions, my understanding is that used to be a (state-by-state) thing that the ACA federally outlawed. We live in NYC where the state had already outlawed it, so even if the ACA is rolled back we should be fine.
We have very good insurance atm. I would go so far as to say, ignoring the general craziness of dealing with the US system and the occasional billing frustration, we have better coverage now than we did in Australia because _almost everything_ is covered (even most things Australia would consider "elective" and hence one would pay for out of pocket). We pay a token $1/month for premiums because law says we have to contribute and my employer pays our deductible. As long as we stay in-network we have basically no out of pocket costs.
If I lose or leave my job I have to find a new one and transfer my visa within 30 days, or leave the country within another 90 days after that. There's a thing called COBRA which allows you to pay a relatively low fee (iirc it's ~$700/m) to continue with exactly the same insurance post-employment for a short period (I think 9-12 months? Unsure exactly). Otherwise we'd just move back to Australia. We're both Australian citizens and we aren't really interested in making the transition to being US permanent residents.
Boy, are you going to be in for a surprise if you ever utilize COBRA. If there's a "we" involved, plan on about double that, because you will pay the full, undiscounted premium. They don't want you on that plan, and they only do it because of federal law, so they're going to make it as unappealing as possible.
insurance post-employment for a short period (I think 9-12 months? Unsure exactly)
18 months.
What I think we need, however, is a model that doesn't depend on single-pricing to work, because the real world isn't single-buyer.
People tried to solve it by creating healthcare savings accounts, but the solution itself is very complex, and the end user is often in situations where they don't have the ability to negotiate (e.g. emergency health care). So in practice, the financial benefits seem to accrue with low-care patients, not low-cost-of-service patients, meaning it doesn't affect the system in the right way.
Ultimately, I think the only way to fix it is to start adding negative pricing pressure in small ways to the system, not trying to tackle the whole problem at once.
For example, waive deductibles for treatments which are billed below average (mean? median? in any case, this has to be independent of list price). That creates a financial incentive for insured patients to both seek out billing information, and to lower it.
What's great about that (for insurers) is that you're specifically altering behavior of your most cost-conscious customers, who tend to be your lowest margin customers, without mucking about with the profit margins on your most valuable customers.
Why is "use less, pay less" a bad thing?
Going a bit deeper, however, it will most likely increase health care costs over time. This is because it splits the population into two separate risk pools (low-risk low-use, and high-risk high-use).
To save myself the time of explaining it in full, just compare it to the current state of the credit card market. When Discover pioneered the idea of splitting the risk pool (by offering cash back rewards to low risk clients), then it created upwards pressure on credit card fees (because the general risk pools slowly became high-risk pools, meaning that existing risk fees didn't cover the necessary spread). The traditional cards now started charging more to merchants, which left room for larger rewards for the low-risk pool in a vicious cycle.
Sorry no.
Long term unemployed people in the US qualify for free medical care, celphones and basic dental work. The process is arduous, yes, but it is comprehensive. I had entire recurring blood panels, multiple MRIs, neurological impairment tests , every hospital visit and all of my prescriptions provided for free.
Lumping all levels of poor together is just lies that obfuscates larger issues.
https://www.theguardian.com/news/2016/nov/23/enormous-pop-up...
And other articles too. People inside the USA, travelling ( sometimes for days) to queue (sometimes for days) for a dentist. Why are there organistations in the US whose purpose for existence is to travel around, providing free dental care to any and all comers? Like a medical mission to a country suffering enormous poverty.
Programs: California Medi-cal (which covered all of my medications, tests, etc), Denti-cal (all dental work thats not cosmetic), my obama phone, calfresh (for ebt food) and calworks (cash monthly stipend) are the only programs I can speak to.
I'm grateful for what I had to fight to receive during a bad period of my life and hate seeing misrepresentations like this being spread without specific context.
Had I not been able to finally get working again, I would have eventually qualified for free housing, utilities and all the other benefits available from programs that are funded from various sources. I made several friends through the course of going to these offices over a long period of time who were admittedly worse off than me (mentally) but somehow knew all the inside information on how to game the system. (Ex: if you are considered impaired you can get free bus/subway/van service card, which they all knew how to easily acquire). I had to ride my bicycle or walk everywhere to get back and forth from these appointments.
https://www.marketwatch.com/story/no-other-state-comes-close...
https://www.kff.org/health-reform/state-indicator/state-acti...
It seems like the US healthcare system is too far gone, and we need to hard reset it. Anyone who lives in another developed nation would be absolutely outraged if they had to deal with half the things Americans do when it comes to healthcare and the respective insurance.
Then, once the revolution comes, how many people are you willing to let die while you iron out the operational bugs in your new system.
Fixing the US healthcare system is going to be like changing an engine mid flight. It will require long term planning and consist of a lot of bandaids and ducktape while we work on it. Unfortunately, our political system is by-polar, so plans need to be designed not by what will work best, but by what cannot be dismantled when leadership changes.
Most developed nations have a public health system. Akin to how the US has public schools and emergency services.
The revolution could be the government bitting the bullet, and spending a fortune on bootstrapping a public health system that undermines insurance and private health.
Yes, it will hurt that sector a lot, it won't happen overnight, it will cause huge deficits, and it will inevitably cause higher taxation. But it's ultimately what needs to be done. We just need to give up on the sunk cost fallacy and go with proven models.
We already have a public healthcare system, it is called medicare. We can expand medicare so that private insurance takes up a smaller segment of the total market. I believe that approach will provide incremental improvement and give policy makers leverage for further incremental improvement, but it is not a revolution.
While many of our politicians are talking about revolution, what they are all proposing is incrementalism. The reason for that is very simple; revolution is a bad idea and incrementalism has a proven track record of working.
As an aside, medicare-for-all is still a long way away from a public healthcare system; it makes one area of the healthcare system public.
Is there any empirical evidence to back this up? There are enough successful examples of revolution and incrementalism from around the world, but I can't find stats.
No we can't. Medicare pays below cost of care, and hospitals make it up from private payers. You can't just switch everyone to Medicare, you would have to reduce expenses somehow (which means firing people).
The regular pricing also builds in an assumption that some patients can't or won't pay. If they can more easily get Medicare, less padding is necessary.
It's probably actually at least a month of waiting time.
The "provider" is not a single person. So to reduce the income of the organization, you have to fire people or reduce their salary.
I think you are thinking you can reduce their profits, but you can't. Instead if you feel they are charging to much, that directly translates into lost jobs or lower pay.
It might be necessary, but just as long as you know what you are advocating.
Can you imagine a politician running on a platform of firing healthcare workers?
From https://www.iii.org/fact-statistic/facts-statistics-industry... it seems insurance companies add about 20% to the cost of healthcare.
https://www.politifact.com/truth-o-meter/statements/2017/sep... says 12%.
The same article says Medicare is 2% with the assistance of industry groups, but would cost more without them.
So, abolishing insurance companies would save maybe 5%. That's not zero, but it's not exactly a lot, and would not come close to what's needed.
Or, uh, "Medicare for all", since medicare is an existing, functional single payer system (not actual "public health system" but still, there, works already for a significant fraction of the population, is an existing proposal.
We just need to give up on the sunk cost fallacy and go with proven models.
This, definitely. It's worth saying "sunk cost" arguments often go more with entrenched interests than any actual benefit. Unfortunately, this doesn't make them easier to counter.
I think we could start by expanding military medical benefits. For example, give lifetime benefits to all honorably discharged service members, not just those who made it to retirement. We already have a government funded and run system. It has some excellent assets, such as Walter Reed, a research facility. We could just start quietly expanding that in a way that people could get on board with.
(Changed "honorably discharged veterans" to "honorably discharged service members" for clarity.)
Then we continued to underfund the VA.
It’s only logical that it’s where it is.
Some of us foretold this from before the wars.
I agree that certain jobs do not have to be done by the government and in that way, doing them via government gives rise to all sorts of bad incentives and inefficiencies, but I would not want to paint anything run by government employees as cost inefficient (especially if it's a core government competency) compared to the private sector alternative without some clear evidence.
The comment was directed at the VA, there's no reason it needs to be run by government personnel for the most part. A few could be on hand to handle classified matters if necessary. People hired by the government are not necessarily the best subject matter experts, as the rigid pay structure doesn't allow offering to pay what they're worth - and more often, to pay less, as many job classifications are simply salaried too high. Maybe strictly in matters of government policy could an expert find their niche, and I'd agree be a core government competency. Most other government agencies I can think of would be better off contracted out to enact the laws set by the President and Congress, with the flexibilty of private employment pracitices.
If you're speaking from personal experience I'm interested what happened.
My point is not that interacting with folks at the VA is bad (generally folks try to do their best) but that at a certain point if a single organization runs a specific function incentives get turned around to the point where you lose the ball somehow, and there's no pressure to improve. This seems to have happened to a certain extent at the VA and I see the pattern happen a lot across large institutions, generally. ESPECIALLY if they are not in a competitive environment.
Usually you’ll see a couple of regional banks, the local big bank outpost, and insurance companies. That’s lots of money and lots of jobs, lots of votes.
Unlike banking, the arcane processes actually created more middle class jobs while banks nuked jobs over the last 30 years. If Clinton couldn’t push universal care in the 90s, nobody is going to do it in the foreseeable future.
There is a lot of profit in medicine yet almost no competition around prices.
The simplest fastest solution, for now, is to pass a law requiring transparent prices!
If a majority of the poor in America are not educated enough to understand how public healthcare will benefit them and the country, or are educated enough to understand but not educated enough to realise media outlets have a politcal agenda and might not be reporting accurately, then public healthcare is still not going to happen.
(and they might not want socialism, but it seems like they dont understand that democracy has problems too. and healthcare is the living example. but again, it circles back around to being educated enough to understand that democracy is good, but it isnt perfect, and no system is)
Isn't the contrast between capitalism and socialism? It seems like I could have democracy with either.
Of course it doesn't help the conversation that Americans use term socialism differently than Europeans or Marx himself did.
(Besides, we can probably find a lot more cases of dead children in the US where they were simply denied or unable to afford coverage ...)
But in the US there would have been the additional funding step: the parents would have had to get insurance companies to pay for futile treatment, and no compnay would do so, or the parents would have had to crowd-fund this treatment.
Here, for anyone interested, are some of the legal documents (in date order) around the Alfie Evans case. They clearly show that parents have a right to a family life and to care for their child as they see fit, but that this right isn't total because the child is also human and has his own human rights. The paramountcy principle mean that the rights of the child come before the rights of the parents.
Please note that because of the involvement of the Christian Legal Centre in some of the court cases there's been a lot of misinformation spread about the case.
I know that there's nothing I can say to change your mind: you have an ideological viewpoint, and that's okay. But I think you should at least acknowledge that your opinion is not based on fact.
https://www.bailii.org/cgi-bin/format.cgi?doc=/ew/cases/EWHC...
https://www.bailii.org/cgi-bin/format.cgi?doc=/ew/cases/EWCA...
https://www.bailii.org/cgi-bin/format.cgi?doc=/eu/cases/ECHR...
https://www.bailii.org/cgi-bin/format.cgi?doc=/ew/cases/EWHC...
https://www.bailii.org/cgi-bin/format.cgi?doc=/ew/cases/EWCA...
https://www.bailii.org/cgi-bin/format.cgi?doc=/eu/cases/ECHR...
https://www.bailii.org/cgi-bin/format.cgi?doc=/ew/cases/EWHC...
https://www.bailii.org/cgi-bin/format.cgi?doc=/ew/cases/EWCA...
https://www.supremecourt.uk/docs/in-the-matter-of-alfie-evan...
The details make me uncomfortable (with the court decision), he had an offer from a qualified intuition for help.
Thank you.
Opposition from incumbents ensures that any change will be a difficult process, and a "new normal" will not come easily. Any long-term planning efforts will be sabotaged and subverted toward capture of profits. The best we can hope for is a series of smaller disruptive shifts (each followed by a resettling) that eventually improves the situation.
Something needs to happen. Increasingly it looks like dissatisfaction with the current system will boil over and force a major shift, but other events (wars, for instance) could pop up and distract the public for a time.
Key thing I've noted about was it was designed to get people covered and to stay that way. That's the opposite of neoliberal ACA which is designed to be annoying and has traps designed to rat fuck people.
The ACA was a stalling tactic, and it has been rather successful in that role. People are starting to see through the ruse though.
That's been my opinion, more or less the ACA was just to set the take by the Insurance/Health care parasites to 17% GDP no more no less.
Healthy SF was really about access and outcomes.
Tens of thousands.
But my lord there is no such force.
> looks at US uninsured death rate and medical bankruptcy rate.
> horn blows.
A new power is rising. Its victory is at hand.
Not to be callous but if they're poor, is that enough?
Because 64,000 Americans died of drug overdose in 2016, and 72,000 in 2017 (200/day). (2018 stats not yet out.) 2/3rds of those are linked to the opioid epidemic, but those numbers haven't been enough to engage with the same sort of cultural change in other areas of the American psyche, as socialized healthcare would be. (NOT proffering an opinion on that here, just pointing out the body count may not be enough. Sadly.
Honestly- don't even know how we could 'fix' this. The fact that we need study after study after study to tell us what we already know, it's gross.
Coupled with the fact that it seems impossible to communicate to people just how bad it is (only when they have to personally experience the horror of our medical system to become believers) - I'm personally terrified.
What's the real kick in the pants, we all will need medical care at some point in our lives...
The market can remain irrational longer than you can remain solvent.
This is the justification I hear for a lot of my "bernie or bust" friends. I always just assumed they were trying to justify voting themselves tax cuts. I mean, in a revolution, those of us in the tech sector... I don't see it going well for us. Normal people hated us before we became the new "upper class" - if it ever becomes acceptable to go around killing "rich" people - I bet we'll be among the first.
the problem is that this means we end up with trump, who teams up with a lot of people who think that it's good that people without good jobs don't have access to healthcare.
I work in the healthcare insurance industry, lots of market swings due in part to talk about medicare for all, but also drops in expected profits because Trump is pushing for transparency in Rx costs.
I certainly can't think of one.
https://news.gallup.com/poll/245195/americans-rate-healthcar...
You’ll never hear this in the media, but the reason there isn’t sweeping change on the horizon is because a large majority of Americans are satisfied with their healthcare.
A majority even report being satisfied with their personal healthcare costs.
> Seniors, Medicaid/Medicare Recipients Rate Coverage, Quality Most Positively
So, the people most satisfied are the ones with healthcare provided by the government, which is what many are proposing.
"Pleased" with your healthcare is a relative term. It doesn't mean you couldn't get better. I am pleased with my healthcare compared to the healthcare I used to have. But I'd go back to the public healthcare I had in the UK in a heartbeat.
I really think that we need to stop listening to attitude and perceptions' based studies, and focus on cold hard numbers ($).
People don't understand the system - not by a long mile and will swear up/down/sideways that they do...We need to take a more analytical approach and look at the numbers.
There should be the Price. The amount that insurance Covers. And the remainder is the Patient Responsibility.
Either that, or a cash patient cannot be charged more than the Medicare allowed amount for the same procedure.
Insurers should not be horse trading to pay more or less for one procedure or another. And if you happen to be treated by someone who is out of network, you shouldn’t be paying an exhorbinant price on top of that higher copay or deductible.
The entire concept of negotiated rates is a fraud IMO, and could be reformed with a simple regulation that would I think be supported by a vast majority of Americans.
Price changes should have to go into effect for all patients at once, and be published in some ledger at least some number of days ahead of time.
Recently lost insurance due to a unexpected company closure (with apparently no COBRA responsibility in that case). So I started asking our current providers to find out what it would be to pay out of pocket for some services. Here's an actual item:
Provider bills $285
For out of pocket cash price, they will reduce by 25% (so $213 or so)
Our insurance however got a bigger discount and only had to pay $100 with no further patient responsibility (beyond deductible)
It absolutely should be illegal to price like that.
This leads to funny things like there being Treatment X variant A-E for getting a different price for the same treatment based on some arbitrary thing. It also means that now the insurer knows exactly what has been done because the bill says replaced filling on 3rd upper molar with this and that material etc. Before it was just “filling”.
Also if you want to provide better care and need more time or better materials to do that you can only do it within the determined budget and they are quite tight.
You can have different levels of materials with different prices, but two people still need to see the same price if they choose the same thing, or substantially the same thing.
Of course some people will game the system trying to make infinite variations, but at least that one apply to common blood tests and office visits, MRIs, X-rays, plenty of stuff is standardized.
So what you are describing sounds a step beyond what I am thinking, which is just a standard published price list which is actually the price, and not a published book price which is an absurd ripoff, and then a secret price which everyone with insurance x, y, or z pays.
That would do great damage to the poor and greatly benefit the well-employed. Just like airtravel, the richer pay for the poorer. This has been so since the 50's.
> There should be the Price. The amount that insurance Covers. And the remainder is the Patient Responsibility.
Iron triangle of healthcare: Price, Access, Quality. If you control the price, you fiddle with access or quality.
> ither that, or a cash patient cannot be charged more than the Medicare allowed amount for the same procedure.
Medicare wellness exams pay 90 bucks. Insurance pays 150~200U$S (up to 300U$S). VERY different services can be provided at those levels.
Take a OneMedical office with 3 doctors, and 16 1/2 hour appointments a day. 48*300U$S = 14.400 U$S max revenue. At medicare rates, they go down to 4,300U$S. Just having the same facility, same rents etc, to get the same revenue they would need to see 160 patients. So the appointment length they can give would be 7 minutes. Or they could move the office to a much cheaper 3rd floor place many blocks down, sacrificing access, but that might save you only 10k a month.
Price, Access, Quality.
However, a given service must have a single price for everyone who gets it.
A "Wellness Exam" can certainly be offered with a different levels of service. But you cannot charge two different prices for the same exam.
And once we've established that it should be illegal to charge two different prices for the same exam, then we can get to the interesting work of making those prices more transparent, and maybe even I want to choose between the $90 and the $300 wellness wellness exam on a litter "Good", "Better", "Best" menu, or maybe my doctor recommends which one would be appropriate, and spends 1 minute explaining that and showing me the price at the start.
This happens at my chiropractor, and even at my eye exam (e.g. adding an optional retina scan). If there's only one price for an MRI of a particular part of the body, then when the doctor is ordering it, they can actually tell you what it will cost!
To your last point about rich paying for the poor. This is true, but it is accomplished by changing the price of insurance coverage, but it should not be accomplished through changing the price of the billable service based on lack or type of insurance coverage, because those are very poor signals for capability to pay. In fact, the poor are most likely to be overcharged through this type of policy.
Same doctor, same location, same duration, same scope of care, same supplies, same patient-risk, same market demand, same season, same malpractice liability, etc etc ?
A same price requirement pushes the economic adjustment to other variables. A simple example: do you take patients saturdays? All staff is more expensive to work a saturday, but revenue is the same. (adjust access).
If anything, the market does not have enough price adjustments, which is why eeryone is so price insensitive, particularly the patient.
Let's keep in mind where we are today, which is that price is entirely arbitrary and capricious, and they are allowed to do that.
I think people seeking medical care deserve much better than "arbitrary and capricious". Substantially similar services should not have two orders of magnitude differences in pricing. That should be illegal.
EMR coding already provides the basis for establishing a non-discriminatory pricing regime. The problem is the billing system takes the EMR coding of the procedure performed, and then convolutes it with a pricing matrix which discriminates on what kind of insurance you have.
I walk into CVS and try to fill a prescription.
- That'll be $78 dollars they say;
- OK, I have this benefit card, it is not insurance but it provides a discounted rate, and I paid nothing for the card. It's like a coupon code. That'll be $55.
- OK, I have this prescription drug coverage insurance card, which carries a $200 deductible and a $20 copay. I've already exhausted the deductible. That'll be $20 and insurance pays $3.07.
CVS is selling the same drug, from the same distributor, to different customers at wildly different prices (before an insurance contribution) based on some sort of shell game.
To say nothing of the cases where insurance companies agree to pay more for one drug, like insulin, in exchange for charging less for other totally different and unrelated drugs, just because in their insurance pool it helps them optimize the number of patients which ultimately will pay the annual out-of-pocket maximum.
Thats what insurance companies do. Basically their entire work is assigning different value to different care, based on quality metrics, on differential costs for different services, patient populations, etc.
But insurance companies can't see how much are you willing to charge as a provider, thus the provider and the insurance are very much adversarial.
> EMR coding already provides the basis for establishing a non-discriminatory pricing regime
EMR is probably the main reason why upcoding has become a wide-industry practice. EMR allows you to think in how to maximize insurance values which is not the same as medical value, or patient experience. It is also not true that EMR's convolute with pricing matrix's, each insurance has a different negotiated price for different procedures. This happens for a multitude of reasons, and they are all crappy but real.
> CVS is selling the same drug, from the same distributor, to different customers at wildly different prices (before an insurance contribution) based on some sort of shell game.
Yes, but thats not a price problem, its a principal-agent problem. Insurance should not be covering regular medical services and procedures. It should be used for highly expensive-out of control actuarially sound events. But competition for clients has made it the way it is now since the 1950's. The way to solve that is High Deductible Plans. HDP people really price-shop and put pressure on providers to talk about cash pricing and caps.
No properly functioning market behaves like this.
It’s just a confusing concept to these people. This is what happens when most people use someone else’s money to pay for things. Nobody knows or cares what anything is supposed to cost.
The legal system is often abused. But it sounds like you've got an actual legit issue, which is what the legal system is there for. Why not use it?
If you don't want to pay for a lawyer, you can write your own strongly worded letter. Just be sure to stick to facts, and keep very good records. In your letter, explain the issue briefly but clearly. Explain how you've attempted to resolve the issue. Explain how if the issue is not resolved, you will be forced to take action.
Address it to the hospital CEO, or whoever is in charge. Post it using registered mail.
Your local library may have a subscription to LexisNexis or a similar legal database. This will have form letters and chunks of legal text that you can copy and paste.
HN user patio11 wrote a thing about writing letters on this website that I can't just find. But find it, and read it. It also has helpful advice.
Yes, you'll get anything not used back, but the last time I needed a strongly worded letter I had to pay the $1500 retainer and finding a lawyer under $200/hour in my area is extremely difficult. I got my remainder back the following month, but the strongly worded letter cost $400 and tied up $1500 for about five weeks.
The reality is the average person -- if we go off all the studies pointing out the large swathes of the population that can't meet a $500 emergency expense -- may not be in a position to tie up cash, even in markets where a lawyer is considerably cheaper. It's also a cost-benefit equation, and the value of that (regardless of the outcome) is different for everyone -- I'm someone who'll go tooth and nail to get $20 back on principle, but for some people that threshold might have to be $2000+ to care.
If hospitals and insurance companies are already tracking their income/expenses they should just be required to publish the anonymized data via a centralized API so we can all work on creating systems to analyze the average cost of the products. It will help insurance companies and patients as well as doctors and everyone in the end. Also, beyond the standardized API system which should easily cover all the standard financial points we can have multiple people / organizations analyzing the data.
Say one particular health issue shows up in the system as costing a lot of the insurance cash pool, we would notice it right away and could funnel more cash into prevention.
I'm not familiar with the industry so maybe there is already something similar available?
How did Europe do this with that whole payment services directive (I think that this is what I'm thinking about) - the one that forced all payment systems to have open APIs and such?...
How would we get something like this in the works? It would require a mandate from ??? Congress / the President / Bigfoot???
I can only imagine how these companies would not like this information out. Even if one were to explain that having this data would yield optimizations of their internal systems, saving them money, as the information would most likely make many within the organization look badly.
Adding to this: Oftentimes there isn't a single person in the place that even knows what X costs...and hasn't a clue how to determine that number.
Years ago, I was between jobs and asked for the 'cost'. The reply I got was "$20", a typical copay at the time. When I explained my situation and was asking for the actual out the door costs...20 bucks. They really didn't even understand how to approach my question (could see it in their eyes/response). When I asked for another person in the office - 20 bucks. Hell, even the Dr told me 20 bucks. The bill I received was not 20 bucks - surprise surprise. And what could I do really - hold them to the 20 bucks? Where was my 'proof'...
Many of the people doing the admin work simply are not trained nor equipped to understand the gravity of the position. They can set you up on a calendar and fill out a postcard - beyond this, and there's problems. And why should they? They are being paid to be calendar/postcard filling person only.
The system itself was designed weirdly to begin with, it assumes that you are a wage earner of a large company that is paying insurance as an employment perk. If you deviate from this model - then these sub-systems don't know what to do.
But if they told you some four-digit number you'd bolt.
We like to hold medical professionals in high esteem, but these days it's also a business transaction. They know this. As such they are very much a part of this very large problem.
The last thing I personally want to do is have to argue with insurance companies and negotiate prices down through the labyrinthine healthcare system after dealing with enough nonsense at work. Even worse if I have to do said negotiation from a hospital bed due to an unforeseen problem, as most health issues tend to be.
I needed a procedure that was going to be ~$1500 at any one of a half dozen places within a 90 minute drive; some were a bit cheaper, but they couldn't see me for more than a month. There were a couple places that were ~$1100, but it basically would have been a whole day's enterprise for 2 people to get me there and back. To save maybe $400. $400 is not nothing, but I wasn't even actually 100% sure their pricing would actually be what we finally paid - no one could guarantee that. So we may have had 2 people take an entire day from earning on the partial chance of saving some money. Might even have been cheaper in another state, but then you've got travel/hotel costs to add as well.
Many people that I know talk about how people need to know how much something costs - but these systems themselves don't know how much anything costs.
Furthermore, they know this and therefore unwilling to guarantee anything.
Knowing prices is great, but I feel is a non-starter when thinking about how the system can be 'fixed'. Also, you can't price shop when you're having a stroke.
All in all, we have to just acknowledge that the system for everyone is broken - beyond this, I haven't a clue as to the next step.
And you can't consent to anything when you're having a stroke, or in a car crash, or having surgery, etc. You're hit with thousands of dollars of bills when you're unconscious or not mentally competent, and it can stick with you for years.
Price shopping to keep costs down - yes, fine, it's a nice little component that would probably help a portion of our medical ecosystem. If I can save $14 on some particular medication by choice of pharmacy - sure, why not?
I've maintained for years - either single payer, and/or have insurance go to a primarily individual/family policies that people purchase themselves - get the employers out of my business. People are tied to jobs due to insurance concerns - employer-provided health insurance contributes to labor immobility. Employers have less incentive to hire less healthy people, likely keeping some people from improving their lives.
Remove 'tax deduction' for employers to provide health insurance. Ensure all taxpayers can fully deduct 'health insurance' costs from taxable income, starting from $0 (none of this 7% of MAGI bullshit). OR... increase it? 150% of your premium is deductible in year 1. 130% year 2. 115% year 3. 110% year 4. 100% year 5. Incentivize people to actually own this.
We had 18 months of "let insurance companies sell across state lines" BS during our last election. It's already possible between many states - it's simply far too much regulatory burden to deal with for most companies, that's why most aren't doing anything about it, even when they can.
REAL reform would be changing who actually pays for it - let them become the real 'consumer/customer'. An employers' incentives and mine don't always align, and if they're paying the bill...
How on earth is this type of pricing legal?
And so this practice thrives.
This mechanism may be a foundation of legality of health industry pricing practices, but it is grossly abused. Contrary to what is advertised, U.S. health care is not a free market. The pricing is made opaque by insurance industry and other middle man. This is the main reason why price gauging of that magnitude is possible. It is a cash cow that just keeps on giving and trying to change that will be extremely difficult.
What's coinsurance? ACA regulates copays, deductibles, and so forth. Ah, but no one said anything about coinsurance. It's totally not a copay, premium, or deductible. See? It's different.
Surprise billing is how hospitals pushed back against insurers. Consolidate and then outsource all actual work, so the hospitals no longer get stuck with the bill. Oh, that specialist you saw in our hospital? Ya, she has nothing to do with us. Ya, you should have asked your insurer if her office has an arrangement (collusion).
I'm assuming that the patient cannot read the results. i.e., They go to the hospital. Doctor asks for the tests. Patient gets the test results from their lab of choice and go back to the doctor with the results. This is a fairly common model, at least elsewhere in the world. Labs and hospitals are separate entities, and the first visit to the doctor is just a consultation with nominal costs. Doctor's costs don't kick until the test results are back.
I previously worked for a company owned by Quest Diagnostics, so have some insight into the parasitic nature of these lab companies. (The other titan in the USA is LabCorp.) Once a facility is up and running, they basically print money. Some wags even created "speedometer" dashboards to show real time revenue per minute.
One time I went to UCSF hospital, and they ended up billing me several hundred dollars. For the exact same lab codes. Actually, I think they billed well over $1000, but my insurance company at the time allowed several hundred in charges.
I called them up, but they were unwilling to negotiate. I ended up paying, because I figured that it wasn't worth fighting it.
One time several years back I fought a fraudulent charge from a doctor who billed me for a more expensive procedure than the one he actually performed (this practice of "upcoding" is actually pretty common). I eventually got them to remove the charge after a lot of complaining to the doctor and talking to my insurance company, but it wasn't worth the stress involved for the amount of money I got back.
I'm a life long patient, so not my first rodeo (dozens of blood tests). I had no idea it was possible for a lab to "out of network", so would never have occurred to me to ask. But at some point the rules changed. And no one thought to tell me, as they're supposed to (eg verify insurance coverage before doing any work).
Surprise!
Living in Europe is pretty great. Healthcare mainly is based on income here, if you are low income you pay next to nothing if you are high income you pay up to €5000 per year in tax and insurance. I think that's fair as it makes it accessible for everyone.
If that was more than a handful of tests (usually separate drawings), then it was probably still subsidized. I think the out of pocket prices are in the same range though, at a private lab clinic, here in Southern Ontario.
The reason insurers end up paying $1,000 for this service in the most expensive places is mainly that insurance is ubiquitous in some places. If nobody asks the price, how can it stay down?
There is an online calculator with the maximum amount a hospital may charge for its services: https://www.diagnostiekvooru.nl/tarieven (use the checkboxes for whatever you want tested, apologies for it being Dutch).
This is the maximum amount the hospital may charge by law, the insurance company can lower this by up to 10% by negotiating the rates.
Seems to me that all of the warning signs are there, is it corruption in the regulatory agencies?
I don't buy that it's purely regulatory overhead. That you see this price gouging at supposed nonprofit hospitals as well, it can't be purely rampant unchecked capitalism when you have 15x markup from the pharmacy.
One of my pet peeves with US medical is how the billing is handled. Visit the ER? Get ready for an untold number of bills. One from the hospital, another for imaging, another from the pharmacy, yet more from specialists, radiology, etc. There's no one clear bill about what you owe. This is due to most of these technically being subcontractors. Yet, I dont know of any other industry where I have to pay subcontractors directly, rather than paying the contractor at once instead.
Details: the hospital would do it after an "initial out-patient visit" costing "1,000 to 1,800", the ECG price is "500", and those are "estimated prices ((...)) subject to change."
They claimed you can get high on it if you drink a bucketload of it.
I wish I knew Chinese better
1000 is in Chinese yuan
I really hope this goes through. Right now, the opacity of prices for health care is a huge problem.
A friend of mine that works in health care admin and IT described walking into a doctor’s office ‘like walking into a used car lot.’
It seems to be one of those few holdout areas where the information economy hasn’t affected. Maybe it’s even perverted it, by enabling data holders to optimize inefficiency for their own benefit.
They are less certain whether a particular course of treatment will be coded in one way or another.
It's probably not a good payment model, it doesn't make any sense for the insurance company to be taking on risk that the provider should be bearing, but here we are.
The data simply needs to be price per code per insurance policy. I understand providers may not want people bickering over what codes are used, but they ought to be able to produce that report easily.
- It costs exactly $20
- It costs not more than $30 allowing negotiation
- You may only charge one price for all customers
- You may not charge more than some n percentage over the national average in the last business quarter
The problem now is there is no downward price pressure from competition and transparency. Market controls are an extreme solution which will likely have unintended negative consequences.
None of these exist today in the market for US healthcare...but they do for fast food. Trying to compare the two would be extremely disingenuous.
It is in medical providers best interest to raise prices.
Efficient markets need more competition, but in healthcare the market is fragmented and once a provider or insurance gets big enough it gets acquired by another leading to larger duopolies.
I'm in favor of what you suggest, but it will come with increases in Medicare costs.
So hospital utilization would not change.
Remember I'm talking about the payment for any particular procedure, not the number of procedures an average person has.
I know from when I was healthy individual in my 20s, that I tried to avoid doctors visits as much as I could - even though I had killer coverage (90-95%).
I still paid premiums (well my company did) but I simply didn't go.
Prices negotiated between payer and provider today are already 1 + N year length contracts. Having one transparent national price list would 1000x easier than the hundreds of thousands of healthcare administrators that exist today whose sole job is to negotiate and determine price lists.
What exactly do you think is going to change in the market?
We were getting a blood work for wifr, and when we checked pricing online we were shocked to learn that self pay price was around 300 and through insurance it would be 8k. Crazy, and no free market would function this way. Except when they are not free and have messed up regulations.
(Semi-)serious question, actually. What would they do? There's no contract.
Even if I did sign something in an emergency, I can claim to not have been capable enough to reason about it, due to shock/mental issues given the emergency; and anyway does all this paperwork (that having good insurance I sign without reading) actually say "I agree to pay whatever you charge me"?
Might be the only good that came from their company.
[0]: https://www.azcentral.com/story/news/arizona/politics/2015/0...
It's incredible how a little health problem, can kill your finances so quickly, even if it's for something simple, but doctors have to discard so many other things (which I'm grateful to live in a time, where those things can be a reality... just hope for a more accessible solution).
Eventually I got a "guesstimate" of $200-300 for the visit. I cancelled the appointment.
Not sure if I'm going to do it, or if there is an ideal moment to do it so I can have a positive.
It is extremely difficult to determine how much things will cost in the US system ahead of time and there is no reasonable way you can "shop" around for better prices when it comes to healthcare.
It's like you go out for dinner, but the restaurant won't tell you how much things cost, just that you should definitely order X,Y, and Z. And all the restaurants in town have the same policy. You order it, and then they mail you the bill 2 weeks later. Only for you to find out the exorbitant costs. Plus, they decided to charge you for the extra ketchup you requested.
Good luck trying to figure out what inpatient services are gonna cost ahead of time though. I work in a hospital, and a doctor asked me for data two weeks ago about what a sample set of ten of his patients were getting charged, as well as what his clinic was getting reimbursed. Took an email chain eight people long before we found someone who could actually pull the right info. Ridiculous.
Actually, it can be very easy. Quote a price prior to treatment and you are not allowed to charge more. Providers will lose money on some treatments, but on a large scale that can be predicted and rolled into the average price.
If there is a small provider, or particular treatment with high financial downside risk to the provider that the uncertainty is potentially crippling for the provider, then the provider can take out insurance to cover their loss if the treatment turned out to be far more expensive than originally anticipated.
That approach is why the $10 test costs $400. Medicaid mandates $10.01 payment, and selling it to someone for less than that is a crime (fraud). Everyone else gets a percent off of list.
If the actual cost of covering the unexpected costs is less than the margin they are tacking on, then that is simply over charging, and is not meaningfully different from the overcharging they can do anyway.
Regardless, I am not proposing a price ceiling, I am proposing determining the price prior to rendering services.
The article below estimates that 7.3 percent of all living Americans have served in the military at some point in their lives.
https://fivethirtyeight.com/features/what-percentage-of-amer...
A married military member gets "free" medical coverage for their spouse and children. The ridiculous cost of having babies as a civilian is some minor out of pocket expense, medically speaking, for military members. It's common for people who aren't planning to make a career of it to try to get the kids out of the way before they exit the service. If you put in twenty years or more and retire from the military, you have lifelong medical benefits for you and your dependents.
Most articles about the problems the American medical system is rife with seem to not bother to delve into what goes on in the military medical system, what percentage of our medical system it constitutes, etc.
It actually makes me a little nervous to leave this comment. It makes me wonder if I am going to mess up the super secret club or something. Because it's really bizarre how we seem to completely leave out the military medical system entirely from any analysis of the American medical system.
In any case, you get born, you die. Two absolute certainties in people's live. Dying typically involves medical bills and delaying that also involves medical bills throughout your life. That's why medical insurance is not optional in most countries. The notion that children can be uninsured or that people die because of entirely preventable and curable conditions just because they lack insurance is not a popular one outside of the US. It's not communism/socialism, just common decency and pragmatism.
Which has nothing whatsoever to do with my point that all the hand wringing, critique and analyses of the broken American medical system conveniently overlooks a piece of the picture that's fairly substantial and largely unquantified.
Without including that data, you have an incomplete picture. Period.
Also, I think you are romanticizing a bit how good that system actually is even for the military.
I'm certainly not one of its many naysayers.
Some of the assets of our Military Medical system:
The David Grant USAF Medical Center (DGMC) at Travis Air Force Base in Fairfield, California, is the U.S. Air Force’s largest medical center in the continental United States and serves military beneficiaries throughout eight western states. It is a fully accredited hospital with a National Quality Approval gold seal by the Joint Commission, and serves more than 500,000 Department of Defense and Department of Veterans Affairs Northern California Health Care System eligible beneficiaries in the immediate San Francisco-Sacramento vicinity from 17 counties covering 40,000 square miles.
https://en.wikipedia.org/wiki/David_Grant_USAF_Medical_Cente...
The Walter Reed Army Institute of Research (WRAIR) is the largest biomedical research facility administered by the U.S. Department of Defense (DoD). Official mandate: Basic and applied medical research supporting U.S. military operations is the focus of WRAIR leaders and scientists. Despite the focus on the military, however, the institute has historically also addressed and solved a variety of non-military medical problems prevalent in the United States and the wider world.
https://en.wikipedia.org/wiki/Walter_Reed_Army_Institute_of_...
DGMC is where I got the cutting edge diagnosis that helped save my life.
I seem to run into lots of homeless veterans when I go to the US; most of them with obvious health and mental issues; possibly directly connected to their activities for the military.
I happen to know a lot about homelessness. You see a lot of homeless veterans in part because military members know how to camp and tend to be less tied to a city or state than most civilians. They have a relationship to the federal government which helps make a lot of local stuff less relevant to their lives.
Of course, service to country chews up a lot of people. That's part of why the military has its own medical system: to honor its obligation to the soldiers who so often wind up maimed in the course of doing their duty.
Wars are not won with harsh language.
(That's an Aliens reference)
Really?! Homlessness is a lifestyle choice? You are not really selling it here.
In any outcome, there is some part that is beyond one's control and some part that is choice. Most homeless people wish they had better options, but some "choose" homelessness as the lesser evil.
Having skills, like survival skills, can make sleeping rough or in a tent that much less problematic and intimidating.
I would usually supply a list but what you said is so ridiculous I don't even think I need to.
I mean I can't even think of a country where what you said is true.
Greed is trumping the health of the people in basically every country in the world.
It is only reasonable that people answer on topic (abusive medical billing in the US)
You are going off topic (wealth distribution) to try and prove a point. This is called whataboutism (when one topic is discussed and someone says 'well what about this other topic') - it's generally frowned upon as it degrades communication for those who like to find the truth and further understanding. Whataboutism is generally classified as a sophist technique (persuasion) vs what most rational people I know value: dialectics (inquiry and understanding)
You are trying to limit the scope of "greed" to something that only applies to the US, when in reality it applies to pretty much every country in the world.