California's ‘Surprise’ Billing Law Is Protecting Patients and Angering Doctors | Hacker News Reader

California's ‘Surprise’ Billing Law Is Protecting Patients and Angering Doctors

nytimes.com

169 pointsavocado4234 comments

Physician here.

The problem with this law is it takes the medical reimbursement contract system and then shoots the physicians in the back.

When insurance companies are trying to get people to join their network, they offer competitive rates. Once they are large enough, they start to exert downward pressure on physician reimbursement to both existing and new medical service providers (hospitals and physicians). The only way to counteract their pricing power is to be willing to walk. Physicians do not like going out of network; the insurance companies make it incredibly painful, refuse to pay you, and instead send the check to the patient who is expected to deposit it and forward it to the patient (if they pay at all).

However, what has happened post-ACA is massive consolidation across the medical services sector so that large staffing companies would deliberately go out of network to force better rates strategically. It was no longer the individual physicians choice whether or not to out of network; rather their employers'.

However, these laws are a huge gift to the insurance companies. They remove the physician/hospital's ability to negotiate, and already, we are seeing insurance carriers refuse to negotiate or offer rates greater than 125% of Medicare. It also completely eliminates the incentive for insurance carriers to even bother creating a provider network. This is not the intent of the law and fundamentally is acting as a wage-cap.

Medicare rates are intentionally set by fiat and often below the cost of goods sold. 125% of Medicare is an arbitrary "sounds good" number that is not helping anyone but the insurance companies.

Instead, a better version of the law would be to have payments indexed to the FAIR health claims database [https://www.fairhealth.org].

Yes, I agree the medical reimbursement system in the US is not ideal; however, this is tantamount to price fixing which in EVERY thread on compensation for software engineers, people think what Google/Apple/et Al did to prevent wage increases and poaching was unethical and unfair to workers. I don't think this is any different.

If 125% of Medicare is below cost of goods sold then costs need to come down. Medicare reimbursement rates are too high compared to the rest of the world.

Nobody needs to be paid $300 for a 5 minute visit to get a prescription for routine issue. 10 years of training is not necessary for most instances of routine care. Most of it can be done by a midlevel with 4 years of post-high school training.

There's no need to require $500 MD visit ($150 from me, $350 from employer/taxpayers) to get tretinoin cream. I should just get it online for $20 like I would in the UK or Australia, no MD involved.

Scope of practice laws need to be rewritten. Every instance of "you must have a medical license" should be replaced with "you must uphold standard of care". This will allow companies like CVS or even Amazon to provide a lot of routine care directly to patients through midlevels, software, and operations, with direct government safety oversight.

Emergency care with inelastic demand should be federally regulated and socialized.

Federal government should determine scope of practice and standard of care. MDs (all of whom are overtrained in the US) should focus on complicated cases and on pushing medical science forward.

It's time to move away from archaic Flexner-era cartel.

You can't compare the US standard of care with the rest of the world's standard of care. If you want equivalent costs to the rest of the world, expect the US expectation of care, turnaround time, and time-to-service to decrease drastically.

You have a habit of posting in healthcare threads and denigrating physicians. Your favorite replacement (midlevels) do not make less money. They are only paid less money; the hospital gets either equivalent (Oregon) or about 85% of that paid to a physician. You are getting WORSE care for the same price when you see an NP or PA. This is why I personally avoid seeing them.

You have a huge trust in the US government that large swaths of the population simply do not have. Have you spoken to many veteran's about their experience in the VA healthcare system? Some VAs with academic affiliations are ok....many...are not. Do you think the government now doesn't already massively regulate healthcare through CMS mandates?

It's easy to say "expect the US expectation of care, turnaround time, and time-to-service to decrease drastically", but many people in the US have terrible turnaround time, terrible time-to-service, terrible expectation of care. They simply can't access decent care in less than six weeks without breaking the bank, or can't access decent care at all. If we're looking at maternal mortality, for instance, the US just sucks by all measures. If we're looking at infant mortality, we're a total failure. And that's before we're getting to the cost part, where you go to the hospital expecting to push out your normal kid in a normal way and get a normal bill, but then it turns out the person who put in your epidural at 3 am was out of network and you didn't ask because you were, like, busy, and you picked your hospital and your OB and everyone else beforehand and made sure they were in-network.

Having been through the US pregnancy and birth wringer, I can compare the US standard of care with the rest of the world's standard of care, and we suck. Cost more, cut more, die more, and spend six hours a week on the phone half the weeks calling a provider, getting a referral, calling the insurance to approve the referral, calling back the original provider. I made four phone calls for every appointment after 32 weeks because of a minor and common complication that had zero effect on the birth except having to get that f*(&ing approval to see the only doctor in two states who would deal with the thing reasonably.

And at the VA max wait for a primary care appointment is 20 days.

> You can't compare the US standard of care with the rest of the world's standard of care.

This is a meme I hear a lot from Americans but having lived in America and elsewhere, I don't believe it at all.

Do you have any data supporting it?

The best I could find is life expectancy (US is #31 worldwide) and maternal mortality rate (US is #46 worldwide). The US doesn't seem to excel here by any means. Can you point to data where the US does excel? Is there evidence that people entering an American hospital exit with better outcomes than people entering say a Swiss hospital or French hospital?

And anecdotally, my experiences with healthcare in the US were strictly negative. Things like $600 for some regular over the counter medication from a hospital (and that's just the co-pay at an in-network hospital). Living in Australia and Switzerland, my experiences were much, much better.

> You are getting WORSE care for the same price when you see an NP or PA.

Whenever I get to choose between NP/PA or MD I will always choose the former. MDs are typically overworked and condescending. Most of the time I already know what the problem is and just need a prescription from them. When I tell that to MD they get offended - I am a dumb patient and MD is a demigod with superior intelligence. Hence I'm supposed to act dumb to make sure I don't offend MD's brittle ego who will otherwise retaliate by billing for some extra "nontrivial" visit.

If I see a nurse or a PA the person will speak with me like an equal, take the time to examine, won't hide their reasoning from me, maintain open notes, etc.

> the hospital gets either equivalent (Oregon) or about 85% of that paid to a physician

People shouldn't be going to hospitals (with rare exceptions). People should be seeing NPs through CVS Minute Clinic, One Medical, Future Amazon Clinic, etc. When you walk in to CVS clinic to see an NP you just pay a flat $45 without insurance. That's how it should be for most care.

The fact that anyone (MD or NP) is being reimbursed over $75 for a short visit (let alone more realistic $300-500) is simply a flaw in the system that needs to be fixed. MDs (or midlevels) don't create enough value to be reimbursed that much.

Note: in France you pay MDs 35 for a visit, 16-ish of that is covered by social security, while a private security costing 50-ish/month covers the rest. I've always got a same day visit if I called before noon.

Edit: I moved out 5 years ago, so the numbers might have inflated a tiny bit. But not much, knowing France.

Australian here.

I’m curious about what you see as wrong with our standard of care?

I can see my GP same day, bulk-billed via Medicare (so no out of pocket cost to me) for whatever I need. Likewise, with a day or two notice I can see a specialist at my local clinic. Also bulk billed.

Out of hours, I can order an in home doctor service over the internet with an average wait time of 4 hrs. Again, bulk billed so no out of pocket cost to me.

I don’t think I’ve ever waited for longer than 24 hrs for a doctors appointment in the 12 years I’ve lived here.

My usual example is the NHS. A lot of medical imaging AI papers are published using NHS data with great claims like

"Normal chest radiographs were detected by our AI system with a sensitivity of 71%, specificity of 95%, PPV of 73%, and NPV of 94%. The average reporting delay was reduced from 11.2 to 2.7 days for critical imaging findings (P < .001) and from 7.6 to 4.1 days for urgent imaging findings (P < .001) in the simulation compared with historical data." https://pubs.rsna.org/doi/10.1148/radiol.2018180921

Except their baseline image interpretation turnaround times (TAT) are completely incompatible with the US. If any radiology group sat on an exam for 11 days, they'd fired by the end of the month. Many hospital medical staff bylaws require final signed reports within 24-48 hours, not even including the professional fee interpretation contracts which can set TATs at 30 minutes.

You can't provide that level of service with NHS-type funding. Oz is probably one of the few systems that's currently functioning well. There's a ton of reasons British consultants leave for there.

> You can't provide that level of service with NHS-type funding.

The crisis with the NHS is not only a mismanagement crisis but also a funding crisis so I think they'd agree. Happily, healthcare funding could be increased to more normal levels (in comparison to other well functioning public healthcare systems as a share of GDP) and still be well short of the high costs of the US. The UK government just prefers austerity over properly functioning healthcare.

So combining your comments with the other comments on the thread.

Radiology has to have a 48 turn-around but it's OK if many patient don't actually see a doctor without multi day waiting times and some portion can't see doctors in any reasonable timeframe. But radiology, we got that covered! It is an important part of health care but it is clear US priorities as reflected in "standards of care" are completely off-kilter (if you're not seeing a doctor at all, radiology turn-around can't help you or is there something I'm missing).

The way standards of care drives up costs seems like a scam but I know not all of it's a scam. In ways it's worse, in the sense it's harder to get a handle-on and stop, being a spectrum that shades from mostly scam to actually good but sometimes too-expensive approaches and so-forth.

>You can't provide that level of service with NHS-type funding

Places like Singapore do well at providing good service on sub NHS funding. Also people actually like the system there unlike the US and to some extent the NHS. (Brit here - NHS is ok but a bit rubbish at times). I think it's worthy of study / emulation.

I think they are something like 1/3 or 1/4 of US spend and #1 life expectancy in 2019 vs like #30 something for the US.

I hate the US' health care system as much as anyone, but I don't think it's reasonable to compare Singapore to the USA that way

Singapore is the size of a US city and has a population of 6 million

It doesn’t come free, you or another demographic is losing. Public schools comes to mind, slow congested public transport ... etc limited beds in public hospitals

Lower quality of life because of High taxes

Waste because old people see a doc as a free social interaction

I don’t know both systems are not right

So you're saying US public schools are great, US public transport is great, and people can easily get treatment in public hospitals for the same price that they would suffer bed shortages for in Country X?

Just trying to understand your points because I think they are quite easily refutable.

I live in Germany and am not a fan of the high taxes but see more from the 42% I pay here than the 33-36% I paid in the US.

Your points are all very handwavy, but to answer. There are good public schools in my district.

The state is currently building a huge new high school a block from me to cover upcoming demand.

I’ve gotten a bed whenever I’ve needed one in hospital. Perhaps that one is not even everywhere and can tend to be an issue in rural areas, but not where I live specifically.

Public transport here is good. It’s congested, sure, but nowhere near as bad as other cities I’ve lived in. The state is currently building several new transit lines.

In terms of tax, I pay roughly the same overall as my US peers. I do earn a bit less, but that’s because it’s AUD.

I don’t even know what to make of your comment about old people. That sounds completely weird. I certainly don’t know any of my older (70+) friends who do that because there are lots of social programs and activities in my local area.

It sounds like most of the US population simply can't afford that level of care, yet is forced to "go with it". In a way this may subsidize those who can afford it.

If patients had an option - a la you can get an appointment now with an external consultant for $X, or wait two weeks - then that would make sense. But instead you pay for health insurance to literally insure against catastrophically expensive health-care costs (that's the point of insurance - "socialize" risk so that the individual doesn't get "wiped out" in case of an extraordinary event), yet you may still go bankrupt even if you do everything right!

Also, most other countries have a two-tiered system. Public health insurance, possibly worse and slower (don't necessarily agree), or you pay extra for private health insurance and get nicer hospital suits, better doctors and short wait times.

I have one of the best health insurances, it costs dearly, and yet I have no way I could get an appointment for anything without weeks wait. Perhaps with exception of emergency room. And it's expensive as hell. And not in a single place I see a price list, and no physician would ever tell me their cost upfront. That's what you call "standards"?

Because "health insurance" is not designed or used as "insurance" anymore. Real insurance takes into account numerous factors which rate your risks of something bad happening to you and comes up with a rate tied to your particular set of circumstances that influence that risk.

Unfortunately, when "health insurance" covers day to day conditions, procedures, etc and costs the same for everyone regardless of circumstances, then it's no longer "insurance" but effectively pre-paying for access to a set of services.. and hopefully, it's services that you want and might actually need.

In the US, it's more of a "healthcare access fee" than "health insurance."

This sounds like armchair musing rather than a determination from actual data. It generally costs a lot more to treat problems as they arise than it does to prevent them. Paying up front for day to day procedures would significantly reduce the burden that guaranteed emergent care places on society already. It also potentially makes federal programs such as SSI/medicare cheaper as previously insured people are much more likely to be healthy.

The numbers are subject to some debate, eg the arguments over the Mercatus Medicare For All paper, but hand waving and claiming insurance that covers day to day procedures isn’t actually insurance is dubious. Not to mention, many modern plans have high-deductibles and function as you suggest, to where a healthy person may receive little covered service but also pay less out of pocket.

https://www.amsa.org/wp-content/uploads/2015/03/CaseForUHC.p...

I think you misunderstood me. I'm not proposing any policy or treatment changes. My point is calling what we have "health insurance" is confusing at best and deceptive at worst, so let's call it by a better name.

That may cause policy changes if people's mindset and behavior shift but at least we're building on better models of the world.

Here in germany if you have a private insurance you will kinda get scammed. Cause hospitals can make more money out of you they will make all kinds of tests on you, cause private insurance will pay it. This wastes your time and doesn't actually benefit you. On the plus side, the waiting times are reduced greatly, you are basicly a high priority patient for them cause, again, you make them more money. In theory everyone could get a private insurance but in practice only very rich people, self employed and people working for the government (the latter two are not eligible for public insurance) do actually get one. I don't know anyone here complaining about healthcare, it generally works great.

You can get gesetzlich versichert (for example with the TK) if you are self-employed. You pay a ton, probably as much as private insurance, but you do get insured.

> You have a habit of posting in healthcare threads and denigrating physicians

Ad hominem arguments are very much out of place here. You have points that don't require an ad hominem yet you chose to use them anyway. I can't understand why, it only weakens your argument.

I agree that ad hominem is of dubious utility; however, here I'd argue this is not an ad hominem in that I made no judgment of the poster, but rather pointed out he has frequently posted on this topic, calling for "investigation of medical cartels by the FTC" and claiming we are "overtrained", and that it is time to "end the Flexner tyranny".

They also heavily advocate for midlevel care as a replacement for physicians because we are "overtrained".

I'm yet to find a physician (especially somebody trained at Harvard/Stanford/etc plus a couple fellowships) who is actively practicing, and who hasn't told me with intellectual honesty that 80% of the patients they see present with trivial cases which could have been handled by a resident or a midlevel. They mostly put up with it because they get reimbursed a couple hundred $ for these trivial cases, which they shouldn't be.

Same for rads fighting over high RVU MRIs and CTs for 30 year olds without prior history. Half of those shouldn't have been ordered in the first place, the other 40% can probably be read by RAs.

That's why I think physicians are overtrained in the US for the type of work they de facto perform.

> There's almost no job where 80% of it couldn't be done by someone significantly junior. Especially when people are going to die if the person in the role can't handle the whole job, and there's no cost-effective way of presorting the work, it's not at all a sign of overtraining that 80%—or even 90%—of the work items could be done by someone far less skilled.

Nobody is going to die if nurses start prescribing acne creams and performing digital rectal exams. I'm talking about trivial routine care which is bulk of entire volume.

Emergency care where people die is a different story. Nobody should be reimbursed anything in emergency care. EM docs and midlevels should be on a salary like in Kaiser, with best outcomes at lowest costs being the only incentive.

> I'm yet to find a physician (especially somebody trained at Harvard/Stanford/etc plus a couple fellowships) who is actively practicing, and who hasn't told me with intellectual honesty that 80% of the patients they see present with trivial cases which could have been handled by a resident or a midlevel.

There's almost no job where 80% of it couldn't be done by someone significantly junior. Especially when people are going to die if the person in the role can't handle the whole job, and there's no cost-effective way of presorting the work, it's not at all a sign of overtraining that 80%—or even 90%—of the work items could be done by someone far less skilled.

> If you want equivalent costs to the rest of the world, expect the US expectation of care, turnaround time, and time-to-service to decrease drastically.

I'm already waiting upwards of 3 months to see a specialist. Every GP I go to wants me out of that room within 10 minutes. If I'm in the hospital, your "rounds" last maybe 2-5 minutes - you guys are constantly interrupting me. Your admins have you on such a tight schedule that you'd rather just send me for another scan, more panels, etc. It's easier to code and bill the heck outta me and my insurance companies that way.

Your industry is 100% anti-consumer... and I have GREAT health insurance as a tech worker. I hurt inside to imagine what those who have worse coverage (OR NO COVERAGE) are going through...

I recently watched the following https://www.youtube.com/watch?v=8LZJz7GtJA0 and literally cried thinking about how I wish someone from your world would respect me/my health like these men vs. cutting me off every other word when I'm telling you about symptoms.

You think it would get worse? Well in my mind it's already trash service because it's a whole bunch of competing industries trying to survive/make money off of each other with the patient as the last priority. The US healthcare system is brutal even if you have the coverage.

> You can't compare the US standard of care with the rest of the world's standard of care.

Also. Uh... yeah I can. We're America.

Please respond. I sincerely want to hear what someone with "MD Harvard Medical School. MGH Radiology Fellow." on their profile would have to say about this.

Funny, I visited a doctor while in Barcelona, it was a much nicer experience than any of my recent experiences with US doctors, I was able to get in same-day with something not particularly urgent, and it was a $50 CC swipe at the door. My friend’s mom broke her hip in Italy, and she was extremely well taken care of. I guess I just don’t see where they’re failing at standard of care.

How many life-years will the US standard of care coming down to the rest of the developed world cost me?

I can enumerate how much the cost of care coming down to that of the rest of the developed world is going to save me. You tell me there's a cost to this. Great. What is it? What exactly are we getting for the ridiculous money that we dump into your industry?

Related question: How many years of life do I buy from your billing guy spending $100 of his time to argue with my insurance company's billing guy (whose time also cost $100), over a $500 procedure? Because as far as I can tell, the net win for me in this transaction is that the procedure you performed costs me $700 net, instead of $500.

The US standard of care is below that of most of the developed world.

> If you want equivalent costs to the rest of the world, expect the US expectation of care, turnaround time, and time-to-service to decrease drastically.

I'm a Canadian that moved to the US. My wife has bilateral hip dysplasia. One side was corrected in Canada, and the other side was corrected after we moved to the US. We have great health insurance here

In both instances, wait time for appointments and surgery was the same, standard of care was actually better in Canada, she had a team of orthopedic surgeons vs in the US she had one surgeon and a handful of nurses and so forth.

But the US hospital had a better food menu, so there's that I guess...

>You are getting WORSE care for the same price when you see an NP or PA.

I am skeptical of this statement on average.

You’d agree that an important part of patient care is listening to the patients, correct?

In my personal experience, NPs tend to do so. Oftentimes I’m coming in for fairly obvious medical reasons and it’s a painless visit.

With doctors, it’s been a crapshoot for me. They adhere to whatever they learned years ago with complete inflexibility.

I still recall my high school dermatologist insisting that diet doesn’t affect acne and even showing me some stupid pamphlet to support her argument despite my insistence that it does from anecdotal evidence. Lo and behold it turns out she’s wrong! I doubt she cares since that’s not what she learned 15 years ago in school.

Simply put, most doctors don’t give a shit if you don’t fit the general case. If a side effect is not on the label, surely you’re imagining it and we can set up some therapy sessions.

It’s bewildering to say the least and very patronizing.

Imagine you had a tech lead try and “fix” any bugs you’re encountering without ever bothering to read the code or see what your approach so far has been. They just spitball some suggestions from what they’ve seen before. That’s how it feels.

It's certainly not better.

Well that is a massive difference from “it’s worse”. If Americans are paying so much more than other countries on their health care for something that isn’t leaps and bounds better, then they are getting fleeced. And given how many health outcomes in the US are fairly middling for a country of its size and wealth, it’s not a stretch to assume the health care isnt actually better. At the very least, you can conclude that whatever benefits their are to our stupendous health care are more than offset by the damage done by the prohibitive cost. Fantastic health care isn’t fantastic if people can’t afford it.

>You can't compare the US standard of care with the rest of the world's standard of care.

That's right you can't. The USA is 31st in life expectancy and falling, behind virtually every other industrialized nation in the world in addition to countries like Chile, Slovenia and Costa Rica.

https://en.wikipedia.org/wiki/List_of_countries_by_life_expe...

That's disengenuous at best. Health care only goes so far when half of our population is obese. I would think survival rates for various diseases would be a better metric.

> You can't compare the US standard of care with the rest of the world's standard of care. If you want equivalent costs to the rest of the world, expect the US expectation of care, turnaround time, and time-to-service to decrease drastically.

I think the legal standard of care is mostly just a mistake on the part of the US. Surely it would make more sense to let different people have medical care performed to different standards.

Never personally had a quality interaction with the VA. Neither has any other vet I know.

Your first mistake was having an opinion that the government is ineffective at spending or regulating thing.

The second mistake was thinking this forum would support you.

> we are seeing insurance carriers refuse to negotiate or offer rates greater than 125% of Medicare... fundamentally is acting as a wage-cap.

Sounds good to me.

Sorry I feel your pain but medical costs are out of control and you’re part of the problem.

Consult with your friends in the industry and figure out how to make billing reasonable and fair or it’s going to be imposed on you.

> Sorry I feel your pain but medical costs are out of control and you’re part of the problem.

To put things in perspective, physician salaries are less than 10% healthcare costs. A 25% decrease in salaries would only lead to a 2.5% change in healthcare costs.

----

There are a lot of reasons healthcare is expensive. Most of those come down to processes and practices that are out of the hands of individual physicians.

That’s actually an ton. For all of the heat big pharma takes regarding drug prices, the spending on prescription drugs is like 8%. Meaning the entirety of the costs of the pharmaceutical industry is less than just what we are paying for physician salaries.

IMO, pharmaceuticals aren't the problem either. Most drugs aren't outrageously priced (or have well priced generics). The hysteria over drug prices typically seems to revolve around a small set of outrageous cases.

My opinion is insurance as the primary billing method is almost exclusively responsible driving up costs. It adds a ton of complexity and admin work while discouraging general improvements to care.

That will be a great incentive to get people into medical careers. I can't see how a race to the bottom salary and factory-like approach to healthcare would be the end result to this.

Right, I'll get on repealing Medicare, EMTALA, and now Balance Billing legislation before I can legally offer a sane bill. /s

The proposed solution to balance billing is linking the "out of network rate" to the FAIR health claims database. It keeps the insurers honest and allows competition at the market rate.

If you gut everyone, hospitals will close and access to care will shrink.

The big problem with healthcare in general is administrative churn that eats away at the money available for actual Health Care [1].

[1] https://www.americanprogress.org/issues/healthcare/reports/2...

Everyone pays for the bloated administrative machine that is the elephant in the room that no one seems to ever talk about.

FAIR Health is a claims db. It doesn't have a single price. You think every doctor should be paid at what percentile - 90th? Doesn't make that much sense to me. I know that's typical UCR.

Also, you don't have to do everything, but you could start by doing something other than complaining about doctors who have ruined many people's lives getting paid less.

I'm working on setting up a Bay Area chapter of https://rightcarealliance.org/ (which is national) for grassroots healthcare organizing - feel free to hit me up if you'd like to participate.

I'd settle for 75th percentile to force insurance carriers to actually negotiate and not deliberately keep pruning their provider networks by offering terrible rates.

You can’t have all the doctors paid at the 75th percentile. That’s like saying you want everyone’s children to be above average. It doesn’t make mathematical sense.

At some point someone actually has to set the rate for things. If market mechanisms aren’t working there needs to be another method.

The point here is that sticking customers with out of control surprise bills they have no way of foreseeing or avoiding needs to be removed from the list of options.

75th percentile would be for when out of network. It would work to reduce ridiculous charge-master surprise bills but still provide a redress mechanism for monopolistic insurance companies playing hardball and cutting reimbursement 60% in one year (see Anthem BC/BS to pathology in multiple states).

The argument here is that by destroying the threat of out of network, the insurance company has literally no incentive to offer rates better than Medicare. That’s a huge unfair advantage to insurance companies.

> The argument here is that by destroying the threat of out of network, the insurance company has literally no incentive to offer rates better than Medicare.

Yup. Works for me.

> That’s a huge unfair advantage to insurance companies.

Not so much. Guess what I think the next part of the plan should be?

Sounds like they “prune” non-competitive providers with likely inflated rates. WAI

> allows competition at the market rate

What market rate?

For-profit hospitals mark up prices by more than 1,000 percent because there's nothing to stop them: https://publicintegrity.org/health/for-profit-hospitals-mark...

What kind of market does not allow me, the customer, to know, at all, what my financial liability is?

What kind of market has players mark up prices by more than 1,000 percent because there's nothing to stop them?

That's no market - that's extortion, plain and simple.

> I'll get on repealing Medicare, EMTALA, and now Balance Billing legislation

The EMTALA has been unfunded for decades.

Hospitals bill $50k for a sprained ankle, write it off after they harass a patient to pay $5k for it, claim the $45k as a loss and pay $0 in corporate taxes because of all these "losses".

Hospitals support the EMTALA because they get these large write offs and federal, state support. Not because of the warmth in their hearts.

Balance Billing?

As long as we are talking about unethical principles, why don't we talk about withholding all cash funds that patients walk in with as a "security deposit" and deduct $150 of it as "handling fees"?

After all, they sat down on the chairs, enjoyed the AC, watched the TV - none of this is free you know.

> insurers honest

Let your patients worry about their insurers. Your patients, more often than not give the insurers a very hard time, for troubles unlikely caused by the insurance company in the first place.

The insurance company happens to collect the money they summarily dispatch to providers and drug companies: the business model they follow actually gains from them reducing their premiums, which they would very much like to, if they could.

Infact, the ACA has capped the amount of profit an insurance company can make which has reduced their interest in negotiating better provider rates.

Here's a diagram from a very detailed post I wrote: https://qph.fs.quoracdn.net/main-qimg-d68aea3ca1e466f166752e...

https://www.quora.com/Why-is-private-healthcare-in-the-US-so...

EMTALA is precisely the problem. We cannot ask for any money before seeing the patient; nor can we ask for a deposit.

Further, we are medicolegally liable for all care we provide even if we don't get a dime.

That was the original intent of going out of network; we'd tell the patients "we don't accept your insurance because we could not come to an agreement; if you'd like to continue, we can see you but it will be billed to you. We'd appreciate you telling them you want to see us as a subscriber"

However, with the corporatization of medicine, the individual decision making has been lost.

What the hell do you think the alternative is to EMTALA? Asking the heart attack victim to wait while you run their credit?

Do you offer a price list to the out of network patient you tell that to? Or perhaps a quote for the services before you perform them?

Haggling in the emergency room doesn't even sound that terrible to me compared to the reality, which is a stark ultimatum - if you want to be treated, it's a blank check.

I am not happy with this solution, but I must say medical establishment - maybe not physicians themselves, but certainly whoever takes care of pricing and billing - were doing everything for years to invite regulation. Because people can tolerate what's going on only for so long. When every time you go to a doctor, you never get a price on anything and then you get a flurry of bills with cryptic codes and unexplainable charges and are expected just to pay exorbitant sums and shut up - people will only go with it for so long. No other good is sold this way, and no other business is conducted this way. I am generally pretty laissez-faire guy, but even my blood starts boiling when I see how the business is conducted there. I tried a couple of times to figure out some of the medical bills, and I almost went crazy. The impression is literally nobody - or at least nobody mere mortal is able to talk to - knows how it actually works and is willing to tell me - who pays the freaking money for the whole charade! - what's going on.

I know one medical area where it isn't this way. Dentistry. When I go to a dentist, whatever is the procedure, I can know upfront what are the costs, what I am paying for, and almost always (excluding rare exceptional cases, which usually also are handled by the dentist) which part is out of pocket and which will be covered by insurance. That is before we even start. But if I go into a non-dental clinic - suddenly billing is a riddle, wrapped in a mystery, inside an enigma, nobody can say anything - you just have to wait for the bills to come, and then you'd know.

No wonder it ends up with the state coming in and putting the boot down. And no wonder it will be done in a ham-fisted way state regulation usually works. Because however laissez-faire I am, I cannot but see current situation is completely fubar. I'd prefer medical professionals and insurers and administrators and whoever they are figured it out and proposed me a market-based solution that doesn't make each visit to a doctor a reverse lottery - but that doesn't seem to happen (well, there are a handful of medical establishments with proper predictable pricing, but rare and far between). So, no wonder this is happening instead.

> When every time you go to a doctor, you never get a price on anything and then you get a flurry of bills with cryptic codes and unexplainable charges and are expected just to pay exorbitant sums and shut up - people will only go with it for so long.

Nailed it, buddy. I just went through a bad few months of health issues that required numerous trips to see specialists, in-patient and out-patient care, etc.

Even though I do have supposedly decent insurance which costs about $1K month between my employer and me, the bills just started piling up day after day. Cryptic codes on all of all of them and absurd costs which were reduced by the insurance company and then sent to me. I'd consistently see crazy, clown-world prices like a one-night hospital stay charged for $25K, reduced by the insurance company to $1200, and then billed to me for $500. It's like they just made up the prices as they went along.

And even after doing my best to figure out which bills were valid and which weren't, I still had almost $10K of bills out of pocket, even though I have a deductible for $3K. Turns out the hospital who guaranteed me to be in-network allowed the use an out-of-network anesthesiologist (who billed me twice - once through the hospital where it took place and once through some anesthesiology company).

If any other business or industry played these kind of games they'd be instantly bankrupted as consumers would refuse to play, force their credit card companies to make charge backs, or find alternatives. Any other industry with these type of practices would be instantly sued by the SEC and DOJ for RICO act violations and collusion.

And while I know it's not just doctors causing the issue, they play a huge part. No sympathy from me if their whole industry were nationalized and they were forced to take government set salaries no higher than GS-15.

> $25K, ~~reduced~~ [negotiated] by the insurance company to $1200

$25K is the sticker price that someone uninsured would see. Sure, they'll get parts "forgiven," but this markup makes patients feel ripped-off, and it almost looks like an accounting scam. I'd like to see something that the sticker price can't be more than 10% greater than the lowest negotiated price.

IIRC, the “forgiven” part of that “debt” is considered income by the IRS. Just as a nice cherry on that shit sundae.

Not sure it applies to a disputed debt. Otherwise I could bankrupt any (non-billionaire) person by just claiming they owe me a billion dollars and then "forgive" them. And then I could get a billion-dollar tax write-off. I am pretty sure IRS is not that insane to fall for such a scheme. Though maybe with hospitals it works, it's a bizarro world there.

If physicians are not going to get on board with solving the problem, then I'm not too sympathetic when it doesn't work out well for them.

Physicians who see patients while out-of-network without asking permission are outrageously unethical.

And if someone is unconscious or dying, then you can't ask permission.

I have direct knowledge of an ophthalmologist splitting surgeries over two days that could have been done in one session, because it nearly doubles their billings.

They justify it by pointing at their less educated yet better-compensated college buddies working in finance. I've seen similar bad money-optimizing behavior from PCPs (e.g. it was insisted to me that I schedule an appt for lab results, which was justified by a lie about HIPAA preventing me from being able to get them over the phone).

The rot goes deep.

Or you could not have insurance play games where they pay less because something is done on the same day.

We used to have this in Radiology. If a patient came in for a Cancer restaging CT, payers could pay 100% of the chest, 50% of the abdomen, and 25% of the pelvis.

Just because these were done on the same day doesn't mean it's any faster or cheaper to interpret each of those portions. Yes there's some savings in the technical components (placing the IV etc), but it takes me just as long to read the three scans if they are done on one day or 3. Why should I take a 125% hit when I'm providing a convenience for the patient by doing all their scans on the same day?

"Why should I take a 125% hit when I'm providing a convenience for the patient by doing all their scans on the same day?"

You don't see what is wrong here? If your mechanic told you he wanted you to come to the shop 3 times instead of one for his convenience, you would find another mechanic.

I'm from the US and I've lived in Singapore and the UAE for many years. And I've had to deal with the US system from time to time as well. Medical services cost a fraction in Asia and the Middle East compared to the US and the paperwork is much simpler. And most of the doctors are educated in Europe. And lately I've seen more US doctors moving abroad simply out of frustration.

One time I was in West Virginia with my family and I had trouble catching my breath so we went to the ER. 1.5 hours of waiting, literally a 5 minute visit from the ER doctor and a 3600 USD bill. No treatment. No meds. Later I had to negotiate with the hospital over the bill. Eventually they told me that the insurance reimbursement rate for my vist would have been 600 bucks, but because I had no insurance, I was expected to pay 3600. I eventually got it down to 2200 after much angst and effort. Sick people don't need this aggro. Nor do they need the pain and discomfort for visiting the medical facility 3 times instead of 1 because of the vagaries of the US insurance/hospital billing system.

The US system is broken.

The entitlement in this single post is staggering. You are part of the problem.

You realize that the physician could have done both eyes in the same sitting, and then used the saved time to perform a procedure for someone else, right? Doing so would have been better for everyone, rather than riskier and much less convenient for the patient.

> Why should I take a 125% hit when I'm providing a convenience for the patient by doing all their scans on the same day?

Because what you're doing otherwise is unethical. Padding the bill by spreading out the appointments is a form of theft.

Why should the sick care whatsoever? Why do we need to have this discussion about competitive rates and charging these competitive rates to people who are in genuine need? And most of the time (for the doctors of this discussion), because they are in dire medical need.

Provider networks are just artificial competition. They don't need to exist. They just drive up costs and sink people into pouring money in a system that already sucks.

I've been dealing with it for the last 6 years with my mother. I wouldn't wish the added stress on anyone. It's ridiculous and wrong and backwards.

Correct me if I’m wrong, I’m not in the field.

I thought the ACA put limits on insurance company’s profit margins, by saying that they had to pay out a certain minimum from the total monies collected.

This is a perverse incentive for the insurance company to encourage the medical industry to increase costs.

Am I wrong about the ACA?

No, this is a terrible (but surprisingly common) argument. Most insurers operate in competitive markets - even if they let costs balloon, their competitor probably doesn't and can undercut them. There are a few that operate in non-competitive markets but the larger and startup insurers (e.g. Oscar Health) are aggressively entering new regions these days.

Most insurers are pretty aggressive at managing costs thru managed care techniques (described at https://en.wikipedia.org/wiki/Managed_care#Techniques).

Their profits are capped at 20% by law. They can increase profits in one of two ways; either by increasing premiums or by increasing subscriber count.

The upstarts can try to undercut the big guys, but they still are stuck at a 20% profit margin; if they make too much, they have to refund the excess premiums.

No, their net income margin is capped at 20% (well, technically their total administrative expenses are capped at 20%). Their total valuation is mostly a multiple of total net income, which is driven by higher revenue. New upstarts are probably looking to operate at a lower margin anyhow (similar to other growth-oriented companies e.g. Amazon) to achieve higher valuation from revenue growth.

It's quite clear that the insurers are aggressively trying to control costs when you consider that networks on exchanges are extremely narrow and denial rates are actually pretty high - IIRC nearly 1/3 of claims are initially denied for ACA plans.

These companies are also bringing the narrow network model to the small and large group markets too, where utilization review is also quite aggressive and has been for a long time.

It basically works out like textbook oligopolistic competition models where the Nash equilibrium resembles a prisoner's dilemma. For companies to increase "total market size" by allowing costs to balloon would require unusual collusion and there's no evidence of it.

These factors would then push for the insurance carrier to lobby state legislatures to cripple the negotiating position of their contractors.

Narrow networks are a big problem, having been denied access myself while trying to be in network.

What do you mean about lobbying? There's always lobbying by both sides.

Narrow networks are usually a symptom of few and picky doctors imo. But I don't really know. Economics suggests that more insurers in a market should benefit providers.

Insurers will deliberately not credential physicians on their plans when trying to keep networks deliberately narrow.

I and others have been denied enrollment because the "panel is full". Narrow networks are not always because the physician doesn't want in. Sometimes it's a deliberate insurance strategy.

That seems like the type of thing your state medical association should lobby against.

Btw, in California the state medical and hospital associations are definitely more influential than insurers. And I bet that's true in MA too.

”No, this is a terrible (but surprisingly common) argument. ”

Well I don’t know it’s a terrible argument. You confirmed that there is a cost floor. This does create a perverse incentive. Whether it is or any consequence is another matter.

If the perverse incentive is pushing insurance companies to have their costs go up depends entirely on the market conditions, I.e what are typical profit margins w/out ACA and what are the cost of market entry. there could be an equilibrium where insurance companies want their costs to go up.

There is another equilibrium where the allowed profits are far above and therefore ACA limits are meaningless.

Now, you can argue that we’re in the competitive operating regime. Fine. But give me numbers And citations, not adjectives!

This is correct. Their profits are capped at 20%. If they make too much money, they have to refund premiums.

Even pre-ACA, I don't remember insurance companies having margins that big. Progressives like to paint insurance companies as villains, but they're not printing money, and definitely not like tech or financials.

Not that insurance companies don't add bloat, but healthcare cost in the US is due to a lot of factors.

- Overtreatment to mitigate liability - Overtreatment of the elderly - Poor end-of-life management - Insurance bureaucracy - Siloed providers - Intervention rather than prevention - Conflict with other policies (like the farm bill)

The ACA tried to fix, um, not really any of them. But props to Michelle Obama for axing the food pyramid.

Insurers are absolutely villains (But not the only villains in this game). They are the reason that hospitals have such bloated billing departments, and who gets to pay for all that? Well, I, as the patient, do.

Insurances make money but a lot more money is made from the whole intransparent chaos by many player.

To be clear, I’ve never gotten mad at my insurance company. They play a game and they lay out the rules.

It annoying that I have to read reams of papers when I start a new job. But they play within those rules.

My hospital, on the other hand, doesn’t know what they will charge me for a service they will do yesterday.

Honest question. If I ask a doctor "will I be billed for this procedure," and they straight-up can't or won't answer me, what's going on? Whose fault is that?

It entirely depends on if they are independent and work for themselves, and therefore know their contracted rates with the insurance companies. If the physician in question is an employee or a member of a large health organization, it's entirely possible someone else does those negotiations on the person's behalf, so they would have literally no idea.

By law, we can only charge one price to all payors. We cannot charge variable numbers; however, you can accept less money than charged. Medicare will pay what they pay; they don't care what my charge is. However, other payors (private insurance) will pay various amounts which are usually higher than Medicare. If I set my top price too low, I'm leaving money on the table. However, I cannot "enter the negotiation" even with a cash-paying-patient legally without charging the top-line price.

These top line charges are called "Chargemaster" rates. I can probably get a hold of my institution's charge master schedule and figure out what they'd charge you, but as one of literally 200 radiologists in my current practice, I have no say in those rates at all.

> By law, we can only charge one price to all payers

My last visit to one medical for a pretty average checkup netted my a bill of ~$450. I checked their website, and saw a price for the same “procedure” for 100. When I called up they said that was the price for uninsured patients who had that procedure and that because I was insured, they were legally compelled to charge me $450. Ultimately the support agent hinted at me to say some magic line about financial hardship so she could lower it to ~250.

As a patient all the doctors and admins are pointing at the insurers and all the insurers are pointing at the doctors and admins.

It’s hard to trust any of you.

Any place that accepts insurance is bound by the terms of the insurance contract, which usually includes a most favored nation clause, meaning that you won't accept cash payment for less than the negotiated reimbursement from the carrier.

Similarly, you cannot charge less than you accept from Medicare/Medicaid.

What we can do is bill you, then write off whatever is equal to the highest contract we have. People in private practice approve this not infrequently; but corporate and mega groups have removed individual decision making and stripped us from pricing discretion. These are the pains of 3rd party payers.

I advise everyone who has an HDHP or no insurance to find a reasonable cost direct primary care. The subscription is often much cheaper than you'd think.

> If the physician in question is an employee or a member of a large health organization, it's entirely possible someone else does those negotiations on the person's behalf, so they would have literally no idea.

They personally might not, but their organization certainly does. If they are large hospital, they won't negotiate rates with each person anew, they already have everything figured out. If the doctor can't access it with a couple of clicks on their PC, it's an organizational failure. And if the doctors don't raise a stink about it every day but shrug and tell the patient "you'll see when we send you 20 separate bills, 20 line items each, all coded with internal codes you have no access to" - then it becomes their failure too. I can appreciate they are part of a large organization, but they are not totally powerless and if they really pushed for it they probably could do something. Maybe not one radiologist, but if every radiologist would ask the billing to implement that system, I think they'd think about doing it sooner or later.

> However, I cannot "enter the negotiation" even with a cash-paying-patient legally without charging the top-line price.

Yes, this is true and if you try and settle with a cash-paying-patient who's insured, the insurance company can drop you as well as pursue breach of contract damages.

> By law, we can only charge one price to all payors

What law is it?

because this is absolutely untrue in a country that does not follow an all payer rate set system and the U.S. ain't one.

In the U.S. the VA pays one rate, Medicare another, private another, Indian Health Service (IHS) and Tribal Health another and so on.

Here's a helpful chart for you that shows all the different parties each of who pays different rates for the SAME CPT CODE: https://qph.fs.quoracdn.net/main-qimg-72f33aa55c71c439fc4660...

Infact a lot of avarice ridden providers refuse to treat Medicare patients, who need the most help, precisely because Medicare pays less than private party care.

> one of literally 200 radiologists in my current practice, I have no say in those rates at all

Oh yes you do.

Most radiologists dont even attach themselves to a network because they can bill OON.

Which is why 35 percent of adults have surprise bills for imaging services: https://www.radiologybusiness.com/topics/healthcare-economic...

Let me quote another article: http://www.ncsl.org/research/health/counteracting-surprise-m...

> As an example, a woman seeks care for a broken limb. She is careful to go to a hospital that is in her health insurance plan’s network. She remits her copayment and receives an X-ray. Several days or weeks after the visit, the woman receives a bill for hundreds, possibly thousands, of dollars. Even though the patient was seen at an in-network hospital, the radiologist who read her X-ray was not in her insurance network. Still, the patient is responsible for picking up the out-of-network cost.

No one is forcing a radiologist to be OON - it's their own decision and they do it exactly to have a say in their rates.

It's fine to want to make money.

Whats the big deal with all this smoke and mirrors?

Here's how a business transaction outside healthcare in the U.S. goes:

Party A: Hey B, you have X, which I need

Party B: Yes. I have X, and I want $Y from you

Party A: OK, but can you try and do it for a bit less, say $Z?

Party B: Yes.

Here's how a business transaction in healthcare in the U.S. goes:

Party A: Hey doctor, you have X, which I need

Doctor: Yes. I have X, and I accept your insurance!

Party A: OK, here I am. $30 co pay, right? Doctor: Yup!

Doctor (3 months later): Oh, turns out you owe me $250 for the local anesthetic and $1700 for use of the camera I shoved down your throat 3 months ago. Also the thing I did was surgery because I went inside your body so it's not a $300 in office visit but a $750 one. If you don't know what endoscopy is, it's your fault you ignorant slob. It's your fault you didn't know all of this. I didn't go to medical school for nothing, now pay up or I will repo your house and garnish your wages.

The pain is showing now. People are really upset about how they have been and continue to be taken advantage of

> they straight-up can't or won't answer me, what's going on

The answer is they probably don't know. Or if they do know, they can't be 100% in their answer.

-----

There are literally thousands and thousands of insurance combinations. Aetna might approve one thing while Blue Cross won't. Even within the same provider network, your specific medical history (or even your claim processor) can affect if you'll be covered for a specific procedure. Even if the doctor contacts insurance, it won't guarantee something will be covered. You have to wait until things get billed to resolve specifics.

Lol if it’s too difficult for an MD to know. For all their capability of understanding and working as a professional to answer a simple question about costs, then something is wrong.

If doctors were obliged to answer this question, I bet we would have a simpler system because the physicians would put pressure on the system to simplify.

If MD's controlled billing, they'd absolutely be able to answer. You see this with doctors that have switched to entirely cash pay. They can provide quotes and estimates much like automotive maintenance or general contracting.

> The answer is they probably don't know. Or if they do know, they can't be 100% in their answer.

So whose fault is that? It's inexcusable to be forced to accept a service before being told how much it costs. If the doctor really is completely helpless, I want to know who's forcing them to go along. "That's just the way things are" is not an acceptable answer.

>"That's just the way things are"

Unfortunately, that's what it comes down to in practice.

-----

It really comes down to insurance companies. Some doctors are switching to private pay only (i.e. you pay out of pocket). This allows them to operate much more closely to a traditional business, like auto repair or general contracting. They have easily itemized costs for materials and a standard labor rate.

When insurance comes in, absolutely all of that goes out the window.

* Insurance never wants to commit to exact costs. Doing so removes their leverage to minimize bills.

* You remove the incentive for high efficiency (which simply becomes an issue in every aspect of health care).

* Patients never even attempt to shop around for costs.

* Patient satisfaction scores are completely at odds with billing efficiency. You either do too much to minimize visits or risk loosing money if you choose to tackle something iteratively.

-----

In general, I think the entire health system would be drastically better if health insurance took the approach of automotive insurance. Insurance is only for catastrophic events. Standard care and maintenance is an expected cost that comes out of pocket.

It sounds like insurance is causing the problem, then.

I don't believe that this is the only, or best, way to provide across-the-board medical coverage, given how many countries seem to manage fine.

As a patient I can’t disagree more. I have been hit by a $5000 fee because I was seen by a doctor who wasn’t in the right network, despite it not being a choice I was able to make.

Doctors lose negotiating powers and are paid a lower wage? I am fine with that. Wait until we have universal health care.

It’s not fair to extract full market value from users when the penalty from not paying is death.

If all of your employeer's and most private doctors didn't try to systematically fuck over your patients and brag about it (I worked in major health management orgs), you wouldn't be getting the big regulation stick. I don't really have sympathy.

> It also completely eliminates the incentive for insurance carriers to even bother creating a provider network.

This is extremely disingenuous.

The reason for the regulation was precisely because most physicians never bothered joining a provider network knowing that doing so would cap their income and the ability to hold the patient hostage.

Hey - it's ok to make money. But it's not OK to make it unethically.

You are extremely lucky that people dont think too deeply about the root cause of the outrageous costs of healthcare in U.S. and get quickly distracted, blaming insurance companies and the govt. about their crippling medical debt - because when they do actually run the numbers, look at the statistics, the invoices, the claims, they realize the root cause are the providers themselves.

It's very likely though, that some here in the HN crowd will come to this realization because they do think deeper.

There is 0 reason for an insurance company to charge more than absolutely necessary. The cheaper the premiums are, more volume they have.

Here are my thoughts:

Nothing stops a provider from telling a patient "Hey, I will cost you $10000 at most. Do you want me to treat you?".

The provider does not have to know what network the patient is in, what their deductible is. Whether the patient is employed or not.

All they have to know is that the maximum they have charged for stitching a cut, that this patient in front of them, has, is $10000 and that is what they inform them.

If a provider thinks that this question distracts them from providing the best of care, nothing stops them from joining an insurer's network and continue to do the good work.

Provider does not want to handle money at all? Fine - work at a hospital that has someone willing to do that. To have the numbers ready. Or even have an estimate printout in a new minutes.

Computers do that now.

Do you, personally, think this is a fair expectation?

No one is asking a provider to quote down to the last two decimal places what a visit might cost.

The expectation is to know, atleast, what the maximum financial liability could be:

$500? $2000? $10000? $50000?

Crickets. Indifference at best.

Instead - here's what providers have been doing: They explicitly try and stay OON to extract the maximal possible revenue from patients who were in a desperate situation with 0 leverage.

> It was no longer the individual physicians choice

The bulk of the individual physicians NEVER chose to be in network in the first place. Not when they were independent. Not now.

The American people are hurting from the thousands of dollars in medical debt foisted on them without them even being told what they are getting into.

Thousands of dollars in surprise bills from tens of different providers in addition to the tens of thousands of dollars from the hospital after spraining an ankle, dislocating an elbow, getting a cut.

I am not talking about blood gushing out of an open wound. I am not talking about a head cracked open.

Nickle, dimed and harassed by collection agencies that add on fees and interest rates multiples of prime if you can't settle in full.

I understand the medical education system in the U.S. is expensive and long but I, as your customer, should have the ability to know, UP FRONT, how much seeing you, might get me into debt so I can make a decision whether I should work with you or not. NOT after the fact.

Do you, personally, think this is a fair expectation?

Not a SINGLE doctor in the WHOLE of California has ever come forward to answer this question of mine, which at this point is more than 3 years old: https://www.quora.com/How-do-I-find-a-general-physician-in-S...

All this question asked (details can be found in comments for those logged in) was: Is there any general physician in San Diego that will provide an estimate (NOT a guarantee) of a visit planned weeks in advance with their staff.

I have found tens of doctors in Mexico who were more than happy to provide a quote down to the last two decimal places and they went beyond what was expected of them.

Yet, 0 responses so far from the WHOLE of California sans one extremely disingenuous, snarky Anonymous remark that stood up a strawman argument that I somehow wanted the estimate for free (which I did not and was more than happy to pay for)

Every regulation is a response to societal pain.

This pain has been cutting in too deep for far too long.

> Every regulation is a response to societal pain. This pain has been cutting in too deep for far too long.

I feel like the societal pain and the regulatory response cycle in healthcare in the US is out of control. We have an itch, and we've been scratching it aggressively since the Kennedy Administration. We've scratched so deep we're not scratching, we're digging deep to the bone.

Everything that's good about the free market is gone from this system. Prices are not dictated by supply and demand: to the contrary, the suppliers (doctors) and consumers (patients) are the ones farthest from the negotiation of price.

Everything that's good about a regulated market is gone from this system. The system is so complex that the only people knowledgeable enough to write regulations are the ones whose profits need to be reigned in the most. The fox is guarding the henhouse.

The system is fucked. More regulation will make the system more fucked. Less regulation will make the system more fucked. We're fucked.

> More regulation will make the system more fucked. Less regulation will make the system more fucked.

That’s pretty ridiculous given that it essentially concludes there is no way to create a viable healthcare system, when most other first world countries are not having these problems.

The issue is that the US system insists on clinging to the idea of a “free market solution”, without any of the crucial ingredients for making a free market solution work. The information regarding who pays what for what services is as opaque as any industry out there. People receiving the health care are different from the people paying for the healthcare, and the how the costs trickle between parties is unapparent until after services are rendered, and even then it’s fairly inscrutable. How is a free market supposed to work when people can’t actually shop around and compare prices? On the other hand, you have massive consolidation and monopoly creation occurring in both the hospital administration field, as well as for insurers and PBMs. Barrier of entry is also sky high, so in reality there is little to no competition going on, which is crucial for any free market solution.

The reality is that people need to accept that the functional “free market solutions” simply don’t exist for certain industries, chief among them healthcare.

> This is extremely disingenuous. The reason for the regulation was precisely because most physicians never bothered joining a provider network knowing that doing so would cap their income and the ability to hold the patient hostage.

I'm sorry but this is incorrect. The opposite is the case. Post-ACA, insurance companies deliberately pruned their provider networks to be so narrow so as to restrict access to care, in direct hopes that patients would go outside the network out of frustration. I can tell you personally as someone applying to be in network, I have been frequently denied as "they have too many people in their network already of my specialty" (exact quote).

[0] https://www.modernhealthcare.com/article/20181204/NEWS/18120... [1] https://www.nytimes.com/2016/10/18/upshot/savings-yes-but-na... [2] https://www.npr.org/2017/11/26/566634747/aca-s-narrow-networ... [3] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4547685/ [4] https://www.firstquotehealth.com/health-insurance-news/narro...

> You are extremely lucky that people dont think too deeply about the root cause of the outrageous costs of healthcare in U.S. and get quickly distracted, blaming insurance companies and the govt. about their crippling medical debt - because when they do actually run the numbers, look at the statistics, the invoices, the claims, they realize the root cause are the providers themselves. It's very likely though, that some here in the HN crowd will come to this realization because they do think deeper. There is 0 reason for an insurance company to charge more than absolutely necessary. The cheaper the premiums are, more volume they have.

I'd like to split this into three topics: Insurers, Physicians, and Hospitals. For insurers, profits are capped at 20% of premiums by the ACA. The only way they can increase profits is to increase premiums or increase subscribers. That's it. Insurance companies do not make up anything on volume. Occasionally, an insurance carrier will make too much money and be forced to refund premiums.

[0] https://www.healthinsurance.org/obamacare/billions-in-aca-re...

Physicians cost at most 20% of total health expenditures from CMS data, even though this number is at the high end and does not include individual practice overhead. However, the really outrageous bills that get people up in arms are frequently hospital bills (where people love to complain about overpriced tylenol).

[1] https://www.cms.gov/research-statistics-data-and-systems/sta...

> Here are my thoughts: Nothing stops a provider from telling a patient "Hey, I will cost you $10000 at most. Do you want me to treat you?". If a provider thinks that this question distracts them from providing the best of care, nothing stops them from joining a insurer's network and continue to do the good work. Do you, personally, think this is a fair expectation? No one is asking a provider to quote down to the last two decimal places what a visit might cost. The expectation is to know, atleast, what the maximum financial liability could be: $2000? $10000? $50000? Crickets. Indifference at best. Instead - here's what providers are doing: They explicitly try and stay OON to extract the maximal possible revenue from patients who were in a desperate situation with 0 leverage.

We don't like staying or going out of network, because it is hell to get paid. However, there are national private equity staffing groups that deliberately will go OON to force better rates across a state; since these are PE backed, they can stomach the pain it takes to get payment from angry patients. This is not a physician decision; the staffing group makes this decision. I personally think it should be illegal for non physicians to own physician groups like it is with legal practices, but currently, it is legal.

As I mentioned in a sibling comment, we can always provide a charge master rate, but it's usually extraordinarily high (because we have to charge a single rate to all payers) and people want to know what their insurance will pay. Can't easily just query the BCBS API as much as I wish I could.

> It was no longer the individual physicians choice The bulk of the individual physicians NEVER chose to be in network in the first place. Not when they were independent. Not now. The American people are hurting from the thousands of dollars in medical debt foisted on them without them even being told what they are getting into. Thousands of dollars in surprise bills from tens of providers in addition to the tens of thousands of dollars from the hospital after spraining an ankle, dislocating an elbow, getting a cut. I am not talking about blood gushing out of an open wound. I am not talking about a head cracked open. Nickle, dimed and harassed by collection agencies that add on fees and interest rates multiples of prime if you can't settle in full. I understand the medical education system in the U.S. is expensive and long but I, as your customer, should have the ability to know, UP FRONT, how much seeing you, might get me into debt so I can make a decision whether I should work with you or not. NOT after the fact. Do you, personally, think this is a fair expectation?

I think this is a fair expectation; why not make it so insurance companies actually stop hiding this information?

> Not a SINGLE doctor in the WHOLE of California has ever come forward to answer this question of mine, which at this point is more than 3 years old: https://www.quora.com/How-do-I-find-a-general-physician-in-S.... All this question asked (details can be found in comments for those logged in) was: Is there any general physician in San Diego that will provide an estimate (NOT a guarantee) of a visit planned weeks in advance with their staff. I have found tens of doctors in Mexico who were more than happy to provide a quote down to the last two decimal places and they went beyond what was expected of them. Yet, 0 responses so far from the WHOLE of California sans one extremely disingenuous, snarky Anonymous remark that stood up a strawman argument that I somehow wanted the estimate for free (which I did not and was more than happy to pay for) Every regulation is a response to societal pain. This pain has been cutting in too deep for far too long.

I'd suggest you seek out a concierge or direct primary care practice. It's not absurd to just pay for people's time. If I were in primary care, I'd probably just set an hourly rate for people to purchase medical advice consultation and bypass insurance entirely.

Of all specialties, I'm the most sympathetic to billing issues because our billing is very predictable: an imaging examination is an encapsulated episode of care. However, the problem is that a lot of hospitals own imaging equipment and use it to cross-subsidize their other departments.

> Of all specialties, I'm the most sympathetic to billing issues because our billing is very predictable

Most billing is predictable. Doctors in India, Mexico (two countries I have first hand experience in) quote down to the single digit, a price. Some surgeons guarantee it - as in 0% variance. You pay what you sign up for. I am talking triple bypass surgery. Sounds pretty complicated.

I don't have medical training but is triple bypass surgery way less complicated than an office visit for a flu symptom?

I don't believe doctors in India or Mexico receive special price estimation training that doctors in the U.S. is banned from attending. My body is still the same irregardless of whether I'm in India or Mexico or the U.S., so why all this baloney?

Now I don't fly down to India or Mexico to treat my flu symptoms but when I was in India, a physician visit was a flat USD $1, no matter what the issue was unless you needed hospitalization. I am talking walk in prices as in "go right now to see a doctor because I'm running a fever".

The $1 was the unsubsidized, full retail price paid by those who could afford to pay, like myself. There was no health insurance fad in India when I was there. There was 0 need and demand for it. The doctors would often take way less for the poor or completely waive it and these doctors would still be making bank.

Yet a visit here is an involved appointment process with multiple day waits and you still don't know what you owe as the copay is just the starting price.

It has become ridiculous.

> I personally think it should be illegal for non physicians to own physician groups like it is with legal practices

Hmm, I thought that applied and the board of directors all need to have a current medical license?

> I think this is a fair expectation; why not make it so insurance companies actually stop hiding this information?

First, I really appreciate the time and dedication you have shown here. YOU REALLY care about your profession and I love you for it.

Thank you.

It will be a pleasure to speak with you in person or over the phone or however we can connect. I am looking forward to it. I am my handle at gmail. Please, reach out.

I am sure, if everyone in your professional felt like you do, we would not be having this conversation right now.

Now, for some reason, it seems to me that you detest insurance companies. IF I might estimate why - perhaps they make processing claims very hard. Sometimes they don't pay you what you expected. We can have that conversation, but do understand that there are no lack of providers that outright defraud these insurance companies and while you might be extremely ethical, you are having to shoulder the burden of those who have betrayed the trust.

To address the topic at hand - no insurance company has ever refused to give me the information you claim that they hide - they just need the CPT CODES and they will gladly run the numbers for me. They will even give me a list and contracted rate for CPT codes.

The issue here is that I need a provider to tell me what those CPT CODES are.

Neither I NOR the insurance company are in the medical diagnosis business and only the medical diagnosis providers get to generate those CPT CODES.

I have a 250MB spreadsheet full of CPT codes and their negotiated rates for my plan, but I have no clue how D6010 ($2050) is different from D6190 ($125) or when they apply (these are not medical CPT codes because I have them at a secure location but you get the idea).

Just to be clear: The insurance company at no point in time tried to hide this information from me.

I can answer the coding question. They have automation that will select the highest level code for a procedure they think they can get away with without being sued. They brag about this. Like using emergency codes for specialty at a satellite facility they claim is physician owned but isn't soley so they can just bill insurance the higher rates.

Of course it's different. Being a programmer is just a job, whereas being a doctor is a privilege granted by society.

> Being a programmer is just a job

That's like saying building bridges is just a job. The word you're looking for isn't "privilege," it's "responsibility."

Access to doctors is something that every person needs be they rich or poor and something that must be accessible at a reasonable price. Being a doctor is a privilege granted by society on the understanding that society sets the rules of how the healthcare system works.

Bridge engineers are free to charge what they want if they feel they are worth that much.

Doctors lost the right to complain about wage fixing when they decided to be a cartel.

"carriers refuse to negotiate or offer rates greater than 125% of Medicare" ... "This is not the intent of the law and fundamentally is acting as a wage-cap." Having lived in both Canada and the USA, I think this is great. The doctors in the USA are vastly overpaid (that is why it is/was so hard to find a primary care doctor in Vancouver, they all moved south for the money), and the healthcare, both statistically and in my personal experience, is not better for it.

That's good. Doctor salaries need to come down. You're not entitled to be compensated arbitrarily more than Medicare.

None of what you suggest addresses the absolutely criminal and despair inducing practice of a surprise out-of-network RNFA charging $40,000 for an hour procedure in order to milk as much as possible from an insurance company and patient.

The US system is such a mess.

It's supposed to be a free market, and yet the middlemen and the doctors are arguing about who should set the prices. Guys, this is not how capitalism is supposed to work. Imagine this model in any other sector - it would be illegal and also a total joke.

How about scrapping insurance, scrapping medical licensing, clearly advertising prices at doctors' offices and requiring patients' signed consent for any costs incurred? That's what an actual free market solution looks like. It wouldn't be perfect but it would be a damn site better than what you have currently.

This is why I think our government should not have much to do with healthcare other than to look after safety, accountability and exercise regulatory control where absolutely necessary. They have made a mess out of the US healthcare system and healthcare is the last thing they address.

BTW, my wife is also a physician and we have several additional physicians in our family both in the US and abroad. And, of course, through their respective networks you get to have interesting conversations with other physicians (I enjoy going to conferences with her for this reason).

This is where my conclusion comes from. I developed this idea that we need to eject politicians from almost everything related to healthcare in the US save the areas I mentioned above.

One example of this is the constant regurgitation of different hair-brained insurance schemes to "fix" healthcare. We don't have an insurance problem. No manipulation of insurance will fix healthcare. And, no, "Medicare for All" won't do it either, in fact, it will make a mess out of it.

The problems we have are structural (at least that's my term for it).

It starts with the cost of education. Government guaranteed loans have caused a situation where medical practitioners, at every level, graduate with massive debt. This establishes a floor on what they have to earn in order to not only make these payments but have a life, a family, enjoy life in general. Government needs to bug out of student loans, which would put significant downward pressure on the cost of an education.

The next issue is equally large: Tort reform. Medical practitioners at every level have to carry very expensive insurance in order to protect themselves from often ridiculous lawsuits with equally ridiculous financial outcomes. Companies developing, manufacturing and selling any medical product have to allocate non-trivial costs to the potential of becoming entangled in brutally expensive lawsuits. Anyone who thinks a pair of forceps used in surgery is expensive has no idea how much of bringing that product to market was made expensive by the potential of unbounded litigation.

Moving on, I would add to this an expensive (in time and money) regulatory infrastructure. Personal anecdote: I have had interest in developing innovative tools for the treatment of both Strabismus and SSD (single side deafness). These two afflictions, as far as I am concerned, are still in the stone age today. I actually developed prototypes a couple of decades back. And then I discovered it would cost tens of millions of dollars to put them through the regulatory process (only if you have a smooth straight path, far more if you stumble). So I moved on. Far easier to work in aerospace and robotics than to endure the financial torture and risk that an entrepreneur has to undertake to be in the medical industry.

There's more, but I think the above are easily the top three. I would add to this the abject failure of not pushing through and having a solid nation wide medical information system that is efficient and patient focused. The fact that you can expect to have to fill out ten pages of the same questions at every doctor you visit is reprehensible at best.

There is no amount of insurance or "Medicare for All" magic that will improve our healthcare system until we, at the very least, address the above, none. It's a farce. It's false promises for votes, I don't care who it is or which ideological extreme they come from. Notice that there is one thing in common with all of the above: They all address costs. Our healthcare system is ridiculously expensive because our costs are ridiculously high. Fix that and then any reasonable insurance scheme should be able to deliver access to excellent care at reasonable prices. And, yes, we should also be able to cover everyone in the process.

The system being ridiculously expensive is only half of the problem. The other half is that this expensiveness is completely random, opaque, nondeterministic and unpredictable. It's one think if the doctor says to you "you need a procedure which will cost $TONS_OF_MONEY", quite another if the doctor says "well, we'll do the procedure, but we won't tell you how much it costs except that it's a lot, and you'd be getting bills for months from now, and will have to become an expert in negotiating with various billing systems, and we will mercilessly try to fleece you like a sheep every time, just because why not, you're already on the hook for it and we'll ruin your credit for the next decade if you make any tiny mistake on the way". The former is bad enough. The latter is absolutely terrible. And the medical professionals, by not pushing for the solution for it, and just saying "it's not our business, we just do medicine and do not concern ourselves with the lowly matters of money" share the responsibility for it.

Well, half is a big chunk!

Also, a lot of these problems are very much interrelated.

Until you've been in the shoes of a practitioner who has to worry about getting sued into oblivion for every decision they make you can't really grok some of the things that happen in US medicine. I only know because my SO wears those shoes and we have a lot of medical professionals in the family and beyond.

The fitness function they have to optimize for every day has consequences. And half or more of that has to do with what I discussed in my prior post.

I once got a surprise bill from in-network ER because they invited a specialist for consultation, That specialist sent me a separate bill later.

No one told me upfront it will cost additional $450 to hear from the specialist that "sometimes kids are having stomach pain for no any reason".

Edit: Additional information - Blue Shield CA HMO, Cedars-Sinai ER , circa 2012. $150 ER co-pay, later $10,000 bill fully paid by insurance + $450 specialist bill not covered by insurance.

I'm an ER doc. A couple of points:

1. If we consult a specialist, that usually means we have no idea what's going on. Sometimes, we do it for "customer service" if a patient really wants the consult and doesn't seem to trust what we're telling them. If we know ahead of time that a specialist is going to say that they don't know the cause of the pain and there's nothing to be done, then in absence of customer service issues we usually don't consult the specialist. I'm sorry you feel you got a raw deal on that.

Why we focus on customer service issues is another interesting topic. It basically comes down to hospital admin, like most other bureaucrats, love customer feedback surveys (Press-Ganey being the most common) and doctors can get in trouble or even lose their jobs if their customer service scores drop low enough.

2. Unfortunately doctors are completely ignorant about the financial aspects of this. Likely the specialist didn't even know you would be charged $450 for his consult. I don't see any good solution to this problem, especially as we're taught in med school that the patient's health is the most important thing and financial aspects should be secondary. Not saying I agree or disagree with this, just that even if a doctor disagrees with this there's no way for them to change the facts.

https://www.google.com/amp/s/www.nytimes.com/2014/09/21/us/d... <— this sort of thing is completely indefensible.

I’m just about the most free-market person you’ll ever meet, but the current situation in the US is completely untenable. I’m beyond caring about how the insurance companies tie your hands, how you’re just a doctor focused on patient-care/“customer service” (that’s a new one) or anything else. Here’s the bottom line: doctors have the most to lose by not fixing this nonsense. Insurance execs, hospital administrators, and other various parasites can go MBA something else. You lot are the ones with specialized and non-transferable skills. If you all collectively don’t start using your knowledge of the medical system to propose real changes, then the rest of us about going to impose changes on your profession that I promise you will not like.

Unfortunately doctors are completely ignorant about the financial aspects of this.

It's rather mind-boggling to have someone say they're completely ignorant on the financial end of things but simultaneously replying and seeming to defend what happened.

I remember helping a friend get plastic surgery, dealing entirely with a physician for the surgery before hand and then arriving at the hospital and being handed a request for several thousand dollars for the hospitals end of it. And when this was broached to the physician, he made noises whose meaning were somewhere between "I just work here" and "isn't that what you expect when you go to a hospital?".

I don't see any good solution to this problem, especially as we're taught in med school that the patient's health is the most important thing and financial aspects should be secondary.

I'm not sure why you knowing how this works means it is insoluable. An obvious solution is the California bill which keeps hospitals and doctors from making such outrageous charges (of hospitals think the consultants are necessary, they can find a way to engage without the out-of-network charges - as a "your problem, you should solve, not us" thing).

The sort of discussion veers in just weird implications - "I'm a doctor and I'm ignorant of these, that means you should be too and you avoid considering obvious changes to make thing more rational just as I do..."

I appreciate your insight.

It was a good doctor. I googled his name and apparently he is co-author of nobel-nominated work, so I think his time really worth much and I am little bit sorry ER bothered him about such trivial thing.

ER doctors really seemed to care, they tried to eliminate all possible things why my kid got stomach pain. Did x-ray, maybe even ultrasound (don’t remember) and ultimately it was nothing.

It was a surprise bill nonetheless, one I could barely afford at the time.

Bullshit they didn't know. I've sat in the meetings where the hospitals explain this, and instruct how to maximize the revenue.

Oh, while I had mono and was pretty delusional my doctor sent me for an cat scan to make sure I didn't have appendicitis - 4000 dollars later... yup, just mono. And I was on vacation at the time and out of network so... fun.

I'm not familiar with US healthcare. As the customer in such a circumstance are you within your rights to refuse any such diagnosis tests when you reasonably believe they are unnecessary? e.g you have prior history of those symptoms.

I have heard stories of some doctors and consultants making biased recommendations that are ultimately to line their pockets not cure the patient.

Yes, you can refuse testing that you recognize as superfluous, but, well, I'm not a doctor, they are. More often it goes the other way - eg most of the time I request a test that WebMD has convinced me will tell me that I don't have, well, cancer, and doctors are willing to oblige, but only at my behest. Serina Williams famously almost died because her doctor didn't think a test was warranted. Her advocate had to lobby the doctor to run a test which led to a diagnosis that saved her life. (A combination of racism and sexism certainly played a part there.)

The problem is that the profit motive is hard to deny, simply because healthcare is run as a profit seeking venture, which makes money on the difference between the cost of running a test and the price a patient's insurance will pay. Pharmaceutical companies bribing doctors to prescribe specific medication doesn't help.

These out-of-network bills have successfully been challenged and a law passed to address them in NY (https://www.dfs.ny.gov/insurance/health/OON_guidance.htm; I think).

But, in the first place, these bills were never really valid: in no other market am I informed of the cost after I have received services. This fact is why the law was passed, though it shouldn't need to have been passed. The "contract" is already unenforceable.

Corrected URL: https://www.dfs.ny.gov/insurance/health/OON_guidance.htm

There can be a lot of psychological pressure. "Don't you want to get to the bottom of this? If we don't figure it out now, this could come back and be worse." Or with a kid, "The responsible thing to do would be to rule out (cancer or whatever)."

It takes a lot of courage and knowledge to say yes, my child is in pain, and I will decline additional medical treatment and testing and just wait it out. I have declined a lot of tests and some interventions. I can do this because I have a physician in the immediate family who I can call for a second opinion at any time, and I read said physician's medical journals, and I have academic access to journals so I can do some of my own research and decisionmaking. And maybe I'm a little hard-hearted or hyperrational or something, and I can plan out a course of watchful waiting and stick to it much more than other people I know.

> As the customer in such a circumstance are you within your rights to refuse any such diagnosis tests when you reasonably believe they are unnecessary?

Of course. You're within your rights to refuse any medical test or procedure whatsoever, including one that would save you from imminent death, unless you're first declared mentally incompetent, which is not a quick or simple process.

But most people will trust the doctor when he says "we need this test to treat you effectively." He's the expert, and I don't want to bet my health on the possibility that he might be scamming me.

And docs honestly believe that the test will help. Many are not scamming you, they really want to know the result.

The single most helpful question I have if you're deciding on whether to take or refuse a test is this: "How will knowing the result change the course of treatment?" I avoided an intestinal biopsy once this way, as the answer was, "It won't. It would just be nice to know."

Thanks, that is a good question to ask. I'll have to remember that.

Yes, you can deny any treatment, as long as you are able to comprehend reality and express your denial, which the parent suggests they weren’t able due to their illness.

due to illness...and lack of medical degree.

It should go further. End the in-network / out-of-network crap. One price per procedure that is the same for all customers. All providers should accept all insurances. The system we have is insane.

Currently rates are set via negotiation between providers and insurers. Roughly, when the provider and insurer can't agree on a price, then the provider will be out of network for that insurer.

Let's say we remove this, and now we have a doctor who wants to charge $200 and an insurer that wants to pay $100. How should it be resolved?

The insurance company could do their freaking job and crunch the numbers to figure out what the average price is going to be at the providers their customers go to and set their premiums accordingly so they can cover what they expect to pay.

Some of their customers will go to a doctor where a procedure costs $200, some where it costs $50, some where it costs $100. If the prices were published patients could actually make a choice based on that information.

Insurance should be just that - insurance. It's for catastrophies, not for sore throat visits. You should only claim health insurance benefits in exceptional circumstances. You don't use Geico for oil changes. And at the same time there shouldn't be any place that would charge you without warning about cost. Analogy: when you go to Firestone to rotate tires, they tell you upfront what's it gonna cost. You don't go there and they would be like: "we can not tell you how much it would cost. Every car is different. We might need to call for specialist from discount tire and he would bill you for consultation separately". No, that does not happen. They take your car, and they tell you exactly what they need to do and what will be the cost. Health care should be the same, competition on price and quality, and none of this insurance third party nonsense

> And at the same time there shouldn't be any place that would charge you without warning about cost

This isn't unique to healthcare, though it's worse in healthcare than other places. Say I hire a plumber to put in a toilet, and when they open up the wall to run their pipes they find major problems that need dealing with. It wouldn't be code compliant to seal things back up without fixing them. Now it's going to cost me $10k instead of $1k. (Analogy to complications during surgery, though it's less time sensitive and I would have the option of evaluating multiple people to fix the bigger problem.)

If the patient chose to see someone who charged $200 vs $50 would the patient pay a different amount?

Perhaps the insurance would choose an amount to reimburse and the patient could pay the difference if they want to go somewhere more expensive. Isn't that the way most other insurances work? If my homeowner's insurance pays me to repair my house, they don't make me go to an "in-network" contractor. And if that contractor has an "out-of-network" subcontractor I don't suddenly get charged 10x more.

If the patient could choose any doctor because they aren't limited to in-network only and the doctors couldn't charge different prices for insurance vs. cash, and if patients actually knew what the prices were beforehand there would be actual competition and downward pressure on prices.

> If the patient could choose any doctor because they aren't limited to in-network only and the doctors couldn't charge different prices for insurance vs. cash, and if patients actually knew what the prices were beforehand there would be actual competition and downward pressure on prices.

This implies that there are enough doctors. But current reality is that supply is artificially limited and there are not enough doctors.

If supply is already limited, then surely further limiting it by restricting patients to only "in-network" doctors can't be helping anything.

> doctor who wants to charge $200 and an insurer that wants to pay $100. How should it be resolved?

Insured patient: Doctor gets $100, can't bill the insurer's patient any further. If the doctor isn't happy with this, he can refuse service to patients insured by this insurer, or he can find a new line of work.

Uninsured patient: Doctor can bill this patient $200

You're describing the way things work in most of the US right now, except that if my doctor doesn't take my insurance I no longer have the option to see them anyway.

In the case of surprise bills from hospitals this is a big improvement, but in the normal case of "my work gives me Cigna but my long-term doctor I'm very attached to doesn't take Cigna" it means people can't stick with their doctor.

In Canada, the province sets the rate.

Or the government sets the price and then all doctors are independent contractors to the government, and file for reimbursement for their services rendered. The patient can then pay on their 1040 according to their means, literally solving the problem once and for all like every other developed country.

The solution is right in front of America’s nose, but too many are running around with their fingers in their ears screaming simultaneously about the communists and how much they hate the system they’re advocating for.

Many countries don’t do it that way, including many with ostensibly universal healthcare. (Germany has 100+ different insurance companies, for example.)

Good luck with this.

Those insurance contracts can keep you from paying cash for services. If they can do that the in and out of network is much simpler to defend in court.

Recently had a situation where we were pressed for time and was waiting on insurance approval. I offered to pay cash and the Dr had to ask permission from the insurance company.

Upvoted!

The most efficient solution is an "all payer rate set system" - aka One price per procedure.

YES, the system we have is insane.

NO, unfortunately none of us are doing anything about it because we don't think beyond "single payer" system which itself has its own set of issues no one digs into because "single payer" is so awesome.

Everytime I mention "all payer rate set system" the discussion halts as if I am an alien from outer space.

If we are make ourselves go through an overhaul, and all the pain and suffering it entails, our sights should be on an "all payer rate set system" that's already proven to be way more effective than whatever people mean by "single payer" system.

> The most efficient solution is an "all payer rate set system" - aka One price per procedure.

I'd like to hear more about this. According to Wikipedia [1], Maryland uses an "all payer rate set system", and it had one of the first per-capita costs. On the other hand, Germany also has the system, but much lower healthcare costs. What's going on?

[1] https://en.m.wikipedia.org/wiki/All-payer_rate_setting

YES! MFN pricing would be a huge social benefit.

What would it mean to have one insurance vs a different one then? That just sounds like nationalized done payer with extra steps

You could have a low cost high deductible plan, or high cost low deductible plan but the procedure would always be billed at the same price.

Anything that gets the US to single payer is fine.

Just today I called my local hospital asking them how much they were going to charge me for an ultrasound Id already preformed. I’m in the middle of a qualifying life event and the new insurance retroactively kicks in.

I need to know how much this will cost to decide which plan is better, mine or my spouses.

The lady didn’t know how much they would charge. This is the only industry where they don’t know how much they’re going to chi argue me after the procedure

An orange farmer has a price for his oranges months before his orange trees blossom.

These geniuses can’t figure out the price after they delivered the product.

> An orange farmer has a price for his oranges months before his orange trees blossom

The futures market, how can we do that for people?

Joke.

My mechanic gives me a more or less binding estimate before he starts working, and calls me to confirm before doing anything that costs more.

I understand that's not necessarily practical or helpful in an emergency or operating room, but if we could get that for office visits, it would be great.

Ill be satisfied if I knew how much something will cost after I got it done.

Its a first step.

Then, maybe in a distant future, we can move on to reasonable estimates an hour before a non-emergency procedure.

In this utopian future, I will have access to a chart with all the procedures atomistic broken down and codified with a corresponding prices for every code so can add up the cost myself.

Of course this magical cost sheet already exists. I’m just not allowed to see it.

Seriously though, if you applied cold rationality to healthcare and did not let human dignity get in the way, we would treat the healthcare industry more like an auto-repair shop or a veterinarian office.

It is only undignified in your mind. There's nothing wrong with being open about your prices, healthcare or not

Here’s the report the NYT drew much of their data from: https://health-access.org/wp-content/uploads/2019/09/ha-ab72...

This is extremely welcome and much needed change BUT please, everyone reading this, pay attention to the fact that IF you get healthcare through your employer (aka "Group" health plan), this regulation MIGHT NOT APPLY to you and your plan if your employer did not purchase the plan through the ACA marketplace!

Group health plans are, EXEMPT, from most state regulations. I know it does not make sense and sounds unbelievable but unfortunately your employer has more lobbying power than you do!

As a result you, the employed, could still be on the hook for hundreds of thousands of dollars in surprise medical bills with little recourse (because you are employed and don't qualify for financial relief) and can have your wages garnished, which WILL be exercised by the provider if you refuse to pay the bill.

The providers are OON precisely because they make more money that way and there's little reason for them to be in-network (they have nothing to gain by being in network!)

So if you go to the ER today in an ambulance - that's highly likely to be OON - and have your XRays and/or CT scans read by a radiologist that's also highly likely to be OON and attended to by specialists that are also highly likely to be OON, you ARE on the hook for everything unless you're lucky enough to have a CA state regulated health plan.

Most individual plans purchased through the ACA marketplace are required to be in compliance with the regulations of the state that the employee is resident of.

Group health plans are not.

If your employer did not purchase the plan through the ACA marketplace, even if the plan is ACA compliant, it might not be required to comply with the regulations of the state that the employee is resident of as long as it's in compliance with current federal regulation of health benefits.

This can take a lot of employees by surprise, specially employees of multistate employers where the employer chooses the cheapest plan in compliance with current federal regulations without necessarily looking into state level details.

I put in some details here: https://www.quora.com/In-the-US-the-majority-of-people-under...

I really hope each of you take measures to decouple health insurance from employment.

How do we, in this day and age, still think, an employer has the right to solely dictate the standard of care we receive?

Please, if you think it's logical to so severely and tightly couple health insurance with your employer, let's have a discussion.

Yes, self-insured employer plans are exempt from state law under ERISA. It sucks but the big multi-state corporate lobby doesn't want to have to deal with the patchwork of state laws.

I believe the DOL could fix this via regulation, but doubt they will.

S 1895 Lower Healthcare Costs Act would fix this nationally https://www.natlawreview.com/article/beyond-surprise-billing...

Loved the link, thank you.

I personally believe, the main way to untangle this mess is to make it indifferent for employers to provide primary care plans and repeal Executive Order 9250 that allows employers to claim exemptions.

They are free to provide any secondary and supplementary plans

It's past the time employers and health insurance are tightly coupled.

It's holding back progress.

Everyone who knows anything about healthcare policy has been on board with decoupling for decades, but the big corporate self-insured plans lobby plus the union lobby plus the loosely-informed general public is too strong.

ACA exchanges set up the infrastructure to decouple in a market-oriented way.

But single-payer would also fix it.

tl;dr version, law works as expected and takes money out of the pockets of people who were over charging. They are mad and so they are throwing around as much FUD as they can dig up in an effort to keep this from spreading.

I know, the question of "over charging" is a difficult one to answer. All of the evidence on people willing to be doctors in California suggests that there are plenty of suppliers who will work willingly in the new system. That says to me it is working as intended.

> the question of "over charging" is a difficult one to answer

Not really. Just disclose the price up front. Prior to the procedure. The problem with these billing practices is the consumer has zero clue what they'll be billed by whom ex ante.

Honestly, let's go a step further - make those procedure prices publicly listed so that third parties can easily aggregate those list and let people find cheap care - then, finally, there will be market pressure to actually provide competitive services.

Do you mean "hide them away in a price list you must pay a fee and request by registered mail" when you say "publicly listed"?

That also only works if the patient can choose a different provider. If the only anesthesiologist authorized to assist in the only in-network hospital in the area equipped to do a particular urgent surgery charges an arm and a leg, there's not much knowing the price will do

This gets into some murky areas as well though. For example, infectious disease physicians struggle a lot under pay for procedure-based schemes because so much of their work is supplementing existing teams and consults, rather than "Did Thing X".

Good. Free market doesn't work when refusing to pay for the product costs you in health or even life.

Actually - this is an effort to bring the free market into the system. Ie, doctors have to tell you UP FRONT what they will charge you, and cannot just drop by your room while you are out and then bill you for the evaluation.

You can then decide if the specialist out of network is worth it, or go in-network or to your medical / medicare provider and work with them.

In particular (for those who don't know) California's law protects you ONLY if you go to an IN NETWORK facility. If you do, then if somehow an out of network doctor drops by or helps with the knock out gas or whatever, they can't then bill you for the "out of network" service. It turns out this was pretty common (my guess is some kind of kickback to the in-network facility to allow this).

You can still be charged or over charged by any provider if you agree to be, and sometimes still even if you don't (ambulance ride to out of network)

Prices being known ahead of time is not an inherent property of a free market. Fair billing is not an inherent property of a free market.

The "free market" doesn't really exist. It is an ideal, and an ill defined one at best. What does exists are mechanisms. A law that forces prices to be visible is a mechanism that is likely to increase economic efficiency at little cost. In absence of a rent-seeking doctor's guild, it would not be needed, true, but it is certainly better than nothing.

In fact, full availability of information (including price and quality) is a key feature of a free market, at least as defined in my ECON 101 class.

It's generally called a "racket" rather than a "free market" in the absence of pricing information, free choice, and fair billing.

Without accurate an available information, there is no free market. Just lots of betting.

"I'm going to buy this great new car. I wonder if it will cost me $15k or $45k? Can't wait to find out!" Said no market participant ever.

It’s more like: you get in a car accident and the mechanic forces you to get a new car. The only thing is: you won’t know the price of the car until you receive the dozens of bills for the different steps of manufacturing (one for the steel press factory, one for the leather factory, one for the aluminum factory, one for the person who put it together, one for the factory it was assembled in, etc.) You also can’t find the price of this new car online and the mechanic won’t (or sometimes can’t) tell you.

Practically everything about the health care system makes it the opposite of a free market. Patients often lack the domain knowledge to know what care they need, or what it should cost; even when they do, they often have few choices of where to get it (due to geography and/or insurance restrictions), or no choice at all (if they're receiving emergency care, or if their care requirements change while they are hospitalized). All of this adds up to a marketplace where "customers" are largely forced to pay whatever they are charged, and have very little choice in the matter.

I think there is genuinely a libertarian argument that healthcare is partly expensive due to government over-regulation.

A lot of what you said also applies to car mechanics. But they are less regulated, and there's unregulated alternatives, which makes things cheaper and more competitive.

But since the US does have a high amount of government interference (apparently it's a big deal when a child dies, while a dodgy mechanic is something we just deal with), maybe it's best to just create a public system rather than a highly compromised hybrid with most of the cons of both public and private systems (the US actually has a higher tax burden due to healthcare than Canada, since the people who get it free on Medicare and Medicaid end up costing a fortune - the private sector can be way smarter than the government at the subsidies and incentives game).

Very little of what they said applies to auto mechanics, outside of consumers not having much domain knowledge.

And even less when the seller refuses to disclose ahead of time what you will be charged.

This is called inelastic demand.

> Free market doesn't work when refusing to pay for the product costs you in health or even life.

The free market works great to provide food.

If you are in the US, food is one of the most heavily subsidized items people typically buy.

which "free market" is that?

in the US the "free market" for food continually gets porked up "Ag bills", leaves food deserts in low income areas, subsidizes complete and utter garbage used to feed livestock, and pays farmers directly even though it's not efficient by any means.

despite all of this you almost certainly want this to continue because in the event the ol' "free market" decides that it's not worth, say, maintaining food infrastructure due to a few good years, you'll probably die in a famine or the chaos that comes as a result of it.

This amuses me as I'm familiar with the quality and price of hospital food - both sold to visitors and given to patients. The food given to patients is nearly always of a decent quality since making people sicker really doesn't help, but it usually isn't nutritionally great and it's always over priced - for visitors the food is even more overpriced and the production of it is usually farmed out to a random restaurant in the area that can cater for it so quality will vary wildly.

And just you try to find some competition in terms of food suppliers while you're in a hospital - it's the cafeteria or nothing.

Food is simple. Practically everyone understands what food is, knows where and when they can get it, and (usually) has plenty of choices of where to eat.

All of these things are untrue of health care.

had a child born in a hospital in the bay area before this law and had the anaesthesiologist send a bill that looked he typed it on his typewriter. Wasn't even one of the official one's you see from a dr's group. No website, no email, just the guy's personal #.

Socialized healthcare works. Capitalistic healthcare works. This ungodly mess we've created in the US that combines the worst aspects of both doesn't work. When everything is secret and there's no actual competition between providers but also no regulatory controls to prevent abuse you get the worst possible results.

The most frustrating thing about this is we're already paying for universal healthcare. You can't be denied care if you don't have the means to pay. We just somehow pay for it through the nose, and it's shitty beyond belief.

My wife traveled to Russia earlier this year and did a couple of MRI scans while there (neck and shoulder). Total cost for both was $100. This is all out of pocket and without insurance coverage. Here it'd be $2K+ _each_, _with_ insurance, _excluding_ the subsequent doctor visit to analyze the results. How the fuck does this happen? How is this justifiable? I don't know. The machine is the same. The doctor is far less expensive, sure, but it's not like the doctor is needed for more than 10 minutes to view the results and produce a diagnosis. Whoever untangles this multi-trillion ball of bullshit will forever be remembered as one of the greatest leaders this country ever had.

It's always surprising to me that I an age where it's incredibly easy to have friends in foreign countries, travel to foreign countries, and view media from outside the US people here still think it's normal for the worst thing about a broken leg to be the hospital bill.

Absolutely right. If we had transparent prices and the customer was also the payer and the drug companies weren't colluding then the invisible hand could work for healthcare.

How is this true? If a medical procedure is the only thing between you and death how could you possibly negotiate a fair rate in the free market, especially considering some treatments are monopolies if they have a patent on them. The free market cannot work in health care.

There should be an anti price gouging law which states that a doctor can only change their prices every month or something, and must publish them publicly. This could also include stats indicating with which percentage what procedures are done for a specific complaint. Ex, for a head injury, in 50% of cases an MRI was done at cost X.

Then we could all use our internet connected phones to find the price instantly. If we are unconscious or decapitated at the time, we could set up a set up a ranking system beforehand weighing price, distance to hospital, and quality of service ratings.

Even more minimally, just require them to publish their prices. If you change $10 fifteen time, $50 once, and $150 eight times for a procedure, publish all of that.

And all group buyers should have to publish what they paid for each procedure too, to be fair to the doctors.

The majority of medical procedures are neither unique nor proprietary, and the majority of medical procedures are not to save someone from imminent death.

In other words, most of the time people would have options and time to compare those options. Iff the conditions I described above obtained.

Unfortunately there's lots of money in convincing Americans to vote against their best interest. Expect to see lots of "socialism is bad/will destroy America" propaganda in the future. My guess is socialized medicine will be branded as some kind of evil force and demonized.

As someone who grew up in the USSR, I do agree that socialism would be extremely bad for America and I don't want it here. I believe it'd cause the eventual collapse of the country, much like we've seen with the USSR and for the same reasons. I do not believe that the state is any better at spending my money than I am myself.

The issue here is not capitalism per se, because US healthcare system is not capitalist in nature. Capitalism requires pricing mechanisms and competition in order to work. That's the part that's fundamentally screwed up in US healthcare: there isn't any downward pricing pressure until the prices get to truly baffling levels and there's no real competition. The Trump administration is beginning to work on creating it (https://www.nytimes.com/2019/07/05/upshot/trump-drug-prices-...), but so far without any visible result. While (if it works) this is a good start, I'd like to see some kind of downward pricing pressure on the services as well. E.g. I should not be required to pay 5x as much if I'm not covered and paying out of pocket. This disproportionately affects the poor, quite obviously: break a leg and you could end up paying $50K or more (whereas insurance would pay $5K, if that). Introduce a "favored nations" clause on that as well: if I'm paying out of pocket, I should be paying your lowest "insurance" negotiated rate.

> As someone who grew up in the USSR, I do agree that socialism would be extremely bad for America and I don't want it here. I believe it'd cause the eventual collapse of the country, much like we've seen with the USSR and for the same reasons.

Most of the world's most successful nations have socialized health care, and seem to be doing just fine.

God knows I don't want a Soviet system. But the term "socialism" seems to refer to any sort of universal health care or public safety net these days, so when pundits start claiming that those things are a slippery slone to Stalinism, it's a problem.

You don't need socialism to have universal healthcare. Above in the thread I said that we're already paying for universal healthcare right here in the US: you can't be denied care. It's just that the system grew a ton of perverse incentives and it's not in any way capitalist. Case in point: you can't even get the prices ahead of time for the most part, and doctors treat inquiries about pricing as a personal insult. Therefore there's no way to look for a lower price. That's the goddamn cornerstone of capitalism. So before we throw the baby out with the bathwater maybe we should try what this country is good at: capitalism and competition? Or would you rather give another few trillion dollars to dense government bureaucrats to piss away on whatever lobbyists tell them to piss it away on? People keep forgetting just how corrupt and inept the US government is and has always been.

> You don't need socialism to have universal healthcare.

What I'm saying is that many, many people on both sides of the issue use "socialism" to mean "any socialist policy regardless of the majority economic or governmental system." That's not what Marx intended, and it may not be what it means in the former USSR, but that's usually what it means in English. When someone says "we need more socialism" or mocks the idea that "socialism will destroy America", then barring additional context, it's not helpful to assume they want a full Soviet system.

What I'm saying is "what Marx intended" is utterly idiotic and destructive, and fundamentally at odds with human nature. It has failed every time it's been tried, it just took longer for it to fail in some cases than in others. Sooner or later you do run out of other people's money.

Indeed. I hope nothing I said implied that I disagreed with that.

Healthcare in the US has little that is really socialized, at least for the middle class. The ACA had NO public option, despite efforts to include it. So unless you're poor (Medicaid) or elderly (Medicare), you have no hope of anything "socialized".

Healthcare in the US is a racket -- pure and simple. It puts our health into the hands of middlemen, the insurance companies. And the funny thing is, they don't insure a damn thing. They make you pay thousands of dollars, typically, before even attempting to do their part, and even then, they will charge for preventive visits and other things that are supposed to be 100% covered irrespective of deductibles/etc. They rely on the bureaucracy of the system to force people into the path of least resistance which is to pay the bill.

The simple fact is insurance providers, hospitals, and now doctors, do not care at all about patients. They care only about money. Until we, as a people, take back control, nothing will change. I would ask doctors, what happened to "do no harm"? Financial harm is harm.

And I agree with you. It either MUST be fully capitalistic (get rid of the state boundary crap, make it easier to get affordable individual insurance, etc) or it MUST be fully socialized (single payer). There is no in between that will ever work for patients. And I'm skeptical of the fully capitalistic approach simply because it can still become a racket with price-fixing.

As an aside, part of the problem lands solely on the doctors. Far too often they roll people through like it's an assembly line. Far too often they don't even listen to the patients, especially women, and just think people are hypochondriacs. Far too often they prescribe needless medicine to treat symptoms and never try to find root cause and treat _just_ that. Of course, we have no choice but to "trust" doctors when the time comes, and that's what they and pharma banks on. The family doctor truly is a relic of the past.

EDIT> Bring on the downvotes, it's always a pleasure, Internet.

Medicaid + Medicare is bigger than all private insurance combined, so have huge effects on the market. Federal + State government account for 45% of all health care spending.

Sure its socialized. Insurance is socialism for profit.

Spread the cost across society but add a profit layer. A huge profit layer. Go check out what insurance employees make.

In which countries does capitalistic healthcare work well? Or do you mean just within your theory it works well and that there are none that actually do it?

Switzerland. Netherlands. In one ranking they are the best systems in Europe.

Do any of them not have price controls and a “public option” of some sort? And sometimes prohibition on for-profit insurance (Switzerland, for example, IIRC)?

No public option from what I know. Insurance is all private, Swiss require no profits while Netherlands allows for profit. Government subsidies and restrictions exist on the plans, similar to Obamacare.

Switzerland has compulsory healthcare, insurance subsidies for low-income people, extremely heavy regulation of health insurance companies, and many (mostly?) public hospitals.

Not exactly something I'd describe as "capitalistic health care".

40% of hospitals in Switzerland are private vs 69% in the US (21% for-profit). Most hospitals in Netherlands are private (non-profit). Both have all private insurance, although Switzerland requires it to be non-profit. Obamacare subsidizes and regulates insurance in the ways you stated, but could be made stronger. Perhaps not pure capitalistic healthcare, but a strong role for the private sector.

Netherlands has a mandate, universal healthcare, and free coverage for children up to 18, not capitalistic.

And:

>Affordability is guaranteed through a system of income-related allowances and individual and employer-paid income-related premiums.

https://en.wikipedia.org/wiki/Healthcare_in_the_Netherlands#...

Obamacare also provides subsidies. The point is that the provision and insurance in Netherlands is done with private organizations, not the government directly.

Switzerland and a few other countries have fully privatized medicine. You don't hear about them dying from preventable diseases.

Privatised medicine is not a free market, conflating them like this is disengenuous.

The system in India works for the middle-class and upper. They have fairly elastic supply of doctors so it balances out. Some of their surgical outcomes have higher performance than American surgeries, particularly some heart surgeries. Cheaper, faster, better.

Plastic surgery is capitalistic healthcare.

The incentives are very different. When the doctor says injections or implants will set you back $X it's not a matter of life and death. Or even health at all. You can choose to wait and save up. When the doctor says you need medical treatment that costs $X you're going to have to come up with a way to get the money even if you go broke trying. And that's assuming you're lucky/healthy enough to even be given a chance to price shop.

It's hard to go broke getting boob jobs. It's exceedingly easy (in US) to go broke getting even the most basic of health care.

Good points. When I was taken by ambulance to an out of network trauma center, I had no choice.

It worked well in the US until around 1990.

While I agree with the sentiment behind the article I think it is disgustingly and unnecessarily subjective. They have stripped their readers of the basic human desire to make up our own minds about what they read. Shame on them. The irony with my comment it that it is not in the least bit objective. Shame on me.

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