For Her Head Cold, Insurer Coughed Up $25,865
npr.org
npr.org
We need to socialize the healthcare in the USA and put a stop to this crazy billing practices. (Maybe send a few execs to jail too) Canada really has the right idea here, as even if you are making $bank here, you can be fired for any reason/no reason and health insurance will end. IMO this is by design, as it is much more difficult to leave a job if insurance will end.
The concept of “socializing the health system” papers over the really important issues. Countries with universal healthcare don’t actually have a uniform system. They all have quite different systems. The Netherlands, for example has private insurance and private providers. The U.K. has no insurance and public providers (doctors work for the government). Other countries have various things in between. Single payer, like Canada has, isn’t even the most common system. Overlooking these distinctions means you may not fix the relevant problems. You can “socialize” insurance, but if you don’t impose controls on billing it’ll just be a different entity being overcharged.
The NHS is going to tell them to get bent, that they're paying the agreed upon price for the act and don't care about the rest of their bullshit, and if they're not happy with it they can close their office.
> Conversely, whatever rules prevent such billing practices in Canada could be applied in the US without socializing anything.
It's not "whatever rules". The NHS can negotiate prices and is interested in balancing keeping costs down with having providers.
Not only is this not a thing which can be "ruled", Congress (the GOP) has literally willed away the one lever the US Government has to do this: the Secretary of Health and Human Services is legally forbidden from negotiating prices on Part D prescription drugs.
And even then that'd only be for Medicare itself (though HR3 intends to not only reverse this but makes this negotiation a binding MSRP): the VA can and does negotiate drug prices, but that doesn't benefit people who are not under VA.
In a single payer system, the single payer in question has both incentive and leverage.
The Canadian system has socialized insurance plus price controls. But those are two separate things—you can have one without the other. The Swiss system, for example, has price schedules, but not “socialized” medicine.
As to drug pricing: you’re repeating FUD about Medicare. What should clue you in that this is FUD is that, for the most part, Medicare itself doesn’t cover prescription drugs. (Only drugs you get during a hospital visit.) Prescription drugs are covered by an optional program called Medicare Part D, which is provided through private insurance. So yes, the Secretary of DHHS isn’t permitted to negotiate prescription drug prices for Medicare. That’s because that’s the role of the Prescription Drug Plans under Part D. The private insurance plans that are offered under Part D do negotiate drug prices. See: https://fas.org/sgp/crs/misc/IF11318.pdf
> Determination of Drug Prices in Medicare Part D To bolster market competition and limit the federal role, the MMA included a non-interference provision (Social Security Act (SSA) §1860D-11(i)), which states that in carrying out the requirements of the Part D program, “the Secretary: (1) may not interfere with the negotiations between drug manufacturers and pharmacies and PDP sponsors; and (2) may not require a particular formulary or institute a price structure for the reimbursement of covered part D drugs.”
> Part D sponsors, working with pharmacy benefit managers (PBMs), negotiate prices with drug manufacturers and contract with pharmacies to dispense drugs to plan enrollees. Negotiated price concessions mainly take the form of rebates (after-sale reductions) from a manufacturer’s list price for brand-name drugs.
I assume it's similar in other provinces and therefore your premise is mostly wrong.
In no other profession can one murder a quarter million Americans annually(1) via chart reading apathy or gross incompetence at multiplying by 10, and not only keep one's job, but get paid for rendering the botched services, as well.
Imagine being a plumber who gets paid after making your customers' leaks ten times worse. That's the life of every doctor in the US.
That sounds similar to indentured servitude.
EDIT: I misread the “here” as “Canada”. The US healthcare system has caused me some personal hardships, so I was surprised Canada had something similar. Luckily it’s more sensible.
It (the US version) is not a good thing, correct.
Canada does not have such a system. Canada has taxpayer-funded healthcare. Therefore you have the liberty to quit your job and find more favourable employment without having to deal with the risk of one surprise hospitalization from bankrupting you.
GP is saying Canada did that right. The confusion arises because GP said "here" right after praising Canada, possibly misleading you to think they were referring again to Canada, which they were not.
Also as someone who has switched jobs in the last year setting up new insurance/dentist/optometrist multiple times is a absolute waste of my time and would be entirely eliminated if we stopped tying insurance to the employer.
We already have massive shortages of doctors (and nurses, I think). This will only make it worse.
There's no shortages of doctors, or nurses in major cities.
https://www.google.com/search?q=doctor+shortages+usa+appalac... provides a bunch of links if you want to dive into this topic further.
I would, no kidding, love to see any example of a successful, modern healthcare system that doesn't employ price controls to keep costs from getting out of hand. Allowing "successful" and "modern" to describe the system in the US, it's the only one I know of that doesn't.
I'm not advocating for anything; it wasn't my comment. I just couldn't be sure what the poster was referring to, as the original comment was convoluted.
They really buried the lede there. This sounds like fraud. She went to her doctor, who, I'm guessing, is in-network since the article says he was her primary care physician. The doctor operates a lab that is not in same network he operates his practice in? Is that some kind of coincidence? Is there any other reason for that except to bilk money out of the insurance company?
We have a similar problem in a way with our trains. They’ve all been ‘privatised’ but if only one train company runs your route there can’t be any competition, so our trains suck big time and are really expensive.
For a business to be good for customers it needs to be accountable to those customers. These businesses are only accountable to governments and even then only ever X years when the contract comes up for review. Their motivation is therefore to service the government not the customer and the customer suffers.
End result is it costs upwards of £4k for an annual pass for a half hour train journey.
Add to that the fact that nobody would ever allow the trains to cease operating, and you have a really big question mark over what the point of privatizing was?
We know this doesn't work because we tried it and it didn't work.
But it doesn’t hold water. France, Germany, Spain all have cheap, really good government-owned trains - in fact they also operate some of our trains in the UK and use the profit to fund their own trains.
Prices have gone up by the maximum operators are allowed to increase them every year (there’s a 1 year exception where I think they were frozen for political reasons) https://www.bbc.co.uk/news/business-49331238
Just because we tried something before and did it badly doesn’t mean it won’t work in future if done well. Execution is everything, right?
Define really good? They are less safe, the prices charged to consumers may be lower but what is the overall subsidy (I understand that you want other people to subsidise your commute...other people tend not to be happy about this), and it is fair to say that UK trains are less punctual but the difference is not massive (and we do come ahead of the nations you mention some years too).
The discussion on this in the UK is pathetically weak, and largely a function of trade union lobbying (if you didn't know, the TUC pours money into this cause like nothing else...presumably they just really really care about commuters).
These problems include a tremendous shortage of doctors [0]. Even Canada and the UK have more doctors per capita, and they are known for extremely high wait times (the jokes of the socialized medicine countries, so to speak). There are a number of possible reasons for this, most notably the hassle of occupational licensing (12-14 years of expensive college + 'indentured servitude' residency in the US).
Nonetheless, American healthcare science is still ahead of the curve and subsidizes socialized countries -- ~60% of all new drugs between 2001-2010 were invented in the US, and foreign dignitaries of socialized medicine countries often still get important procedures done in the US [1]. It would be interesting to see how the R&D dynamic plays out if America loses its market incentive to innovate in the space, and no other developed countries have the financial incentive left.
[0] https://data.worldbank.org/indicator/SH.MED.PHYS.ZS?end=2018...
[1] https://xconomy.com/seattle/2014/09/02/which-countries-excel...
The Swiss seem to have something right. They have actual competition between insurers, though you are restricted to changing supplier at the annual window. Everyone is obliged to buy basic coverage from somewhere, but you can choose. And the obligatory level is fairly cheap, maybe a few hundred CHF per adult per month (kids cost fractions of an adult, basically nothing). You can then add on perks like guaranteed single rooms and such, costing as much as they can get you to pay.
In return you get a service that seems magical. My colleague crashed his bike and needed stiches. He was at work in the morning only slightly later than the normal time. The time I needed the emergency room I wondered how on earth that could be room, it was empty. When my wife gave birth it was like a hotel stay, they even fed me (the father) three meals a day for the best part of a week.
The NHS these days is super stressed. Everyone seems busy, the halls seem very old and crowded. If you're not bringing in a kid, be prepared to wait. And there's plenty of articles about waiting times and busy staff, which seem believable given I know some of those staff.
UK private seems to work nicely if you can pay for it. I had a couple of knee operations, and everything was very comfortable. Barely even saw another patient, and there were lots of people attending to me.
Also, I live in Scotland where the NHS has been getting more money for a while...still awful. The NHS drop massive wedges of cash on vanity projects (always over budget, usually issues because of poor project management) but never hit waiting time targets. Definitely, there is an issue with care and old people having to stay in hospital...but there is also something far deeper (my area is rural, total population of 30-40k...the NHS just dropped £75m on a ten-ward hospital...I go there four or five times a week, 75-80% of the people you see walking around are staff).
I don't know what the solution is, I just know that other countries do it better and they have larger private sectors.
There is no such thing. A free market for healthcare will end up with people being trapped or simply lacking access. The entire concept of insurance is just a middle-man on a necessary service, one which should be considered a right for a society as rich as ours.
You either massively regulate private companies to force them to cover sick poor people at a big loss and compensate by making healthy people pay more, or you just get rid of the middleman and cover everyone directly (single payer).
Seriously, what value do insurance companies provide? How is it not just rent-seeking on people's health?
(No-one seems to have actually read the article, it says that her insurer would have paid ~$650 if the lab wasn't one owned by the doctor she saw...and, if I understood correctly, the doctor also did a whole bunch of totally unnecessary testing...this looks a bit like plain ol corruption).
> "I made it very clear [to the doctor's office] that I was unhappy about it," Kasdan says. In fact, she told them she would report the doctor to New York state's Office of Professional Medical Conduct.
> Kasdan says she was not told that the throat swab was being sent out of network at the time of her appointment, though it's possible one of the many papers she signed included a broad caveat that some services might not be in network.
Their fraud relies on insured patients not reading EOBs (because many of us don't).
The parent comment seems to imply the payer is at fault or committing fraud.
All of the noise in this thread about healthcare system in the US is a good discussion but arguably unrelated to the bill in question. Single payer government run plans can be defrauded too.
I don't know how this nonsense isn't the number one election issue in the USA. Instead everyone just puts up with it.
Also to clarify, in Australia there is no cost to anyone with permanent residency status, whether they are insured or not.
Also to clarify, there is no cost for anyone (EU residents) here too if you use the public health system, but if you cannot wait till you're dead then you can use the (optional) private system and pay for that.
Fuck the whole thing, I hope it all burns to the ground. It makes me so very unhappy every time I have to deal with it.
Oh, sincere apologies about not trying to save you money.
The reason it wasn't flagged is that both the insurer and the provider are incentivized to make this as expensive as possible. Insurers cannot make more than 10% in profit, so if they want to make an extra $1000, they need to take in $10,000. Next, providers are paid fee-for-service, so they want to bill as many services as possible and charge the highest rate for each one. Ultimately our insurance premiums go up to cover this, but the whole thing is a racket.
And single payer will not solve this. All we do is subsidize demand and decrease supply in a never ending fashion in the medical industry. We need to 1) Make it easier to supply services (allow doctors to be imported from other countries, easier to start facilities, allow people with less credentials than an MD to perform services) and 2) Stop subsidizing demand (Medicare for All = Use as much as you want).
My ideal health insurance model is catastrophic insurance provided by the government for any bills over $50,000, Health Savings Accounts to allow you to save for procedures beneath 50k, and a total free-for-all of insurance companies beneath the 50k mark. This would radically reduce insurance rates while preventing people from becoming bankrupt. Catastrophic insurance covers you from cancer and being hit by a bus, but for 99% of all health issues the bill would not exceed that.
If there is only one payer, and they refuse to pay your outrageous prices, you either lower your prices or you go out of business. Since a government-run payer does not have to make a profit, it is very easy to incentivize it to keep costs low.
Medicare for All would preempt the lack of price transparency: participating doctors get what the government says they will receive. Period. They can opt out and only serve non-M4A payees, but that will shrink their customer pool. Healthcare spending would plummet across the board.
The U.S. healthcare industry operates outside of the capitalist system. We can either try to make it more market-based, or, acknowledging the high value of life and astronomical bargaining power of medical practitioners in wealthy nations, we can socialize the provision of necessary healthcare. Almost every other developed nation has done this successfully.
Engineer: I will charge X for this project because that’s what competitive projects of equal value go for.
Gas station owner: I charge $1 for a Hershey’s bar because that’s what the convenience store next door charges for a Hershey’s bar, and my customers can just bail or hop over there if I charge too much.
Hospital/Surgeon/Doctor/Pharma exec: Well, it’s complicated. You know there are insurance companies and PBMs, they’re the real villains, what can I do? Look, let me ask you, what’s the value of life? We charge a small portion of that. Do you really want to cut back on something so vital? We save lives, respect our profession. Feel free to go to my competition, they will all tell you the same thing. Stop trying to haggle like we’re spice merchants at the Grand Bazaar.
(Of course, thousands of medical practitioners support socialized medicine, the above is simply a generalization used to illustrate my points on price transparency, crony non-capitalism, and bargaining power)
No it's not. Medical care is a process people don't want to go through to make them healthy.
> When it's 100% free, you have no disincentive to use it.
1. that's just plain bullshit, as demonstrated by the NHS and other single-payer free-at-point-of-use systems, people don't hang out at their GPs office just because it's free
2. you actually want to incentivise people to use medical system preventively, it's way cheaper than having to use them curatively
> So if you want to have the government pay 100% of all medical bills and do nothing to prevent using it, you'll have never-ending increases is costs.
Literally every other healthcare system is cheaper than america's, despite the US healthcare system being by far the one most disincentivising use.
As a sibling comment noted, this doesn't happen in countries where there are existing single payer systems, so your analysis is trivially disproven by example.
Additionally, this presumes the content of "the laws of supply and demand" -- what's the nature of supply when consumers cannot choose between competing providers? What's the nature of demand for a product that people require to survive? These are not standard parameters, and to assert that they can be understood with simple demand curves is disingenuous at best.
As demonstrated in every single-payer system where this… doesn't happen because the single-payer entity decides what they're going to pay for medical acts and if you don't like it tough tits, the gravy train of high-marging acts only works until the next revision where the single payer auditors realise you're making 90% on something and… just slash down what they're paying by 90%. That was pretty widely reported on with japanese neck MRIs a decade or so back, manufacturers created small cheap MRI machines, every doctor's office equipped themselves to feed at the through, review time arrived and neck/head MRI prices were slashed to $100 or so.
> 2) Stop subsidizing demand (Medicare for All = Use as much as you want).
This is the exact same lie as the voter fraud scare-mongering: not an actual issue. Most people have to be pushed to see their docs, the vast majority just want to get better and would rather be anywhere than an md’s office.
The results contradict policy experts' assertions that unnecessary ER use would decline as more people gained access to health insurance under the ACA.
People get insurance, they use healthcare more. This is not a surprising result.
https://www.modernhealthcare.com/article/20170913/NEWS/17091...
PS. Sorry, I hope I did not mess up previous sentences too much to make it completely opposite of what I am trying to say.
We (the United States) are the SOLE western country that does not have state sponsored healthcare, and it shows and it's ridiculous. I don't know how anyone can feel we are the greatest or great in any capacity when a car accident can send a family into poverty.
The point is that everything that's outside of the regulated insurance market, such as plastic or lasik surgery and a whole list of other things are actually getting consistently cheaper while operations that are captured in a totally degenerate insurance market go the opposite direction.
We don't have many western countries that have ever even tried a more market style of health care. Singapore is the most market oriented system in the world and its by far the cheapest when looking at % of GDP.
Both parties have symbiotic relationships with profiteers that stifle progress and innovation.
Second, health care experts don't seem to think much of the new rules, since there's little evidence anyone price shops for care, especially since, regardless of published prices, they're not the ones paying for them; they pay indirectly, through premiums. I think price transparency is a good thing and the rule is a good thing, but I don't think this is "huge".
Third, the "obvious reasons" snark at the end of your comment poisons what would otherwise have been a valuable contribution to the thread.
I heard all about this, and so did lots of people. It was as well covered as anything is these days.
I suggest the obvious reason this new regulation doesn’t get as much press attention as you’d like has less to do with Trump and more to do with its futility.
> Fathollahi, the Manhattan Specialty Care physician, didn't answer our questions about the bill. Neither did Dr. Shawn Khodadadian, listed in state records as the CEO of Manhattan Gastroenterology.
Because they CAN'T. Why didn't NPR publish their response, which is likely along the lines of how they are forbidden to discuss patient charges and procedures?
It's far more likely this was a mistake that will end up costing the doctor 25k when the insurance company hires someone who checks for things like this, which they will.
Such doctors who participate in schemes, entirely unsurprisingly, order multiple standard deviations above their expected imaging needs.
Healthcare costs will inevitably rise in the US however, as labor is scarce, practioners are scarce, people are increasingly unhealthy and older...we are in for a massive healthcare cost spike due to economic conditions and blaming HMOs is emotional and politician inspired at best. Its like blaming insurance companies for a rise in car crashes.
Given how common stuff like in TFA is, plus so much more on smaller and less eye-popping scales, and seeming endless ability for providers to say "oops our bad now it's fixed" when caught and avoid punishment, I'm skeptical that these extreme penalties kick in often enough to counteract incentives to let prices creep higher.
[EDIT] from my personal experience, it's mostly up to individuals to burn tons of time investigating irregularities and escalate them to elected officials & regulators when insurers or providers dig in their heels, to which the officials' and regulators' response is usually a strongly worded letter that makes your particular problem go away, with no follow up, presumably because pursuing it will be difficult, expensive, and unlikely to yield results that help anyone with their next election or promotion. That's kinda how it looks like this one's going, in fact, though maybe there'll be some regulatory follow-up with something resembling teeth, since it got press. It's like the Twitter-complaint model of customer support, but way worse.
People who believe that making it public will massively lower the cost because other socialized systems are cheaper are up for a rude awakening.
No matter in what direction the US system evolved those problems need some amount of addressing and those questions are more practically important then the question about public or not.
Insurers have to create networks so they can negotiate fair rates with doctors and hospitals. These rates often end up being more than medicare would have paid, but not wildly more. Sounds pretty fair. But what to do if the patient goes to an out-of-network doctor? Insurance might say "we won't pay unless it was an emergency," but then the patient gets stuck with a $30k bill. He'll get angry, tell the media, write his Congressman, etc. Somehow the blame will always fall on the insurer (who had no way to prevent this from happening) and not the doctor (who was engaged in price gouging.)
Or maybe the insurer can say "we'll only pay the same rate we would have paid an in-network provider." No problem, says the doctor-- we have the patient's signature on this huge contract that says we can bill them for the remainder. Now the patient gets a $29.5k bill instead of a $30k bill. Still no good.
I'd love to say "just socialize medicine and be done with it", but this worries me too. The US already runs two 100% socialized healthcare systems: the VA for veterans, and IHS for Native Americans. Both are absolute nightmares where people sometimes wait years to see a barely-competent doctor. Many IHS doctors only work there because no private hospital would hire them[1].
I'm not sure what a good solution looks like.
[1] https://www.pbs.org/wgbh/frontline/article/u-s-indian-health...
It says that the bill was 20X more expensive than it shouldn’t have been. I can’t even imagine having to pay that when I go to the doctor. The NHS isn’t perfect, but it’s damn good.
The doctor part owns/is associated with an "out-of-network" lab where the tests were sent. Healthcare providers have default listings which are typically outrageously high, and negotiate with insurers for their "actual" rates. But by the in-network doctor quietly sending the tests "out-of-network", the insurer could be charged the outrageous fee.
With single payer, the price is the price. No bullshit, shady multilateral private negotiations in a marketplace where people's health is what is being wagered.
It's easier politically to blame corporations and whatnot. And it's true - there's plenty of leeching downstream by pharmas, PBMs, hospital admins, device makers, insurance companies, vendors, labs, and many others. But at the base of the supply funnel sit the doctors (and numerous associations like AMA, ACR, ABP, AHA, AAMC, etc) who control the entire supply through licensing and state-level regulations, and are entirely responsible for all of the atrocities. It's effectively a cartel.
There's a reason why any time there's a talk about pro-consumer regulation on the Hill like anti-surprise billing, pro-price transparency, and Medicare for All, each of these association is blasting their members with calls to contact their representatives and resist at all cost. Their argument is easy to understand emotionally - doctors will protect you from the harm, and hence there should be more licensing and supply restrictions. But this is the root of all problems in US healthcare.
https://www.usnews.com/news/health-news/articles/2019-07-03/...
Amid Provider Shortage, California Doctors Oppose Expanding Nurse Practitioner Abilities
https://thedo.osteopathic.org/2018/10/dos-help-defeat-bills-...
As APRNs and nurse-midwives ramp up their efforts to practice independently, DOs are fighting back.
https://www.kcur.org/post/nurse-practitioners-try-shake-free...
As Nurse Practitioners Try To Shake Free Of Doctors, Kansas Physicians Resist
https://www.wabe.org/bid-to-loosen-rules-on-mid-level-provid...
But the vote for recommending the imaging change was 3-2 in favor, with two physicians on the panel, Sens. Ben Watson (R-Savannah) and Kay Kirkpatrick (R-Marietta), voting against.
https://www.aei.org/carpe-diem/whod-a-thunk-it-a-medical-car...
the American Academy of Pediatrics declared that retail health clinics are “an inappropriate source of primary care for pediatric patients, as they fragment medical care and are detrimental to the medical home concept of longitudinal and coordinated care.”
https://www.politico.com/agenda/story/2017/10/25/doctors-sal...
https://fee.org/articles/the-medical-cartel-is-keeping-healt...
https://www.modernhealthcare.com/patients/surprise-medical-b...
Stanford University researchers found that from 2010 through 2016, 39% of 13.6 million trips to the ED at an in-network hospital by privately insured patients resulted in an out-of-network bill. That figure increased during the study period from about a third of ED visits nationwide in 2010 to 42.8% in 2016.
https://www.npr.org/sections/health-shots/2019/12/23/7874035...
https://www.medscape.com/viewarticle/922816
More Than Half of Doctors Get Industry Payments/Meals: Poll
https://revcycleintelligence.com/news/aha-others-to-sue-hhs-...
AHA, Others to Sue HHS Over New Hospital Price Transparency Rule
That is, if you go to a doctor's office, they can try to collect payment upfront, but if they send you a random bill after the fact without your explicit price consent, it doesn't have to be paid. Similarly to how I can send a bill to y'all for the privilege of reading my post (and justify by saying it took me years of expensive training to obtain this knowledge), but you shouldn't be required to actually pay me, of course.
Emergency medicine OTOH should be socialized - everybody is covered in the US by Medicare. For every emergency admission facility can charge Medicare for all up to $X (say $300 in Kansas and $500 in San Francisco) and have to make do with that money. Patient gets between 0% and 30% copay depending on whether they are trying to abuse the system or came with a legit reason. This is the same as Kaiser today, but on a National scale.
But we do need upfront pricing. It should be mandatory in non-emergency situations.
Roya Fathollahi, MD
Report her to the NY Medical Board and Department of Financial Services
https://www.health.ny.gov/professionals/doctors/conduct/file...
https://www.dfs.ny.gov/consumers/health_insurance/surprise_m...