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Comment by platetone | Hacker News Reader

We decided (slash "made the mistake") of going to the emergency room last summer. Spent less than two hours in an exam room before being dismissed with no conclusion and referral to another doctor. Got a $9500 bill about six months later and have been billed a 10% copay on that (insurance paid $5500 already at their negotiated rate). Still fighting it as absolutely absurd, but there's really no hope. This country is fucked. It's an embarrassment.

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As someone not from the EU, this is something totally insane and crazy. Once, after my country got out of the Soviet Union, the US was seen as the dreamland of everyone. Now.. I don't think so, when getting sick with something easily treatable will ruin your whole life. That's just not a place I'd like to live in.

Once I was on a date with a younger girl and she was going on about how she'd like to live in the US, and I, being kind of a nerd had a Sheldon type of moment told her how awful it is, and she said "thanks, you ruined my dream". And she was talking about how she spent a summer as a barmaid there, got tonsilitis, visited a doctor who made her take a test for tonsilitis and got billed for it. Here where I live.. you can see that when someone has 1) a high fever 2) inflammation in their tonsils 3) has a swollen throat and white stuff there because of it then they have tonsilitis and you don't need to make additional lab tests, because it's 100% obvious, you don't need to waste time and money on useless stuff.

It is not always obvious (e.g. strep throat is similar, but one or the other sicknesses may or may not need medicine) and doing things on a hunch is not how scientific fields should do things when there are simple tests.

Testing also provides safety for doctors against medical malpractice lawsuits.

My daughter had an allergic reaction to food last year, which required us to give an epipen. We were told when this happened that we needed to call 911 and have her taken to the emergency room for observation and potentially for further treatment. We did, the ambulance came and took her to the hospital, which is under a mile away. We then had a similar experience to yours - spent about 2 hours in the hospital being observed, then were dismissed. We eventually got a $2k bill from the ER, which our insurance paid, and a $4k bill from the ambulance company, which our insurance didn't pay.

That ambulance bill is insane. Up here in Canada ambulance charges are paid out of pocket but my wife had a low blood pressure emergency and got an ambulance called and was only out 300$ for a three mile drive (through dense city streets even).

I'm even of the opinion that that bill was a bit excessive.

$300 seems low.

'The distance' is basically irrelevant.

You're paying for a highly available, rapid response team to be prepared for almost any medical emergency, 24/7, literally almost at the press of a button.

'Preparedness' is expensive. What happened if the Ambulance broke down? Or a medic decided to say f-it and skipped a day. Or the phone didn't work. Or the critical piece of gear didn't work. Or ooops ran out of gas (hey doesn't happen often, but it happens!)

To get all of those things to 99.999% is quite a bit expensive. Constant vehicle checks/repairs/updates. Backups. Process, procedure.

The amount of training required for Medics should be quite a lot, considering the first few minutes of any problem are usually the most critical, and it can be 'anything'.

My unscientific 'instinct' is that $1K per call seems to be more or less in the right ballpark.

There should be some kind of insurance for this, one way to make it more palatable would be to have it subsidized. People who call more often I think can be expected to pay a little more but we can't be breaking the bank on folks.

Given that healthcare is a skyrocketing part of the economy, I wonder if we're going to end up with a kind of triage in Ambulances as well - i.e. ambulances for crazy life-threatening things, and ambulances for more common things which mostly require 'getting to a doctor quite soon, please' i.e. this is important, I need to go to the front-of-the-line'.

Edit: actually, $300 is definitely 'too low', there probably is some kind of subsidy.

Very crudely suppose an average call may last 1 hour. Suppose due to scheduling, that an ambulance may be idle for 1 hour in between calls. So the 'average call' would be 1 driver, 2x medics, for 2 'man-hours' each. Of course, there's other labor overhead: for each ambulance, there might be 0.3 mechanics, 0.3 dispatchers, this before we get into all the other unit an ancillary costs. $100K/year for any kind of professional in the medical field is ballpark reasonable, that's $50/hour - so we're looking at roughly $300 just for the immediate staffing - not including the mechanic, dispatch, op staff, gas, insurance, training, facilities, advanced equipment etc.. So very crudely ... ambulances are expensive.

Edit 2: yes, I'm talking costs here, obviously this is different than what people end up paying as a commenter has indicated.

As with so many things in healthcare, if it's such a great system, why isn't it used for the military? Medevac helicopters are really expensive, so why not make individual troops decide whether their case merits a few year's pay?

Misplaced sarcasm aside, the military makes very excessive use of basic triage.

Medevac is not called for 'asthma attacks' I can assure you.

$300 is a user fee, a fraction of the actual cost, which in Canada we do pay for through an insurance scheme called taxes. (Most other medical expenses are covered through our single payer insurance, funded though provincial income taxes, but ambulance service is paid for by property taxes, I think).

Different country, but pointing out some reported data on actual costs:

https://www.stjohn.org.nz/news--info/news-articles/st-john-a...

In New Zealand one of the major ambulance services reports costs of around $615 including taxes per callout.

However, the charge passed onto the customer is set at $98 for medical emergencies. This is waived for accidents (covered by the government).

A $4000 ambulance bill is offensive and I don't think justifiable in any way.

Hell, New Zealand only charge $800 (USD500) for non residents!

In New Zealand if you get tested (free) positive for Coronavirus they'll put you in hospital (free). Assuming you've collapsed and need to be taken there in an ambulance, you'll still have to pay the $98.

Meanwhile, I went to the emergency room in a hospital with my girlfriend in London two years ago and it was free for her. We're Americans.

Guess which country has better health outcomes.

Yeah, here in the UK she could've been told that she wasn't going to get tested for coronavirus over the phone for free. It's a much more civilized system. (Though to be fair, we did a little better at adding Italy to the list of qualifying countries promptly than the USA.)

UK tests per million: 387

USA tests per million: 26

Not really the same.

There should be some adjustment for expected exposures, no?

If you believe the numbers, the UK has 6.9 per million infected, and the USA has 4.1, so they're pretty similar.

You shouldn't believe the numbers, though, because the USA is barely testing people—and not because they aren't sick; testing in the US is often expensive, as obviously idiotic as that is. I'd expect the USA to have a higher number of infected per capita in actuality.

>Guess which country has better health outcomes.

The US, by all objective measures.

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

It's actually not uncommon for Brits to travel to America to pay for treatments not available on the national health or to avoid the often years-long waiting lists.

Mmm yeah I wonder.

UK: someone dies of cancer or whatever. Enters the statistics as cancer death. Drags down outcome.

USA: someone dies of cancer or whatever. Was poor. Gets buried. Cancer statistics unharmed.

You still have to report some cause of death.

And how well does that work do you think? Given how many are misdiagnosed or undiagnosed before death, how much money and effort do you think is spent on the cause of death for some random, (literally) poor corpse?

Of course "some" reason will be logged.

You were implying, that sloppiness leads to reduced cancer statistics, painting a better picture for the US. Well, if another cause of death is used instead, the picture will look worse for it. There is no escape.

I think it might actually!

(Like obesity, heart failure, complex some-or-other, "natural causes", take your pick.)

On the other hand, https://www.salon.com/2018/03/05/americans-still-have-to-go-...

Here "Not uncommon" means "Very uncommon" because of course as this story illustrates US medicine is _ludicrously_ expensive and so the only reason you'd _travel_ there to get medical treatment is because that's the only place offering some obscure treatment you want.

Also is that list of really weird stats "all objective measures" ? No. It's just "Here are some numbers somebody seemingly randomly picked from a _vast_ array of statistics kept for the OECD".

>... so the only reason you'd _travel_ there to get medical treatment is because that's the only place offering some obscure treatment you want. <

When is this not true though? Of course traveling farther would be less desirable when moving between developed countries, it adds burden and costs on top of whatever you were already going to have to pay without offering much opportunity for recouping costs. The only exception might be traversing the EU but that's because of geographical convenience more than anything else. America is literally across the sea, if we're cheaper for someone in the UK then someone fucked up somewhere at the NHS.

My point is, if you're sat in say, Liverpool, and you see the elective surgery you want is six to nine months out but that seems forever, you don't go "Oh, let's fly to San Francisco and get it done privately there, we can spend the kids inheritance" you start looking at private providers in Liverpool (there are several) or maybe Switzerland. You are attracted by a good price in say, India, or a friend recommends somewhere in Eastern Europe.

The US is very expensive compared to other private options is my point.

40 million Americans don't have healthcare[1], and another 38 million have "inadequate" health care[2]. Together that's more than the entire population of the UK.

It's not so impressive that if you only treat the richest with the best jobs who can afford the best treatments, you get better outcomes than systems which treat everyone.

[1] https://www.cnbc.com/2018/01/16/americans-without-health-ins...

[2] https://www.pbs.org/healthcarecrisis/uninsured.html

I’m one of the people without healthcare and everyday I pray for my family, “I hope we stay in good health and don’t have to see a doctor or the hospital, one small thing and we’re likely to be bankrupt”

People take UBER to the hospital now instead of an ambulance. #Merica

IMHO, you're mis-stating the problem. One should take an uber/friend to the hospital if the ailment is not time-sensitive or in need of ongoing treatment so that the ambulances are freed up for more critical patients. Ambulances should have some level of cost associated with them to dissuade using them for minor ailments. Should that level of cost be thousands and thousands of dollars? Probably not.

Shouldn’t dispatch triage if you need an ambulance or not?

In other countries they do that so aggressively that we have stroke victims dying, which an ambulance being dispatched.

On the other hand, given that triage failures are rare -- cost/benfit wise it's probably better.

In countries where you can call an ambulance like a taxi, won't that lead to ambulances not being available to people who actually need them?

GP was making the argument that high costs of an ambulance is necessary.

Don't need to be a cost... We could just have 911 send a taxi instead.

I know in other countries ambulances are not always dispatched, because 911 operators decide it's not critical.

Mostly this decision is correct, but from time to time a heart patient dies. (Maybe the alternative should be to send a taxi)

Is that a thing in other countries? Sounds like an excellent idea for a bill here.

In Denmark we have cases where ambulances are not dispatched because operators don't think it necessary..

But I don't think the dispatch taxis instead -- besides our taxi availability is highly limited and extremely expensive (Uber being prohibited). To be fair taxi drivers are certified, and service is IMO high quality.

For example, some years ago on holiday to Edinburgh I had terrible diarrhoea. Probably norovirus infection. Fine, holiday spoiled but I can sit in a hotel room, stay hydrated and watch Netflix in the calmer moments. Then I began shitting blood. OK, that definitely might /not/ be fine, need somebody to check.

So I call NHS Direct, they agree that unexpected blood is potentially urgent and I arrange a taxi in the middle of the night to go to the closest Urgent Care clinic. Taxi driver did completely fail to find the right entrance to the hospital, but I was just sick not stupid so I followed the signs he'd ignored and went to Urgent Care. I was the only adult, every other patient was a sick child whose parents were probably worrying too much. A doctor takes a look, goes yup, just what you'd expect, not serious but thanks for checking, disapproves of my "Crisps and full fat Coke = Salt + Sugar + Water = acceptable rehydration" approach and hands me nasty tasting rehydration powder. Boo but since I'm the one who just dyed a toilet bowl red with their own blood I vow to follow their instructions. Taxi back to the hotel. All better in time for the trip home. Still have the last sachet of rehydration powder somewhere actually, it's probably expired but can't taste worse now than it did then.

NHS Direct is really handy, because it's often tricky to judge the correct amount of urgency or know how best to access the service you need, especially when far from home. But I don't see how you could build a trustworthy service like that under the US system.

one can wonder when Uber would get into the ambulance market.

I paid something like $800 for one crutch when I sprained my ankle once. Think another $300 for ibuprofen. Now I know why there's a crutch market on craigslist/thrift stores. Not sure what my insurance paid for xrays, etc, but my tab was something like $1100 for that ER rendezvous. Thought I broke my leg.

I had a laparoscopic surgery a few years ago that was $35k.

to be fair, you paid a doctor to administer you a crutch and ibuprofen, I'm certain that's not the raw material cost.

That's not fair, because the doctor no-doubt billed separately.

separate line items, typically

Do you really think current health care is giving accurate line items on your bill?

Accurate or not clinician time is typically billed separately, as are drugs, individual procedures, equipment, etc. Some stuff is rolled up but not that much; hospital accounting systems are quite comprehensive and structured in such a way to help them argue with insurance companies.

So the argument that the crutch is expensive because an MD handed it to you probably doesn't hold, the clinician files something, probably under a CPT code, and you were billed for that separately.

This depends on the service of course, you may see say a CT scan where the room time & tech etc. are rolled into one item, but the radiologist review is separate. So it isn't just people vs. equipment, etc.

I never said it was the only reason. The reason it costs so much is because you aren't paying for the raw material. You're paying for a service. That service happens to be laughably bad and expensive, but that's what you're paying for.

I don't understand your contention then, as this was a response to a very specific scenario that does not happen in practice.

I wish that was the case. If you sort the line items by cost, I would be surprised if labor was on top. Maybe for surgeries, but I doubt that.

My insurance got billed 6k for a chest ultra-sound. They paid 4k. Hospital still wanted around 2k, had to negotiate and pay a little over 1k at the end.

The line item for physician cost (billed separately) had 2 digits.

>If you sort the line items by cost..

Do you really think current health care is giving accurate line items on your bill?

Wouldn't a bill with inaccurate line items amount to a form of fraud?

Meanwhile, I got a doctor consultation and referral, X-rays, a temporary ankle brace, and two crutches, all for $240 from an urgent care clinic (no insurance help). That's an actually fair cost. Hospitals tend to be huge ripoffs but maybe not urgent care clinics.

there's a line item in the bill of $750 for "1mL iodine"

My wife just got a replacement mask for her CPAP (that would run 120$ up here in Canada) for 10$ on wish - except for the packaging it appears to be absolutely identical.

$800 for a crutch is insane. especially considering that one could do with some handy woodwork and some sticks if it was truly necessary.

To put it in perspective, I broke my ankle 3 years ago, and in the end, I paid, from my own pocket, 45EUR. For 1 ER visit, x-rays, cast, a few follow-up consultations and renting crutches for a few weeks.

Hopefully, the hospital won't put a lien on your home. Some states allow them to do that.

An opposite example, went to the ER last year and spent a couple hours there. Paid a $100 copay. Haven’t seen any other bills.

Gonna go out on a limb and assume you have good health insurance. Many (most?) Americans do not. I'm on an HDHP for example, so the first several thousand dollars in medical expenses per year come directly out of my pocket before insurance starts helping at all.

i work for a tech company in the fortune 500 top 25... i would assume the best insurance possible, still killing us (paid nearly $7000 out of pocket last year + the actual premium costs of several thousand more). i've got three small kids including one with a heart condition, so it's particularly bad right now.

For insurance, I have found it's difficult to beat the negotiating power of the multiple large Federal Government offerings - and you can shop before you decide to join:

https://www.opm.gov/healthcare-insurance/healthcare/plan-inf...

> i would assume the best insurance possible

That's usually not a good assumption to make, not even among the FANG. There is extreme variability even with the same insurance company, depending on the negotiation between the company and the provider. And very few companies actually have any incentive to even provide the best 'possible' coverage.

Just looked it up and we're only in the top 50 (insert crying smiley).

And I got downvoted here for saying that I would require a LOT higher salary to move from Sweden to the US. Your example is why.

A $5k bump in salary should probably make up the difference in the average year. That's not a "LOT higher salary" by my reckoning. Hell, the difference in tax rate alone would easily make up for that, even if the US salary is lower (which seems likely to be opposite of what would actually happen).

Or the debt collectors haven't caught up yet. That happened to me around 2012 in the US. Went to the emergency room, had some tests done, got the hospital bill and paid a few hundred bucks. Then like 9 months later I get calls from a debt collector saying I owed $1,500 to a separate medical testing company that apparently provided the test I was given at the ER. I had never received that bill and it just took a while for them to send it to collection apparently.

Right, but you also benefit from the fact that it's an HDHP, right? Must you be on an HDHP (because the other plan is too expensive, or because another plan is not offered) or did you choose the HDHP even when presented with the options?

The big up-front deductible and an HSA is pretty much the point of the plan, and it's mostly advantageous to those that are young and/or don't have to go to the doctor that often, with a max downside of their deductible + catastrophic.

EDITL To be clear, I also believe significant reform is required, but there is also a lot of misunderstanding about how plans work which is not helping. The whole industry is extremely opaque.

The HDHP works out in years in which you need no medical treatment beyond the covered annual physical. Once you start needing anything, it ends up being a worse option. I discovered this a few years ago when I broke my ankle.

The big upfront deductible seems like exactly the wrong way to structure a healthcare plan, as it disincentives getting treatment until things get really bad.

True, but if you can offset that with an HSA to cover your entire deductible and sweep the rest into a qualifying retirement plan it makes a lot of sense _and_ you don't have to worry as much about the deductible. Note: I am on a typical PPO and optimizing for minimum catastrophic amounts, generally so this is not the way I usually go but many colleagues seem to like these plans

When I lived in the states I was on a medication I needed to get filled every month (Methylphenidate for the curious) due to life situation my cost to do so varied in this manner over the span of half a year:

30$ (1$/pill) while on uni insurance

0$ on state healthcare while unemployed (Green Mountain Care)

270$ (9$/pill) while employed and not qualifying for employer healthcare

120$ (4$/pill) while employed with my brand name uncovered (but discounted due to an Aetna preferred rate)

3$ (10c/pill) while employed after switching to the generic

Healthcare costs in the US are unpredictable, arbitrary and cruel.

It's pretty crazy how this works. Despite having pretty good coverage, I often use GoodRx because the prices are so much cheaper than using my insurance...

Ha! So I work adjacent to the insurance industry and, hilariously, sometimes tier based copays on medication fills can exceed the pharmacy's price - usually pharmacists will catch this and just never bill the insurer, but sometimes patients can end up paying more for a drug because of their insurance.

Healthcare is all kinds of insane at every level.

Yeah. A lot of people focus on the insured vs uninsured gap - if you're uninsured you're fucked. But the reality is that, even with insurance, medical care is a disaster. Finding a doctor in your network, waiting months to see them, completely unpredictable costs that, to me, borders on fraud, etc.

I've recently started a company, and at the same time a friend was laid off, and over the last 6 or so months I've gotten to experience the absurdity of this system from a few angles. It has been eye opening.

The whole waiting months thing is so shameful, since it is a major talking point from people arguing in favor of the status quo. They point to wait times in Canada, which are entirely misinterpreted and never point to the fact that it can take months to see a specialist in your network in the US. Heck, the number of times I've been told "this Dr. is not taking any new patients" or some version of that, is astronomical.

I'm up here in Canada - my wife's uncle had to wait three months for cataracts surgery, cataracts surgery is good in the long run and extremely non-urgent. He also had to have a rotoplasty in his heart to clear out plaque, he was booked into surgery within a week - my wife's aunt fell off a cliff (a small one) and got a concussion, she had excellent care.

In Canada non-urgent procedures have moderate wait lists, and urgent procedures get immediate attention. In the US monied patients get immediate attention and poor patients get long wait lines.

Honestly, this rationing BS needs to stop, the people spreading it are either maliciously disingenuous or misinformed and I'd bet quite a few are acting maliciously.

Went to the ER last year with fever because the insurance told me to go to an ER. Saw the doctor for five minutes and was sent home. Still calling the insurance and the hospital over a $500 bill that was supposed to be covered but somehow they keep sending it. My girlfriend once got a $300000 after a surgery that required a five hour stay at the hospital. It took her two years to clear that up.

What made you decide to go to the ER instead of scheduling an appointment with your GP out of curiosity?

it was acute gut-wreching pain that we weren't sure what to do about, didn't know if it was going to get worse... we should have gone to an "urgent care" clinic, which was our mistake.

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