Hacker News Reader

Comment by noud | Hacker News Reader

I'm too European to understand why this makes any sense. I think the problem is not really that the insurance doesn't want to pay the bill, the problem is that $18,933.44 for stitches and anesthesia makes absolutely no sense at all. Therefore, the resolution is not to negotiate with your insurance and tell them exactly what happened so that you can split the bill. The resolution is to negotiate with the hospital about the costs of stitches and anesthesia. In Europe (Netherlands in my case) the insurance usually pays everything (part one of the solution), which forces the insurance to negotiate with the hospital about prices (part two of the solution). Keeping most simple interventions low in costs.

View on HN

I have read about this.

The hospital charge as much as they can, because some patients are unable to pay. This way they make up the difference (or make more).

The idea is that you go to the billing staff and threaten that you will go bankrupt and will not pay anything. Then negotiations begin. Rich pay cuz they don't care, suckers get conned, and poor gets their credit destroyed. Classic USA.

It is another 'american' system akin to tipping only taken to extreme.

I'm not American but go bankrupt will affect your entire life in the US.

I don't think they were saying to actually go bankrupt, just to threaten the bank with the possibility of getting nothing out of you.

if you are poor and cannot afford anything then yes, you go bankrupt and good luck with getting a credit for an icecream.

But otherwise you use bankruptcy as a bargain card. Because nither side wants to go there.

>hospital charge as much as they can

to profit, and profit they do. They deliver record returns on investment year over year.

The last time my daughter required stitches, the hospital did it for free. They didn't even ask for my name. I didn't even had to fill any paperwork (which would have been a chore since I didn't have the EU health card with me and I speak very little of the local language). Happened at French alps during last year ski season.

This information would be significantly enhanced with when that last time was, and what country you were in at the time.

Why, do you want to travel to a French ski resort to get some stitches done for free?

No, thank you, but it's a very sweet offer. As an Australian I already qualify for free healthcare, and I don't require any medical attention at the moment.

Referring back to the (G)GP - when trying to put geo-political context around such comments, it's useful to mention the geo-political context of your comment.

> it's useful to mention the geo-political context of your comment.

Really? How so?

I'd tell you, but the Stasi would arrest me.

Same happened in Italy to a friend from latin-america, traveling as tourist.

She left the hospital with a smile, impressed how easy and friendly people were. Nothing serious so nothing to pay. She was very worried and they even managed to make her smile.

This was in Verona, Italy some years ago, in the ER of Borgo Roma. It was late night and just a short queue to wait. It has been a great human experience and we will be always grateful to the doctors there.

I remember a podcast, it had an account of a guy. He woke up in the middle of the night with chest pain and in sweat. He though 'I think I might a heart-attack coming'. He drove his car as he might not be able to afford ambulance.

This was my first time i learnt of US health system.

Imagine waking up in the middle of night, realize you might have heart-attack and the next thing you think of is if you can afford an ambulance.

I'm from the UK, where it's difficult to find price lists, since the patient never sees a bill.

This paper [1] covers "the NHS, child and family costs of falls, poisonings and scalds".

> In total, 344 parents completed resource use questionnaires, with > 95% of children recovering within 2 weeks of injury and almost 99% recovering within 1 month. Mean NHS costs ranged from £2588 to £2989 across injury mechanisms for children admitted for ≥ 2 days, from £719 to £1011 for those admitted for 0–1 days and from £97 to £178 for those attending an ED but not admitted.

All this boy's treatments were on the same day, and he only fell off his bike -- these British figures include accidents like scalding -- so in the UK, he would have been at the lower end, i.e. under £1000.

[1] https://www.ncbi.nlm.nih.gov/books/NBK447063/

> the problem is that $18,933.44 for stitches and anesthesia makes absolutely no sense at all.

It does make sense if you have a law that limits the profit rate for a particular enterprise so it has no other way of increasing the profit than pushing up the price to a level where 20% of that price is the desired outcome.

Netherlands has a really nice system that would probably work for the US as well if there were any political interest to fix the healthcare system. Right now both parties are heavily in the pockets of insurance companies so the only things you can see is failed half-assed, broken solutions like Obamacare that cost billions even to operate a website.

https://www.aeaweb.org/research/regulating-health-insurers-a...

https://www.bloomberg.com/news/articles/2014-09-24/obamacare...

I don't think 20% of that number seems normal, either. It's still ~$4K, for what sounds like stitches and local anesthesia (unsure, as the link does not seem to open the article for me, only gives a list of other NPR articles). That's over one month of pre-tax salary (edit: for the median US worker), which does not equate with the length, complexity or risk of the treatment.

So, what I am saying is that I fail to see what attempts at limiting the price has to do with the price being too high in the first place.

>The ACA requires health insurers in the individual and small group market to spend 80 percent of their premiums (after subtracting taxes and regulatory fees) on medical costs.

Means their profits are capped at 20%. Only way to grow profits is to inflate costs by colluding with private health providers.

Ah, I see. What the parent poster and myself seem to be getting at is that in terms of international pricing, perhaps 1000$ of service happened here (and I'm being generous - in many places, that would be considered outrageously high). A 20% profit margin would put it at 1200$. How it got to 19K is mind boggling.

No. $19K of service happened here as documented in hospital billing, and Insurance company can claim $3800 profit.

As I recall, inflated costs were just as much of a problem before ACA, though?

That's usually what happens. The uninsured tend to be poorer, less stably employed, and the hospitals look to extract marginal revenue from these people. Paying for all of the bill collectors, legal review, etc. to get the original bill amount just isn't worth it in most cases, or so I hear from insiders. I suspect in this case because there is insurance that the family will try and succeed somewhat to get partial responsibility from the insurance company. This was emergency medicine for a dependent child - not a commonly excluded category.

There are some serious lobbying at the EC level to implement private health insurance and replace state/mutual health insurance.

Right now the focus is on the people and freight rail transport system but it's happening.

It's capitalism. No one makes you pay. You can do your stitches yourself. Or, try to find a cheaper hospital.

I know it's more complicated than that but everything has its cost. $19k is the cost for the US stitches and anesthesia.

Edit: I'm not a fan of this system but it works. Isn't the US the #1 medical care quality country?

That might be possible if healthcare companies were upfront about the cost of their services. But I bet you couldn't find an upfront cost for stitches from 3 hospitals in your area.

Not only that, I tried to look up pricing prior to an emergency visit. I got a massive excel spreadsheet that was every single name for each codified medical procedure they had. On top of that it’s often not possible to anticipate what all treatment you’ll receive. I was expecting to just receive stitches real quick but ended up in surgery overnight.

If that is capitalism then capitalism can go get fucked in my opinion.

Honestly, we're not talking about having a wart removed here. It's basic medical treatment for a child. That should be beyond reproach in any civilised country.

"Illness is neither an indulgence for which people have to pay, nor an offence for which they should be penalised, but a misfortune the cost of which should be shared by the community."

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

NB Of course, it is perfectly possible to disagree with this view, it just happens to be something I personally strongly agree with.

Agree, but I think that the US can decide for themselves. It is a democratic country where people (majority) have the power.

Largely when polled the people are in favour of single payer healthcare so what gives if you believe that to be the case?

> If that is capitalism

its certainly not free market capitalism. part of the problem is that the government makes it illegal to turn away ER patients. maybe you think thats moral or maybe you dont, but the point is that an ostensibly free market becomes corrupted with outside influences like this. you cant create a system designed for the free market to be the mistake fixer and then make the market not free and not expect bad mistakes.

i think this is the greatest failure mode for america: pretending non-free markets are free. in some cases, its the worst of both worlds by a very large margin.

I sometimes wonder if this argument is an example of the "no true Scotsman" logical fallacy. No matter how little regulation is imposed on a market someone will still find some example to point to and say "if only we weren't subject to such awful regulation the market would be free and everything would work perfectly".

The very concept of such idealized free market is a red herring. It doesn't exist in human societies (the closest is what you have between criminal gangs and during civil wars). There is no market in isolation from politics.

It's kind of like wanting to talk about electric field around a charge while pretending the magnetic field isn't a thing. Much like physicists noticed that electric and magnetic fields form a common entity together, perhaps it's time more people recognized that market and governance are just as much intrinsically intertwined. Either one needs the other to exist in any but most degenerate form. And both actively try to influence each other.

"The #1 medical care quality country"? Is that the medical care quality everyone can afford? That's what matters.

> Isn't the US the #1 medical care quality country?

It depends which indicator you choose ... if you choose life expectancy, the #1 rank turns to #36 :

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

In absolute terms or in terms average quality of coverage for the population? Because in absolute terms, sure. In real “quality of healthcare”. Most likely not.

The fact that life expectancy in the US is lower (and decreasing too) than any other developed nation is pretty much all you should need to know.

You're not a fan but it works for you. Hope you don't find yourself in a bad economic situation.

Also. Is it better to have the best medical care (if it's true) for some or a great system for everyone?

"While the United States spends more on health care than any other country, we are not achieving comparable performance. We have poor health outcomes, including low life expectancy and high suicide rates, compared to our peer nations. A relatively higher chronic disease burden and incidence of obesity contribute to the problem, but the U.S. health care system is also not doing its part. Our analysis shows that the U.S. has the highest rates of avoidable mortality because of people not receiving timely, high-quality care..."

"First, greater attention should be placed on reducing health care costs. The U.S. could look to approaches taken by other industrialized nations to contain costs, including budgeting practices and using value-based pricing of new medical technologies. Approaches that aim to lower health care prices are likely to have the greatest impact, since previous research has indicated that higher prices are the primary reason why the U.S. spends more on health care than any other country..."

https://www.commonwealthfund.org/publications/issue-briefs/2...

The states are riddled with obesity, depression and overworking - still I think health care should be evaluated on the actual structures and services available, not on aggregates statistics that depend on a lot more.

My wife on NHS (UK) gave birth on a sofa with pretty much no equipment - and they conveniently missed the time when epidural could be administered. Waiting times are bonkers. And NHS was touted as a best system in the world in 2018.

It's just political propaganda if you ask me.

Who touted the NHS as the best in the world? UK's own politicians? The same guys who under-fund the NHS year on year? The same guys who are trying sabotaging it so they can privatise it?

The NHS is a great institution but the UK government seem hell bent on destroying it while passifying their voters with misleading soundbites about their investment in it.

The Commonwealth Fund

https://www.commonwealthfund.org/

https://www.theguardian.com/society/2017/jul/14/nhs-holds-on...

Seems slightly surprising to me - I would have assumed it would be France or one of the other EU countries.

Edit: I'm a supporter of the NHS but it has been chronically underfunded and had too many management consultants trying to "improve" it over the years.

NHS is clearly not the best HC system when taking into account most factors (18th in the world) https://www.who.int/healthinfo/paper30.pdf

The US is at 37 - which is amazing for the richest and most powerful country in the world.

That sounds like an awful experience and I’m sorry your wife had to go through that.

I just wanted to add that when my wife gave birth in the UK on the NHS last year she had an amazing experience and the level of support before during and after was incredible.

In general all my experiences with the nhs have been positive. In comparison the only other country I have experience with is Hong Kong where I had a dr laugh in my face when I enquired about a genetic condition I may have inherited.

The nhs is far from perfect and could use improvement. I think it’s just that most other countries are even worse.

What makes you think that "the US the #1 medical care quality country"?

Of course, it depends from the indicators you use... Who tried, came up with this:

https://www.who.int/healthinfo/paper30.pdf (World Health Organization - Measuring Overall Health System Performance for 191 Countries)

At page 18 you will find the results. Spoiler: The US are not n.1... not even top 10.

> You can do your stitches yourself

You cannot. We're talking about anesthesia and stitches for a child. Even if it were legal to do these procedures without a medical licence, which it absolutely isn't, it would still be a terrible idea, even if you could get your hands on the right supplies.

> try to find a cheaper hospital

We're talking about emergency medical treatment for a child. You think there's time to search around for the best price?

> Isn't the US the #1 medical care quality country?

Absolutely not. The WHO ranks the USA as 37th out of 191 countries: (PDF) https://www.who.int/healthinfo/paper30.pdf

> We're talking about emergency medical treatment for a child. You think there's time to search around for the best price?

Exactly, this child got the emergency treatment. His dad wasn't asked to pay 19k upfront.

I write all this because I was born in a country where all medical treatment is free for everyone.

Guess what? It's super low quality. Doctors got paid less than in McDonald's. If you have a serious problems you literally have to search for a right doctor. It might be someone not even in your large town. And, you pay upfront! So, I'd rather live broke than die because no one even treats me.

There is a middle ground between the two dysfunctional extremes that works well in a lot of countries.

It's not a just matter of finding a 'golden mean' on the spectrum of nationalisation/privatisation, there's another dimension: competence of execution.

I'm sorry to read that but just because that system sucked it doesn't mean the US system doesn't also suck. Other countries have better healthcare systems both in terms of cost and actual quality of service. America should be modelling themselves after the best in the world rather than comparing themselves against the worst and saying "at least we're not that bad"

I'm sorry the quality was so poor in the country you were born in, but that doesn't necessarily mean that it's (only) because the service was free (there could be other reasons), or that poor quality is a necessary consequence of healthcare being paid entirely or mostly with public funding.

Public healthcare isn't entirely free where I live, but the fraction of the cost paid directly by the patient is small enough that it qualifies as mostly free to most people. Complaining about public healthcare almost seems like it's a national sport, and it's true that you can get shorter queues and faster response in non-emergency cases if you go private, but the quality of public healthcare as a whole still doesn't suck, and especially emergency care and treatment for serious conditions is still pretty good.

Doctors get paid less than e.g. in the U.S., but they're still among the most well-paid professions.

What I think leads to disaster is if funding to public healthcare is poor and the quality is low, which leads to people not appreciating the service and thus towards further devaluation of the public system, which becomes a vicious cycle.

It may also make sense to not have healthcare entirely free so that people don't start going to see a doctor too easily for reasons not requiring a doctor, but I think a system where it's potentially way too expensive does at least as much damage.

I don't claim to know what happened in your country of birth, but there could be factors other than just free healthcare.

Sutures: https://www.amazon.com/Non-Absorbable-Surgical-Practice-Vete...

I'm not certain what your point is here. You can buy veterinarian training equipment online, but so what?

It’s likely a local anasthetic and simple stitching. Both of these can be found in normal first aid kits, so I would bet that you can legally use it at home.

Even in the hospital, this work was probably done by a nurse with a 2 year degree. You can go to any clinic and have it done. If the kid were at summer camp, they would have probably had the staff nurse do it.

Emergency rooms are both overkill for this, and happily overcharge as well.

We are all talking as if the hospitals performed a dangerous complex procedure and saved the kids life. If so, then isn’t 19,000 a small price to pay? If not (and it’s a simple task as I believe) then why did they charge so much?

> Both of these can be found in normal first aid kits

Neither are found in a normal first aid kit.

> I would bet that you can legally use it at home

No, suturing is a surgical procedure.

> this work was probably done by a nurse with a 2 year degree

I'm not a medic, but from what I can gather online, suturing is considered an advanced specialised skill for nurses.

> If the kid were at summer camp, they would have probably had the staff nurse do it.

I doubt it, even with a qualified nurse on site. No summer camp wants a reputation for being reluctant to take injured children to the emergency room, neither do they want liability.

> Emergency rooms are both overkill for this

Does any first-world country agree with you on this? As far as I'm aware suturing is always treated this way, it's not just for-profit medicine and artificial gatekeeping.

> We are all talking as if the hospitals performed a dangerous complex procedure and saved the kids life

It's routine emergency medicine. Nothing more, nothing less.

> If so, then isn’t 19,000 a small price to pay?

No, it's absurdly inflated.

> If not (and it’s a simple task as I believe) then why did they charge so much?

Because they could. There's a deep power imbalance at play. You can't go price-shopping when your child needs emergency treatment. You might know going in that medical expenses are the top cause of personal bankruptcies in the USA, but you can't haggle. You won't even know what you owe until after the fact.

Brits like myself are generally horrified at the way American medicine is run. This kind of thing simply doesn't happen in the UK. (That's not to say our healthcare system is perfect, of course.)

I don’t really know what to say except that your experience doesn’t match mine.

I could look up research articles on best practices but I often find that those things just pay lip service to what we are “supposed” to do and not what actually happens.

Also I take exception to this notion that unless your country has economic power in the top 20 of the world, then whatever practices you have has no value.

Extreme specialization is a byproduct of rich economies but that shouldn’t be confused with it being a good practice in all cases.

The idea that this is a free market system is patently false The cost is not $19k , it is whatever the billing department decides to surprise the patient with.

The medical care quality isn't relevant to the point, but it is dependent on how you want to measure it. If getting basic care to your citizens at an affordable cost is any important metric , then the US fails miserably.

I never goto the ER even if I need to anymore. I'm too busy paying off my $30k bill for a single EKG.

> The idea that this is a free market system is patently false The cost is not $19k , it is whatever the billing department decides to surprise the patient with.

Totally agree. And even if the billing department could tell you the price, which they can’t, is the dad supposed to call around for quotes while the kid bleeds?

Free market and competition relies on the consumer being able to make an informed choice. How can they if there are no published prices, and then no way for these entities to compete?

It is designed this way like a cartel, inflate prices, nothing free market about it.

I disagree.

This is not capitalism but government meddling and third party payer inflating prices.

Sure, the USA is one of the best medical care systems in the world (and it's definitely better quality than any public service you will find in Europe) but it doesn't cover cheaper services.

Under an unregulated market, with pure capitalism, you would see cheaper, smaller hospitals pay-as-you-go or via cheap insurances.

How do you propose to find a cheaper hospital when is nearly impossible to get a hospital to tell you how much a procedure will cost before they do it? Nevermind doing that while your kid is bleeding on the pavement.

> $19k is the cost for the US stitches and anesthesia.

No it's not. $19k is what that hospital arbitrarily chose to charge for stitches and anaesthesia. What it actually cost the hospital was significantly less. Several orders of magnitude less I'd wager.

The fact that the insurer was able to negotiate a payment of ~36% (less than half the original price) and the hospital still had enough margin to be profitable should be telling.

> I'm not a fan of this system but it works. Isn't the US the #1 medical care quality country?

No. Not even remotely. It's 36th in the world as ranked by WHO. It is, however, ranked #1 in the world for the most expensive healthcare system. And by some margin too. I don't consider that a placement to be proud about either.

The whole point is that $19k is not even close to the cost of doing stitches for a kid. It's a simple procedure that takes half an hour of doctor's work and the same from some assistant; if you need a million-dollar-per-year specialist for that, even then their work costs less than a $1000; double it for overhead/facilities and youŗe at $2k (instead of $19k) for a very conservative estimate (private nonsubsidised facilities in high cost of life parts of Europe would offer to do for much less for uninsured foreign patients and still make a healthy profit on that).

$19k represents a ridiculously inflated markup that's not even in the ballpark of what the costs are, even in USA. Things like liability insurance etc add some extra costs, but not nearly enough so that tenfold increase would make any sense.

This isn't a free markets issue, this is a prime example of crony capitalism.

To paraphrase Marc Andreessen, with free markets and competition, you now can buy an amazing giant 65" 4K LCD TV with all of the latest greatest features for barely $500. Stuff gets better, cheaper, and more convenient for the consumer, while the companies duke it out to get ahead.

But when things get overly regulated, subsidized, or effective cartels are formed, you end up with situations like monotonically rising US healthcare costs, monotonically rising US housing costs and monotonically rising US college costs.

This isn't an issue of too much free market competition.

That's not capitalism, that's libertarianism. The two are not really related, just confused by some biased media. Much the the American concept of 'socialism'.

But it isn't capitalism, at least not a free market. While you may have a limited choice on what hospital you can go to, good luck with getting a price beforehand. This problem occurs because of the parasitcle nature of health insurance and the hospitals, and that you are pretty much required to have health insurance. Once the government mandates it, you are losing the capitalism. And there is a lot of corruption and Negligence between insurance and hospitals

>I'm too European to understand why this makes any sense.

This really reads as "Is this some peasant joke I'm too rich to understand".

No it just means that it’s beyond comprehension. As a Canadian, I feel the same way.

Everything about the American healthcare system feels like a nightmare to me. From the cost, to the fact that it’s usually tied to your employer (!!) and that even if you have good insurance, you have to make sure to get care from “in network” healthcare professionals.

It seems to require a tremendous amount of energy for very little benefit for average citizens.

You can understand or not understand something -- it has 0 to do with your nationality. "As a Canadian" is just nonsense. It doesn't bring much to the table.

"As a Canadian doctor" is authority. You often find this with appeals from "As a mother" -- it's just a fallacy.

I don't think this is a very charitable reading. "As a European", "As a Canadian", etc. isn't a statement of authority or a value judgement that makes someone better, it's just stating that they come from a cultural context where this isn't the norm, so it seems bizarre.

Including the cultural context you're viewing things from can be useful so that people can understand where you're coming from.

My personal favorite was the $2000 copay, like healthcare is the same as car insurance where you might forgo the repair of a dent.

A reference to feudalism is a bit strange there, but I'll weigh in with the observation that in Australia it's comparably challenging to understand.

I think in almost any western country (and many non-western) 'free' (or close to) healthcare is a basic right of citizenship, so it's extremely difficult to try to comprehend how 20-40% of the average person's salary could be consumed by treating a child's minor accident.

Well, yes. America has a hugely wealthy private sphere for some people, and an impoverished public sphere.

Reply on news.ycombinator.com