List price for stitches at Stanford Health Care: $93K
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That is absolutely insane to me. I really don't understand how that's possible at all - I know no one really pays sticker price on any medical bills but still.
It blew my mind - how can you NOT know?
Also, does your insurance cover these random bills or is it copay/80%?
As someone in the healthcare field - the best way I can describe it is that providers and insurers fight it out however they can. The problem is is that patients get the shit end of the stick.
I think calling out that both hospitals and insurers are fucking over patients is a positive change. Hospitals used to always get a pass, but they’re a huge part of the problem.
I don't think many uninsured people are paying sticker. Sometimes they automatically get charged with a discount, sometimes they have to call and get it. Some folks don't know to call, but these folks' bills are, I expect, not usually getting paid in full in the end anyhow.
Which is stupid, since the price has no basis with reality.
The insurance companies know this - when they negotiate, they look at $90k for stitches and say “yeah, we’ll pay you $1,200”.
The uninsured get screwed because the hospital acts like their charge master prices have some basis in reality.
Since you're in the space, what do you think of the startup they mentioned in the thread, turquoise.health (or rather the idea behind it, not literally the startup)?
I went to the same ER in San Francisco with the same problem 3 months apart (kidney stones). The first time around I was uninsured and the bill was $2000- they told me that they'll cut it down to $500 if I paid on the spot, which I did. 3 months later I had the same problem, had purchased insurance, my bill came out to $8000 and my deductible was $2000.
I have been assuming the magic discount is some sham the insurance companies push for to scare people into believing they would not get it if it weren't for the insurance.
It's BS IMHO to not be advertising the ACTUAL cash amounts they would quote somebody..
One reason that stitching up minor cuts is so expensive could be that those who need that treatment (e.g. because they were in a fight) are statistically less likely to ever pay their bills…
But it still sounds scammy pricing tactic to me. That is not how stores or anything else works or should work.
I work in radiology and entered a few common procedures I see a lot in our data on https://turquoise.health/ (also linked in the Twitter thread). Then I entered information for our own HDHP+HSA plan. Guess what, having insurance costs you 40-60% more if it's an acute issue. So if you're healthy, you have zero incentive to use your insurance if you suddenly need a CT of something. The rub of course is if you pay cash, it doesn't count toward your multi-thousand dollar yearly deductible, so if it turns out to be a chronic issue you just shot yourself in the foot. But if it doesn't, you just burned thousands by using your insurance when you didn't have to.
It's a complicated issue and anyone who says they have the solution, including "just make it free / just have the government pay for everything," is either being disingenuous or doesn't understand the problem. As was stated in the Twitter thread, running a hospital 24/7 is astronomically expensive. Everyone has their finger in the pot trying to get paid for their services in a world of increasingly small reimbursements. Attending physicians as resident-run hospitals will sleep overnight while getting paid literally half a million dollars a year. Insurance companies will just decide not to pay something and will spend years in court to defend their right to pay whatever they want, down to and including $0. Vendors will charge tens of millions of dollars to implement monolithic thick-client applications where everything is so configuration-heavy that you literally can't have a test environment because it won't match. Interoperability is managed by a text-based standard named HL7 that if you're not familiar with, will make you rip your hair out. The standard itself is ignored by every organization who ends up with their own flavor, so every app needs to be configured to support nearly any value in nearly any field. Hospital IT is staffed by people making $40k/yr who don't understand modern computing, and run by executives with no technical background.
Every single entity and company involved in healthcare is complicit in the end result, which is skyrocketing patient costs with at best no change in patient care or patient outcomes.
But you said something that stood out - "Everyone has their finger in the pot trying to get paid for their services in a world of increasingly small reimbursements." Given the rising prices, why isn't the pot getting bigger?
What do you think of Epic systems and EHR stuff?
I think the pot is getting bigger but it's getting bigger for gigantic organizations like Kaiser (not calling them out specifically but it's a name everyone knows). Someone pointed out, either here or in the tweet thread, that the 2011-2020 price increases are just going to Stanford. The physicians don't see any of that because they have their own reimbursement, and the patient gets their own bill. When we ran billing in-house it was not uncommon for patients to call us with billing issues because they didn't understand (nor should they have had to) that our radiology service bill was separate from the hospital. Which was separate from the anesthesiologist. Which was separate from the lab. Etc.
I see the pot getting bigger mainly for insurance companies, and large hospital systems, in that order. Some docs in some specialties are doing as well or better than they were ten years ago but a lot of the primary care specialties just get whatever the Medicare reimbursement is and don't have any control over it. Insurance companies will pay them whatever they decide to pay them. So short of increasing the cash price on that minority patients, all of whom are going to be very price sensitive, the independent docs and small practices can't do much to move the lever. Healthcare software vendors seem to be making out like bandits because their clients are typically the large systems and insurers who are flush with cash.
How does almost every other country in the world manage to do exactly this then? Clearly it's a feasible solution elsewhere, so why not in the US? As much as I'd like to believe we're exceptional, I know that in the end we're really not.
There are some extremely good elements of American healthcare. Our healthcare education system with all its flaws is among the best in the world. We're a global center of medical and pharmaceutical research. Changes to the provider side need to take that into account or the entire world could suffer as a result.
The MBA-ization of healthcare - they realized they could, so they did. Mostly because the business processes around medical billing have become so convoluted, with so many layers of middlemen, that it's essentially impossible for a layman to understand and reason about.
How can anyone price shop without knowing any of the prices, and if no one is price shopping there isn't any pressure to lower prices.
The prices are a perfect storm of what is essentially a unionized tightly gatekept profession, obviously perverse inventives in insurance, and the consequent inflation. Swap debt for insurance, and you have the dynanic of the education market as well. Both of them are artifacts of regulatory capture.
Arguably, instead of teaching kids to code we could teach them to handle 50%+ of emergency room visit causes and the resultant widespread competence and research impact would make medicine progress at the rate tech has. I suspect the main reason we don't have biohacker first aid kits for routine procedures is drug controls on anesthetic, but there is a already robust global black market for drugs that could meet this need. A list of procedures sorted by risk and pain could be solved pretty fast. Of course there will be wildly irresponsible malpractice, but compared to the consequences of the current system, it probably nets out, and for medical industry people who don't think it would, they aren't really in a position to object to a free market in health services.
If we can create a market, knowledge networks and a disitribution system for 3D printed guns, we should apply the same ethos and skills and come for medical care next. We need a Cody Wilson of medicine.
But "can I do it?" and "can I do it well?" are different questions. For instance (IIRC), badly done stitches can leave more of a scar than expertly done ones and a badly set bone may heal in the wrong position. There's also knowing the difference between typical situations and more unusual ones that look similar but require a different treatment.
It's not a bad thing to know how to do those things for an emergency, which is the context an army field medic would do them, but that's quite different from an everyday accident with accessible medical care.
An Uber for medical toursism would even be more cost effective.
What we shouldn’t do is look at what nearly every other developed country has done to manage this situation, to the point where the most expensive amongst them is still half as expensive as the US system.
/snark
It still completely astonishes me how often Americans will come up with pie in the sky non solutions to solve problems that other similar countries have solved decades ago.
CPT 12011 - "Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes"
See: https://www.cms.gov/medicare/physician-fee-schedule/search?Y...
In medical parlance, this is called uncompensated care or uncompensated revenue. The Center for Medicare and Medicaid provides a ton of detail [1].
[0]: https://en.wikipedia.org/wiki/Disproportionate_share_hospita...
[1]: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manual...
Like any negotiation you want to start high rather than low.
i know Americand are imagining a horrible 3rd world facility, but its not. its a beautiful hospital with very kind people who take great care of you. we got the fancy big suite, so we could accommodate a bunch of family and friends. we were there for four days and i ended up paying about 4k USD, out of pocket, without insurance.
and I think this is where the problem is. I personally have friends who are doctors here (private sector) they have great lives financially, (nice cars, big house, trips to europe, etc). I get a feeling healthcare professionals in the US arent satisfied with upper middle class, they want to be hyper rich.
Maybe if youre the only person that can save me from a strange cancer you should be hyper rich, but not if youre doing regular procedures.
So if you really, really don’t want medical intervention, make certain your friends and family will respect your wishes.
I wish my dad had just gone to the hospital as soon as he knew there was a problem instead of trying to be a financial hero.
I’d be curious what the price is for non-face stitches.
Also, can a wound sized 2.5cm or less that can be stitched up be complicated to stitch? I would think/guess many of them would be glued nowadays.
There are different codes for more complex work:
Intermediate repair (CPT codes 12031 – 12057)
Complex repair (CPT codes 13100 – 13160)
according to this some manage >15% and profits are best ever https://www.forbes.com/sites/robertlaszewski2/2020/02/05/pro...
In a competitive market, companies with high complexity penalties can’t compete, get pushed out or are forced to reduce complexity by force. In this case, there is no external pressure to reduce complexity but an increasing number of parties seeking to benefit from it. Which leads to predictable consequence of complexity growing like crazy.
The universal healthcare solves the insurance problem, not the cost of the hospital. What US needs is not insurance for people that don't pay for it, but reasonable prices at hospitals. We have this in my country: we have both public and private insurance and public and private hospitals. The competition in the system means private hospitals will never have such prices, otherwise there will never be clients.
Instead of universal insurance coverage, you need strong competition to hospitals so there is a market price that is closer to the costs. Here the private hospitals cost more, but offer a much better quality; still, the prices are double and most middle class people can afford to pay it without insurance if needed, so these stiches would be maybe $100 while in public hospitals it would be $50-60 and covered by the public insurance. Even here in Europe there is no full, unlimited insurance, emergency care is free but everything else is covered by a mandatory insurance every employee has (paid only by employee, not the employer) and it covers the spouse and kids (under 18 years old or in college) of the insured person. That means there are people without insurance and they receive only emergency care for free, nothing else.
Some employers offer as a benefit a negotiated private insurance co-payed; for good contracts the private insurance cover all the costs in private hospitals, for my company it covers about 50% of the doctor cost for consultations and about 20% of the hospital costs. I pay about 50% of the cost of this insurance, the benefit is a discount price versus the regular price of the insurance (about 10-15%).
Without a requirement that hospitals list their prices by billing code and must actually charge that price to everyone across the board with no adjustments or discounts laws like this are basically useless.
Though just a few years back, it was like pulling teeth to get the insurance negotiated prices (which I pay entirely having an HDHP). Hopefully, more transparency results in more cost shopping, but it's been a surprisingly slow social change.
I got one at an ER in an "expensive " private hospital here in Mexico. I paid less than $50 USd for the EKG and a doctors' checkup.
I understand that I the US salaries are 3X what in Mexico but even that doesn't justify the $1000.
If people are traveling for medical tourism and it is profitable, it seems like we could incentivize other countries to set up shop here.
It does not occur to them that in a single-payer system, the incentive on everyone is to find ways to lower the cost of healthcare, while in a privatized healthcare system the incentives are reversed. And examples like this twitter post show the result of those incentives.
Any evidence to the contrary is met with “but my freedom”, idk how to fight back against this
I would not call that I hate the whole Canadian system, but parts of it for sure. Especially the ones when they let you wait for months for some things. Some people died because of it. All because the guvvamint only allows for so many procedures per period allowed. The rest does not fit into budget.
However you will find enough of deaths in the US that can be attributed to a lack of money as well.
Depending on how one gets sick the may hate Canadian system or the one in the US.
When the candidate “with a plan” estimates that single payer wouldn’t reduce costs, does it take a “massive disinformation campaign” to convince people that, by the time all is said and done, costs would go up significantly?
why is this? Here in Chicago all govt run institutions are out of money with out of control budget overruns. eg: public transport( CTA) , usps ect. Not to mention pensions/pension debts which have spiraled out of control.
I am no big fan of the American healthcare system but I don’t think any country (don’t bring up Switzerland and Singapore as examples, they are too small and don’t have the diversity, size and complexity of the US) has demonstrated an ideal healthcare model.
Hard to tell from this what else falls under "knee replacement" category of urgency. I personally know ppl who traveled to india to get a root canal. Weird to dismiss it as " deliberate propaganda campaign " and link to npr article with no actual statistics.
Why would health care be harder to scale up in terms of the size of a country than, e.g. the military or the fire brigades?
As for diversity... I don't buy it for your specific example. Switzerland has:
- Four official languages.
- A federal system with similar levels of decision-making devolved to the cantons as to the US states
- 11 political parties significant enough win seats in the parliament
- High levels of immigration: 30% of the population are immigrants.
The reason Switzerland shouldn't be brought up is that the health care system isn't particularly good, just different. In particular it's the second most expensive in the world.
The worst?
HN is one of the few forums that repeatedly leaves me speechless.
Even during Covid lockdowns that Sydney is going through at the moment, I can get a GP appointment this week with a 5 minute travel time.
We have a health system delivered by the States of our commonwealth, enormous distance to cover and extremely high health outcomes.
If raising my taxes by $10k eliminates that, I’m extremely ok with it.
The cost of US healthcare is 2-3x the cost of healthcare in the rest of the developed world - counting both public and private spend - and with very similar outcomes.
As would I, if there's a $15k savings. Is there any data to support that?
You mention costs in other countries. How do salaries, taxes, and cost of living compare as well? It seems that many places have lower cost of living, which seems to influence prices for any number of services.
From a patient perspective or system perspective?
"Health care costs about 50/month if you have income."
That's what is billed. What do the systems actually cost on a per patient basis adjusted for population risks (like obesity)?
https://www.npr.org/2019/11/01/775339519/heres-how-warren-fi...
> Warren bases her plan off of a recent analysis from the Urban Institute, which estimated that under current law, Americans would spend $52 trillion over the next decade on health care — that includes many types of spending, from employers, individuals and all levels of government.
> Warren's plan estimates that total health costs could be held to $52 trillion and that $20.5 trillion in new federal spending would be necessary.
Like with schools (where America also pays more and gets less), most spending in the healthcare system is payroll. An American nurse makes twice what a UK NHS nurse makes. The idea that we can cut those costs meaningfully is laughable.
While I'm a proponent of universal healthcare, it does have some negatives.
I don't think this is completely true. That greatly depends on the population. Regardless of single payer or private insurance, it's the underlying mentality of the people, or restrictions placed by the plan (which people then complain about). Many people think they have coverage, so they might as well use it. This can happen extremely often and for minor things. Think people going into the doctor or urgent care because they have cold symptoms (for less than a week) and want antibiotics. Most people want the easiest, most beneficial thing, like why diet and exercise when you can just take a pill for your type 2 diabetes, cholesterol, or blood pressure?
People don't think about costs during the most costly parts of life - end of life care. People want doctors to do "everything" to extend a person's existence, even if the outcome isn't likely to result in extended life. When the system does make choices about who to treat or how to treat, there is generally some public backlash (like NY letting many elderly die because they thought they needed to save the ventilators/beds for younger covid patients).
It's the views and intelligence of society that dictate behavior-based costs. This includes what restrictions are placed on both supply and demand sides.
For one, people are using Stanford for the name and presumed quality of care (see tweet about price being much higher than other hospitals). That's shows patients are willing to spend more for treatment there. If you want to dig deeper into the cost, then we would need to know why the price is listed that high, as it is likely a mistake (also speculated in the tweets). It's not really a good idea to compare anecdote that is suspected to be a mistake against an unspecified cost in another system (implied by parent).
I think this is not realistic, and it's the opposite of my experience in relation to all the people I've known.
I know far more people that _should_ go to the doctor and don't, or do it after a long time (sometimes too long) rather than people who go to the doctor's too much.
I actually can't think of anybody that goes to the doctor "too much".
I've known only one case of person going to ER for simple cold symptoms (excluding the epidemic problems), as one is going to briefly checked, then made to wait for a very long time.
That example I gave about wanting antibiotics for a cold was something I've seen in real life, multiple times. There are hypochondriacs and other people who do go too often. They even have a code/name for people like that to let other doctors know by reading the file. I personally know of a guy who would call 911 just to get a ride in an ambulance. Eventually they stopped responding to him.
I do know people who probably should have gone to the doctors sooner too. I don't know that many of them, but it's possible they are more common in other areas.
"I've known only one case of person going to ER for simple cold symptoms"
I said urgent care. Urgent care is not the same as the ER. I know of people who go to the ER just for the free ride (Medicaid transportation provisions).
https://slatestarcodex.com/2020/04/20/the-amish-health-care-...
Edit: why continue to downvote without comments?
Americans are all too ready to blame their individual selves for problems caused by the state and capital. A lot of people from other countries would make their voices heard.
Although this isn't by coincidence either. The government has been feeding this individual responsibility line with various forms of propaganda mixed with racism to the people. It's also been silencing anyone who dared to question the underlying system entirely.
Reminder that the FBI sent letters to JFK aimed to getting him to kill himself.
MLK Jr? Or maybe there’s more to the JFK story than I know…
Do you have anything backing up that assertion?
I've been to the hospital feeling rotten on more than one occasion, and the doctor has said "You have the flu. Antibiotics won't help. Go home and get some rest." The doctor has no incentive to prescribe me drugs I don't need. There's always a few shitty doctors at clinics/hospitals who will over-prescribe, but the health care system has an incentive to find and stop those doctors- they're wasting taxpayer money.
Meanwhile in the US, the doctor would be financially incentivized to request a chest x-ray and prescribe whatever drugs might be helpful "just in case", fearing a lawsuit for doing too little and fearing their employer being mad at them for not up-selling to bring in more money.
I don't see how changing the healthcare system would implicitly change the torts. Medicare and Medicaid haven't changed that.
I also don't see how the single payer system would prevent over prescription or unnecessary treatment. These also occur under Medicare and Medicaid, as does substantial fraud.
Uh...what else do you suggest that sick people should do? Be irresponsible and go to work or something?
The point is that people decide when they need care, and some of those people are idiots.
And if I don't know that something is cold, I don't assume it's cold.
There's some kind of horrific cost disease going on in America. Sure, the insurance doesn't help, but it's not the main problem. The cash price - with a discount - for me to get the five-minute opinion of a nurse practitioner is $125-$150. Self-insured companies are paying 20k+ in premiums for an employee's family health insurance plan.
This is reflected in the fact that a lot of hospital systems in the US are already publicly owned! Taxpayers in much of the US are already paying directly to built facilities and pay doctors and nurses for anything their billing doesn't cover. (Not even counting the VA system.) 64 million Americans are on Medicaid, about 20% of the population; [1] 18% of Americans are on Medicare. [2] (There's some overlap, so those aren't strictly additive.) More Americans than Canadians are already the beneficiaries of public health care! And Medicare/Medicaid is already the one of the biggest US government expenditures. [3] Whatever natural incentives are in place are already there. It may be the case that specific government policies are partly responsible for hamstringing cost-cutting, but I see no reason to believe those policies and worse ones wouldn't perpetuate themselves.
There's a lot of factors driving the crazy costs in the US. Unfortunately, I don't see a reason to believe single payer would do anything but mildly slow the rise, unless combined with a lot of very unpopular policies.
[1] https://www.cms.gov/newsroom/fact-sheets/medicaid-facts-and-... [2] https://www.statista.com/statistics/200962/percentage-of-ame... [3] https://datalab.usaspending.gov/americas-finance-guide/spend...
Personally, I would like to see the government use the VA to demonstrate what level of care and overall experience the public can expect if switching to a single payer or other government involved system. Most of us that have any knowledge of their workings would not be too optimistic about US government expanding their role in the general system. It's such an embarrassment.
I honestly haven't heard anything good about the VA other than it's free (but was really earned through service). The good care tends to be at what I would call the active duty facilities, like Walter Reed and Bethesda.
You had mentioned hospitals being incentivized to reduce costs. They could do that by avoiding sick patients. Or not treating sick patients.
Some “providers” already have this business model.
Also, it’s all but guaranteed hospitals would seek to increase revenue by providing non medical services at high expense.
$2000/meal. $500/night parking. $500 for a hospital gown.
America needs to address its weak administrative state, underfunded and under-qualified civil service, and overall shitty public sector before taking on a massive project like this.
It takes a special kind of delusion to believe that when every single country in the world that has a public health system is in fact not worse than the US system.
I think a large part of the problem is that Americans are brainwashed from birth to believe that the "Free Market" will solve all problems, and that it is superior to public systems 100% of the time.
As an America this is a very sad thing for me to say. But the basic mechanisms of government are failing.
My advise is to respond to the bill and let them know you'll only willing to pay $200 and that's all you can afford. Negotiations with these predatory billers go a long way.
I had to go to the hospital for an allergic reaction on a visit to the USA. They let me go with $600 in cash.
When I asked for an itemized receipt, it has thousands in charges but nobody there really seemed to care if I paid that. The insurance company was welcome to pay if it wanted to though.
https://arbor.com/blog/how-does-rent-factor-into-the-consume...
And you know what? Fine, whatever, in some twisted version of the world I can accept this as an argument. But I wish people would at least realize that by only having private healthcare they are fucking themselves over as shown here. The prices, the copays, the restricted access, the in and out of network treatments......all of that is completely made up to feed the system.
I think another argument is that it'll be less effective (ex: longer wait times, etc) and that people will abuse it, ex: in Canada, I used to see people show up to ER because they were sneezing and I've seen people wait forever to get a doctor, etc, you're much less likely to do that if it costs you something.
No saying it’s the right approach or not, but it’s an interesting one.
The US spends more as a percentage of GDP on healthcare and has the lowest life expectancy of all developed countries[1]. They are already spending their hard earned money on other peoples treatments, they are just getting less bang for their buck.
1. https://www.commonwealthfund.org/publications/issue-briefs/2...
Infant mortality is counted differently. The US system will try and save a kid that other system don’t - that’s a death where other systems don’t count it as a life.
But physical and mental healthcare plays a major part in the other 95% of deaths.
In the current US system, that money goes to private companies, which is good.
Don't bother questioning this because it's axiomatic. It has ceased to be merely political theory; it's now core to many people's identity. Any threat to that status quo is a personal, existential threat.
An example: https://www.cbc.ca/news/canada/british-columbia/a-tale-of-2-...
"Then I found out that this other country — which I thought had a healthcare system that was so superior to the U.S. — doesn't test for the tumour marker that saved my life, and doesn't cover this drug that is responsible for pushing my cancer into remission after traditional chemotherapy failed to do that."
It should be added that a healthcare system that relies on insurance companies isn't necessarily a problem, as evidenced by the number of countries (the Netherlands, Germany, Switzerland, etc.) with highly regarded healthcare systems that rely on private healthcare. Germany has a hybrid public/private system, while the Netherland system relies on mandatory personal health insurance. But these systems work because they are highly regulated and are designed to benefit the individual, with limits on how much providers are allowed to charge, for example.
But it is anyway in fact, since that's how insurance works even privately.
There is a model somewhere in between, like the swiss system. Here we pay a deductible amount of our own healthcare per year, which can be one of several set amounts. After that insurance pays 90% up to some set ceiling, then everything.
Costs including monthly premiums are regulated for essential treatment, and people who really can't pay can ask the government for assistance. The differentiator for health insurance is in add on packages. You want a private hotel room if you ever need to stay? Extra. You want something not covered by the basic insurance (most things you might reasonably need are covered)? Extra.
This has the advantage of making the cost of unnecessary healthcare visible to people, which discourages unnecessary use a bit, while making sure that if something really does go wrong you will be treated and you don't need to worry about going bankrupt. It isn't tied to employers either.
It isn't a perfect system but my point is that there is in fact a reasonable middle ground compromise if 'everything is free' isn't acceptable. It is also quite possible to make money even with a system that charges for basic healthcare.
I agree that the US system is probably unchangeable - too many entrenched interests. It seems a shame though. We need some level of safety net as a society.
In a public health system waste is considered bad, and we would work to lower it.
In the private system waste is called shareholder value, and we work to increase it.
edit: I phrased this poorly, but certainly stand by my point. If anyone would care to discuss this or educate me, I am always open to change my mind.
OK, so if I understand your point, US healthcare is not free-market enough and even more deregulation is the cure. In that scenario even more hungry profit centers are allowed to flourish between the patient and their doctor. But, that is even more "waste" from a patient money -> healthcare provided point of view.
What has become apparent to me is that some aspects of civilization are not compatible with privatization. Oof. This was a very bitter pill for me to swallow as my background is having escaped Soviet controlled Europe when I was a child. It has taken a lot of time for me to realize that the ideal solutions for our species may not be at the opposite extreme of ideology. The big realization may have been that solutions in reality are often closer to a tensor than any one-dimensional concept or pure ideology.
* Note: by "ideal solutions for our species," I mean optimizing for the survival of the species, and growth of our technological civilization.
Through a botched 12 lead ECG, I ended-up in their cardiac unit over a holiday a few years back. It was better than most hotels. Insurance covered 100%. I don't think I ever saw the actual costs.