Hospitals lift curtain on prices, revealing giant swings in pricing by procedure | Hacker News Reader

Hospitals lift curtain on prices, revealing giant swings in pricing by procedure

healthcaredive.com

487 pointspaulpauper442 comments

Local hospital released this as an Excel spreadsheet (Chargemaster).

They have a column called "Uninsured cash price." These prices are <25% of the insurance "discount" prices, but the really amusing thing is that this column was set to 0 size so that when you download the Excel sheet you have to know to auto re-size all the columns, or you cannot see it.

And, no, I don't think this was by accident as they have updated this Excel spreadsheet several times and only that one column is always set to 0 size.

And this can really cause issues for people who are insured because if an insurance company decides not to cover something (very very common, even in-network) then the inflated price is what you end up getting billed for.

That is until you call the hospital and find out there's all sorts of "sliding" prices etc...

I had a procedure billed for one of these drastically larger "insured" codes which got denied based on the nature of the procedure from the insurance company (apparently too new of a procedure at the time, however common now).

It all got worked out in the end but what I realized was that hospitals are largely subsidizing the cost of the uninsured by over-billing the insured folk's insurance companies. We've set the American healthcare system up to be a cat and mouse game where those in need are represented the least.

Best insurance here is "don't get sick"

> if an insurance company decides not to cover something (very very common, even in-network) then the inflated price is what you end up getting billed for...

Is there any reason why this kind of windfall shouldn't be illegal? I realize it isn't, but is sure seems like it should be.

I was stuck with a charge from a doctor for 7x the price my insurance would have paid. My pre-ACA insurance refused to cover the procedure and I ended up on the hook for the inflated price. The doctor wouldn't negotiate and demanded the full fee. Neither the doctor, nor I, knew this would happen until the procedure was already done.

It feels like an agreement, to me, when the practice takes on a patient knowing who their insurer is. I feel like the reimbursement rate that insurer has negotiated, regardless of whether the insurer ultimately covers any procedures, should act as a cap for the fees charged to the patient. It feels a lot like negotiating a contract, except that one party gets to unilaterally change the amount of consideration. How does that fly?

Insurance has the worst moral hazard: the winning strategy is to sell a product that pretends to cover your customers but actually doesn't. Your customers give you money for nothing and they will only realize it once in a blue moon. You can probably buy off the few who are capable of causing actual blowback, and if that doesn't work just rebrand.

Until everyone becomes a contract lawyer capable of devoting weeks to insurance shopping every 6 months, the only good insurance market is a heavily regulated one, even though heavy regulation comes with its own gigantic bag of worms.

Payouts and premiums aren't where the money is in insurance. It's in the return on investments the insurer makes with the money they hold in trust. From an insurer's point of view, the best market isn't one with no payouts, but one where there is a highly predictable amount of payouts, because the better they can predict how much they need to payout, the more aggressive they can be with their investments.

Yeah, there's a decent amount of regulation around payouts to protect the consumer, but it pales in comparison to the regulations around making sure that the insurer has enough liquid assets on hand, that the total valuation of their assets (ie investments) remains large enough, and that they're charging a minimum amount of premium for the risk that they're taking on.

Aren't insurance rates regulated meaning if they payout a smaller amount than expected the rates will go down next year?

Insurance isn't inherently a moral hazard.

Reminds me when my dentist charged me $50 for a cup of fluoride (nothing too special about this fluoride).

I asked why they said it would be covered. They said when they checked with insurance it says it’s covered, but for my age or whatever it’s not actually covered.

So then I said why is it my fault that you gave me something you said was free but actually wasn’t because your check wasn’t thorough enough?

They said they already spent it so someone has to pay…

In the end I didn’t pay for the fluoride after hours of argument.

Next year at a different dentist, same situation. I learned my lesson and just paid for the damn fluoride. Land of the free, home of the brave!

I never pay for this.

"No cavities again! Would you like a flouride rinse?" "Why would I do that? I have flouride in my mouth rinse and my tooth paste." "Well, ours is a higher concentration that I paint onto your teeth." "Didn't you say I had no cavities?" "Well, yeah." ".... so what I'm doing seems to be working without your rinse" "Well, it's only $16" "My flouride rinse has the exact same active ingredient as yours and costs $5 for an entire bottle." And it just goes on and on.

> Is there any reason why this kind of windfall shouldn't be illegal? I realize it isn't, but is sure seems like it should be.

because our senators and congress critters are all on the buy for really cheap... it's not even hidden. something like medicare for all is the thing that makes sense but has a hard time finding traction because the people that it will negatively impact have the means to buy those politicians out.

> It feels like an agreement, to me, when the practice takes on a patient knowing who their insurer is. I feel like the reimbursement rate that insurer has negotiated, regardless of whether the insurer ultimately covers any procedures, should act as a cap for the fees charged to the patient. It feels a lot like negotiating a contract, except that one party gets to unilaterally change the amount of consideration. How does that fly?

You aren't exactly talking about "balance billing"[1] but you'll be pleased to know the No Surprises Act[2] tries to address this situation with required cost (estimate) disclosures in advance of a procedure and capping the out-of-network amount that can be charged in the event of an emergency where there can't advanced disclosure. The HHS recently promulgated regulations[3] under the Act but the compliance date is January 2022. For some reason I think there is at least one (maybe two?) other proposed rules in the works but I can't recall what they address and I can't seem to find them.

Edit: The other proposed rule is relating to air ambulance services[4]

[1]https://en.wikipedia.org/wiki/Balance_billing

[2]https://www.congress.gov/bill/116th-congress/house-bill/3630...

[3]https://www.hhs.gov/about/news/2021/07/01/hhs-announces-rule...

[4]https://www.healthaffairs.org/do/10.1377/hblog20210913.57633...

I've had this thought as well. If insurance is negotiating with the provider then that should be the final say. What's the point in negotiating if the patient gets charged the difference?

I believe this is called 'balanced billing'. Some states prohibit it under certain conditions but it seems either the government or insurance should be prohibiting this practice.

There are services you can use which will negotiate the rate back down to the neighborhood of what the insurer pays. They won't negotiate with you specifically, you have to retain one of these services to negotiate on your behalf. They have direct access to usual and customary charges insurers pay per region.

Was in a similar situation as you were, but unfortunately, what I'd have had to pay was still too much as it was clearly fraud on the part of an outpatient clinic - one side, the clinic, was approved by my insurer, the other side, the surgery center, was not, and they willfully lied about this distinction. I threatened a law suit and they demurred.

I think it ought to fall afoul of "informed consent." Did someone actually consent to paying without being informed of the price, or is it non-consent by virtue of being coerced by lack of information?

> Best insurance here is "don't get sick"

Recent New Yorker article looking at the "Costa Rica model"[0] raised this point as well. America, by contrast to Costa Rica, has a very weak public health sector and infrastructure, and this leads to a real weakness when focusing on preventable illnesses and issues.

[0]: https://www.newyorker.com/magazine/2021/08/30/costa-ricans-l...

Yeah I read that too - just cherry picking here:

> All adults have tests and follow-up visits to prevent and treat everything from iron deficiency to H.I.V. It’s all free. If people don’t show up for their appointments, she makes sure their team finds out why and figures out what can be done.

It's common sense why they have better results and outcomes than we do here... Our system is optimized for capitalistic profit. I've got insanely good insurance and I still have no idea how screwed I am if I go to the doctor or especially a hospital. Although I've only had one major billing snafu years back I have real anxiety about going to the doctor here.

And hell, even if I go my PCP is going to be stuck in an "all or nothing" mentality where it's either OTC or getting in their own conflict with my insurer... ie: "If I can't justify this test with your insurer..."

---

Costa Rica's model is better than America's. The reason for this is because it's not optimized for profit, it's designed from the ground up to optimize for patient outcome.

In a well functioning health care system screenings like that is actually of debatable value as it generates a lot of false positives and un-necessary procedures.

> if an insurance company decides not to cover something (very very common, even in-network)

Which is why hospitals charge higher prices to insurance companies.

Insurance companies often blanket deny every single claim made against them. This forces the hospital revenue cycle department to have an appeals nurse review just about every procedure done in the hospital, and justify its use. This almost always results in a "discount" for something by virtue of a care provider not justifying every action they take.

Revenue cycle management departments used to be small, about 1 per 1000 hospital employees. Today, they are so big - and make so much money* - that hospital systems are spinning off their revenue cycle management companies for billions of dollars. Private equity firms have been acquiring in this space like mad since about 2016.

* Really, they are actually getting the money that is already owed.

That last sentence would be a great opener to the explanation of what insurance is, it’s not healthcare, insurance is something you don’t want to have to use. Healthcare is just healthcare, you can buy it from all sorts of places in various forms without billing to insurance.

Just like how car insurance is not a mechanic.

>> They have a column called "Uninsured cash price." These prices are <25% of the insurance "discount" prices

> And this can really cause issues for people who are insured because if an insurance company decides not to cover something (very very common, even in-network) then the inflated price is what you end up getting billed for.

That doesn't sound like an "inflated" price? 25% of what insurance companies are billed for?

I'm confused. I'm not sure y'all are talking about the same things?

He’s saying if you go in as an insured patient and get denied for a procedure by the insurance company after it’s been performed, you’ll get a bill from the hospital for the insurance-negotiated rate, not the uninsured cash pay rate. You can generally talk the billing department down to the cash pay rate, but that requires having a lot of meta-knowledge of how American healthcare works.

omg, I see what you mean. Confusing as heck.

Underpayment is a few percent of hospital revenues. It's a component of costs for sure, but only a small one.

https://www.aha.org/factsheet/2019-01-02-uncompensated-hospi...

My understanding is that you would usually pay the price set by the agreement your insurance has, even if they deny coverage of it.

"I realized was that hospitals are largely subsidizing the cost of the uninsured by over-billing the insured folk's insurance companies."

1. You have to back up claims like this.

2. I imagine for-profit Insurance companies would love to blame their prices on the uninsured.

3. Many poor people actually have insurance in the USA. Even if they don't apply for it, insurance can be applied for after the fact.

4. The wealthy, and the poor are usually covered by insurance. It's the middle class that needs attention. They have insurance, but it's not great.

I still don't belive our healthcare costs are due to the uninsured. Oh yea, every hospital has a fierce Billing and Collections department.

They are allowed to go after your assets if you can't pay your bill, and they do. Obamacare gave patients some rights, but hospitals blatantly abuse the regulations.

The right to collect in municipal court was never taken away from hospitals.

In my local newspaper, it's not uncommon for a hospital to sue a patient over a bill, and put a Judgment lien on the patients assets.

They claim they only do this as a last resort, but bankruptcy due to medical bills are still the number 1 reason people end up in federal court (Bankruptcy).

Your protections under a bankruptcy are not great either.

There are many hospitals that forced a former patient to sell their home (homestead exemption needs to be higher. In TX, they can't touch your primary residence.). under a bankruptcy.

In CA, for example, the primary home gets a $250,000 protection. (Look up that last figure. I know it's very low in CA, and needs to be raised to at least a million. You have a $600,000 home. You are only protected by $250,000 of it's worth.

So in America, if you do get sick, and can't pay all your medical bills, you have no protections. These for-profit medical companies will come after you with more zest than an unpaid credit card. I think CC companies are less aggressive.

1. All you have to do is look at the chargemaster flat files that have been coming out. There are literally two different columns for insured and non-insured procedure cost and for every hospital I've obtained a chargemaster flatfile for this is the case. Other comments in this thread have backed this up, and have even claimed their hospital's chargemaster had the non-insured pricing column hidden potentially in bad faith.

2. I mean, I have no idea but for-profit insurance companies aren't out there really blaming anyone as they're just a faceless corporate entity. I've only heard hospital staff and normal people blame the uninsured.

3/4... no - poor people don't have insurance. I've grown up around people who were not economically privileged/who were struggling and this is just 100% untrue that poor people can get insurance as you posit. I've had private insurance and it's just not something someone can afford if poor. And, if you're referring to things like "Christian Healthcare Ministries" they're straight-up scams. Outside of that, there is no way American restaurant owners, retail franchises, etc will cover an unskilled laborer's health insurance - that just does not happen here.

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> I still don't *believe our healthcare costs are due to the uninsured.

When it comes to hospital billing - yeah. It is a huge thing that's baked into their SOP. See item #1 above.

There's police around hospitals constantly and if they get a whiff that you have a fake ID they're going to be talking to law enforcement sooner or later.

Also this isn't going down to your corner liquor store and flashing your drivers license... that thing is going to get scanned etc.

---

Actual protip: If you're uninsured and need care they legally can't turn you away at an ER. They have to provide the healthcare to get you stabilized regardless if they're going to be able to bill for it or not... which ironically this is a big part of why the insured end up subsidizing the uninsured at the hospital.

Also, if this ends up being you - don't sign anything until you're in the right mind to sign something. They're going to try to pin you to bill your ass off one way or another and if you're half way through a heart attack or something do not sign anything until you can 100% understand what you're legally agreeing to.

I've often wondered what would happen if you went to the ER, carried no identifying documents, and just refused to identify yourself. Just hope nobody recognizes you there.

Giving a fake name is fraud, and people have been arrested for doing that at the ER. (Fuck America.) But I don't know that there's any legal obligation to give any name at all. If you don't give them a name, you're not lying to them, and oops, looks like they don't have a way to bill you. As you note, hospitals are legally required to provide emergency stabilization without regard to ability to pay.

I suppose the hospital could try to call the police, but AFAIK the police cannot compel you to identify yourself without reasonable suspicion that you have committed a crime.

This is why we need reference based pricing. You can't charge more than 1.2 * Medicare and if you pay cash, you get the Medicare price. This change alone would remove 25+% of unnecessary bloat from the US system.

>"This change alone would remove 25+% of unnecessary bloat from the US system."

Where do you think the money is going? Insurance companies are not as profitable as you might think, drugs are not a massive burden on healthcare expenditures, and many hospitals are non-profits. The truth is that most of the money is going to staff wages; if you want to reduce healthcare spending, the only way to do it sustainably is to increase the numbers of doctors and nurses, so as to drive down their salaries (but this is not a popular option).

I didn't downvote you and in fact, I agreed with the fact that a significant portion of the exorbitant healthcare prices in the US can be traced back to administrative bloat, MBAs who are in the management and to a degree, the significantly-higher-than-OECD-average salaries of the doctors in the US.

Having said that, your belief that many hospitals are non-profit might not be as simple as it looks from the outside. I recently read an insider writing something about it on Reddit: https://old.reddit.com/r/SelfAwarewolves/comments/pruk4x/the...

Hope that gives you an additional viewpoint regarding the "non-profit" label of the hospitals.

A substantial portion of the money spent on wages at primary care physicians offices is on staff to negotiate with insurance companies. At a previous employer, where I worked closely with many primary care physicians offices, it was not uncommon for there to be three or more staff members working entirely on billing. That is ludicrous.

Even if you drive down staff salaries physician, nurse, and everyone else working in the hospital, the profits that are made from those changes would simply be pocketed by the CEOs and MBAs in the system.

Many business which successfully reduce costs don't pass on those savings to consumers.

I will also point out medical students graduate (after 4 years college and 4 years medical school) on average with $210,000 of debt and make $60,000 dollars a year while working 60-80 hours a week for 3-8 years of residency. While yes doctors after residency are well compensated they have gone through 11-16 years of post secondary education by the time they achieve these salaries. Cutting salaries without reforming medical school tuition and residency salaries would be a mistake.

> increase the numbers of doctors and nurses

and tort reform to manage the lawsuits to enable lower malpractice insurance costs.

and a scheme to drive down med school pricing. Maybe more competition? Enabling more MD and DO schools? There are <200 medical schools (both MD and DO schools) in the US.

You are forgetting about all the brokers and all the staff at the insurance companies whose jobs is to negotiate different prices for procedures with different doctors. Most brokers charge 5%. Additionally, this change would cause a loss of some clinical jobs. A lot of the urgent cares would no longer be profitable and would have to get shutdown. Additionally, all these changes would ripple in other ways. Some providers may start offering sub Medicare cash prices to attract business. There is no reason healthcare costs needed to go up 6% per year and the main reason it does is that it can.

> many hospitals are non-profits.

That can't possibly be true of a hospital that charged $3000 for something on Tuesday, and $53000 for the same thing on Friday.

(Under reasonable assumptions like that Tuesday wasn't done at a $25K loss relative to breaking even; why would such be the case? And that they are busy with procedures, not simply doing a way overpriced procedure once every few weeks, and then just burning through cash in between that time.)

>the only way to do it sustainably is to increase the numbers of doctors and nurses, so as to drive down their salaries

Getting the hospitals to accept a price ceiling which forces the issue is another way to do it.

> Where do you think the money is going?

To the millions of people making a living in the health care system that have no actual role (direct or indirect) in improving the health of patients.

This is what other countries with large well functioning private systems (Netherlands, Germany, Switzerland) do - they set reference prices that generously cap the costs that can be charged.

What people don’t understand is the appetite for healthcare spending is practically limitless - there is always something more you can do even if the benefit is marginal. As such you have to control spending somehow and the options are (not exhaustive):

- ration care by capping total healthcare spending - “we will do 1,000 hip replacements this year, everyone else waits”

- make the cost visible to patients so they ration their own care - Singapore does this even in their public system. There is no free care, you are expected to pay something according to your ability. This is what the US is trying to do with the move to HDHPs

- closely regulate coverage and prices. Many systems do this.

> These prices are <25% of the insurance "discount" prices

There are some clever insurance companies whose entire model is "tell the hospital you don't have insurance, get the cash price, pay it with this debit card we give you."

Not technically "insurance", these are cost-sharing companies. Often religious due to Obama's brilliance.

Is there evidence that Obama wanted those religious exemptions and bullshit cost sharing plans? I would be willing to bet that was a concession to other politicians in Congress in order to get ACA passed.

I'm thankful the concession was made. The lower price of cost-sharing made it possible for my parents to keep eating while providing for the family.

That's great until the church decides your parents are sinners and refuse to cover anything, and have no consequences for stealing their money.

The parent comment never said anything about President Obama's desires regarding the Affordable Care Act, just that his 'brilliance' resulted in this outcome.

You misread. Parent thought those are a decent option and it's unfortunate that their availability is restricted.

They are required to have some shared religious belief to be exempt from the ACA.

Is it illegal to state you don’t have insurance when you do? Or is this product not considered Insurance in the legal sense?

I don't think it is. Sidecar Health is doing just fine on this model[1]

It's pretty perverse that you, an insured person, would have to lie about having insurance because the provider would charge you more for being insured.

[1] https://cost.sidecarhealth.com

The same goes for pharmacies. Walmart advertises $4 generics. If your insurance has a $25 drug co-pay, then they will charge you the full $25.

I do this. Once my insurance company got upset that my procedure was so expensive and rang the hospital. The hospital immediately tripled the price. The insurance became even more upset and asked me to fix it. Still much cheaper than the equivalent procedure in the USA.

It's not illegal here, but in any case nobody asks, I just tell them I'm paying cash.

It's not insurance. They're "fixed indemnity plans." Sidecar Health is the one I'm familiar with.

https://www.brookings.edu/blog/usc-brookings-schaeffer-on-he... (Fixed indemnity health coverage is a problematic form of “junk insurance”)

Health care consumers are absolutely free to pay providers directly even if they carry insurance coverage.

They could be running as a "health spending account" where you can spend the money on whatever you want provided it's health-related. You don't technically have "insurance" but you're insured.

Please provide an example or two.

You inspired me to look at the local hospital we just delivered our first child at.

They release 'standard charges' which as far as I can tell means 'the range of charges for this particular diagnosis based on past data' as an excel file.

But the price list is a text file delimited by pipes (vertical bars... |) which just seems unnecessary. They also do nothing to define the variables or column names they use...so that's nice.

God, I used to work in medical billing, and people would think these file format issues were some kind of scheme. NO they are not. They deal with the obvious problem that clinicians are NOT always programmer friendly, and will put things like tabs in case notes, will use commas etc. At some point you use a delimiter that is much less likely to be used - | - is one of those, not a lot of clinicians use it and you can say, please don't use this.

A surprising amount of stuff (at least medical billing side) can be flat file moves, especially if you are billing into lots of different systems.

And yes, the idiot new person with a phD says, just quote every field with a ". Great - you program all this up, along with the required escape sequence handling, and then escapes for escapes. \ and / get used a fair bit sometimes already and we are dealing with tons of systems.

> God, I used to work in medical billing, and people would think these file format issues were some kind of scheme.

I think it must be at this point. The hot garbage that is medical data formats (HL7, in particular) and the ways you can break it as a user, unknowingly and silently. It’s incredible that a format this bad has hung around this long.

It’s not ok that users can type certain characters into a field and break the system.

Pipes are commonly used as delimiters in healthcare settings [1]. A quick quack suggests Python, Javascript and Perl ecosystems have HL7 parsing libraries available. I assume most languages do.

[1]: https://en.m.wikipedia.org/wiki/Health_Level_7

Yep, probably an HL7 message. In the case of vertical bars, pretty sure it's HL7v2

Except they usually call them “tubes”.

(Can’t find the original source, but it goes “Cant breathe? Put in a tube. Can't pee? Tube. Can't poop? Tube. Bleeding? Tube. Infection? Tube. Heart attack? Tube.”)

> But the price list is a text file delimited by pipes (vertical bars... |) which just seems unnecessary. They also do nothing to define the variables or column names they use...so that's nice.

They likely just exported the prices as HL7 from their EHR system and used Excel's built-in delimiter support, then called it a day

> HL7

And there is the problem.

Sometimes medical procedure names have commas in them. Instead of text qualifying them, it can be faster to write code that uses a different semi-standard delimiter.

It sucks, but, like, I don't really blame people for being in a hurry to fix a problem.

Or they could be using a legacy system that exports data in that format from times before CSV was invented/standardized.

For example, SCO Unix's Informix SQL's `UNLOAD TO <file> SELECT ...` queries output in a format that's very much like what avs733 describes, only that the values aren't separated by pipes, they're terminated by them, so every record ends with a pipe character.

If that's the case, there's unfortunately no built-in option to get it to include column identifiers in the report. :(

If it’s HL7 (likely) the format is more complex than just a CSV anyway. There are multiple separators for different purposes.

This is the GDPR cookie popup annoyance equivalent of requiring hospitals to disclose their chargemasters, but not spelling out that the published data should be reasonably human-readabale. Malicious compliance.

Oh but, if you read slightly between the article’s lines, you’ll notice that the law does require both human- and machine-readable publication.

The machine-readable part is mandated here: https://www.federalregister.gov/documents/2019/11/27/2019-24...

As a taste of how specific this is:

    (5) The file must use the following naming convention specified by CMS, specifically: <ein>_<hospital-name>_standardcharges.[json|xml|csv].

And here’s the consumer-readability requirement for 300 “shoppable’ services: https://www.federalregister.gov/documents/2019/11/27/2019-24...

They aren’t always quite as stupid as people make them out to be, these lawyers.

From your second link:

> c) Format. A hospital has discretion to choose a format for making public the information described in paragraph (b) of this section online.

This is how you get Excel files with certain column widths set to zero. All it has to be is searchable, free, public, and updated regularly.

File a complaint with Health and Human Services [1]. It is clear they are not acting in good faith. Take snapshots of the URL with the Internet Archive for notarization [2].

[1] https://www.cms.gov/hospital-price-transparency/contact-us

[2] https://web.archive.org/save

I actually might, the wording on this page:

https://www.cms.gov/hospital-price-transparency

Does say "provide clear, accessible pricing information" which I would argue this is not.

edit: Filed a complaint.

Fantastic. In return I will review my locals and see what they report.

I genuinely appreciate that you took the time to do so.

EDIT: Thank you all for your efforts.

Thanks for posting this. I just looked to see if my local hospital had prices available. They have a webpage set up, but they give you a dummy link! Outrageous! I will absolutely be making a complaint.

I'm also going to post a review online, since poor reviews seem to get attention from them.

I'd love to look up uninsured prices and compare them 1-1 to what I was charged for my little girl's 2 week ICU stay https://kingsley.sh/posts/2021/two-weeks-in-the-icu-as-a-bab...

What's hilarious about that - is this:

Instead of giving a hospital your insurance info, say "you don't know if you have it, the last one expired" - even if you have insurance they couldn't prove you did "know you had it".

Then get the bill in the mail.

Submit the bill to your insurance company.

Bill gets paid.

Hospital doesn't get to inflate.

Reminds me of that time I exported a bunch of strings to Excel for translation. Was very confused when I got surprisingly short translations back.

Turns out the translator didn’t know you could resize the rows, so they had only translated the first few words that happened to be visible in each cell.

It's like that "display:none;" thing in CSS.

Excuse me. But fucking cunt asshole motherfuckers, we should be lining the people who are intentionally deceiving the public up against the wall, they are causing people to DIE.

The most sane comment here, sadly.

Anytime I have a procedure, imaging, anything I ask for the out of pocket price. You can save a lot of money doing this especially imaging.

My local hospital offers a cash discount of nearly 50% if you pay at time of service.

That sounds pretty unreasonable. Most people can barely stay on top of payments with a payment plan, let alone paying everything upfront

That's why they're so eager to get the payment upfront that they'll give a heavy discount. Apparently a lot of people have trouble keeping up with their bills.

Especially after a major traumatic event that requires an ER or hospital stay and especially if that bill is 5 or 6 figures.

I would think hospitals like people paying the cash price?

They make less that way. If they know you're insured they won't allow you to pay the cash price, only the much higher negotiated price.

> They make less that way. If they know you're insured they won't allow you to pay the cash price, only the much higher negotiated price.

This is not correct for all practices

My wife's practice (of plastic surgeons medical providers only in a reconstructive practice 75%, cosmetic 25%, attempting to be in-network with every insurer, with administrative front-office doubling as billing, and dedicated personnel for resubmits) vastly prefer cash paying because they get the money right then, and they don't have to haggle with insurers around things like pre-authorization, billing, etc. Insurers regularly make physicians go through the ringer to get an pre-authorization for a vital surgery. Even worse, insurers will ask for a "peer to peer" and then have some underqualified medical provider understand what a board certified surgeon is doing, based on a complex diagnosis, and not understanding the actual surgeries or procedures involved. Insurers will forget pre-auths, and then reject billing, and they have a whole bunch of shady practices around, even with in-network practices for cancer cases.

So much of this price transparency stuff is a giant racket because it helps insurers, and not the actual medical doctors, PAs, NPs and other medical providers. However, it is medical insurers & Payors which are driving all the paperwork (Horrible EMRs, ICD codes, pre-auth, auths, etc) along with growing the tsunami of administrative personnel)

Insurers try to use being out-of-network to reject medical bills, so they use it as a weapon vs practices/hospitals, very effectively unless it is an emergent case (medical emergency).

What is completely missing from this conversation is who this benefits, who this harms, and how insurers exploit the status quo.

Cash paying customers should always be the cheapest option, since there is little overhead for them.

There is a loophole in ACA specifically for this. A loophole that you can drive 20% of all Americans through (That's roughly the percent I've heard).

https://www.nytimes.com/2020/01/02/health/christian-health-c...

https://www.nytimes.com/2016/12/10/opinion/sunday/should-i-l...

But someone told me insurance companies are bad and are stiffing those poor, struggling doctors and hospitals.

Every head of the insurance/drug/provider dog points at the other two heads when somebody accuses it of being the problem.

Voters not wanting to pay for comprehensive care for everyone is a 4th head. The current system of healthcare is great for allocating different amounts of healthcare to different classes of people, so that it is great for 20 to 30% of people, okay for 20%, and not good for 50%, and that is why it persists.

There is no reason Medicare should be restricted to those over 65, or why Medicaid is implemented differently (and reimburses providers more poorly than Medicare). Or even Tricare. We have at least 3 different taxpayer funded healthcare programs specifically so not everyone can get access to equal care, but so that various classes of people can get healthcare proportional to their political power (which usually scale with money, but also votes in the case of old people).

Just because hospitals are also evil doesn't mean insurance companies are not.

Everyone says that. But it's pretty clear that healthcare services themselves just cost an obscene amount of money no matter who's paying.

Things they would love more:

Accepting the cash price after billing the person for the full price and writing off the difference.

It can go the other way too. Some hospitals will charge uninsured people much more than they would charge the insurance company for the same procedure.

Would a local news outlet publicise this?

I am one of the people responsible for making these lists. The fact that the general public as well as journalists think this data is accurate in anyway is really funny. This an exercise of futility that only increases the overall cost and provides job security for me :)

No one working in a hospital knows how much do we acquire things for, or how much we get paid for doing things in advance. And only like 8 people can tell you that information 3 months after the fact.

Take the simple exercise of figuring out cost/revenue of an aspirin administration.

Cost depends on: 1. Are you an outpatient/Obsveration v. inpatient v. ED? 2. Are you on Medicaid? 3. Is the hospital a part of GPO organization or not? 4. Is contractual obligations of GPO includes/excludes Aspirin?

Reimbursement depends on: 1. Insurance 2. Group which you are under the insurance from 3. Contract language whether its a fee/service or bundled 4. Is the visit covered or not 5. how the visit/procedure was coded (most important and opaque factor)

Everybody in the know, knows that these lists are a joke, but no one can prove it.

Requiring hospitals to make these lists may help the situation improve.

> No one working in a hospital knows how much do we acquire things for, or how much we get paid for doing things in advance. And only like 8 people can tell you that information 3 months after the fact.

This is the problem. There has to be prolonged pressure put on multiple parts of the system until it will start to optimize in different directions.

A nontrivial part of why no one knows these things in the hospital is because nobody has to know these things, the entire system (not just the hospital but the surrounding insurance system, the billing systems, the vendors, etc) is used to not needing to care about these things.

So these lists, as imperfect as they are, increase that pressure a little bit. Ideally, seeing the price fluctuation and seeing the reactions of doctors to these lists will prompt more in-depth questioning[0] from regulators, judges, and consumers. The fact that the lists are a joke is why they're not a joke. People need to be publicly reminded, again and again, over and over, that the way health procedures in the US are priced are generally broken, often arbitrary, sometimes opportunistically exploited, and almost always unnecessarily complicated.

The more obvious that becomes, the more attention that other parts of the system will get.

[0]: https://www.healthcaredive.com/news/baffled-judges-price-tra...

I think this is the best argument for these lists that I've heard.

Forcing this stuff out into the light helps the system get fixed. This is a pattern I've seen in internal tools development for businesses over and over. When my solution increases visibility into a problem, suddenly people start solving the problem without my help.

> The fact that the general public as well as journalists think this data is accurate in anyway is really funny. This an exercise of futility that only increases the overall cost and provides job security for me :)

People are literally dying out here from administrative bloat and you're joking about job security. Your comment comes across as cavalier and even a bit callous.

With that said, I respect the systemic and historical complexity of the problem and don't mean to suggest that you personally are the problem. I understand that you're pointing out the Kafkaesque futility from within the trenches; I think I get where you're coming from.

May I suggest that you rephrase your critique next time in a way that would communicate empathy so that we might in turn empathize with your situation? If these spreadsheets are feel-good window dressing (not that I agree), then state your case and let's stop wasting time on them. What do you think should be done instead?

Let us improve things together.

You're in charge of literally saving lives but you can't handle something as standard as cost estimation? How can you joke about that? Figuring out the cost to the hospital in terms of materials and labor should be standard.

Example, an x-ray. You know you need to pay an x-ray tech X$/Hour and after doing 1,000's of x-rays, a hospital should have it down that somebody with a broken leg will require N hours (maybe .5, maybe 1.5) to setup and take the x-ray. x-ray film costs HAVE to be known. the x-ray machine life time and number of shots should be known. Then do something like a 30% surcharge for admin fees and boom, x-ray cost.

Every other industry estimates this way, what makes a hospital different?

You forget that the x-ray is propping up about 50 admin job positions that don't directly generate revenue. The army of compliance, insurance, billing, etc etc etc employees have to get paid somehow.

But hopefully this price transparency helps us ask the question of why does an x-ray have to pay for a ton of positions which have nothing to do with x-rays, and how do we correct this situation.

You could say the same about any other service work. If I have the internet guy come out there's probably 50 admin job positions that bill for that time too. Internally they bill the installation department. Hospitals are just complaining to make it seem more complicated than it actually is.

> You're in charge of saving lives but you can't handle something as standard as cost estimation.

The irony, coming from a profession which is notoriously bad at cost estimation.

But in any case, the difficultly is not so much the materials/services as much as figuring out what the patient's insurance company (which is completely different then the practice) will cover and by how much. But of course that's actually what matters to the patient.

They know medicine, not the intricacies of your particular insurance policy.

Source: Am founder of rivethealth.com which does cost estimation.

Because the broken leg could be a gun shot wound, or an alcoholic who fell down and now is withdrawing, or a geriatric patients who is abused at home or a person who fell due to side effects of drugs with alternatives, or a cancer patient with bone metastases.

No one gets an x-ray for a broken leg then leaves with their foot broken. Even assuming that you are just trying to figure out the cost of an x-ray - there is a radiologist involved (unless you want to read it the x-ray on your own) and how they bill is a whole total beast!

I'm not following why any of that matters to the cost of an x-ray. If there's a gunshot wound and there needs to be a nurse attending to the patient while the x-ray is being taken, the nurse is an extra cost, separate from the x-ray and the x-ray tech. The cost of the x-ray itself shouldn't change.

But we are just talking about an x ray here. Estimating the price of a radiologist per hour is not hard.

It shouldn’t be this difficult to price x rays at a per hour or per shot basis.

Pretty much every industry has variability in their jobs. Sometimes they eat some money and sometimes they make more based on what actually happens during the job fulfillment.

No one expects (or should expect) hospitals to literally know the amount of parts and labor for every single x ray they could perform. However, like literally every other business, they should know rates and tiers such that on average they make money. Then, disclose that.

I'm talking about the x-ray, nothing more and nothing less. If they have a broken foot and need a cast, the cast should be an estimatable line item based on where it's broken, age/gender/size of the patient, and materials used. If a doctor has put a cast on 1,000 broken feet on men aged 12-16, they should have a very good idea of the material and time it will take and the number of nurses or whatever else they need to put it on.

To be fair Boeing doesn’t know how much an airplane cost.

There's R&D, and then there's the actual manufacturing. Sure, prices go down after a while, but you can track costs accordingly.

If you know (because you have blue prints) that the materials will cost 1,000,000 to build the plane (because your suppliers gave your price quotes), you can have a very good idea of what that plane will cost before putting it on the assembly line.

>> Cost depends on: 1. Are you an outpatient/Obsveration v. inpatient v. ED? 2. Are you on Medicaid? 3. Is the hospital a part of GPO organization or not? 4. Is contractual obligations of GPO includes/excludes Aspirin?

Those considerations aren't part of what anyone calls cost. How much does the hospital pay for aspirin? How much do they pay someone to administer it to a patient? That's cost. If it's very complicated to determine what the patient or their insurance pays, well that's part of the problem.

This. It's telling that people working inside this system operate on a totally different set of rules for how to determine basic things like the cost of some input.

You're making the reasonable-sounding (but incorrect) assumption that the cost to the hospital of a drugs is the same for every patient. It's telling how people on the outside have no idea how complex the system is, as if there's one simple way to cost an item (hell, there's not even one simple way to cost an item with GAAP accounting for a widget). These lists are kind of worthless in the current iteration, but they'll hopefully get better with more targeted intervention.

How does the cost of a drug change based on who is consuming it? That's like saying the cost of a loaf of bread changes based on who is buying it.

The price you charge for the bread might change, but the cost is the same regardless of who is purchasing it. There's a difference between varying costs of an item based on accounting methods, versus varying costs of an item due to who is buying it. There seems to be huge disconnect here between people working in healthcare, and pretty much everyone else.

The hospital's drug cost is the price the distributor charges it. That price varies for each individual patient. It's turtles all the way down.

>You're making the reasonable-sounding (but incorrect) assumption that the cost to the hospital of a drugs is the same for every patient.

Why shouldn't it be? How hard is it for a hospital to project their annual aspirin/paracetamol/? usage and budget for it?

Easy.

Now try it at a rural critical access hospital for rattlesnake antivenom with a short shelf life, so it usually expires unused. They are required by law to stock it or they cannot have their emergency room open. Estimate the revenue generated from treating the one patient who needs it every other year, and by the way, you have 9 contracted payers with different rates and you don't know which one, if any, the patient will have. Rinse and repeat for every other drug required to provide "critical care". Maybe layer on infusion of exotic chemotherapy drugs or monoclonal antibodies to treat a new pandemic virus.

It's not easy.

I wouldn’t call it worthless at all, because of the rest of your last sentence. It provides a starting point.

We need to start setting the expectation of transparency for some small subset of info to get further transparency. Change takes time, as much as we’d like it to drastically improve overnight for real life and death situations like medical prices.

The cost of the aspirin depends on these things lol. Look up 340B.

There is a drug called Oncaspar. It's >$16,000 for one patient, and 5 cents for another (acquisition cost). Same drug, widely different acquisition cost.

When two pills coming from the same company are being made at the same time on the same machines, then they both cost the same. It's pretty obvious that the patient status changes nothing about that. However, the hospital's acquisition cost is variable because you're further down the supply chain and you're seeing the exact same kinds of arbitrary behind-the-scenes price swings that this article is talking about.

It sounds like within the industry, hospitals are facing the same problems as consumers, and they need more price transparency from their suppliers as well. Hopefully increased requirements towards hospitals to explain their pricing will lead to hospitals demanding slightly more transparency and slightly more consistency from the other companies they work with.

Drugs typically have a pretty in elastic demand. Whether it costs $16000 or $0.05 for a pill, the end user - whether a doctor or a patient - will simply figure out a way to pay for it to alleviate the pain, symptoms, and perhaps to avoid dying.

Seems like 340B (I hadn’t heard of this before, thanks!) may have been created with recognition of this inelasticity.

If we can limit prices this way, all it would take are a few more laws to put more price limits in place.

Sort of? As we're seeing with the pandemic, a not insignificant portion of the population is so used to healthcare being utterly inaccessible that animal medication seems like a reasonable alternative. That $16,000 pill isn't getting to patients, people are simply dying without it instead, going to faith/crystal "healers" instead.

There is much more elasticity than you think. Most medicine is not about “not dying”. Here is an example: I get heartburns pretty often. I take a heartburn medicine omeprazole daily. It’s an over the counter drug, costing something like $0.3/dose. If they bumped the price to $16,000 I would just stop taking it, and started getting regular heartburns again. These suck, but I lived with them before finding this drug, and wouldn’t pay tens of thousands of dollar annually to get rid of them.

Under capitalism, a thing's cost to manufacture has nothing to do with the price of that something.

Read that again and work through your objections. Ideally something's price is higher than its cost so the company can make a profit, but there are so many obvious exceptions that its nice, but not necessary. Thus, who cares how much the pill coming down line costs to manufacture, unless you start hacking into the free market and set price controls, and say that pharmaceutical companies are only allowed to make 20% profit (or however much), Martin Shrekili's play, of buying pharmacutical companies and simply raising prices of drugs, is a legal move under capitalism, no matter how reprehensible that move may be.

Eh, technically yes, but that's not really what I'm talking about. The way we use the word "cost" varies depending on the context, and I'm responding to a specific usage of that word. I'm not making a broad claim that drugs need to be sold at cost, I'm making a claim that drug costs are not so highly variable that coming up with a consumer price needs to take days of research after a procedure.

jonathan-adly is making the argument that the inherent "cost" of drugs is itself highly variable for hospitals, and that means it's normal and expected that hospitals should not be able to tell patients the price of procedure before it happens. I'm arguing that the "cost" of the drugs is not actually that variable, that hospitals are just downstream of another part of the industry that is engaged in the same price-hiding behavior that hospitals are engaged in.

Of course, under Capitalism "cost" doesn't determine price, the market determines price. But I would also point out that under Capitalism, signing a contract usually involves the terms of that contract being made upfront. Pretty much every other industry in America has figured out how to put a price tag on the products they sell, and I'm not sympathetic towards the medical industry just because up until now it's never needed to learn how. Apple sources its components from manufactures, those manufacturers could change their prices someday. But Apple still puts a price tag on iPhones, and because it needs to put a price tag on iPhones it's incentivized to form long-term contracts with suppliers and to demand a level of consistency in the prices its suppliers offer.

Hospitals haven't needed to do that in a long time.

Price transparency is an important part of most industries under Capitalism, and the medical industry hiding behind variable "cost" as an excuse to avoid pricing their products shouldn't be something we tolerate.

Martin Shrekili's practices (as abhorrent as they might be) are a different conversation. I think that price limits and price transparency are two very different issues.

Under capitalism, with that kind of price difference, someone else would move in and start manufacturing the same drug and selling it for less to gain market share. That's competition for you. Or if no one else wants to do the job you could just make it yourself. Cost and price are indeed two different things, but competition keeps the prices of goods down to a relatively low multiple of their manufacturing cost.

Unfortunately what we actually have, between patents and other monopolies the government has instituted on drug manufacturing and distribution, is nothing like capitalism.

Not trying to be rude but he already told you the answer. You really should look up 340b. It's a federal program to rebate drug costs for certain types of patients and is a legal form of price discrimination. When you provide a drug in a healthcare setting, it can be a very different price depending on who receives it, because the federal government has the 340b program.

Your argument about cost to manufacture isn't relevant in the same way that the marginal cost of a flying one more passenger on an airline isn't relevant. We all pay different prices for airline seats. Hospitals pay different prices for the same pharmaceuticals.

There are a lot of smart people working in healthcare. A lot of people go into the industry thinking they know better and wash out. See the latest Berkshire Hathaway + JPM + Amazon failure.

What's preventing the hospital from at least telling me the baseline price without 340b rebates and then listing those rebates separately? Does the hospital even know the baseline price without 340b rebates? If not, doesn't that strike you as a problem?

> Hospitals pay different prices for the same pharmaceuticals.

Right, that's exactly what I said:

> It sounds like within the industry, hospitals are facing the same problems as consumers, and they need more price transparency from their suppliers as well. Hopefully increased requirements towards hospitals to explain their pricing will lead to hospitals demanding slightly more transparency and slightly more consistency from the other companies they work with.

The more I read about US healthcare, the more confused I am about how it's grown this perverse for this long. Prices are hidden (until the government forces them into the open), but they're badly distorted anyway by perverse incentives, which all seem to ladder up to the root cause of providing healthcare for profit.

Thank the private free market.. /s it goes this way because the government involvement. If anyone else in another industry attempted the same thing they would be sued for fraud.

I think the issue here is that the system that has been setup is so dysfunctional that there is some validity to the phrase "the cost is unknowable".

But prior to this regulation, it was extremely difficult to even ascertain just how dysfunctional it all was. Putting it out in the open means more accountability for providers and insurers. Which in due time means more regulation :)

Which is how it goes when an industry misbehaves for so long. Eventually the public will get fed up, and demand that changes be made. This is just one step on that journey.

Exactly this, though I’d like to point out that word “misbehaves.”

Many people may not see the medical cost world as misbehaving at all. It sounds like healthcare companies, from drug manufacturers to hospitals, are charging what the market will bare.

The inelasticity of the products and services for sale are what allows this market to become so out of whack. I don’t need an iPad that badly, but I do need to have these drugs to have a good quality of life.

I’m glad we’re taking these steps on the journey of making costs more transparent and understandable. And perhaps putting into law what we the people think is a reasonable approach to charging for life-saving treatments, rather than “whatever the company can get away with.”

I see what you're saying, but much of the factors driving the "misbehavior" is due to companies being in-cahoots with each other on creating convoluted pricing schemes, kickbacks with various parties, and muscling through legislation that favors healthcare providers and insurers, to the detriment of patients.

It's true that this can all be explained in economic terms, but it's true in the same sense that the behavior of warlords can be described by economics.

That neither the people prescribing/providing the product, nor the customers/insurers can ever know the price before they are billed, shows that this is not a market, or certainly not anything like a free market.

The real scam is that the health insurers have convinced people they "fight for lower prices", when in fact they collectively profit from price hikes and the annual marginal increases fuel their growth as well.

The spirit is here is that you should fully open all those factors and fully open how they influence the cost paid by the patient. Make an excel sheet, a web app, an API, whatever. But let people know and simulate the cost - include all required factors.

If the prices you charge differ from the prices provided by your open data platform, or if some factors are omitted from the open platform, you should get a lawsuit on your hand - and lose it.

If your excuse is that building the open data platform is too complex and expensive because too many variable are involved, explain how you were able to build a reliable system internally - and open that one.

If you cannot do that as well, you know it's time to rethink your pricing model, in order to simplify it.

The end goal of the regulation is to push as many health institution as possible to reach the conclusion that they really need to rethink their pricing model.

There is no internal reliable system. Healthcare in the US uses faxes.

People here thinks that their local hospital is Google, while in reality it's a badly managed/badly funded 100 year old non-profit organization full of middle managers who just learned how to use their email.

I think if your point is "the system is broken today", basically everyone agrees with you.

If your point is "it is not possible to have transparent pricing", that seems also insane.

IMO we should pass a law that says if you can't give people transparent upfront pricing, you can't bill them at all. The idea that you can "figure out a price later" seems absurd.

It is not possible to have transparent pricing in the current broken system.

It's like trying to put a bandaid on an arm that met a chainsaw. Not really a good first step and a waste of time. The solution is to go to the OR, and give him a new arm. The more bandaids and time you waste, the worse it is.

By demanding transparent pricing (and other aggressive policy, like say not being able to bill patients without them seeing a price and agreeing) might we force the system to replace itself? Because these companies are very good at complying with regulations, but the regulations allow them to use faces to communicate because most of the regulations are designed to keep most of the system compliant.

> 100 year old non-profit organization full of middle managers who just learned how to use their email.

As someone who works in the industry, you gave me a hearty chuckle - well done, too true

It seems like in 2021, doing better than faxes is pretty reasonable. If things like that are legitimately the significant barriers today, then doesn't that suggest it should be very easy to get them fixed?

I think you made the biggest argument for requiring these lists in the first place.

For your simple exercise, it seems like we need to have that breakdown for those four different factors (and have that explicitly listed). Then we can figure out why the cost for a $0.22 jumps to $20 for those with insurance but $12 when paying cash. I agree it probably is a huge plus for you and your job security. :)

> The fact that the general public as well as journalists think this data is accurate in anyway is really funny.

If they are inaccurate, these hospitals should be sued into oblivion and replaced by trustworthy, competent organizations.

> Cost depends on: 1. Are you an outpatient/Obsveration v. inpatient v. ED? 2. Are you on Medicaid? 3. Is the hospital a part of GPO organization or not? 4. Is contractual obligations of GPO includes/excludes Aspirin?

> Reimbursement depends on: 1. Insurance 2. Group which you are under the insurance from 3. Contract language whether its a fee/service or bundled 4. Is the visit covered or not 5. how the visit/procedure was coded (most important and opaque factor)

Your convoluted process should not be the patient's problem.

Write an app that allows the user to input their provider and group, and search for the procedure to get a price.

I think the point of making the lists public is to provide information that can lead to iterative improvements. I'm not sure it will do that but I'm a bit more confident that it is a necessary first step.

I thought the lists were a red herring for the problems with privatized healthcare - i.e. look at how complicated pricing is, not how it is being complicated by for-profit middlemen.

One interesting aspect of the No Surprises Act regulations that would seem to support your claim is the three hour required waiting period for non-emergency same-day procedures. The waiting period is ostensibly to prevent patients from feeling rushed or pressured into agreeing the price but the "long wait" boogeyman is another common red herring in the healthcare discussion and the three-hour wait seems unnecessary. The wait applies only in non-emergency situations so logic would follow that if the quoted price were too high the patient could leave.

>And only like 8 people can tell you that information 3 months after the fact.

It's like that in every large organization. But it turns out businesses are pretty good at tracking costs, no matter how complex.

Besides, the specifics of any single case don't matter all that much. The variation can be smoothed out given enough data and a few common points of comparison.

But all of this is asking the wrong question...not 'how much does this cost now?' which is hopelessly mired in historical cruft but 'how much would this cost if done efficiently?'.

I wonder if the VA has open books...if not, they should.

But this list doesn't care why the price was charged. It only needs to know, bottom line, what amount of money changed hands for the procedure?

>Take the simple exercise of figuring out cost/revenue of an aspirin administration.

>Cost depends on: 1. Are you an outpatient/Obsveration v. inpatient v. ED? 2. Are you on Medicaid? 3. Is the hospital a part of GPO organization or not? 4. Is contractual obligations of GPO includes/excludes Aspirin?

Wrong.

Cost depends on "how much does the raw aspirin cost in bulk + some standard overhead cost"

Can you say more about why the information process isn’t automated, allowing for easier and faster determination of these things?

Doing it manually seems rife for error and to be awful toil

if most patients were paying cash with no insurance such that hospitals had to compete on price all of these items would somehow become clear

> Take the simple exercise of figuring out cost/revenue of an aspirin administration. [...]

In your opinion, is this something that could be exhaustively modeled in software? What would the bottlenecks be? I'm guessing probably the biggest is the fact that the necessary data isn't digitized, or if it is, it's not easily accessible.

Yes. It could be. The bottleneck is selling it. Healthcare has lots of problems that can be solved with software. The bottleneck is always making a business case and selling to hospitals which is a nightmare.

So long as a shitty excel sheet with inaccurate data fulfills the regulatory requirement, you will find a lot of trouble getting people to pay money for it.

Alas, this makes sense.

I’d’ve assumed that it’s all done by software that takes into account all the factors, but I wouldn’t be surprised if it’s a step-by-step guide in a physical book. (Hospitals are horribly outdated with technology)

At this point, I think your colleagues' nihilistic humor is totally lost on the American Public. Your flippancy is a strong argument for legislative reforms of the healthcare industry.

The convoluted cost formula is a process that shouldn't exist in the first place, so your comment only reinforced my internal rationale for why these types of lists are important.

Pricing in general for any non commodity is the same kind of statistical joke.

That said, these price lists are an attempt to turn healthcare service delivery into commodities. Transparency, yes, but the lie is that healthcare is a market.

The alternative is nationalized care where all sorts of financial flows that now are optimized for profits, are so optimized no longer.

Most people living under and working for a nationalized system tend to like it. Most who live under or work for a commodity system tend not to, except for those positioned to receive profit flows.

Around 2012 before my wife and I were married, we both got pneumonia. I was insured through my employer, she was uninsured.

We went to urgent care at the same time on the same day, saw the same doctor and got prescribed the same drugs.

About a month later when the bills came, her bill with no insurance was somewhere in the $160 range. My bill after insurance was nearly $300.

I'm still peaved about this.

Did you have a HDHP (high deductible plan)? In that case, you have no co-pay or anything until your deductible is used up. Employers typically contribute a good amount towards this deductible (or even more than) using an HSA.

It's still crazy that the bills were so completely divergent.

That's not the point. Your explanation is exactly what the issue is. Why is cash price cheaper than insurance price ? And in that case, why do we even need insurance for most of these visits.

In my view, the amount you pay for stuff before you hit your deductible is just another type of premium. If the cash prices you can pay for what you reasonably think your care will be in a year are less than your deductible, then it can save you a little money to do that. If you happen to be wrong, you'll have still have to pay for your deductible.

I pay for a specific medication OOP with goodrx because it's not covered by my insurance, and paying for it through them would be nutty ($1600/year versus $90/year). But other things I just lump in b/c I use a fair bit of insurance every year.

I think the problem is, it's insurance. I pay $1200/month for my ACA insurance as I am a freelancer. Those with full time jobs pay a similar amount, just indirectly. In a given year, if I am healthy and need minimal medical care, then my insurance puts me way behind financially. If I have a sudden medical emergency, it can really save me. That is of course, assuming the insurance company will honor their end of the bargain which is another matter altogether.

I don't want health insurance. I want health care.

Make no mistake, I think the entire health insurance industry is a meat grinder for profits and we should move to single-payer like most other affluent countries.

Was there any difference in ability to sue the provider in case things went wrong?

I heard that sometimes they ask the uninsured to sign away the ability to sue the doctor and get lower prices in return. I am not too sure about details, this is just hearsay.

I remember she did have to sign a lot of paperwork. I have no idea what it contained however.

And that’s because the product you were buying had a completely inelastic demand. You might have died if you didn’t get treatment.

Perhaps allowing healthcare providers to incentivize things like this is… not great? Because we’ll sign pretty much anything if we’re sick enough.

It will be fun to watch people be positive on this until they are reminded who we have to thank for it.

Edit: CNN hasn't forgotten, notice the obvious negative spin, with literally zero argument of how this may be beneficial: https://www.cnn.com/2021/01/04/politics/hospital-price-trans...

I'm not a fan of the guy, but this is probably the most important/good thing he did with his presidency. Price transparency is the most fundamental first step to driving down health care costs. Once people get a taste of it, it will drive even more, better and accurate data. Start real conversations about costs and open the door to measureable improvement through innovation.

Price transparency is a pointless shell game designed to keep everyone strung along on the entrenched, failed system. When you're having a heart attack, the last thing you're doing is shopping around for the best prices on heart attack emergency treatment.

The free market has no place in health care, because in the hands of the free market the first thing that will happen in a life-threatening emergency is for you to transfer 100% of your wealth to the party that has 100% of the leverage.

Not all health care is heart attacks. "Health care" is a huge bucket containing everything from buying a bottle of cough syrup to the heart attacks you mention.

For life threatening emergencies, I'm with you. Let's fund that care through the state.

But excluding the market from everything is not the answer. The problem with using insurance for all these non-urgent things is that insurance distorts the market and price discipline goes out the window.

We don't have to reinvent the wheel. Other countries have solved these problems. They have better health care than we do. It's measurable, it's been measured, and no surprise, they have flat-out superior outcomes. They are dramatically more efficient. Our market focus is a cargo cult.

What market focus? Prices were completely opaque until just a few months ago. Any economist on the planet will tell you that would lead to awful outcomes for everyone except the powerful healthcare lobby.

Not sure how you get reinventing the wheel from my comment.

What I described would move us in the direction of the countries you're talking about.

I have lived in the UK, and seen doctors through the NHS. I have bought cough medicine at the chemist, and no it was not state-funded. I have visited patients at NHS hospitals where you are one patient sharing a room with 20 others in the same ward. I have talked to people on the waitlist for months to get surgery.

I still think the UK system is better than ours in the US for urgent care. I don't want anyone to be financially ruined because of some unforeseeable accident or emergency.

But I maintain that "health care" is way too big a category to be absolutist about using or not using free market principles in it. There are parts of health care where markets do not make sense. There are other parts where they do.

There is no silver bullet. Your absolutist perspective undermines your argument.

>When you're having a heart attack, the last thing you're doing is shopping around for the best prices on heart attack emergency treatment.

This is a tired, nonsensical argument. The vast, vast majority of medical procedures are not last minute emergencies. Furthermore, with price transparency you will clearly be able to evaluate which hospitals may or may not be generally in your price range and choose a default to visit for an emergency (assuming you're not carted off in an ambulance).

More importantly, this will absolutely force competition and some degree of price correction.

I agree that it's pointless for emergency surgery, but there are plenty of other cases where a consumer could shop around (colonoscopy, ACL repair, etc), and I'd argue these are actually the majority rather than the minority of cases.

To me it comes down to - if we are going to pretend we have a market based system for health care (that's what we say we have now), we need pricing transparency to have any hope of it working.

> I'd argue these are actually the majority rather than the minority of cases.

For well-insured middle-class people. Poor working people only get emergency care

I think forcing hospitals to at least list something is a good start. It won't be perfect but it will make people more aware of how hospitals and insurance companies are working usually to screw people when it comes to billing. Any transparency is a good thing whether it is perfect or not.

Price gouging especially in a system with transparent pricing is not difficult to prevent with laws.

This is really is the ideal place for government in healthcare. Make the laws, set the standards, level the playing field and let the free market work just like in every other facet of society.

It’s funny people who see how incompetent and irresponsible our government is on a daily basis think that handing healthcare over to them is a good idea.

You mean Bill Clinton in the early 90's? It was part of the Clinton health care reform. But maybe you're not that old. ;-)

Every president has pushed for this except Bush Jr.

Glad it finally happened even if it was under who I consider to be the worst president* in the last 100 years of US history. Doesn't mean I need to thank him. If you were being tortured in a Mexican cartel prison, would you thank the torturer for giving you glass of water?

Thinking that trump is the worst president in the past 100 years just betrays either an insane privilege[1] or just ignorance. You realize the hundreds of thousands of lives lost directly or indirectly in the war on terror, a war almost completely engineered by the Bush administration, are actually real right? They were people with hopes, plans, dreams that were all wiped out, and for a lot of those who are still alive they are condemned to live in a cycle of violence caused again by the war on terror and it's ripple effects. If you compare that to what trump did in his 4 years and come up with the conclusion that hey, it wasn't as bad & Donald truly is the worst president... Then I don't even know what to tell you.

I'm Muslim and I've grown up my entire life with that war and its consequences in the background, especially since we mostly consumed arabic media. I've thankfully not been affected directly, but man do these takes completely discredit the side that keeps pushing them instantly for me.

We are at a point where even the notoriously neocon hawkish republican party and their voters are a lot more willing to acknowledge just how horrible those people were, yet democrats have no problem completely rehabilitating the old neocon crew because hey yeah they killed people but at least they were... Polite about it? I get that it's unhinged crusading politics and we just have to paint the adversary as the worst person ever to feel the rush of being morally superior but when you are at the point where you defend George W Bush to own the magahats, maybe take a step back and reflect on what you are doing.

The worst part is that now that bed has been made and apologism for those neocons became a mainstream talking point, everyone is just doubling down because admitting that trump isn't actually even close to being worst would be to admit that maybe the hysteria to score political points didn't warrant sweeping under the rug 2 enormously destructive wars.

[1] as in the privilege of not having ever been affected by the war on terror. Which in turn leads to pretty insignificant events like being concerned about the presidents tweets or feeling that you are part of some sort of feel good #resist movement for 4 years just registering as being more impactful than a region getting destabilized far away

That's a fair criticism, although you really pulled out the big hyperbolic guns. Insane? Not really. And you continue to make personal attacks even in your footnote. But hey, it's an internet discussion board, I'm guilty of the same.

The guy broke democracy and started a trend that IMHO will inevitably break the US. There's no stopping the nihilistic-right's rise fueled by an uneducated white minority bent on revenge via politics for their oppression at the hands of those they vote for. This nihilism, meaning its not that side A is correct or side B is correct: there is no "correct". That's worse than two pointless wars, IMHO, and it springs directly from Trump. A fountainhead of corruption the likes of which modern democracy has never seen. And I stand by that.

Yet that white minority is more willing to stop bombing non white across the world. It's a bit unreal but it's the truth. You ought to realize that you are also coming from an imo pretty... White-democrat point of view right? And my argument is exactly that a segment of the country, mostly white, went to such a extent to get revenge on the 2016 election that they sided with literally everyone they used to hate not even a decade ago. I'm sorry but how is that for nihilism? Your arguments are again very philosophical, but in a way just dismiss the destruction of an entire generation of Iraqi (and Syrian, by ripple effects) because a nihilistic trend of your political opposition rising? I'm sorry but come on! Like you are exactly doing what I was critizing in the first place. "those people may have died, and that region may have been hopelessly destabilized but at least Bush (who literally was elected by the supreme Court which makes this even more ironic) wasn't nihilistic?". The guy that came up with you are either with us or you are with the terrorists?

Of course it's worse than 2 wars you have never been affected by. The entire USA had a complete meltdown over allegations of Russians rigging the elections, without any American casualty. In fact I'd bet that one of the reason you are saying trump broke democracy is probably related to those allegations. But when the US is destroying entire countries it's no big deal? I hope you can see the cognitive dissonance there or at least why your point of view is very very white centered. And that's without even getting into how the democrats attacked the integrity of the elections for years, rightly or wrongly yet I don't see how that didn't directly undermine trust in democracy. It was a dance-à-deux, and if trump ends up breaking democracy down the line it's not because one side pushed against it. My point here is that no matter how you look at it, the entire thing is related to partisan politics not a righteous crusade that couldve somehow justified arguing that 2 desastrous, decades long wars were in fact less important/bad.

But that's all unrelated. Look, I'm not American, not white and not Christian.to me it boils down to this. I don't think anything is more cynical and cold than to publicly downplay and rehabilitate a figure that caused so much more pain and suffering because that would score points. That's it.

I really didn't want to come off as insulting you, honestly. And I get that some things can't really be expressed in a non offensive way (even if that's not the intention) when it comes to heated subjects like this. That's why I'm not going to touch on some of your other points. Again, it's not because I'd have insulted you otherwise, but because I don't know how to express what the war on terror felt like from the "inside" without inevitably sounding hyperbolic.

> I'm sorry but come on! Like you are exactly doing what I was critizing in the first place.

Shit. That's an excellent point. Thanks for making me realize it. I'm being absolutely glib about 1M+ deaths. Yeah, that's totally privilege. My bad. I'll go think on that for a while. Yes, I'm a white liberal and I haven't been called out this succinctly and correctly in a long time. I responded like shit because I got angry, my apologies. Thanks again.

I also really hate how much people ignore the actions of other presidents and hyper focus on one mainly because of the massive amount of consent manufacturing by mainstream media. Hundreds of thousands of people are dead as a result of other presidents, and a lot of those were women and children.

I think it's sad that you can end a sentence with Bush Jr and then not call him the worst president in the next sentence. My vote for worst president in living memory is the guy who started two pointless trillion dollar wars, the latter of which took 20 years to close up in a humiliating retreat, but that's just me. This is not a defense of he who isn't being named here btw.

I mean, that's nice, but I'm not going to fall all over myself thanking the people who have fought viciously for decades to maintain the current profit-driven health care system and block single payer health care. It's like an abusive spouse who, out of the blue, brings you flowers and chocolate.

Wasn't really my point. My point is that you should expect to see all kinds of mental gymnastics around answering the question of if this is a positive change or not.

Even a blind squirrel finds a nut once in a while.

Biden doesn't run his mouth when he shouldn't, but foreign policy with China and along the southern border are essentially the same as under Trump, and the Afghanistan withdrawal alienated some NATO allies. Biden is carrying over more of Trump's policies than you'd expect.

Presidents come and go, but the Blob is eternal.

It is funny/depressing to think how different our country would be today if Bernie had been the 2016 dem nominee.

The most depressing thing is that it likely wouldn't have changed much. Congress (of which Bernie is still part of and has been for decades) is the one with the power to make these changes, the President is just the scapegoat/hero.

This will probably help a bit but in an emergency people don't have the time to compare prices. And with US health care, it just takes one accident that sends you to the ER and where someone that's out of network performed a procedure to end up with a bill that's tens or hundreds of thousands of dollars.

There is a little bit of good news here from the omnibuss budget passed at the end of 2020. Search for “NO SURPRISES ACT” on this page:

https://congressionaldish.com/cd227-coronabus-health-care/

“Starting on January 1, 2022, any health insurance company that provides “any benefits” in an emergency department can not require pre-authorization of those services or deny coverage because the emergency department is out of their network. If emergency services are provided out-of-network, there can not be any limits on coverage any more restrictive than what would be covered by an in-network emergency department and the out-of-pocket costs can’t be more than they would be in-network. Out-of-pocket payments at an out-of-network emergency room must count towards in-network deductibles and out-of-pocket maximums.”

Yes but emergencies are the exception, not the norm for most hospitals. Most hospitals make 40-60% of their revenue on elective surgeries, ie things that can wait 2-6 months. So patients have time to shop around.

Source: currently work at a big hospital in IT.

Emergencies are the norm, not the exception, for most people. Elective surgeries are mostly the well-insured and the wealthy. Poor working people go to the hospital when it hurts so bad that they're missing work, and when they miss work they don't get paid.

The other big conflict here is that I'm not an expert and I'm not about to turn down services if recommended to me by an expert in a field which I have no experience.

I get the whole "do your research", but often it's in areas in-which I have no real capability - especially with healthcare.

---

> And with US health care, it just takes one accident that sends you to the ER and where someone that's out of network performed a procedure to end up with a bill that's tens or hundreds of thousands of dollars.

Agree. And to add, all it takes is one procedure that your insurance company doesn't want to cover to put you into literal billing hell for months on end. My point being, even with price transparency they can just chose not to pay even if they're obligated (and they do this). If there's any way they can weasel out of paying they will.

I'm still 100% in support of price transparency in healthcare however... there's just so much broken with it and I've lived through the hell.

> I get the whole "do your research", but often it's in areas in-which I have no real capability - especially with healthcare.

Oh the system has answers – just happen to be high enough at your company, or the spouse of someone who is.

> While a benefits expert at a mid-sized company may create a narrow network, an executive's spouse, for example, may want to go somewhere not in the network. "And there's a pillow talk that happens. And the next thing you know that hospital is in the network," Ladd said.

This whole "employer provides your healthcare" thing we have going on in the US is just nuts.

A recent federal regulation which implements the No Surprises Act of 2021 should reduce some of those abuses by hospitals.

https://www.cms.gov/newsroom/press-releases/hhs-announces-ru...

Emergency care accounts for just 2% of healthcare spending.

https://www.politifact.com/factchecks/2013/oct/28/nick-gille...

That is not a useful statistic here. We are talking about an individual’s financial obligations in a medical emergency. A $10,000 bill is not 2% of an individual’s yearly spending.

You’re missing the bigger picture. It’s worthwhile improving transparency around the vast majority of healthcare needs/spending. ER costs are also a problem, but it’s an orthogonal issue. Don’t let the perfect be the enemy of the good.

No, I don't oppose hospital price transparency. My comment was basically a procedural one. Saying that ER visits are 2% of nationwide costs does not meaningfully address the toplevel poster's concerns.

> ER costs are also a problem, but it’s an orthogonal issue.

It's natural to want to discuss this orthogonal issue, and the solutions to the two issues are not mutually exclusive.

And yet: Using a conservative definition, 62.1% of all bankruptcies in 2007 were medical; 92% of these medical debtors had medical debts over $5000, or 10% of pretax family income.

https://www.amjmed.com/article/S0002-9343%2809%2900404-5/pdf

That is old information. In the US, your deductible and copay have to be the in-network price in emergencies, and balance bills from the provider will not be allowed in emergencies starting next year (and you can already usually get the balance waived with sliding scale charity etc.)

The whole out of network aspect in hospitals is ridiculous

Yes, in a single-payer environment everyone is in-network.

Every doctor in Canada providing covered medical services is in-network.

I was told by a cancer patient in the US, who is a Canadian citizen, that specialized equipment and certain tests are not available in the entire system, or months-long wait times.

Medical bankruptcy is the most common form of bankruptcy in the US. I would say that for the massive portion of the US that is un-insured, under-insured or faces bankruptcy in the event of a medical procedure that substantially any tests and equipment for them are not available.

Canada has some of the best cancer survival rates in the world, and is substantially identical to the US. [1]

Further the US tends to skew towards early detection without a commensurate increase in survival rates, which means 5-year numbers in the US are higher than elsewhere in the world but it does not necessarily translate to lower mortality.

[1] https://www.ctvnews.ca/canada-gets-high-ranking-for-cancer-s...

Not all treatments are statistically useful. In the US you can get anything you can pay for, even if it costs a million dollars and hasn't been shown to have any beneficial effect. In a national system you make statistical decisions based on cost and effectiveness.

I'd imagine that prices will now plummet simply due to the fact that prices are now transparent and real competition can actually exist.

You don't pay up front in an emergency, so people can consult the information and ask questions before they do pay. They can call their insurance company and ask why they pay more than average. And so on.

Its just the first step

To shock and awe into future laws

Full openness is a good first step to make this insane system a little better. Next step would be for hospitals to quote the same price for the same procedure no matter if or where you are insured. I can’t think of another business where prices are different by hundreds of percent for different customer groups.

Also get rid of the whole in and out network system.

> Next step would be for hospitals to quote the same price for the same procedure no matter if or where you are insured.

After that, decouple health care from employment.

Finally, fully excise the connection between health care and ability to pay.

I like the idea of getting rid of in/out of network. Both recent administrations have taken steps in this direction.

Psychologists want to charge $200-$250/hr, but insurance only reimburses $120-$160/hr. You might think these are high prices, but chargeable hours isn't hours worked for psychologists, since they have to do notes for every meeting, manage the business, appointments, etc, which reduces their total take home to something below $200k/yr, which is below a typical bigtech Eng II with only a couple years of experience, potentially not even going to college if they are clever and self motivated enough. While a psychologist has gone to school for 10 years and paid for it.

It's gaps like that that lead to the entire in/out network split.

> You might think these are high prices, but chargeable hours isn't hours worked for psychologists, since they have to do notes for every meeting, manage the business, appointments, etc, which reduces their total take home to something below $200k/yr, which is below a typical bigtech Eng II with only a couple years of experience, potentially not even going to college if they are clever and self motivated enough.

Silicon Valley/big tech is not the center of the universe. How is what "typical" engineers at big tech companies make relevant to a discussion of what psychologists and other medical professionals make? Are you suggesting that the medical profession is doing battle with big tech for (future) workers?

Any ambitious and smart enough American who wants to make a high income in exchange for working hard at prep has a choice of jobs they can go into. Many people who go into medicine are not necessarily the most passionate about medicine, but want a high paying, prestigious job.

So yes, it does effect the supply of future and even current psychologists and doctors. Supply is dictated partly by cost of that supply vs the demand in dollars for it, and the cost and barriers to med school and licensing is a big factor of supply costs.

> Any ambitious and smart enough American who wants to make a high income in exchange for working hard at prep has a choice of jobs they can go into.

I suspect that the number of people who are driven solely by money and prestige is smaller than you believe, but even so, careers in different fields aren't fungible for the simple fact that even ambitious and smart people aren't universally capable of excelling in any field they choose. A top heart surgeon, for instance, wouldn't necessarily have the ability to be a top software engineer, even if he or she tried, just as a top software engineer wouldn't necessarily have the ability to be a top heart surgeon.

> So yes, it does effect the supply of future and even current psychologists and doctors.

Do you have any hard evidence indicating that the lure of big tech jobs is reducing the number of individuals who are pursuing careers in psychology, medicine, law, etc.? A study perhaps?

Yes, all high paying careers are competing with each other for ambitious workers.

FWIW I pay mine in cash from my HSA because he doesn’t accept any insurance due to the headaches involved getting reimbursed.

That's fair but for people without HSA they should still file a claim against maximum out of pocket.

Networks are a double edged sword. They're a pain to use (especially for things where network facilities have non-network providers or network providers steer you towards non-network accessory care like labs and what not), but network agreements are also a way that insurers control costs. Forcing insurers to cover every provider means insurers can't exclude overpriced providers.

Yep. These agreements cut out some ridiculous fees some might try to charge.

E.g. when my wife had surgery, the hospital tried to charge $20k for the surgery room and $20k for the recovery room. Our insurance pointed out that by their agreement they aren't allowed to charge for use like that.

Instantly cut the hospital portion of the bill from $49k to $9k.

That’s the insanity. You are the same person, same procedure, everything same but somehow the hospital can reduce its bill from 49000 to 9000. That is just not normal for a business like a hospital where they have a ton of fixed costs (unlike a software company where delivery of their product often costs close to zero so they can easily give rebates). This seems to indicate that the 49k is an insanely high price with very high profit margin.

Completely agree with your point, but I want to point out that a lot of businesses (most?) adjust pricing based on the consumer group.

Ever heard of coupons, rebates, bundles? All ways of adjusting pricing based on consumer price sensitivity.

It's not as pervasive, but a good deal of consulting work is priced, at least partially, by the size of the problem you're solving rather than the labor required to solve it.

That can lead to price discrepancies similar to (although perhaps not quite as severe) as what you see in healthcare.

I studied this years ago for years. My summary:

- a mandated MLR of 85% means the insurance companies have zero incentive to reduce the cost of items. In fact, their toplines and real (non%) profits increase as healthcare gets more expensive.

- industry profitability for insurance companies is around 3%. So, their overhead is around 15%-3% = 12%. They have an incentive to do their job cheaper. This pales in comparison to the 85% cogs.

- the small company cfo (me) has negative incentive to get involved in my employees' healthcare decisions. In fact, even being aware of cancer, pregnancy, etc. can be used against management in an employee lawsuit. No thanks. We just accept the situation and pay the bill.

- huge companies that can afford to self-insure can do it as they can firewall healthcare information from employment decision makers.

So, who in this system is going for cheaper healthcare:

- employees ... no

- insurance companies .. no

- healthcare providers ... no

- business paying the bills ... no

This bullshit billing structure is the tip of the iceberg. We have no freemarket incentives to keep down the cost of healthcare (i.e., carveout for high deductible insurance plans). Why would we expect otherwise?

The solution is to make the consumer participate in driving costs down. One employer I know of has an excellent solution to the problem: Make employees pay 100% of the bill up to a certain amount, such as $6000. That's a large amount, but the employer then contributes a large amount to your Health Savings Account (HSA), such as $4000. This amount is for you to keep regardless of whether you have any health bills or not. (This money can be used for medical expenses only, but can be used any time, including after retirement). So the maximum you will spend out of pocket per year is $2000. How does this encourage the consumer to scrutinize and control medical expenditure? Because the first $6000 of medical spending in a year is "your money". This is money you'd be able to keep in your HSA if you didn't have any medical expenses. This gives the consumer a strong incentive to reduce costs, question charges, avoid unnecessary services, and so on.

100% agree. It's a good start.

Also, I think emergency healthcare should be contemplated differently than ... I'll call it "premeditated healthcare". In one instance, the individual can make a deliberate shopping decision and weigh cost/benefit. That's fundamentally different than an ambulance taking you to the ER when you're bleeding out ... no price shopping then.

I've worked in healthcare my whole career and you hit the nail on the head. Costs keep going up because nobody involved in healthcare has an incentive to make it cheaper, including the patients. We've designed a system that is doomed to fail and nothing short of tearing it down will fix it.

If you are interested in this topic, I found this podcast to be enlightening: https://www.econtalk.org/keith-smith-on-free-market-health-c...

Basically, there's a surgery center in OK which posts every price online and doesn't take insurance. A surgeon who works there talks with the host about how it works and the nuttiness of health care pricing in America.

Seeing the price range you pay is interesting, but I'm not sure what we are supposed to do with it.

My wife had her prenatal anatomy scan a few months ago at Stanford medical, $11000 for a 1 hour ultrasound. I personally was on the hook for around $500 and insurance paid $10500.

End of the day, what say do we have as consumers? How did the insurance company negotiate a rate of $11,000? Does the insurance company really care when every year they can just increase premiums and shrug and go "costs are going up! sorry!"

It feels a lot like a pyramid scheme, at some point the gravy train has to stop

healthcare insurance is the best example of a state-sponsored scam I've ever seen.. and it just continues unabated. I can guarantee that almost no one involved in that transaction actually knows what the per-unit cost for a 1 hour ultrasound actually is.. and when I say 'cost', I mean how it costs the hospital. Health insurers, hospitals, doctors are so awash in money they probably can't believe they're still getting away with it after all this time. Just look at all of the new hospitals and care facilities that are getting built. You don't do that if you're 'squeaking by'.. Hospital lobby is full of shit. You can probably trace all of this back to the HMO model where insurers began to add a lot of distance between the caregivers (i.e. doctors, hospitals, etc) and the patients. Like wall street did (with basically every financial instrument), they add layer upon layer to the cost chain, which adds an equivalent number of money-takers, to the value proposition. Insurance companies amortize the total cost across their subscriber base and 'poof', you've got our ever increasing health premiums. Just ridiculous and so obvious.. but since they're 'doctors' and 'care givers', we automatically just assume they're not motivated by profit and therefore beyond reproach...um, wrong.

The insurance most definitely did not pay $11,000 USD. They paid a percentage of an adjusted figure, and the balance was passed on to you. Billing and payment amounts usually differ by an order of magnitude.

Oh yea they paid it. Negotiation for rates happens before you pay coinsurance. I’ve called them and discussed it all. They send a $10000 check.

Odd part was in this case, we had a follow up ultrasound for another $2500 for a second hour after they “saw something odd” and it turned out to be nothing. Second hour had billing codes that were 75% less for some reason.

https://imgur.com/a/Ffmt8YT

Wow, that's an absurd disbursement, even if the procedure might have been done out-of-network. Glad everything turned out okay. The administrator should have taken you out to celebrate. :)

So deducibiles are a sham?

Holy shit, that's just insane!

Here in the UK we paid for a prenatal scan and NIPT a few years ago (this was in addition to free NHS scans at our local hospital), and IIRC it was £200!

When I was working in healthcare, I found out that hospital groups negotiate their own Code prices with each carrier individually.

So one group will have one rate with Blue Shield vs what another hospital will have.

Its absolute bullshit.

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If youre mandated to have insurance - then procedures should be regulated to a set cost regardless of who performs the procedure.

Another thing is Medicaid pays below the cost of care so that is balanced by the private insurers payments. This is why you see many county and rural hospitals struggling because the private hospitals have taken the cream of the crop private insurers. First step is the make sure hospitals are not drowning in covering for costs of Medicaid and uninsured patient care.

This Frontline documentary talks about this issue.

https://www.youtube.com/watch?v=UVvEkeH4O8o

Alternative spin: Medicare/Medicaid are the only insurance that is any good at keeping prices under control. Everyone else in the medical industry is in the city, bilking people who have money. Expanding medicare/medicaid will help us slowly bring costs down, more in line (PPP-adjusted) with the rest of the developed world.

I am willing to take some time and build a publicly available API of this. I care so much about this issue that I would build this db at my own cost and hope it truly helps people. if anyone wants to join forces, feel free to send any suggestions.

I don't understand why US healthcare providers are allowed to charge different customers a different price for the same service or good.

As this is clearly being systematically abused to extract the most wealth from patients and insurance companies, is anyone seeking to require healthcare providers to not provide such variable pricing?

Why is it that insurers in the US are seemingly the only industry where the person paying the bill can a) negotiate it after services are received; and, b) just decide not to pay it if they don't want to?

Hospitals should set a price for a procedure. There will be some variability of course as people need more or less anesthesia, identical surgeries can take longer to perform (=== more OR/surgeon time === more money), etc. But a $22-102k like in the article is absurd. Insurance companies should be required to pay whatever the hospital price is provided it can be justified. There should be specific courts to handle these disputes until the industry realizes it isn't special. Regardless, the onus shouldn't fall on the patient. Outcomes should be limited to: 1) Insurance company pays without complaint; 2) Insurance company doesn't pay, is sued by hospital, and is ordered to pay by the court; 3) Insurance company doesn't pay, is sued by the hospital, prevails in court, and hospital adjusts accordingly, eating 100% of that loss.

But, we'll likely just stay where we are now where people pay $100 for Tylenol PM and insurance companies get out of paying claims because one person out of 12 in the OR were out of network and they're all contractors.

US Insurance Aetna President Karen Lynch Compensation 2020: 7.33M https://www.comparably.com/companies/aetna/executive-salarie... Ferengi Rules of Acquistion #87 : A friend in need means three times the profit

<critic>Imagine the most advanced country in the world can not get their healthcare in order... Imagine one of the most Christian countries in the world (>75% are believers) yet they are not "good Samaritans" to their own people...</critic>

>yet they are not "good Samaritans" to their own people

The state of the secular healthcare system is unrelated to the religiosity of the population. Further, in some states (like TN), there are in fact christian organizations that do take on a substantial portion of the social safety net, especially for the homeless. Critics will say that the time limit on food and housing is unethical but I think its important not to create a permanent dependence.

I'm not a religious person but the disdain which people commonly speak of [white] Christianity online is really offputting and, frankly, ignorant.

Our system is so byzantine. I prefer to go to Kaiser, if possible, for no other reason than everything is in-network by definition. The only reason I don't have Kaiser right this moment is my current company only has one Kaiser plan, and it's a Cadillac plan -- zero deductible, zero out of pocket maximum, and so it has a fairly high premium (whereas the PPO plan I'm using has a premium essentially zero, the company pays almost 100% of it). Which brings me to something else I loathe -- that my health coverage is related to my job. Dammit, I don't want to change doctors when I change jobs.

There is debate about healthcare nationalization.

As always, that which lends itself to regulation via market should be private and that which does not should be nationalized. So which one is medicine?

Medical care that is needed suddenly and urgently must be nationalized because the consumer of this care doesn’t shop the market and therefore the market is not capable of regulating its participants in that case.

Medical care that planned ahead of time, not urgently needed or otherwise allows people to shop the market should be private.

But this is not the issue. Whether or not medicine of one kind or another is private or public doesn’t matter as long as the medical establishment is corrupt and inefficient. Corruption and inefficiency are possible in both scenarios. Too few people in the public appreciate that it is the massive corruption and inefficiency of the medical establishment that is the cause of America’s healthcare problem. Doctors are in hundreds of thousands of dollars in debt by the time they wear a stethoscope. Hospitals are charging ten dollars for an aspirin. Patients can sue and cause material damage to medical practitioners even if the medical practitioner did nothing wrong. The system is broken. It doesn’t cost 300k to train a fucking doctor. It never did in the past and it doesn’t now either.

There are 6000 hospitals, 20% for profit businesses, 17 of which are publicly traded. They write off procedure costs to some degree. The amount written off is so widely variable and lopsided, the IRS or the SEC would have a nearly impossible task of determining what is true. I'm curious, do hospital CFOs sweat the risk of IRS discovery that write offs are artificially inflated if/when the data becomes easily known and calculable? How many years and how many procedures were written off to which extent? To what end did asymmetric data play in avoiding taxes or violating SEC regs?

The csv from my local hospital is 247MB. Still going on 3 mins trying to open it.

There is obviously a ways to go to create a system where price transparency is feasible, but I’m very interested in how the community might think it would affect the value based healthcare industry with respect to total cost of care management and bundled services? You cannot always look at a service in isolation because of complications on episodes like joint replacements or the impact of chronic conditions over the longitudinal total cost.

"You cannot always look at a service in isolation because..."

The medical industry is adept at excuse making and impeding change. If we wrap ourselves around every conceivable axle then nothing will be achieved. As it is providers and payers already employ elaborate coding systems to represent work and ascribe costs. Step one is to kick open that door and make this transparent. Should the result prove inadequate to sufficiently represent every imaginable nuance then the medical industry can engage in the necessary rework under that pressure.

You’re right, my estimate for a short surgery in a private Thai hospital last Monday was “10k/11k THB excluding fees.” I walked out of the hospital 2 hours later having paid 9.1k THB (270 USD) painkillers included.

Estimates are fine, it’s just that they don’t benefit US hospitals. Stop justifying them, they’re scamming you.

sure. any given procedure has a happy path and many different ways it could go wrong and become much more expensive. you can't really predict what it will cost for an individual. but after performing the same procedure hundreds or thousands of times, the hospital ought to be able to figure out a standard rate that (statistically) covers its costs. I don't see a good reason why a large organization with tons of cashflow shouldn't be able to quote a price up front after taking any pre-existing conditions into account.

of course, we might not like the prices they quote if forced to do this, but it would at least be better than rolling the dice every time.

This is what bundled payments are attempting to accomplish. These bundles take into account the procedure (cot codes) in addition to transmissions and rehab costs generally. Disclaimer: not an expert on this specifically.

> You cannot always look at a service in isolation

But in the American system it's setup that you must. This is the whole "coding" thing that you hear people refer to which is taking a procedure and breaking it into individual codes that can be used in billing you/your insurance.

This was addressed in the "Methodology" section of the article:

> Data was collected for three services, determined by specific codes.

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> I’m very interested in how the community might think it would affect the value based healthcare industry with respect to total cost of care management and bundled services?

You mean... releasing pricing for individual codes.....? Finally showing that hospitals will bill different prices for the same code based on the patient's insurer...?

I read the article and all I got was that hospitals are releasing pricing information under the Trump mandate. I'm not sure what you're positing for an "effect" here as the effect is literally just transparency in hospital billing?

The US healthcare system is slowly moving away from the fee-for-service model and towards a value-based care model. Under that model, providers bear much of the financial risk. They might receive a single bundled payment for a joint replacement including all follow-up care, with penalties for failing to meet clinical quality measures. Or they might receive a flat per-patient per-month fee to completely care for people.

>Under that model, providers bear much of the financial risk.

Actually, practices currently bear the risk already, because they are subject to reimbursements unless they are cash-paying. Remember, the patients are regularly not the bill payors - the Payors are actually insurance companies/medicare/or, rare HMOs out of the area.

> They might receive a single bundled payment for a joint replacement including all follow-up care, with penalties for failing to meet clinical quality measures

Certain medical interventions like cancer treatment or joint replacement may require a long tail of treatment, counseling, physical therapy, aftercare, global periods, etc.

The applicability of that is fairly limited since many things do not trigger a global, and don't fit into this definition.

Good faith - not trying to be a bastard...

I've heard rumblings of this too but every time I've interacted with healthcare it's still the same coded system that you see in regards to the chargemasters etc... even as recent as-of a few weeks ago this was the system in a modern hospital in a large west coast city.

So, two things:

1. I think we're on the coded system indefinitely, or at least that's only what I can expect given recent experience

2. Even if we were to implement this, providers and insurers will still fight like cats and dogs because there's just too much money to be made here that I can't imagine the same problems won't manifest itself in a "bundled payment" system. I would actually expect this to make matters worse. Often when you bundle something it obfuscates and confuses the value of the individual "things" in the bundle - the middlemen will do everything they can to extract margin from this. I'd personally like to stay with codes to maintain transparency through having an auditable receipt of known services directly tied to a fair price.

Procedures will always be coded using a terminology system like CPT4 / HCPCS / SNOMED CT regardless of the payment model. The issue isn't coding but rather who bears the risk.

Bundled payments give providers the freedom and financial incentive to find innovative ways to efficiently deliver high quality care. No one benefits when hospitals have a separate line item charge every time a nurse administers a pain killer over the course of a hospital stay.

> Bundled payments give providers the freedom and financial incentive to find innovative ways to efficiently deliver high quality care

Until someone financially incentivizes a higher quality of care I don't expect to receive it, especially by a bundled pricing model.

> No one benefits when hospitals have a separate line item charge every time a nurse administers a pain killer over the course of a hospital stay.

And as someone who's been billed insane amounts for things like OTC painkillers I disagree with this so hard. I have zero, and I mean zero, confidence that they will not continue to overcharge me. When everything is individually coded then at least a patient can go back and "look at the receipt"...

In my adult life I realize that almost everything is weaponized against me (the patient) in healthcare. I cannot expect in good faith that removing the line items from the receipt will help me in any way. In America, I can only expect this to hurt me or I'd be an idiot.

Sorry to disagree, but there is no way that bundled pricing is going to serve the patient better as it makes auditing services rendered much much harder. As someone who's had to get into the weeds on this stuff between insurer, hospital billing, etc. I can only imagine that bundled pricing would have made my life more difficult as it really did come down to the codes.....

Got three plates and a few screws put into my smashed hip last year, cost me 120 Euros for the stay.

I'm in Austria, obviously... The only thing wrong here in Austria is there's still more than one health care insurance (one of regular employees, quite a few on federal and state level and one of self-employed) and there's a separate one for accidents (AUVA) and almost all of them are just playthings to the power hungry and greedy government.

I bet that this ends up resulting in higher prices. Once hospitals know what the others are charging, it is more likely to cause the cheaper ones to raise their prices than it is the more expensive ones to lower them. Medical care is a scarce good and (mostly) the end consumer is not footing the bill directly, either for the care or the insurance.

I'm not sure how useful these lists are when hospitals are not in competition. In many areas that aren't a major metro, you may only have one hospital you can even choose, and the law prevents new hospitals from opening without permission. This 'market' is the very definition of inelastic.

Great, now mandate that it is viewable via API

Can even use the healthcare industry standard for EHR which is JSON and RESTful

Even better: Mandate them to upload the data to some government system and let them provide a central API, transparency reports, ...

Germany did this for gas stations:

> Since 31 August 2013 companies which operate public petrol stations or have the power to set their prices are obliged to report price changes for the most commonly used types of fuel, Super E5, Super E10 and Diesel "in real time" to the Market Transparency Unit for Fuels.

https://www.bundeskartellamt.de/EN/Economicsectors/MineralOi...

Have JSON and REST been meaningfully adopted in healthcare? I thought most things still used the god-awful HL7 with hopes of migrating away.

HL7 FHIR is a counterpoint. A comprehensive, well specified REST API based on JSON.

As mentioned upthread, faxes are still in use.

In the meantime, since we have the data, this could be a good project for volunteers to glue together all the different documents from the different hospitals into a single system.

These files are provided as excel documents in what I assume to be a (hopefully) mostly unchanging location on each site. A script could download all the files, match up the procedures and then push it to a pretty tool for everybody to use when comparing prices.

Most enterprises have terrible dev/IT talent but when it is a cause as important as this, talented people tend to show up to provide a great solution.

I was thinking of doing this. I even started a bit, but I didn't end up getting very far. I'm torn between trying to run it as a service and running ads or whatever, or trying to run it as a wiki with contributors writing ETLs for individual hospitals and trying to tame the data set.

Seems like we need a public project to attract a groups of developers to help make this a reality.

Hospitals didn't "lift curtain on prices." They were forced to do so. Accept no framing that allows them to appear heroic or selfless.

https://www.cms.gov/hospital-price-transparency

Just spent last night in an Urgent Care watching my youngest child get stitches (closest thing around for miles). Can't wait to see how that bill plays out, hopefully one day I can see how their prices compare to larger hospitals and such.

> At a Sutter hospital in San Francisco, a procedure can range from $22,865 to $101,571.

What if ... that's actually a very egalitarian approach? Procedure cost is what you can afford.

Hospitals rig the economy. They intentionally break price comparisons, patients able to decide-before-buy, pricing pressure, and a million ways to rig prices.

Contact your state legislators and ask them to put large fines which go to the patient if they are discriminated against for their insured status.

My third world country has better regulation than this

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