Comment by danShumway | Hacker News Reader

Comment by danShumway | Hacker News Reader

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> It most certainly is the norm when purchasing complex custom services.

An x-ray is not is not a complex custom service.

> But how much is that worth when the entirety of the hospital visit is going to be a variable cost?

This is the exact same argument that hospitals used to use against itemized pricing, and yet it turns out that requiring hospitals to give itemized bills on request has pretty solidly been a good thing for consumers.

There are a huge number of reasons for this, not the least being fostering competition and putting natural pressure on the market to justify its prices helps it become more efficient, and these kinds of opaque systems will almost always naturally lead to inflated prices. There's little reason to believe that up-front price transparency for individual itemized procedures and drugs wouldn't also be good for the same reasons.

At the very least, this would help with the many health decisions that consumers make that aren't happening during life-threatening situations. Most of the time that I get an x-ray, most of the time when I'm being offered pain medication, most of the time when I'm making decisions about whether or not to opt for anesthesia before a procedure, I'm awake and not in danger of immediately dying.

It really doesn't make sense to keep leaning on the most extreme life-or-death situations as a defense for why a hospital can't walk me through the price differences in several different brands of pain medication. But sure, we'll make an exception for surgeons operating while a patient is literally unconscious during a time-sensitive procedure. Most health visits (and the vast majority of all preventative care procedures) do not fall into that category.

> jonathan-adly has done a great job explaining why drug prices are difficult to calculate upfront.

Let's make this simpler. johnathan-adly says:

> The cost of the aspirin depends on these things

Here's Rite-Aide's page that comes up when I search for an aspirin: https://www.riteaid.com/shop/medicine-health/pain-fever-reli...

Why is it that Rite-Aid can give me an upfront cost for an aspirin, and a hospital can't? 340B is a rebate system, it doesn't force doctors to avoid talking to patients about the baseline price differences between comparable off-the-shelf name-brand and generic drugs.

>Most health visits, and the vast majority of all preventative care, does not fall into that category.

The kinds of easy issues you're talking about don't need to happen in a hospital. You can already go to an outpatient imaging clinic for an x-ray, a dermatologist's office to have a mole removed, or an urgent care to suture a laceration.

If you need emergent care or you want an elective procedure that requires a hospital stay, you're into the realm of custom services with variable pricing.

>This is the exact same argument that hospitals used to use against itemized pricing, and yet it turns out that requiring hospitals to give itemized bills on request has pretty solidly been a good thing for consumers.

Has it? Has it driven down prices? Has the demonstrated value been worth the cost? Or has it just pushed hospitals into creating longer bills with more creative items and charges. Creative line items like $500 for aspirin perhaps?

> The kinds of easy issues you're talking about don't need to happen in a hospital. You can already go to an outpatient imaging clinic for an x-ray, a dermatologist's office to have a mole removed, or an urgent care to suture a laceration.

Even better: clearly the market has proven that it's possible to offer these services with transparent pricing. Why can't hospitals keep pace?

This also raises the question why preventative care often falls into the same category. Lawyers have a predictable billable rate, personal physicians and doctors often don't. Most scheduled hospital procedures require multiple consultations and planning before the procedures take place. Most of that stuff is not transparently priced.

There's no reason why a hospital shouldn't be able to figure out the cost of minor anesthesia before a scheduled minor surgery. That's not a surprising part of the procedure, that should be something that's fully negotiated with insurance and disclosed to the patient beforehand so they can decide.

> Has the demonstrated value been worth the cost?

Yes, absolutely, you can find tons of stories online about people negotiating smaller bills because itemized bills turn out to include services that they never requested (and in some cases services that were never even actually performed). If you talk to experts about managing personal health costs, pretty much all of them will tell you to always request an itemized bill after you visit a hospital or doctors office.

It's also absolutely worthwhile because you're seeing creative line items like $500 for aspirin that prove that the costs of the services aren't being based on market rates. That's really important information because it opens the door to other questions like "why are these prices what they are", and "can you tell me in advance before you give me a $500 aspirin?"

I mean... you're saying this is the norm in complex industries, it absolutely is not. Complex industries are complex because they don't know up front what they'll be billing you for. That's not even remotely the same thing as "we think your stay should cost $5000 for reasons we can't disclose, so I guess we'll jack up the aspirin cost after the fact to try and prevent anyone from questioning us."

It is extremely worthwhile to put hospitals in a position where they have to answer consumers why an in-patient aspirin is priced so much higher than the market rate for the drug. I don't know if this is your intention, but what you're implying when you say that the itemized bills aren't accurate is that hospital pricing isn't based on any kind of competitive or visible market rate, or even anything objective at all. Which is a pretty bold claim.

Other industries with high-variability pricing exist, but they're not just making up numbers completely out of thin air after the fact and then lying about line items to try and justify that cost. Hopefully hospitals aren't doing that either. But if they're not, if they are actually basing their prices off of the combined prices of the services they provided... then we gotta ask about that $500 aspirin, because that's a weird price.

>Even better: clearly the market has proven that it's possible to offer these services with transparent pricing. Why can't hospitals keep pace?

1. You shouldn't be admitted to a hospital for those minor clear-cut procedures. 2. Hospitals receive public funds to offset the costs of some services. 3. Hospitals are required to provide certain services regardless of the customer's ability to pay.

>Lawyers have a predictable billable rate, personal physicians and doctors often don't.

Laywers will tell you their billable rate, and can give you a semi accurate estimate for simple services. For more complex services their estimates have enormous error bars.

>There's no reason why a hospital shouldn't be able to figure out the cost of minor anesthesia before a scheduled minor surgery. That's not a surprising part of the procedure, that should be something that's fully negotiated with insurance and disclosed to the patient beforehand so they can decide.

If you're talking about local anesthesia sure, but in that case you're unlikely to actually need to be admitted to a hospital unless it's an emergent condition. If you're talking about general anesthesia then there's a reason that an anesthesiologist or a CRNA with many years of training is required to be present.

> Yes, absolutely, you can find tons of stories online about people negotiating smaller bills because itemized bills turn out to include services that they never requested (and in some cases services that were never even actually performed).

Yes but do you have actual data that the benefits are worth the cost? Has it actually driven down health prices in the US overall? Was the additional complexity actually worth it?

>It's also absolutely worthwhile because you're seeing creative line items like $500 for aspirin that prove that the costs of the services aren't being based on market rates.

I think you're not understanding the point of this. You're not going to actually save money by declining to take an aspirin. Of course hospital services aren't based on market rates. Hospitals are required by law to offer certain services regardless of the ability of patients to pay, most patients are insulated from the actual costs through insurance, many patients have zero out of pocket costs, complex procedures are impossible to accurately estimate, and the free market has an inherent problem with extremely price inelastic services.

It's not a free market, and unless we are willing to make drastic changes to society, it never will be. Pricing transparency for hospital commodities is such an insignificant part of health care costs that it's a gigantic waste of everyone's time.

> 1. You shouldn't be admitted to a hospital for those minor clear-cut procedures. 2. Hospitals receive public funds to offset the costs of some services. 3. Hospitals are required to provide certain services regardless of the customer's ability to pay.

1. All of these simple procedures are part of hospital visits. If your leg is broken, you're going to get an x-ray. Most surgeries are scheduled, and those scheduled procedures also don't clear this bar. And again, we get into the question of why preventative care suffers from the same problems. Your position seems to be that once any part of the procedure becomes variably priced, there's no point in trying to price any other part of the procedure. That's a pretty big leap to me, that's not how other industries work. And hospitals don't even work that way, because they itemize their eventual bills to insurance companies.

And I guarantee that insurance companies are not saying "who cares about the individual procedures you performed or what a technician's hourly rate is, the whole thing is variable anyway so there's no point in justifying any of it, just charge us what you think is fair."

2/3. I'm not asking them to tell me what their rebates will be or what discounts they might give me, I'm asking them to tell me what the maximum amount is they want for a standardized procedure. Possible rebates or lower prices that they can't predict are fine. I want a max price for that specific item.

> For more complex services their estimates have enormous error bars.

And hospitals still can't even clear this bar, they can't even tell me what a procedure's price is including error bars.

If hospitals could price their services as well as lawyers, we probably wouldn't be having this conversation right now.

> Yes but do you have actual data that the benefits are worth the cost? Has it actually driven down health prices in the US overall? Was the additional complexity actually worth it?

To those people, to the people who reduced their bills, yes. Is your assertion that we should only be looking at aggregate benefits? Community health pools and charity drives haven't reduced health care costs overall, but they have helped individuals avoid bankruptcy, and I suspect those individuals are grateful they exist.

I'm also confused at what you mean by additional complexity. Are hospitals giving itemized bills to insurance companies or not? It's really not a big ask for consumers to want to be CC'd into that conversation that should already be happening.

> It's not a free market, and unless we are willing to make drastic changes to society, it never will be.

Then socialize it. If you want to argue that the free market isn't a good fit for health care, fine. But that's not really an argument for keeping prices secret, it's an argument for socializing health care and taking it off the free market.

Which, incidentally, if your position is that health care should be socialized, line-item pricing also helps with that because it makes it obvious that the pricing is screwed up. You're upset that line-item pricing doesn't solve everyone's problems, but you can't solve a problem until it's obvious that it exists. At the very, very least, itemized bills and transparent pricing show that a problem exists.

That, on its own, even if nothing else mattered, would make these regulations worthwhile. No entrenched system in the world ever changes unless you put pressure on it.

>And hospitals don't even work that way, because they itemize their eventual bills to insurance companies. >Are hospitals giving itemized bills to insurance companies or not?

Hospitals can provide an itemized bill after the fact. Not before. They also go back and forth with insurance companies multiple times. It's not actually based on the costs to the hospital. The final itemized bill is the end result of complex negotiation. It isn't actually based on cost.

>"who cares about the individual procedures you performed or what a technician's hourly rate is"

Insurance companies don't care what a technician's hourly rate is.

>I'm asking them to tell me what the maximum amount is they want for a standardized procedure. Possible rebates or lower prices that they can't predict are fine. I want a max price for that specific item.

No surgery is standardized. If you literally want the max price, it's going to be so high you'll never be able to pay it. It won't help you. The individual items don't matter--they're fiction.

>Then socialize it. If you want to argue that the free market isn't a good fit for health care, fine. But that's not really an argument for keeping prices secret, it's an argument for socializing health care and taking it off the free market.

It's not. And it should be public. As long as it's not a free market, none of the normally price discovery mechanisms work at any level in the supply chain. There's no way to provide prices upfront. Any attempt to will fail is just a colossal waste of time. Any list of prices you see is going to be an elaborate piece of fiction.

>To those people, to the people who reduced their bills, yes.

Those people didn't actually reduce their bills because of itemized pricing. They would likely have been able to reduce them regardless. They negotiated with the hospital successfully after the fact the same way an insurance company would.

Hospitals are usually willing to negotiate a bill because they'd rather have some money than none. Whether that's knocking off a line item for $500 aspirin, or nocking 10% off off an opaque $5,000 bill makes no difference.

>Which, incidentally, if your position is that health care should be socialized, line-item pricing also helps with that because it makes it obvious that the pricing is screwed up.

Average prices for procedures can be calculated after the fact. They can be useful in the aggregate. For non commoditized services the averages aren't remotely useful for an individual.

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