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Comment by tromp | Hacker News Reader

> Before her surgery, Ms. French signed two service agreements promising to pay “all charges of the hospital.”

> In Centura’s view, the service agreements “were unambiguous and French’s agreement to pay ‘all charges’ ‘could only mean’ the predetermined rates set by Centura’s chargemaster,” the court said.

> But the court found that Ms. French wasn’t responsible for paying those rates because she didn’t know the chargemaster even existed and hadn’t agreed to its terms.

> “Indeed, Centura representatives testified that the chargemaster was not provided to patients, and in this very litigation, Centura refused to produce its chargemaster to French, contending that it was proprietary and a trade secret,” Justice Richard L. Gabriel wrote.

Beyond ludicrous...

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It’s amazing that any of these “agreements” are ever upheld by courts. As standard procedure, you have to agree to any and all charges, but in most cases they refuse to give any estimate of what those charges might be. They are “trade secrets.” But if you don’t agree, you cannot get lifesaving care. It is unconscionable. In this case, she is lucky they gave her that insurance estimate. Usually they refuse specifically for the reason of what happened in this case. They expect you to agree to pay whatever they decide later. And people keep trying to argue the US has a great healthcare system. It is beyond broken. The very rich don’t have to worry, the very poor don’t have to worry. The rest of us can get screwed if we have the very bad luck of being US citizens who happen to get sick or into an accident.

Totally agree. All these agreements are signed under duress and ask the signer to agree to pay an amount while making it impossible for the signer to know whether that’s possible.

If you don't sign and you need treatment to live, aren't doctors obligated to treat you per the Hippocratic oath?

Are you dying, like, right now? Or are you just going to die in a few months? Come back when you're dying.

You can always try a different hospital for better service. Of course this won't work in situations where timing is critical, but most surgery is scheduled. We might as well treat it for the business that it is. If they can't give you a reasonable estimate up front, then don't sign the paperwork. If they care about earning your money they will negotiate with you, and it's always better to negotiate terms up front proactively than deal with it reactively. The strongest power a consumer has is to vote with their money.

> If they can't give you a reasonable estimate up front, then don't sign the paperwork.

That's the issue, they don't give you estimates that they are actually bound by.

And if you're an hour away from being in the operating theater, and they have all the specialists there, and in that moment you choose not to sign-- it's more their problem than yours.

…no it isn’t? You need to get surgery, they want to provide surgery

That's what makes it your problem. They can just say 'no' until you sign the document agreeing to pay whatever they bill you later.

I think GGP commentor typo'd - it says the opposite at time of writing.

They'd likely ask you to sign way before that..

You're assuming the hospitals don't all do this. You're basically discussing market dynamics with a legalized cartel.

This is like when people point out problems with fiat currency which are very real, and then people suggest theoretical solutions from cryptocurrency. It doesn't actually help solve the problem in any meaningful way, and you are living in an alternate reality from the problem space we are discussing.

People say it's impossible to negotiate prices at modern grocery chains. They only had brand name lactose supplements. The manager gave me a hard time about it, I asked about a price matching policy, shrugged, and let me pay the generic price. I'm sharing this anecdote because I don't think people try hard enough and you might be surprised if you do. You won't win every time, but try asserting some authority.

By assuming markets are so rigged against you, it discourages people from even trying. Price discovery can only happen if you attempt to be firm. If you'll roll over instantly, then sure, they can do as they wish.

I've had the misfortune of suing insurance companies in the past; I'm very aware of how the system works. You are technically correct. It's just that you're grossly exaggerating exceptions as though they will ever be useful to a majority of people.

I'm not sure it exists. Every hospital I've ever contacted is a complete shitshow and can never accurately tell you the price of something ahead of time.

Dealing with our fertility doctor was great though. They knew the price of everything. But they were ran out of an office, not a hospital.

It’s funny how anything elective or cosmetic is like that. To be clear, infertility is a serious medical condition, and I’m not making light of it. The distinction I’m making is an economic one. When patients have more choice as to whether to even be a patient, you see much, much more consumer-friendly openness about pricing. So it is possible. Fertility treatment is a great example. So is elective eye surgery. These areas of healthcare are very different from the “sign your life away now and we’ll send you the bill later” standard of most healthcare.

If something goes wrong in the surgery and you need emergency care do they just cover it free through their own for of elective surgery insurance, or is it an opaque cost?

This reminds me of the situation with the telecoms in the east europe - it's almost the same. There were no incumbents, so both internet access and private healthcare are leagues above US. It's just not comparable. Also include online banking here.

You need stuff done - you go and get it, end of the story. No bullshit, no courts, no nothing, and it's orders of magnitude cheaper.

Bascially, the joys of free, open, not schizophrenically regulated market mechanisms and competition, unlike the U.S. healthcare system, which despite many common claims to the contrary is a shitshow of protectionism, half-assed regulation regimes and all sorts of bizarre half-measured meddling.

Dentists can usually give precise charges.

Kaiser Permanente usually has a precise copay for just about anything they do. So you have a good idea what the charges will be going in. And nothing like an extra $10,000 because one of the surgical team was "out of network".

Maybe in some libertarian dream land only, not in reality. You think a hospital will personally negotiate rates ahead of time with a single patient? Absolutely fictitious.

They could offer a flat rate based on the length of the procedure...

Huh? Over here in Germany, every single step of a treatment is documented and has country-wide standard rates. The actual cost depends on the specifics of the treatment, expressed in various parameters like required personell and their working time, goods used, complexity etc. In the end of course the insurance company pays for everything, but you still get to see how much everything costs - insurers are of course very keen to keep costs down. On the other hand, I know a few MDs which constantly complain how much of a hassle it is to document everything, but live over here in „liberarian dream land“ is very much real and a joy as the patient.

You can try to comparison shop all you want, but no hospital will give you details in the chargemaster if they aren't legally obligated to.

Even if you are in a position to shop around, journalists have documented their futile attempts to do price estimation for routine procedures. Here's one example: https://youtu.be/Tct38KwROdw

There have been recent laws that requiring publishing some of that information (which are being heavily contested), but comparison shopping remains effectively impossible in the US.

I tried this exact thing when my wife was going to have a baby.

None of the hospitals within 100 miles, the doctors, or the the insurance company would give me so much as an estimate, and this is for something that they do every day.

This whole nonsense with chargemasters is an industry standard practice. It's hard to find a hospital that will open the book for you.

You need to wake up and stop accepting this as normal or okay.

Hospitals are not just any business and if it starts to hurt us as a society we need to interven.

No, you cannot

I have no time to look it up RN, but I read a few years ago about a new hospital President/CEO who literally could not get a cost/price list for the services their hospital provided - obviously a key management data set, yet it did not exist.

Just because you think something SHOULD exist, does not mean that it does.

The cost accounting for most hospitals is totally opaque. How do you assign overhead to each activity? Does the ER make or lose money?

How much of a nurse's time to give patient a Tylenol? Zero? Five minutes? And how much does that nurse's time actually cost the hospital?

Nobody has the slightest idea.

> How do you assign overhead to each activity?

Every business has to deal with this problem, and hospitals have already done so, because they do somehow come up with the amount to charge you.

The possibilities for manipulation?

Or simple overcharging.

This SHOULD be true, but it is not.

Once again, SHOULD =/= IS

Just because they quote charges does NOT mean that they have solved the problem or that the charges are accurate.

There is absolutely nothing that requires the charges to have any relation with the actual costs, even if they are known, particularly at the item level. Only the total charges must exceed the total costs (less any external support e.g., from govt, philanthropy, grants, etc.), and that is on a basis of multiple years before any serious reckoning happens.

IOW, they can and in fact do literally just make it up. Also, charges that are heavily scrutinized may have some relation to costs, but other charges may be "just add a few zeros" to make up for it.

If you have some detailed and complete internal accounting data from any major hospital that proves me wrong, please post it. But when I read about congressional testimony that a CEO of a hospital literally cannot get the same data that you claim exists because 'of course it's been solved because every other business solves it', I find it difficult to believe you.

I can also state from running a business that the relationship of costs to charges is very loose. Sometimes I will sell things below cost for a number of reasons, and for some customers (e.g., those with high bureaucratic overhead requirements) the charges will be substantially higher. And when those charges are made, I may do detailed studies of what the increased costs are, or I may just say "one data point shows that's going to cost 4% more, but I don't like it, so add 7% - basically a whim. And no one in the world besides me knows the difference (and I forget about it after a few cycles and it becomes the baseline). So, yeah, perhaps stop posting speculation.

Regulated utilities, for example, are under constant scrutiny to be sure that they are allocating costs appropriately, and that any subsidies conform to public policy.

Somehow the medical industry has so far largely avoided such oversight.

Even within a single enterprise, misallocation of costs can lead to inefficiencies.

agreed. You are under huge distress and don't have a viable alternative and your life is in danger and you sign what is really, a contract to pay with the amount to be paid being blank. So essentially and legally speaking, how is this different than blackmail?

is there a limit? Can you legally enforce a hidden 1 billion dollar debt to someone?

It would be dischargeable in bankruptcy so there is a practical limit.

Usually courts won't uphold "unconscionable" charges.

Charge someone $1 billion to change a tire. Nope, nope, nope, as an example.

but somehow 229K is Okay? Where is the limit

Hospitals seem to have the world hypnotized.

> And people keep trying to argue the US has a great healthcare system.

I’ve never heard anyone argue this. The common argument is that it really sucks and that proposed changes suck as well. So the argument isn’t “don’t change because it’s great.” The argument is “It’s terrible and I’m worried that if you change it, it will get worse.”

I've come across a number of HN commenters claiming US healthcare is better than the EU or UK. I'd argue it's pretty broken compared to both. The UK's NHS is far from perfect yet serves the majority of people well without bankrupting them. Countries of the EU will have varying quality of healthcare, yet I'd still trust them over the US due to my fear of the US's highly profit driven system (which can cost you more than money).

I suspect those claiming US healthcare is superior are able to pay quarter of a million without blinking - however they still run the risk of unnecessary surgery and aggressive prescription of addictive substances.

I think we can separate the administration of the care from the are itself. I believe the US has among the best care. I also believe our administration of said care is among the worst, if not the worst.

True, I wouldn't be surprised if the US was amongst the lead in quality of medical procedures - when that procedure is necessary... but beyond administration, there have been numerous instances of doctors being exposed for electing patients for unnecessary procedures driven by profits, and other procedures being recommended when scientific evidence suggest the procedure has no clear benefit - no matter the quality of surgery, it always comes at significant risk and cost to your body, it's not a magic wand; it's a traumatic intervention that requires your body to go through a lot of recovery with possible lasting effects. This can be true to a lesser extent for less severe medical interventions too.

So my point is, what use is excellent "care" if not only it's life endingly expensive, but it's also prescribed immorally to the point of actually causing harm!

One measurement for medical intervention is caesarean births versus natural births by mother’s age, which hugely jumped in the states in the 2000’s: https://www.statista.com/statistics/206438/us-cesarean-deliv... (although rates are highly influenced by consumer demand?). Chance of caesarean jumped in percent from ≈⅔age to ≈age (e.g. ≈20% for 20 year old). High variation between states, although some of that might be state demographics of mothers: https://www.cdc.gov/nchs/pressroom/sosmap/cesarean_births/ce...

And a comparison against caesarean rates in OECD, which can be higher rate of caesarean per birth: https://www.statista.com/statistics/283123/cesarean-sections...

The people who make this claim will cite easier access to desired procedures, and higher quality treatment. They will then make the claim that care is rationed in other countries, and point at some anecdote about someone who had to wait a year for an MRI or wasn't allowed to get the optimal treatment.

These arguments are at best disingenuous

Every time the Single Payer option is this discussed, you hear people say how care in Canada and UK is broken, indicating that it's fine in US, which is not the case.

> And people keep trying to argue the US has a great healthcare system

I've never heard anyone argue that the billing and payment aspects of the US healthcare system are great.

I have heard people argue that the quality of care (by various metrics) or availability of services are great, but that's a different argument, and not mutually incompatible with having a broken payment and billing infrastructure.

> The very rich don’t have to worry, the very poor don’t have to worry.

I'm not sure how you're arriving at the conclusion that "the very poor don't have to worry"

I wonder what would happen if a patient swapped the form with an identical looking form with different verbiage, making the hospital responsible for any overage past what insurance would pay.

I very much doubt anyone would catch it until the bill was contested later. What would a court say? Would it be as legally binding as the standard document?

Edit: Or imagine a disgruntled employee in the copy room changing the form?

There is a story is someone doing something similar with their credit card [1].

Not sure how well something like this would fly in the states, but it would be interesting.

[1] https://www.nasdaq.com/articles/updated-russian-man-turns-ta...

It would have to be signed by both sides to count. I've done it before, but you can't just try to sneak things through if they don't sign.

In my experience these forms are only signed by patients, so why are they valid in those cases?

The signatures per se don't really matter. What matters in contract law is if there was an actual agreement. The signatures are just evidence that there was an actual agreement. They are neither necessary nor sufficient. This is why verbal agreements can be binding contracts, it's just that these are harder to enforce because it's harder to show that a verbal agreement was actually entered into.

Well if the patient swapped the form, it would be pretty clear they didn't actually agree to the terms of the original form.

And if they swap the form in secret in order to trick surgeons into performing an operation which they haven't agreed to pay for, it's pretty clear that they're committing fraud.

What do you mean "in secret"? The hospital received the form in full detail. There is nothing secret about it. It's like claiming the ToS are secret because none reads it.

No, it's not at all like that. If someone hands you papers to sign and you give them different papers without telling them so, that is clear intent to deceive, which makes it fraud, or at minimum makes the contract void.

People keep saying “in secret” but that’d only be true if it happened after it were filed or some such. Giving someone an amended contract isn’t fraud.

Giving someone an amended contract isn't fraud, no. Giving someone an amended contract while making them think it hasn't been amended is a different matter, though.

Fraud is a strong claim, and it's not clear that there is even an implied contract formed - a contract requires defined consideration. An arbitrary amount conjured out of a hat after service is not well-defined consideration.

From my understanding, the medical billing system is so fucked precisely because hospitals bought laws making it so they can arbitrarily bill patients without forming a proper contract (otherwise there would be no way to charge someone who was admitted while unconscious). In the absence of such laws they'd have to fall back to an unjust enrichment claim, under which it would be pretty hard to justify charging someone $25 for an aspirin.

When I was registering as a new patient at a dentist, they gave me the standard form that would let them do things like contact my employer if I didn’t pay my bill on time. I stroked a bunch of that stuff out and initialed it.

If it ended up in court and they produced that form, would my amendments mean anything? Is it a contract when only one part signs it?

The hospital would most likely have a very easy argument that since it's not actually their standard form and you didn't tell them about it, they didn't accept the agreement in any way. And they'd probably try to get you for fraud as well.