I analyzed hospital price lists so you didn't have to
dolthub.com
dolthub.com
It is very good there is are the transparency regulations. It is worth briefly explaining some of the reasons why many facitilities are having a hard time complying. There are some bad actors, absolutely true. However "Hanlons Razor" -- never attribute to malice that which is adequately explained by stupidity -- definitely applies.
Many health systems are a lot more like "medical malls" than they are single monolithic enterprises. Lots of health systems use really, really old technology and also a lot of it from a company called "Epic". Epic does what it wants, when it wants and there is basically nothing anyone can do about it. There is rarely one central consistent mechanism and source of truth for pricing data because it gets generated from a complex web of different entities, systems, and processes. Herding all those cats is why it can take a health system a long time to comply. And also why a fine of even a million dollars can be small potatos vs the cost of actually complying in a timely manner.
Just one facet, MUMPS is a widely used technology which you probably haven't heard of and which very few technologists understand. Lots of people are struggling to create new code to meet the new regulations using 1970s era technology including MUMPS.
Another, a lot of health systems have been around a really long time. The insurers they work with also, (since the 1960s at least). They have Electronic Data Interchange EDI relationships built on the standard called 837. Business logic that surrounds pricing and billing is often buried in 50 years of tech debt. Everyone is deathly afraid of making too many changes too fast because when those systems break the money stops flowing and a health system will literally go insolvent. People still have hard physical lines connected to Medicare mainframes.
This is a similar situation to other regulated industries like banking, airlines, etc. Modernization is hard, time consuming and very expensive. These regulations are a good driver for all that, but it takes time. Having been in some of these boardrooms there is not typically a cartel of evil executives figuring out how to screw patients. A lot of the time it is a group of relatively normal people trying to hold up a technological and business process house of cards with chewing gum, paper clips and hope.
Disclaimer: I have been involved with the development of some of the fee schedules and health systems mentioned/criticized.
You are mischaracterizing MUMPS which is now called M and has been updated many, many times since its invention and has a robust standard library of functions from M vendors.
Regulation is one piece but ultimately dysfunction stems from huge differences between what different constituents want from a healthcare system and what they want it to be (and not be). People hold extremely different views about it. Depending on your circle and where you live you may not realize just how far apart your thinking is from people in other circles and places. Creating palatable compromises between those groups has proved almost impossible and so a lot of what we have in lieu of a compromise occurs by default and accident.
I'd never heard of it -- until I was at an afterparty at last year's AWS ReInvent and started talking to an older couple near us over some drinks.
The guy was well to do and had been in technology a long time. We had a great discussion where he told me about things like MUMPS and other tech I'd never heard of.
When they left, his wife gave me his name. Looked him up, it turns out he was C-Suite at a company nearly everyone has heard of (but is not known for being a tech company).
Makes me wonder how many billions of dollars are being pumped into tech I wouldn't recognize the name of.
From what I read, MUMPS is actually very performant. Although other companies use it, Epic is the giant. Epic was considered a decent company to work at - good reviews, good work/life balance. The downside is mastering technologies that no one else would value. Or so everyone thought. The reality was that if you become well versed in MUMPS and the Epic stack, a lot of hospitals would pay good amounts of money to you - a lot more than what Epic paid.[1] The only catch was that Epic had a 1 year non-compete clause.
At the time I considered them, they were starting to develop stuff with Visual C++ and .NET, so there was a chance you'd learn more transferable skills.
Fun story: The first time I encountered them at a career fair, I knew nothing about them. I was a grad student. At the booth, they asked me my SAT and GRE scores and were crazy impressed, and immediately booked me for their "entrance exam". At the time (perhaps even now), all candidates had to do a written exam - they'd arrange for the university to conduct it. The exam was mostly assessing logical skills, etc. No advanced material.
I didn't know anything about Epic at the time, and was extremely turned off by anyone being so easily impressed by things like SAT scores. I didn't bother to go through with it. I was studying an advanced degree, and wanted to work for a place that was not so superficial.
Fast forward a semester later when I really needed a job. I researched Epic and it actually didn't feel so bad. I felt I would easily ace their logic exam. So I applied to them. This time, though, they made me do an online behavioral screen first. The type where they ask questions like "Are you more of a X or Y?" where you feel you're neither X nor Y. Apparently I flunked that test and they didn't invite me to take the logic test. Bummer.
[1] Not FAANG level money, but still a lot more than industry average, and a relatively cushy job with you being treated as "the expert".
heard this is no longer the case with the pandemic. Apparently the CEO had some questionable perspectives on COVID for someone who managed health tech. None of my friends who had jobs there made it through covid without quitting or watching their team quit.
Anecdotally, their recruiting is a mess and the IQ test type interviewing is very common for them instead of FAANG style interviews. I reached out to them at a career fair and they laughed at me and told me I was unqualified because by resume said "medical engineering with a focus on software" and said they only wanted software engineering. That day I re-wrote my resume to say "CS with a focus on medical tech" (I was formally un-declared as a student at the time) and the same person who threw out my resume offered to interview me - I declined.
* I also would later graduate with a degree in computers not medicine, in large part due to that interaction, despite forming a very negative perception of that recruiters behavior.
From my brief time working there, it seems their recruitment pipeline is wonky for the devs while the support staff are open to applicants of any and all backgrounds (provided they can pass the IQ tests)
But in reality, good regulation is good, and bad regulation is bad.
It sounds silly written out because it's a tautology, but if more people internalized it we could have much more productive conversations. Instead of going back and forth on whether regulation is good or bad, we should try to figure out which regulations are good and which are bad, and then try to get rid of the bad ones and pass more of the good ones.
No one brick in the road to hell is bad. But you can definitely pave a road to hell with the accumulation of "positive" changes. People tend to define positive over too short a timeline or too narrowly.
They're just rules we make for ourselves. There's nothing special about them. Opinions like that are why we can't fix messes like this.
Perhaps its just low pay attracting low talent
The goal of the regulation is to increase prices (profit) while preventing other parties from competing on prices
Suppose I want to sell my product, and find a company willing to buy, a middle manager signs the contract. When the company recieved my product, it refuses to pay, says this person was not authorised to sign the contract on behalf of the company.
Must the company prove the purchase was unauthorised, or must I prove the employee was authorised? Suppose employee was unauthorised, is it my or the company's problem if this guy 'took initiative', who eats the loss?
What if they already used my product and only realised after the bill came due? What if the deal was overpriced like 10x from market average? What if the guy's title says 'Head of procurement' but the company swears their bylaws don't allow him to authorise purchases?
And I think you're talking about contract law, not regulations.
(Source: was doing medtech development for a while in the early 2010s).
I don’t know how it works in the US but at least in France, most hospitals are part of universities so they are also doing a lot of research.
The most competitive/efficient markets generally need the optimal amount of regulation to keep/get them that way. Those regulations would ensure that these conditions continue to be met in order for it to be a competitive market: https://en.wikipedia.org/wiki/Perfect_competition#Idealizing...
Free markets that are completely unregulated will tend to veer towards collusion and monopolies, in which case they're no longer competitive and the customers suffer. Free markets that are overly regulated will also suffer, but more-so due to things like the regulatory burden/barriers for new entrants.
What we have in the US healthcare system is a demented hybrid where some parts are free market but under-regulated, while other parts are free market but over-regulated. It's the worst of free market and state-run combined.
It's precisely the opposite. Its a racket but its not for profit. If you made a health care service that didn't have any of this cruft and just provided great care, it would not be used, because it would not be compliant with insurance, and employees would not get the tax benefit of using it.
If it were for profit, it would work better.
(Germany has private insurance and France as well in parallel, but the main system is "sozialised")
The healthcare systems in Canada, the UK, France, Germany and Switzerland are all distinctive (they’re main commonality I suppose is that they somehow deliver quality healthcare at a fraction of the US cost.). But to hear Americans say we should “do it the way it’s done in Europe” is to understand that the person likely don’t know how the healthcare systems operate in different countries.
The other frustration in talking about this is the tendency to “It’s just” the problems. If this were a simple problem with an obvious solution it likely would have been solved. We are where we are because of a century of organic, and often idiosyncratic, growth. Well intentioned policies of decades ago have come back to bite us with unintended consequences as likely are our best ideas today.
I don’t say we should throw up our hands and give up, but when anyone says there is an easy solution - we just need the political will to let them do what they want - I do see snake oil.
https://www.cigna.com/employers-brokers/insights/informed-on...
Eh, I'd rather listen to duffpkg, with his extensive, real world experience in health tech, than a random comment.
FWIW, a former coworker of mine spent a few years at a health technology company (also worked with MUMPS), and legal compliance was the number one hurdle to modernizing. It was expensive, and created a huge drag.
Fine these people out of existence and let someone competent (if such a person exists) pick up the pieces and start anew.
Passing around financial data on SFTP drops is something that irked me. Having the total not add up from the line items is also pretty ridiculous. The systems in place are all about edge cases that have formed over decades.
Software engineers are not invited to the discussions in a lot of these companies. The area is gate kept by healthcare people, which tend to be people who don't know how to do technical writing or planning.
Our company wasn't a huge one. But the huge ones looked to me as run by accountants. If you can't establish an income stream for them, they won't even talk to you.
I see this a moderate amount in fintech, or perhaps at least older fintech?
Had a colleague tell me about a new financial info provider he was supposed to connect with for data. "Oh this one will be easy" he was told. "They use oauth". OK... well... you oauth in, then you hit an endpoint that triggers a data build which then puts your data file in to an FTP account of your configuration. But you can't even configure it via hitting the endpoint behind the oauth. You have to log in to a web app to configure the FTP account for your account.
You hit the API endpoint and get 'OK'. But... that's it. You might get a file in your FTP account 5 minutes later. Or an hour later. It's just whenever it gets processed on their end. And... if it doesn't show up - you have no indication whether something broke, or perhaps the data service "just doesn't have any data for you today - you can't expect data every single day".
It's insanely crazy how across-the-board poor so many of these mid-level data vendors are. Colleague is currently supporting 8 different integration ingests like this - some deliver FTP daily, some you have to pull down, etc.
One delivers data which is only ever a delta. You have to continually request previous daily info from them to get to the 'first record' for that account, which can sometimes go back years, but... you don't know that up front. So you have to loop and request "day before", pull down data, parse it, then check the day before, until you don't get anything for that customer, then presume the previous was "initial balance". But you also can't just do that once, because... there may not have been any data the day before because... holiday? system down? So in practice you need to go back 3-4 days at least to verify. Oh... and don't keep looping and requesting too fast... you'll exceed the low rate limit ("we don't want people abusing our API").
I can only barely imagine how systems evolve like this, because they don't really seem to serve anyone's interest fully.
And btw, that description given by your colleague brought cringy mental flashbacks on meetings I've recently attended.
I also worked with a state medicaid office. They refused to use DNS, they decided it was insecure. Which was lots of fun any time we changed datacenters (3 times over my 7 years there). They would also go down, and nothing would happen until around 9:30-10am the following work day when they would finally come around and fix it.
"Some of you may not be in compliance. We start you off at a fine of $1. For every month this continues, the fine doubles."
All you need for a sensible regulatory environment is a complete overhaul of how your society works, starting with a campaign finance & congressional staffing system that isn't built on implicit corruption.
Isn't this the desired outcome, that such organizations go broke? And let their assets, employees and customers go to some other organization that isn't saddled with technical debt?
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I mean, I can see why reimplementing could be scary even with org churn.
US healthcare billing certainly could benefit from a massive simplification, and the reason of the success of neobanks/fintech is the same: they always started from green fields and didn't have to fight internal politics battles to change a data entry mask.
> Modernization is hard, time consuming and very expensive. These regulations are a good driver for all that, but it takes time. Having been in some of these boardrooms there is not typically a cartel of evil executives figuring out how to screw patients. A lot of the time it is a group of relatively normal people trying to hold up a technological and business process house of cards with chewing gum, paper clips and hope.
It bears questioning how, in ”the richest country on Earth”, something as important as a hospital ends up held together with spit and twine.
Inside this richest country, the richest individuals and companies have been capturing ever-larger shares of GDP. Perhaps instead of growing private fortunes, this money could have gone towards modernising these regulated industries?
In less rich countries they use paper records, which are worse. Everything is held together with spit and twine.
I personally think it's a very dangerous thing to believe, because it means there's no driving force to improve, and it's a part of the reason the country has stagnated so badly.
She also says that, of the half-dozen medical record systems she has used (here in the US), Epic is one of the better ones. (read: least bad)
I'm sure if you talked to medical professionals in Pakistan they would bemoan their medical record system too. It seems to be popular sport in the medical community.
Of course many countries are worse, but surely you want to look at successes of others and replicate them.
These kinds of reforms would have had to begin decades ago to make much of a difference.
Compliance within regulation is a noble goal? I should think it’s ethical goal.
So... perhaps if we'd had a better goal 50 years ago - single payer or universal medicare or whatever you want to call it - we'd have decades of technical debt that propped up a fairer system, instead of an unfairer one?
Perhaps we need to change our goals today so that 20-30 years from now things will be better then?
Voters are incredibly scared of change because it's so vital. The current situation isn't caused by a lack of resources but a lack of focused will
This statistic is misleading. The US is only the richest country on Earth if you consider the mean wealth. By median wealth, the US is ranked 26th. The wealth gap is enormous, and if you're in the upper echelons of the pyramid your health outcomes are vastly better than the clownshoes shitshow that the rest of the country is subjected to.
In fact, the wealth gap is but a reflection of the underlying cause of the problem: legislators corrupted to the interests of the donor class at severe cost to the actual constituents of those legislators.
And those who generously give may not oversee how money is spent and likely squandered to a certain degree.
Takes an incredibly self sacrificing individual to risk it all, which is what this requires.
What you refer to is actually a collection of hundreds of millions of individuals, with all sorts of interests, sentiments, ambitions, sometimes conflicting ones.
I'm going to ballpark migrating from Epic to OpenEHR without losing data would probably cost you something around $500/patient. So consider a medium-sized hospital that has 250k patient records. $12.5m project. That takes 2 years. (I'm considering all the places that Epic has custom integrations with other systems, with your insurer, etc, in that $500/patient, which is probably low, but gotta start somewhere). Add in the cost of re-training staff to use the new EMR, finding out after implementation the 'shadow IT' systems like someone exporting data to an excel spreadsheet and then doing a huge workflow on that that no one outside the department really knows about but is absolutely vital to the pharmacy's ability to operate...
OpenEHR can help address some things for one part of the system. But that is like saying fixing OpenSSL bugs will make all the internet secure.
At the end of the day, Hanlon’s Razor is just something some dude came up with to explain what is the most likely but not even necessarily correct assessment of a given situation. It is often unjustifiably treated as some immutable law when it is really just a flourish of rhetoric.
In healthcare especially incompetence opens the door for bad actors to exploit weaknesses in the system which amount to huge amounts of money being wasted. Medical fraud, for example, is one of the most sophisticated organized criminal activities in the United States. Mafias setup hijack doctors offices and pharmacies (or setup fake ones) and they know exactly how long it will take until they get caught. In the meantime they can extract tens of millions of dollars from insurance companies in fake claims.
And the fraud pales in comparison to the blatant waste. Doctors office's who order unnecessary CT scans when they or their affiliates happen to own a CT scanner. Pharmaceutical companies who market brand name pills that are no more effective than generics. Insulin manufacturers who manage to charge $1,000 a month for a product that's over a hundred years old.
In the case of pharma specifically, there are a lot of pricing inefficiencies that are deliberately not corrected due to political corruption so that they can be exploited.
Humalog insulin was patented in the 90s, and IIRC, is what Walmart sells for $25/vial. Novo Nordisk (among others) continually improves the product. Those improved products are where you see the $1k/month prices.
The 3 main reasons cited by pharmaceutical companies for the high cost of new prescription drugs do not apply to insulin. First, the “high cost of development” is not relevant for a drug that is more than 100 years old; even the latest and most commonly used analog insulin products are all over 20 years old.8 Second, the pricing is not the product of a free market economy. Free market forces are clearly not operational; there is limited competition on price, the person who needs the product is not in a position to negotiate the price, and there is no relationship of price increases over time compared with overall market inflation. The price of insulin has risen inexplicably over the past 20 years at a rate far higher than the rate of inflation.9 One vial of Humalog (insulin lispro), which used to cost $21 in 1999, costs $332 in 2019, reflecting a price increase of more than 1000%.10, 11, 12 In contrast, insulin prices in other developed countries, including neighboring Canada, have stayed the same. Insulin pricing in the United States is the consequence of the exact opposite of a free market: extended monopoly on a lifesaving product in which prices can be increased at will, taking advantage of regulatory and legal restrictions on market entry and importation. Third, the arguments that high costs are needed for continued innovation and that attempts to lower or regulate the prices will hamper innovation are not a valid excuse.13 There is limited innovation when it comes to insulin; the more pressing need is affordability.
https://www.mayoclinicproceedings.org/article/S0025-6196(19)...
I feel this is why efforts like FHIR are very important, though certainly scratching the surface.
- Insurance companies are in bed with hospitals to collaborate swindling money from the govt: read about kickbacks sent by the US Govt to hospitals as Disproportionate Share Hospital payments.
- Hospitals have a PR arm moving profits to defend their monopolies, including using SALT rules to create barriers to entry by geography.
- Hospitals also use govt rules against it. They were able to obtain an absolute advantage over all other players (ASCs, Independents) by getting the vaulted nonprofit status, which independents cannot get.
- Hospitals use their nonprofit status and barriers to entry to buy out competition: nimbler independent providers that are actually able to lower prices.
So, hospitals create their own rules, drive out competition, and create monopolies that leads them to hoard cash, which then they use to buy out competition and mire them in 1970s technology so we all pay more.
Then there's also PBMs, and Insurers. That's a story for another day, but plenty of blame to go around.
I post that hospital systems are so large, that at the bottom, Hanlon's razor may apply, but at the top, there's incentives one cannot ignore - and a lot of prejudice to keep the game as-is.
Make those programs go away, and CPT codes would eventually die.
It is not going to go away so unfortunately we need to learn to live life with it, and instead make it irrelevant, or niche, just like a ferrari is niche.
The best way to cope is to have an alternative to CPT coding, which means, alternative to insurance-based healthcare, which means, medicine between patients and doctors.
The only way to do that is that insurance and CPTs get so expensive that an alternative system is demanded by the market.. and people opt in (and regs allow for it). In effect, ferraris vs corolla. Corollas don't care about CPTs, Medical Billing, Eligibility, Copays, Coinsurance, or Authorizations.
The only way we can get more honda's is by having more independent doctors and less hospitals.
Hospitals create monopolies, independent doctors break monopolies with competition.
value based care is another iteration of "pray for alternative" to non FFS model, aka the APM.
This is the road of the HMO, the RVU, the QCCS...and i could go on and on. Its the road that we have traveled on since the late 80s. Its the road of the wanderer in the desert.
It doesn't lead anywhere but more profits for the road-builders.
40 years of history with 0 decreases in healthcare costs is all the evidence you need to put this one to bed.
The question might be: can we create an Uber-like business that has gives doctors the tech infrastructure to consult with patients without it feeling like a mom and pop shop?
Not in the strict uber model. Mind you. Providers will need to keep more of a share for it to work.
- The federal government is by far the largest health insurer - through Medicare and Medicaid it pays for 38% of healthcare in the US [1]. - The federal government directly subsidizes private health insurance through ACA [2]. - The federal tax exemption for employer-paid health insurance is by far the largest by dollars exempted [3].
All these government interventions increase reliance on health insurance, which increases the complexity of billing, which grows the medical billing industry.
[1] https://www.statista.com/statistics/237043/us-health-care-sp... [2] https://www.healthcare.gov/glossary/subsidized-coverage/ [3] https://www.npr.org/sections/health-shots/2012/12/04/1664342...
Courtesy of Louis Rossman, possibly stealing the quote, speaking about governments screwing up their fines and regulations.
I'm a professional patient, 99.9% of the doctors I've took treatment from(not U.S.) for major ailments are businessmen masquerading as doctors and I'm not talking about some scrappy hospitals; These are world renowned hospital chains.
What happens when you optimize for profit, instead of medical science? Wrong diagnosis and prognosis; I'm a victim of one and it has ruined my life.
On the other hand, There are doctors who risk their lives every day to serve people in need e.g. Doctors without borders, Doctors who rushed to serve during pandemic(Many of them loosing their life to it) etc.
DSH rules are gamed to extract more from the program
https://en.wikipedia.org/wiki/United_States_v._Microsoft_Cor.... https://en.wikipedia.org/wiki/Epic_Systems
Can you share your insight as to why it is not something that smaller companies or starts up have tried to fix? You can also email me (email is my HN username at Gmail dot com). I'm interested in learning more about this on a technical/"behind the scenes" level.
1. There is absolutely nothing special you need to do when handling values out of the database compared to in-memory values 2. The nested data structure—it's like a nested Python dict, except each level can contain a value and children.
However, even today doing so is very challenging, and before laws like this it was essentially impossible. There's no way to shop around American healthcare, with the system itself working against you at every turn (e.g. doctors prescribing named brand, and you not be allowed to switch back to generic without another $100+ appointment).
You can try calling and getting quotes, but they'll just waste a bunch of time and then give you a RANGE with no assurances. Even getting the quote requires your doctor to write up the entire work-order, which itself can get pushback, and or cost money.
Then you have random things like for-profit life flights, which are automatic bankruptcy machines. Imagine one minute driving down the road, then suddenly waking up in a hospital, and then getting billed $80K for just the trip to get there let alone your hospital treatment or recovery. And insurance doesn't cover it.
Aside but all ambulances around me are "out of network" and don't work with insurance at all. So I guess I should shop around by moving cities..?
https://www.cms.gov/nosurprises/consumers/new-protections-fo...
No, the solution to most social ills in America is to simply not be poor. If you are poor, stop it. Then you don't have to worry about any of this. Consider abortion, a procedure now outlawed in many US states. If you're not poor, you can just pay to travel to another state or country, have the procedure, do some sight-seeing, and come home. The law has no de facto effect on you. Same with every aspect of healthcare. So, just don't be poor and you'll be fine. (Even better if you are connected to the wealthy and powerful in your city & state. It is very nice indeed to be a VIP in an American hospital, court, or anywhere else.)
https://www.aflac.com/individuals/products/cancer-insurance....
> The out-of-pocket expenses displayed are estimated at 40% of the total medical cost, assuming that average major medical plans cover approximately 60% of the expense. Your major medical coverage may be more or less, and if an individual or family incurs expenses for non-covered benefits, these out-of-pocket expenses may increase potential unexpected costs. You will also need to pay for any limits or exclusions on your benefits which may include the number of refills for certain drugs, visits to certain specialists, or days covered for certain benefits.
I'm trying to find a case study but nothing turns up. A story - someone got a major injury, cancer, or other life-threatening hard/impossible-to-cure condition, and how exactly the events had unfolded financially. I.e. how many tens of millions the treatments were worth, how much insurance had covered, and how much was still left to pay and why. So maybe I could see what my insurance covers and see if I need another insurance to fill some obvious gaps.
All that my naive search attempts produce are mentions about people without coverage or with insufficient cheap coverage, which is a problem but a different one from what I'm trying to research. Oh, yes, and lots of mentions of out-of-network ambulance drives' crazy costs - I get this one.
Americans desocialized because of equal rights.
American healthcare works well if you have money and better than anywhere else in the world if you have money and a chronic condition. If you get in an accident, however, particularly while away from your posh neighbourhood, you’re getting the same overworked, hyper-indebted surgeon as the homeless man. (If you’re a billionaire or head of state, that’s different, but that’s different everywhere.)
I had an emergency this year within a very tiny insurance gap between employers and now all of my savings and retirement are gone.
I'm really not sure who it works out better for versus universal healthcare, but I can't imagine it's a whole lot.
My probably naive understanding was that COBRA can be activated retroactively if you get in an accident during the coverage gap.
Not technically true when I used it last. I did have to pay for it.
"Employers may require individuals to pay for COBRA continuation coverage. Premiums cannot exceed the full cost of coverage, plus a 2 percent administration charge." But yes, the American Rescue Plan act allocated funds to make COBRA free. I wouldn't doubt that I was using cobra wrong at the time either prior to the passage of the act. Small pdf warning: https://www.google.com/url?sa=t&source=web&rct=j&url=https:/...
My prescriptions seemed kind of high so I checked with GoodRx and they were cheaper! Cheaper without insurance than with, like how does that even make sense?
Right now I'm trying to negotiate on my last and only unpaid bill, the hospital won't negotiate with 1st parties so I've been trying to go through a newer company called Goodbill or something. I can't vouch for them yet as it's still in process, but just trying to get this all out of the way so I can just move on. Honestly, this whole thing has been so terrible that I'm just like, nope you're not even going in the worry pile. I'll go through the motions, pay it as best I can, and move on. I'll save the worry for the next totally normal work meeting coming up :)
I'm just very fortunate that I don't have a family to support or a mortgage to pay, even though I've been very close to breaking my lease and moving in with my parents until I can get back on my feet. I mean, I make good money too, I never thought I'd be in this situation.
I will absolutely go through the insurance options with a fine toothed comb when I interview again. Mama mía, aye yay yay
Talk to an FCRA lawyer. There are certain notices that if you send them and they are ignored can let you remove the lines from your credit report should they mark them as defaulted on. They will likely also help if the hospital chooses to sue.
This did not stop my insurance company from cashing my premium payments for over three months, even though they silently canceled my policy (no email, mail, or phone call). I only learned I had no coverage when I actually tried to have a dental appointment. Refunds of these premium payments took another another 3 months to be returned!
From now on I'm making sure I have good insurance, which requires a crazy amount of due diligence, but not something I'll take for granted anymore. It's one of reasons I'm currently trying to move to another country. Quality of healthcare is important, but how much does it matter if you're in massive debt, lost nearly everything, and don't have a retirement anymore?
Spoken like a salesman!
It's mostly false. Last time I did a deep dive on this, the US had a genuine but small edge in treatment for diabetes and breast cancer, but that was it -- and the edge was nowhere near proportional to price.
What documentation/studies did you find in your deep dive?
You’re looking at gross statistics. On average, American healthcare is average. If you zoom into the top 10%, it outperforms other countries’ top 10% (in general; of course there are exceptions). This goes from virtually instant imaging with concierge medicine to the Cleveland Clinic’s global medical evacuation jets and helicopters.
Which isn’t saying much. Even for wealthy people in the US, chronic conditions get you labeled anywhere from annoying to chronic drug seeker to mentally ill. Many doctors simply don’t believe that conditions that thousands to millions of people have are real, and no amount of money will change their minds. You do however get targeted for all kinds of scams!
So they will do all kinds of useless tests and treatments because that is what they earn money on.
You will never really know if this treatment is good for you or good for the hospital.
Citation needed.
Medicaid is actually very good coverage.
If you happen to have a kid with a rare disease, that matters.
As the saying goes, "it's the best insurance money can't buy".
Those people deserve it. I mean, some people chose to be born to wealthy parents; if you were too lazy to do that why should I have to reward your laziness by paying to look after you? Really, some people can be so selfish!
> It is very nice indeed to be a VIP in an American hospital
My gf had a life threatening illness and went to Stanford hospital. They gave her the special blanket just for Stanford Faculty so she'd get the VIP treatment. Which in practice meant nothing. Thankfully she survived; now I wonder if I should be glad or not that VIPs get the same shitty health care there as everybody else.
BTW there is a carrot and a stick going on. Yes, the hospital admin wants to make VIP patients happy for donations, but they also want to avoid making the patient unhappy because they have resources to sue, and win. All of this is highly motivational.
When you are a doctor, you're part of the club. Skipping the line and getting a consult in 30 seconds? Well, that is 15 seconds too long. Got a laceration on your child, and want a 3 layer closure by the head of Plastics? No issue there. Want to convene a board on your rare medical issue? Well, there is a doctors only Facebook group for that, with about 500 docs ready to chime in on their breaks.
It goes way behind this too. Indepth knowledge and advice about who the actual locally best doctors and surgeons are, across specialties (not the popularity contest or bought magazine ones either). Early tracks on new promising studies. Handouts of non-scrip medical supplies like event swag. Pharma-reps wanting to market their novel products and spread the info on them. The amount of free stuff is off the charts.
I've seen exponentially more over the top professional courtesy "Good Old Docs" club from my Dr. wife and the associated professional network, than I have in any other profession by far.
In healthcare not being poor is sufficient. You actually have to be quite well off in order to not worry about cost.
No, the solution is to be either poor or well off. The lower middle class are the people that have the most to worry about in the US healthcare system.
I'm not sure this is that common, unless you have an adversarial relationship with your doctor. It's actually the opposite: in most states the Dr. must write DAW-dispense as written or 'name brand only' to get the expensive brand. Otherwise, the pharmacist can and will substitute a generic if available.
I've always found docs to be very willing to work with you on budget issues. If there's a similar med that is available in generic where their original recommendation isn't, they're happy to switch.
BTW, Hopefully the last word is just a typo.
That’s rather disturbing, and from a purely pragmatic point of view, you might consider raising a fuss with your employer…
Which basically summarizes as "EDs that accept payments from Medicaid are required to at minimum stabilize all patients, regardless of their ability to pay or several named statuses."
Funny, I always thought it was just squeezing every last penny out of customers without letting them feel like they didn’t have health insurance for big ones
Also this reminds me of one of the more evil things I have ever seen in healthcare. Practice Fusion gave doctors a "free EMR" because it was being paid by opiate pharmecuitcal companies to create an electronic EMR workflow that intentionally increased unecessary opiate prescribing. Absolute evil in my opinion.
https://www.justice.gov/usao-vt/pr/electronic-health-records...
If you are a hospital, and you are shopping for an EMR to maximize revenue, is that a feature or is it a bug?
Evil, yes, stupid, no.
It's absolutely stupidity.
If you know anything at all about doctors, you know that they have way too much institutional inertia to change from writing one word on a prescription pad to writing a totally different word on a prescription pad, especially if the second word is almost twice as long, and especially especially if it’s just to do something silly like save a patient money. I have an attending who, whenever we are dealing with anything other than a life-or-death matter, just dismisses it with “Nobody ever died from X”, and I can totally hear him saying “Nobody ever died from paying extra for an adrenaline injector”. So Adrenaclick continues to languish in obscurity.
https://slatestarcodex.com/2016/08/29/reverse-voxsplaining-d...
I generally have a pretty high opinion of physicians, but they are incredibly overworked, and typically just lazy enough for this quote to be more true than we probably think it should, especially with e.g. 20 years of history writing a specific word for a specific diagnosis.
Because I have seen many people, and they do the tasks asked of them. They are “stupid” on tasks not prioritized, but their employers are perfectly happy with that.
The idea wasn't to get people to shop around, at least in my opinion, but rather to not use healthcare altogether unless absolutely necessary, because they feel the cost of the services more when they pay for the directly.
I tried paying the cash price. They inadvertently billed my insurance anyway. Turns out, I actually saved like 33% using the insurance price ($180 vs $120 for an xray + analysis).
They said the only way to get a copy of the x-ray was to pay $5 for a CD. None of the computers I still use have a CD reader.
The whole system is such a clusterfuck. I understand the aversion to giving a governmental bureaucracy more control (esp over something as important as healthcare); however, it's hard to imagine a worse way to pay for care than what we have now.
This is about the 6th time this has happened. It's always 15+ e-mails back and forth, then threatening lawyers, then they back off.
I'm wondering if it would be faster if I just take it directly to a small claims court. I am insured and it is preventative care, so I believe I'm entitled to pay nothing. Advice welcome.
I know healthcare billing in the US is f-ed up but Stanford is particularly bad.
I can get the price of my fast food burger to the penny - but good luck getting a quote on something that will cost 50,000.
I did medical billing for a bit and in my space 70% of the issue was stupid politics
I'm due for an ICD battery replacement later this year or early next year and trying to figure out where to get it done.
How or why do you think an echo is preventative care? While insurance plans are free to define any additional menu of services as preventative - an echo is not included in the minimum set required by the federal government - which are procedures based off of US preventative services task force guidelines - there are no published guidelines that include an echo.
I wish you luck on your billing problem but I think you’re going to hit a wall on your own definition of “preventative”.
The simple answer to this is that “preventative” in the case of billed medical services has a specific and clearly defined meaning - it does not even mean all services that ever would be considered preventative. This definition will be found in your insurance paperwork and corresponds at least to the site I posted - so a further philosophical discussion is irrelevant.
To your actual question - No, the echo is usually pallative. However, right off the bat I'll say this is an overly reductionist and not terribly useful schema for classifying the delivery of medical care. While it might be good as a way for the general public to think about prevention, it’s way too oversimplistic to be useful beyond that.
An aside, palliative has a specific and different meaning within medicine: roughly, treating symptoms without a goal of cure. Reducing a broken arm or removing an inflamed appendix is not palliative care in that sense.
But even if we widen the scope of palliative to be treatment an echo would be neither. An echo is diagnostic - it doesn’t prevent nor treat heart failure or disease. Often when an echo is ordered it leads to some form of treatment for some found disease, in which case if we’re going to stick to the simple classification would be “palliative” - we’re using it to guide treatment, we can’t prevent something that we already see.
> If he had violent symptoms it would clearly be palliative
It's just not that simple. Echos are sometimes used to further evaluate or manage asymptomatic disease, for instance A-fib or a concerning murmur. We're using the echo to rule out suspected coexisting conditions, that's not prevention, and it's not treatment either at that point. Also, echos usually have some symptomatic indication - and they don't have to be violent, whatever that means.
> it can only be preventative
Can you actually think of a disease that an echo would be used to prevent?
But again, in practice we don’t think of delivery of medical care in such grossly general terms - it’s doesn’t simplify in a useful way.
Yes, checking the extent of mitral valve prolapse (which I have, doesn't warrant valve surgery yet but it's expected I may need valve repair in 10-30 years if it gets worse), ejection fraction, early detection of dilated cardiomyopathy (which I'm known to be genetically predisposed to), etc.
Ejection fraction is not a disease, but let's call it heart failure. An echo evaluating for heart failure is a good example where we can use it as a diagnostic tool to prevent further progression - but again through other interventions - and if we're evaluating for abnormal ejection fraction we haven't prevented it.
Another example might be evaluating for a shunt to prevent stroke. However we don't routinely screen everyone for this.
Echo for inherited cardiomyopathies is a good example of primary or secondary prevention.
There are definitions within medicine that matter for defining appropriate use criteria, but all this preventive vs palliative is arguing loose semantics - the people you’re up against have already put in place the policy to avoid most of that.
> It's fully preventative in my case.
Fully preventative is not a term of art either for delivery or billing - but there is a difference in categorization between screening tests given to the entire population (ie colon, mammo) and screening given to those with personal risk factors or family history (LD chest CT, echo for congenital HD), and then further on surveillance for personal history of a pre-disposing condition (ie surveillance echo for prior potential fatal arrhythmia).
This is where it starts to get complicated - but the need for an echo every 2 years is not normal. I can't really divine your specific history from the information given - and it isn't necessary - but a history of cardiac arrest alone is not an indication for serial echocardiography. There are numerous specific circumstances where it is recommended, and then there are the cases where it is not consensus recommended but there is controversy. I assume because your insurance company is willing to touch it at all it falls in the former - but we are way off the ranch here in terms of the scope of routine preventative care/health maintenance.
As to whether it should be this way, probably not. If a surveillance echo is clearly indicated to prevent costly sequelae (unfortunately answering this question isn't nearly cut and dry as most think), then it makes sense that an insurance or public health agency would want to do this. Curious if you know if your indication for serial echocardiography falls under the European guidelines? Maybe move there /s. Is Stanford your only reasonable place to obtain an echo?
We should crowdsource a guide to navigating healthcare in Northern California, it’s utterly fucked up.
Even getting a primary care physician is impossible, nobody is taking patients and the websites of any place (sutter, ucsf etc) don’t reflect any accurate info about who could actually become a primary care provider for you.
The best healthcare situation I experienced was via Cedar Sinai while we lived in Los Angeles.
I'm not 50 years old yet, so I had to pay for it myself. A magical experience, since it's the first time I ever saw a medical bill in my life.
It was two pages long. Everything from taking blood to the medication and doctor was listed there, but the price at the end was only 200€. I thought it was a joke and expected a lot more.
I got a physical in Oct 2020, but the coronavirus spiked and it took me until April 2021 to go in and do the labs. One Medical screwed up the billing, coding them as diagnostic instead of preventative (or however that works).
I got nasty letters from both LabCorp and One threatening to send me to collections and ding my credit and all that. I'd text One and they'd be like "oh, just ignore those. We'll fix it." Months go by. "Just ignore them. We'll get to it."
It's such a massive what the fuck.
CD is honestly the easiest way for them to send the images to you, because you can give them to any doctor and they can load them within minutes. For the hospital to send them directly to another hospital would literally take weeks (at a minimum) of back and forth between two overworked and incompetent IT teams.
Last time I had imaging done, my doctor gave me a list of nearby imaging services, and the one I selected was able to electronically send files back to my doctor.
Heck I've witnessed my old dentist send x-rays over to my new dentist, it took like 5 minutes. Then again it seems like dentists are better at technology all around.
The point is to send it to any arbitrary doctor they've never spoken to before, which requires offline media.
If you've ever gotten a cd with your medical imaging on it, it will come with the software required to read it.
Cool dudes. Have you considered letting me download the x-rays I just paid for from that portal?
This is the reason that non-emergency healthcare is so expensive - the purchaser does not know the price of something at the point of purchase.
This results in the price being significantly higher than what the market can bear.
When consumers are informed and can force suppliers to compete with each other, prices go down to exactly what the market can bear.
Emergency healthcare is a different beast, but will probably also decrease if non-emergency healthcare prices was left up to the market to set.
This is only solvable for the cases where what needs to be done is completely known and certain in advance. Which for very complex human biological systems would not be the majority of cases, unless providers decide to only deal with health issues that fit that criteria and send everybody else to someone else.
I think the problem of not being able to accurately predict the required care is an intrinsic part of health care. Some of it actually is taken care of in some way, for example, if you go to ER they will only fix any immediate urgent issues and then send you home. Or, they send you home after n days in the hospital no matter what (example links: https://www.ombudsman.org.uk/sites/default/files/page/A%20re... or https://pubmed.ncbi.nlm.nih.gov/12568426/).
> When consumers are informed and can force suppliers to compete with each other,
Uhm... how do you imagine this would happen? Genetical engineering so all humans become standardized clones with identical completely predictable issues? I think you severely underestimate the inherent unpredictability. Simple stuff like teeth cleaning can be a price known in advance, or coming in only to renew a prescription for a known health problem, but many, most?, of the "real" issues are not.
OR, what would happen if you enforce this is that the MDs would be forced to press the cases into the pattern. They may think they should order an additional test or imaging procedure after actually looking at the patient, but since it's not in the pre-approved plan it would not get paid, so they don't, only things that were known before any doctor looked at the person get treated and only using the predicted methods.
Sure, the GP might want to order tests, but the cost of the test will be known in advance, the cost of the consultation was already known by the patient.
The patient can tdecide which radiologist they want, using price as a criteria if they want to.
The existing method is basically "you can only know what the cost is after you owe it to us", which is, frankly, insane. It allows the sellers to set a price that the ma let cannot bear, which results in secondary markets that provide insurance and skim even more off the top.
Yes what kind of procedure is needed often is known in advance. The details often only emerge after it's been started though. Just because it's routine does not at all mean it's all predictably-in-advance the same throughout, except for really basic stuff, which in turn is unlikely to be the big cost driver.
I dunno that I'd call a broken leg "really basic stuff".
This is what I responded to and what I quoted in my original post:
> "Here is the cash price. We won't know your HDHP insurance price until after we bill them, which could be good for you or could be bad."
So, yeah, the supplier currently knows in advance what it costs to fix a broken leg. There is no reason for the price of more mundane medical care to be opaque at all.
In the US healthcare system because of the lack of price transparency it seems to be impossible to know which hospital or doctor overcharges, and so a free market cannot arise. It is not even possible for a competitor to advertise better prices, because there is no practical way to check that their prices are indeed better.
> a free market cannot arise
A free market is not the best model I think, because even if you had perfect price transparency, people don't have nearly enough knowledge to evaluate the suggestions of doctors. Sure, they will select one the like more, but base don superficial information, not based on actual medical knowledge. For some truly "free market" you really want easily comparable and quite equal things to shop for. Medicine is too individual. Yes I know the desired model is you go in with your list of symptoms, get a few tests based on it, then an algorithm, right now in an MDs head, selects the appropriate treatment - time for the next patient in the overcrowded waiting area. It seems to me, and I had personal experiences with this model's limitations too, that there is a lot of dissatisfaction with this model not least with burned out medical professionals. But it sure is something the business-minds like, you can optimize processes and manage the heck out of such a system beautifully.
I - German (but I lived in the US for a decade and also had a bit of regular contact with various health providers, such as Stanford hospital or a Berkeley orthodontist for minor - and predictable, as you say - stuff like straightening teeth and hypo-sensitization) - am certainly not against a free-market component. I grew up in the GDR and we had a small bit of it even there! As a child my parents and grand parents actually did shop around for some specialists for some very reasonable amount of money, for my eyes for example (it worked out great, I stopped needing glasses as a late teenager, I ran around with one side of the glasses covered for a few years very early in childhood, for example, to strengthen one eye).
I think a little bit of that helps to reward those who care a bit more about their health and go about looking for solutions to problems more diligently and intelligently than others who just go with the flow. But I think this works best in small doses, not with the entire system set up this way.
But caring about pricing is entirely different than caring about the right solutions
It's not going to happen, so the most likely scenario is innovation will be coming from fringe services.
And the medical providers (not the insurance company) will always have discounts on their procedures...just have to ask for them. Makes one wonder how steep the mark-ups are.
Especially our government. Spending. Salaries. It all needs to be public.
A lot of it is. In California for example you can go look up any public employee's compensation at https://transparentcalifornia.com/
https://transparentcalifornia.com/salaries/2021/gateway-comm...
[0] https://transparentcalifornia.com/salaries/search/?q=teacher
> Please feel free to contact me at cindy.petersen@gcccharters.org, or (916) 286-5129.
At least with this much, you have a foundation to ask questions.
Politicians get to calculate the present value however they want today (which always means understating the real cost), and letting the future deal with the problem and playing catch-up to the real costs.
No one cared about this enough so government employee unions and politicians back then got away with underpaying employees in cash (hence reputation of government pay being low), but then give cops and some others 3% final average pay pay pensions including overtime or just averaging the final 3 or 5 years of pay. I have even seen pension plans just use the final year of pay.
The pensions start at 20 years of service, so you can have people earning a couple hundred thousand in their final years in mid 40s or 50s, and then get an annuity worth $200k * 20 years * .03 per year = $120k per year, and then on top of that some even negotiated cost of living adjustments (currently wrecking Illinois’ taxpayers).
Go ask an insurance agent for a quote for an annuity of $120k starting at age 50 until you die and see what they quote you.
They will probably laugh you out of the room.
Add government doctors, lawyers, university management, etc and the costs explode.
Tax revenue might be higher than ever but net available for programs is down. Thus, the feeling by many that government must be wasting money.
If you are talking about state governments in the US, that's approximately true.
If you are talking about the federal government, it's not, because the idea of a fixed purse is simply false. Spending and revenue are separate policy decisions that don't constraint each other.
This is especially useful for valuable gov't employees that want to negotiate a higher salary :) Totally fine by me, but just be aware you may not realize the second order effects. The primary people that care may actually just be the employees for pay fairness
A fairly searchable database of individual salaries
[1] https://github.com/pola-rs/polars
Definitely CSV. Always CSV. It's easy to produce, easy to parse, and kind of human readable. And easy to do some basic analysis with tools that everyone has access to - Excel, Google Sheets etc.
From the perspective of writing CSVs by hand in a text editor, commas suck.
Sometimes CSV files themselves are ambiguous because they don't use any quoting so you end up with some lines that have more columns than others, and require manual repair line-by-line by a human.
Don't use CSV, it's a dreadful format.
It's wild that we haven't just started using unicode and line/group separator characters for tabular data instead of csv/tsv. Whoever decided to use a common semantic character as syntax is an evil, devious bastard.
That said, there is one thing I like about CSV and similar formats: they are inherently tabular. You don't have to worry about someone adding sub-objects to your JSON (or replacing a primitive field with an object/array). Extra columns are brainless to add or process, but converting sub-data to a line is not.
Whoever got this legislation through deserves a pat on the back.
like patent trolls for a cause
That would be Trump.
Per https://www.sihd.org/affordable-care-act-price-list-2718-e and others
One wonders what took so long, of course.
Which is part of this executive order that Trump signed: "Within 60 days of the date of this order, the Secretary of Health and Human Services shall propose a regulation, consistent with applicable law, to require hospitals to publicly post standard charge information, including charges and information based on negotiated rates and for common or shoppable items and services, in an easy-to-understand, consumer-friendly, and machine-readable format using consensus-based data standards that will meaningfully inform patients' decision making and allow patients to compare prices across hospitals." [2]
> One wonders what took so long, of course.
What took so long is that you misunderstand how these rules work, Obama didn't actually do it, Trump did.
1: https://www.federalregister.gov/documents/2019/11/27/2019-24...
2: https://www.federalregister.gov/documents/2019/06/27/2019-13...
Signed 2010, PATIENT PROTECTION AND AFFORDABLE CARE ACT. Sure sounds like Obama did it and not Trump.
Or are you implying everyone just ignored it for 12 years?
Also, Trump's order is significantly larger than what's in the ACA, and Trump actually implemented his order.
You can give Obama credit for trying, but Trump gets credit for actually doing it, and for doing it much better than Obama.
No One doesn't.
One need only appreciate the incestuous network of corruption that controls how long these cans get kicked down the road to fathom what took so long. Unfortunately for the medical industry someone that wasn't beholden to them got into office briefly and made it happen.
https://www.forbes.com/sites/joshuacohen/2020/11/06/on-healt...
Feedback, criticism, comments, directions to go, whatever.
Some of that will hopefully change in the coming months as new data comes in (will write more about that in another blog.)
If you want to look at how prices for different procedures can vary between hospitals, you can get a rough idea from a previous blog post I wrote:
https://www.dolthub.com/blog/2022-05-06-the-most-expensive-h...
https://www.cms.gov/nosurprises/consumers/understanding-cost...
This is a bit of a misunderstanding. CPT codes are part of professional services billing, while DRGs are exclusively for inpatient acute care billing. If you are admitted to a hospital, you’ll probably have to deal with both.
We'll probably run another price bounty in the future to capture the rest of the chargemasters.
I know the people who wrote this law. #2 is actually a false assumption. The law was written like that to incur the least resistance as a first step toward change.
I used to negotiate with hospitals on reimbursement and if I were still doing the job, the first thing is do is pull up this data and say “This other plan of similar size is paying $X. I’m willing to pay the same.”
Sure it will take time to shake out. Hospitals will reject super low prices (that they were possibly losing money) for all payers. In exchange insurers will likely reduce the ultra high payments where they were paying a 500% mark up.
It will likely take a few years for it to shake out, but assuming the transparency remains I could see this actually driving prices closer to cost. Sure, big payers will drive it lower and small payers will pay more, but we could start to see a much smaller range.
Fingers crossed.
You shouldn’t have to do napkin math to know how much it’s going to cost you in worst or best cases for simple visits, procedures, or devices/drugs.
This is a positive change as you can now ask directly and hold parties responsible for a transparent price. No more ranges or “estimates”. It’s been slow rolling, but I did have success when complaining recently to my local hospital. I just hope that the fees for ignoring this start to become hefty enough to change the healthcare industry’s behavior.
Look up price transparency by CMS (the data will be published in this format: https://github.com/CMSgov/price-transparency-guide)
Note: the data being published by payors in machine readable format (MRF) is MASSIVE - terrabytes of data. Example: https://transparency-in-coverage.uhc.com/
It is grotesquely complex, but the core issue here is that patients want to consume their healthcare through insurance, because it is tax advantaged. Thus it is impossible to make a cash business that would cut through all this bullshit for the majority of healthcare.
[0] https://www.federalregister.gov/documents/2022/01/24/2022-01...
Before that, you could call and give them the code and they would tell you the price.
The problem is the doctor will not give you a code, and sometimes that makes sense since they do not know what they will be seeing or doing, so they cannot know the code in advance.
But I have also had doctors not give me codes for completely preventative services, which makes no sense.
- CPT modifiers (The service or procedure has both professional and technical components OR More than one provider performed the service or procedure. More than one location was involved OR A service or procedure was increased or reduced in comparison to what the code typically requires etc.,)
- Bundling (1 line item as opposed to 2 or 3 when the second and third procedures are an outcome of the first. eg: bone-xray + procedure(s) to fix the broken bone detected through the x-ray)
- Rendering provider vs. Billing provider (Rendering provider is the physician or provider that provided the service and billing provider could be the hospital/clinic/lab/ambulatory/billing company etc.,)
But here's the kicker. Medicare is the largest payer in the US and it already has a Fee-for-service pricing schedule. You can be sure that it covers all states, locality-wise price adjustments, hospital density factors in the price schedule and every possible procedure billing scenario. So, one just needs to compare (within a ZIP code or County or other geographic area) the hospitals prices against this to find anomalous pricing issues.
We almost exclusively go there now for everything. Even if they are occasionally more expensive (briefly, until the normal UC would send their surprise bills), it's just so much easier to pay up front.
Thankfully we have an HSA and it's our money.
Pdf your healthcare expense receipts and reimburse yourself from the HSA 50 years in the future completely tax free.
They actually make a ton of financial sense, but too many in the US would rather overpay for insurance rather than have to shop around.
How so? They are capped at like $6k a year.
Can you imagine the same solution for our police? Military? Emergency services?
Journalists, nonprofits, and startups are going to extract every bit of juicy truth there is to find in this stuff. They're going to get to the bottom of every cryptic string by hand if they have to, because there's so much value in this for nearly our entire society. And hopefully, the fines will mean the true gaps get smaller and smaller.
I do not mean to devalue the work. It's great honestly! Thank you.
That said, this is a major league mess most of the world would look at and wonder whether we are crazy or high.
Right now, it appears the US will have to learn this all the hard way. The financials are super attractive for people at the business level, and can be compelling for care providers, who may have expensive school to pay down.
For most everyone else, including many employers, it is increasingly painful.
The nature of the issue also makes change hard. Many people do not want to disturb what is working for them however painful. Can't blame them.
Business practices would have to change. In cases where the all the steps and treatments aren't knowable up front, providers would have to pick a price and stick to it - like any business or service provider they'd make money on some and lose money on others. Instead of issuing separate random bills from various providers, hospitals would have to pay their subcontractors out of their fixed prices, like a normal business. There may be exceptions for emergency care but those would be the rare exception, not the rule.
If you want this to improve: get rid of privatized health care. There are plenty of countries that set the example on how you could deal with this in a far more humane and fair way.
(That's not to say there aren't MANY opportunities to reduce the price and cost, starting with complying with the law to post prices, which many hospitals don't adhere to because the current administration isn't enforcing the EO)
Mainly to understand the expectations, values, and reasoning.
Services are being sold, whether it's private or government ran.
> Having hospitals run off funding by taxpayers isn't a price any more than the military buying an F35 having a per-American price (and no one thinks of it that way)
It is a price, so is the F35, and yes more people should think that way. Whether it's being paid for via taxes collected or paid directly is irrelevant.
The problem is not the method of collection of payment (taxes or direct) but the corruption of administrators.
Here are some examples:
https://www.ktph.com.sg/patients/hospital-charges
https://www.sgh.com.sg/patient-care/visiting-specialist/char...
So even if you’re destitute you need to pay something within your means, even if it’s $5 for a hospital stay.
Hospitals will comply immediately :)
In general, I’d love to see the same consumer protection required from auto shops applied to a hospital. An auto shop must give an estimate in advance.
Also, I'm pretty sure you can write a contract that doesn't have an upfront price.
A contract has to have defined consideration, otherwise it is not a contract. Time and materials (hourly rate + cost/plus) is another standard form of financial consideration, but "we'll charge you whatever we feel like at some later time" is not.
If you make working with the govt on reimbursements too painful, many hospitals in well-off insured areas (good payer mix which is like gold to medicine) will just stop treating medicare/medicaid.
A NYT article about the hospital I'm not even certain does very much.
1. Somehow in the mid-2010s congress decided that anyway that walks onto private property, demands care from a private organization, will receive it, even if they declare they will not pay a dime to the staff working.
2. Congress could have totally create/build a system of hospitals that provides "one time care" for those people, but doesn't.
3. Instead they pass the buck and say "figure it out" to the private industry.
4. Hospitals are squeaking by largely flopping duties on nurses, making their jobs far less enjoyable (wrangling entitled individuals instead of healing people and providing care), and charing double-triple to responsible individuals who will pay for themselves.
5. E.R.s are now becoming "primary care" for large majority of the US population, as they show up, then disappear knowing they won't be stuck with a bill.
6. Members of Congress literally don't give a crap about "common folk" and go on golfing and enjoying their free healthcare for life. Meanwhile commonfolk and the poorest of the poor don't get the same deal. One set of rules for peasants, one set of rules for the 1%.
It seems to make sense and align incentives to have members use the same public systems (eg transport, education, health, housing) as everyone else, otherwise they will never understand how their policies affect real people.
There don't. Them not doing so is part of the ACA. Grandparent was just lying.
What else in your analysis is terribly wrong?
1. https://en.wikipedia.org/wiki/Emergency_Medical_Treatment_an...
False. I mean, not only is this an exceptionally emotionally loaded description of EMTALA, it was adopted in 1986 which is not, even approximately, the mid-2010s.
> Congress could have totally create/build a system of hospitals that provides "one time care" for those people, but doesn't.
Yet another set of independent physical infrastructure would be even less efficient. The multitude of separate payment and delivery systems is a major source of the US inefficiency
> Instead they pass the buck and say "figure it out" to the private industry.
No, instead they find hospitals that have a large share of uncovered patients through the Medicaid's Disproportionate Share Hospitals payments program.
> E.R.s are now becoming "primary care" for large majority of the US population
Some support for this “majority” claim would be welcome.
> Members of Congress literally don't give a crap about "common folk" and go on golfing and enjoying their free healthcare for life.
Under the ACA, members and staff of Congress don't have special government healthcare plans, they have access to plans they are required to have coverage through plans available to others created under the ACA including exchange plans.
I think this misses just how basic much of the care performed in an ER (which is oriented towards critical care for major problems) is. Duplicate infrastructure is OK when the use-cases are totally different. We need better urgent care clinics.
Medical providers suffer under central planning and believe that moving low risk, high value care out of hospitals will make things cheaper. The thing that will make things cheaper is to figure out ways to directly make them cheaper.
And yes, prices should be set in stone and be easily accessible, unless it's something that is hard to evaluate due to one reason or another.
https://www.cms.gov/nosurprises/consumers/understanding-cost...
I'm sure I'll get downvoted here for this part, but government shouldn't be micromanaging care standards, even through a proxy like medicaid and medicare claim criteria. Let the citizens regulate the system instead, and government's job should be to make it easier for them to do so.
Yes, transparency can come through price lists, but prices can never go down until quality goes up first. It's just like code quality: If it's bad, you'll have to spend more time dealing with technical debt than it would have been to invest in the quality up front. Bad medical care breeds more complicated patient situations, and the rate of seriously ill patients increases as a result. Supply cannot keep up with demand.
Analyzing price lists, shaming providers into lowering prices, etc., will not solve this, nor is that idea even novel. But it may be useful as a single part of a more comprehensive strategy to solve the root of the problem.
It's great for business, especially since Michael Moore's documentary made it politically incorrect to deny medical claims for terminally or seriously-ill patients. Still bad for life expectancy, but we'll probably need another "groundbreaking" documentary before the country really wakes up to the scheme.
And for Christ's sake, stop training doctors to ask "what are your symptoms" (when they are already reasonably aware of what the type of issue is), and use more yes/no questioning about specific symptoms. If doctors can't be trained fast enough to be able to do even that, I'd think about fixing that, too.
I think you really don't understand enough about why these things get asked. Yes Gp work often seems like glorified flowcharts at first glance (especially if you only look at some of their study material), but once you dig into it (I helped my partner study for an exams and get to hear her stories every day), you realise the huge amount of background information that can flow into a diagnosis. Asking the patient about their symptoms is an important part of gathering the history and can not be done just with yes or no questions.
I agree, but that wasn’t what I was arguing against. Absence of any yes/no question is what I was referring to.
And I’m not sure your argument is a good one. Things you do in the classroom or other training are intended to overprepare you, and are not supposed to mirror real life. While I did rebuild and scale (as a technical owner) an exam platform later used by millions, I am only mentioning that ironically. Appeals to authority tend to be pretentious, and serve to prop up an even more dangerous myth that professionals always know what they are talking about.
Genuine wishes of good luck to those in dealing with that system and may you avoid it for as long in life as possible.
It doesn’t make sense to pay for a dermatologist at $150 for a visit to look at a rash when a GP would do at $75.
Obviously, I need to pay out of pocket until I meet the deductible, but it all counts toward the annual out of pocket max and I get the negotiated pricing between doctor and insurance company. After I meet the deductible, however, the insurance still pays for a consult for anyone I want to go see. Not necessarily for any procedure though, without justification. But that applies in any situation, PPO or not.
Content is excellent, but the writing feels off.
This is 100% his doing, through executive action. The Dems could have done this but never did. It’s just another example of how neither side of the aisle is truly on your side.
And it was severely under reported.
Recommend sending Biden a message (I guess via whitehouse.gov) that you’re tracking this issue.
It was finalized during the Trump administration, but in no way should he get 100% of the credit.
So it languished for 6 years with no movement. Trump came in a added it with an executive decision, and it was then that there were legal challenges that were denied. And that’s how we got here.
Like I said, Trump is the worst president of all time but give him his dues when he deserves them. This is one of them.