With a plumber you have 100 options and can just reject any who refuse to give you an estimate.

With healthcare providers, your insurance only covers 3 in your area, and they all refuse to give estimates of any kind (and usually act like you're a huge asshole for even asking, and like you're the first person in the history of the universe to ever ask).

Well in the u.s. the decision about severity has to be supported by medical documentation from a licensed provider. That medical documentation has to be converted to billing codes and put on a Medicare designed claim form. Payers, primarily government institutions like Medicare and state Medicaid offices, regularly audit these claim forms by random sample. If they find errors on those forms, such as a severity code that was not supported by the documentation, they extrapolate the number of failed tests in their sample to the population of claims they paid and claw back those payments. Depending on context, they might actually impose treble penalties as well and run your name through the press as committing fraud.

Do they do something like that in South Africa? It's not exactly known for the high quality of it's institutions.

Paying for better care and experience is possible in any country. Perhaps it's relatively easy, in a high inequity country like SA, to pay for an experience you like. Labor is pretty cheap there. It's gonna cost you more in the U.S. but you can get that experience here too, if you want. Find a doctor who doesn't take insurance or maybe look at Atlas. Bring your checkbook...

> It does not have to be a gigantic mess. Being back in the US, I just went to the ER and it was shocking being discharged and not being able to know what I owe.

One of the outright-grossest things about US ERs is they have dedicated vulture-like staff wandering around to extract billing information from the sick, injured, and distraught, but those folks can't even tell you anything about what it's going to cost (and neither can anyone else).

I would point to a few key reasons for the complexity.

1) Value based care - It used to be simpler with a model called fee for service. Get paid for what you provide. Insurers, Medicare in particular, aggressively drove the industry away from that because they argued it incentivized unnecessary care. The general approach now is value based care, where the insurers and providers negotiate a rate for each type of procedure or case, usually quoted as a percentage of the Medicare rate. In practice, that means that hospitals don't get paid for what they did, they get paid for the problem they solved, regardless of what it took to solve it. I'm oversimplifying, as this all depends on the setting for the care and the contract specifics, but this is certainly a major factor in how things got so complicated.

2) Supporting documentation - To combat fraud, insurers require that an appropriately licensed clinician provide medical documentation supporting the problem's conclusion. The insurers actually check for compliance, i.e. that the notes support the conclusion, in a significant number of instances. In response, the provider side of the industry has instituted expensive software (Epic, Cerner) and employs an army of clerical workers to be prepared to respond to audits from payers. These audits come in many forms, the most common is a denial where the payer essentially calls bullshit on a single claim, and the providers have to cough up detailed justification to get paid. Many providers find responding to denials so onerous that they don't even try, they just eat the loss. You can't do that in isolation though, that expected loss gets baked into the prices over time. And now you've got your most highly trained, value add people in the industry, doing data entry, by the way.

3) silos of information and decision making - The hospital cannot definitely tell you what you will pay out of pocket. They may be able to tell you the negotiated rate they have with your payer for a specific service, but they do not know if you will have met your annual deductible by the time you are billed. Your insurer has that information, not the hospital or the doctor's office. Your doctor is also not likely to know the complex billing logic, so even if they could tell you what they typically write in their notes for what they intend to do to you, you would still have a few steps before you could figure out what's likely to be billed (because it has to be converted to billing syntax). You may also know things that would affect the billing decisions that your provider doesn't know yet. If you're going to have a procedure and you've got diabetes, for example, your case might be considered complicated and command a higher rate. The list of complicating diagnoses is long. That's one reason you usually get labs done before a procedure. The provider needs to know what they're dealing with and that information can affect how much you and your insurer will ultimately pay.

Each of these factors complicate the billing logic. They all exist for good reasons. You don't want call center workers diagnosing patients and telling them how much things are going to cost. You don't want providers performing unnecessary procedures to drive up billings. Insurers have found that well intentioned providers are often sloppy with their notes or outright unethical with their billing practices. If the insurers can catch those mistakes, they can deny payment, and make more money, some of which will be used to keep premiums lower.

It all exists for a reason but put it together and you've got a damn mess and no one's happy.

There are plenty of surgeries and medical procedures where pricing is upfront, clear, and competitive.

What they all have in common is that these are procedures that are not covered by insurance. Cosmetic surgery and other elective procedures are all easily cross-shopped.

It would appear that insurance is a significant part of the problem