If hotels billed like hospitals | Hacker News Reader

If hotels billed like hospitals

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48 pointsmeghan62 comments

We just had a baby and I got a fully itemized bill, down to the total time spent with a head nurse vs the lower down nurses (billed at different rates).

I agree that I would have liked to have known that if my wife buzzed for a refill on her water bottle that we would be billed for the nurses time at $120/hr.

But even if I had known that, the total bill was discounted from 10k to 7k due to an agreement my insurance has with the hospital, and then my 80 | 20 kicked in and our out of pocket expense for a delivery, care and 48 hour stay was $1400 + a $300 copay. So many factors involved would have made estimating my final cost pretty difficult.

And that may be the point. It's not so much about transparency, it's more about how complicated the billing actually is.

It's absolutely about transparency though. The origin of the complexity is that insurance companies usually get the bills. And insurance, which has all this machinery to deal with the hospital's machinery (see video), sends you a TL;DR and as long as everything seems reasonable - though who really knows what that is - you send your insurance co a check for some fraction of it and everyone moves on.

There are a lot of things broken about US healthcare, but chief among them is that no one is allowed to talk about cost of services. It's untouchable. It's seen as getting between the patient and doctor - again, whatever that means.

mark_up 2 hours ago | link [dead]

My wife had a baby a year ago, and it cost us nothing.

I live in the "third" world.

As a fraction of my income, my baby cost us less than 3%. Figure out how much your income went to universal health care. I'm guessing it's higher than 3%.

Figure out how much your income

Duder is hell banned, I was just reposting that dead comment. But from myself...

I'm guessing it's higher than 3%.

Well, of course it would be. You're comparing your baby to every heath service for his family, ever, that is covered by his universal healthcare system. Or are you saying that your baby is the only time your family has or will use heath service.

If you cared to make an honest comparison, you would compare the portion of his, and his employer's income that went towards universal to your lifetime of insurance spending, plus employer spending on coverage for you, plus all of your out of pocket healthcare spending (on items that would be covered by his universal system).

Now, I don't care to do that math, but here in the US we spend (gov't and private total) more per capita on heathcare than any other nation. So his kid was probably cheaper.

10K? Wow. My last child was delivered 4 years ago, standard exit method with no complications, and the tab was $26K (before discounts, of course).

I can't imagine the bill if it was a c-section or if neonatal was involved. It would easily double and go up from there.

The funny thing is that the obstetrician gave us a fixed price for the entire pregnancy. All checkups and the standard delivery was one price. It was the hospital (and the randomly-chosen anesthesiologist) that ran up the price.

This was in Provo, UT, a student town where 50% of students and many of those couples have at least one child while attending school (my wife and I are one of those). The city therefore has a significantly higher than average birthrate but since the student population is transitory the population doesn't really grow that much. The effect of all this is that the hospital has an abnormally large amount of childbirths, and has become pretty darn efficient at it.

That probably contributes to a lower cost.

I'm not sure that 'universal' healthcare is the solution either. I enjoy the luxury (in Canada) of not having to worry about finances when going into an emergency room, clinic, MRI centre, etc but the taxes are a killer.

I recall a few years ago when my mother (US citizen) required knee replacement surgery; same itemized nightmare others have detailed.

Given both options, I'll live with them robbing me bi-weekly.

What really troubles me, that I didn't see represented in this video, is not so much the total amount of the bills but the sheer number of them. These days, a hospital visit results in bills from (at the very least)

* The hospital * The doctor (or doctors) who may have spent a total of 10 minutes with you * The lab company that did your blood work (if it was done) * The lab company that did you CT scan / MRI / Ultrasound / X-Ray / other expensive diagnostic exam. * The pharmacy that provided any medications you were given while at the hospital.

What's worse, is that if you look, most triage areas have a sign stating all the services are independently operated and you'll receive these separate bills. Confusing and obnoxious--but ok. The trouble begins when you discover that, though your insurance is accepted by the hospital, it's not accepted by one of the other people or services (of which you had no real choice but to use the service available on-site) isn't. The hospital might assign you a doctor that doesn't take your insurance and then you're screwed.

A family member recently received minor surgery at a hospital. After the procedure was complete, she received a bill for surgeon's assistant, who didn't accept the family member's insurance (the surgeon did). This was a man she never met before entering the operating room, had no idea would be in the operating room, and never saw again.

Every surgical procedure I've had or seen so far, including my wife's two baby deliveries, has been performed in a hospital or outpatient surgical facility where the anesthesiologists are independent contractors.

You have no idea who will be there and no idea if they will take your insurance. But their bill will be the first one that shows up in your mailbox, guaranteed.

Can't forget the sad reality that they can pretty much bill you whenever they want. We've received healthcare bills as much as six months later!

"have a sign stating all the services are independently operated and you'll receive these separate bills"

Those independently billed services must provide the services without regard to whether they will be able to collect. There is no credit checking (obviously).

I did some foresenic consulting for someone in a divorce. The physician had a large amount of a/r that had to be valued. Based on my memory they were easily writing off 25 to 35% of the charges they were billing for services. And this was in an affluent area. The non-paid for charges came from both individuals as well as insurance companies that didn't pay for various reasons. The physicians (a group) simply didn't have the time to pursue the charges. In some cases they would sell off the receivables in other cases they were just written off.

In a traditional business having a credit loss like that (spread among many accounts not one account going bust) would be unthinkable year after year.

Here in the Netherlands every medical procedure has a standardized declaration code. On the site of the NZa (Netherlands Healthcare Authority) you can check the current and historical cost of a procedure for each hospital.

For example go to http://dbc-tarieven.nza.nl/Nzatarieven/zoekSnel.do and fill in declaration code 085090, the code for a MRI. The NZa determines a maximum tariff for many procedures. For other procedures the cost is negotiable between healthcare insurers and providers.

The primary difference, health care is other people's money. We shop where the government policies hide the true cost of our care by minimizing or eliminating out of pocket expenses.

Being on a HSA program now at work really brings home the costs of health care. It shows quite quickly that there is no free ride.

Long term health care will never be free, there will have to be minimum payments/co-pays and the like. Otherwise people will simply abuse it, showing up for every real and perceived problem. I am not saying we do not offer free care to people who cannot pay, but damn, I see people claiming a need for other to pay all the while having eight dollar a month cell phone plans, high speed internet, and car payments that are in some cases what my rent used to be.

Long term health care will never be free, there will have to be minimum payments/co-pays and the like. Otherwise people will simply abuse it,

People never value what they don't pay for: it's just the way folk are.

One can see this on a micro level: buy your teenager a laptop. Make sure you buy the extended warranty: you'll need it.

Long term health care will never be free, there will have to be minimum payments/co-pays and the like. Otherwise people will simply abuse it,

People never value what they don't pay for: it's just the way folk are.

That is completely ridiculous in view of the example of the little-known country called the United Kingdom. People don't pay for healthcare directly, and they don't abuse it. This thread is ridiculous.

There are sometimes proposals to introduce a small fee to see a GP (General Practitioner - the first line family doctor that you'd go to see for anything not an emergency who'd refer you to other doctors for serious stuff that needs hospital treatment or prescribe meds otherwise).

GPs do get a lot of people who don't really need to be there, and it'd be nice if those people would use telephone triage systems like NHS Direct, or go and see a pharmacist. Having said that, an alarming number of people die from preventable illnesses because they "don't want to bother a doctor", so it does work both ways.

While England does have prescription charges only about 80% of people on prescription meds pay that charge, because there's a wide range of exemptions.

There has been research showing that a lot of people don't comply with medication. Interestingly the severity of the illness doesn't make much difference, and neither does having to pay or not pay for the meds. A surprising number of organ transplants fail because people don't comply with the regime of medication. This occurs in the UK (free meds and free surgery) and in the US (expensive meds, expensive surgery). It's made clear to the patients what the result of not taking the meds will be, and the patients know they're lucky to get an organ, and etc etc.

tl;dr I agree that most people don't abuse the UK health system. And the cost isn't something that enables people to abuse it or not.

I don't know the United Kingdom - the only Brits I've met have been guys who left to work elsewhere. And my world travels only took me to Asia. And that was while ago.

If you're familiar enough with the UK and the US, and health systems in both countries and can state with certainty that no one abuses the system: congratulations. You're way more cosmopolitan than I.

But I don't believe that abuse doesn't happen. It's just contrary to human nature.

Abuse of health care happens in the US. Maybe this thread is ridiculous, but there you are.

The problem with comparing the situation in the US to " the little-known country called the United Kingdom" is that the UK is peopled mostly by the British and _not_ by americans.

This small fact seems to evade most people's comparative analyses and renders them largely void.

People don't pay for healthcare directly, and they don't abuse it

You know, when Aneurin Bevan was setting up the NHS, he said the cost of operating it would go down over time as the population got healthier...

I wonder if he was deliberately lying, or if he sincerely believed that.

In summary there's no force to drive down health care costs if prices are not made public. If I need an x-ray, I want to be able to shop around with quality and price information made public.

$200 = ($50 space per night to put self + 20 cleaning + 0.2 mint + 1.80 water + 3 air conditioning + other low-tech things)(1+percentage profit)

$20,000 = ($2,000 for 50 years of training for 5 docs + $3,000(1 + percentage unnecessary to prevent lawsuit) state of art chemicals & tests + 2,000 admin + whatev other stuff)(1+ percentage profit)

if the hotel industry was run like the hospital industry it would still cost $200-400 or so for an ok room. The price size is the big attention grabber in the video. preventing potentially imminent death, and legal responsibility for it, is EXPENSIVE.

also, in a hotel you decide whether to eat chocolate. in a hospital, you might be unconscious or have no clue wtf 'vancomycin' is. so doctors decide. video misses this consumption-decision aspect.

wishing for a free, transparent market in medicine is naive, at least now. healthcare can't be 'disrupted' as easily as javascript library trends. but we might at least wish for a standardized 'economy' emergency set of options that uses off-patent stuff and restricts procedures. ER docs would hate binding rules but it does make a difference in unexpected ER cost, even choosing cheap vs expensive antibiotics.

if you plan 3 months ahead to pay 10k for plastics penis enlargement, that's a somewhat different issue.

Why aren't hospitals and doctors REQUIRED to post prices?

Probably for the same reasons that programmers don't - for all but the simplest of procedures there may be unforseen complications, particularly since they mostly deal with legacy "applications"

Should we[1] be shopping around for doctors? Hire a doctor like you would a Web Developer, what are your prices, experience, show me some of the stuff you've done before, etc. This is typically done with cosmetic surgery but should be we doing it with required but not emergency situations?

[1] when i say "we" i mean you Americans, i'm in the UK and have the NHS

Why not?

Should we[1] be shopping around for doctors?

My wife did this with

* Her cardiologist. He did a _great_ job of heart surgery after her heart attack, but she wasn't thrilled about the way he ran his clinic on her follow-up visits. So she got another guy. That this guy was closer to the house is an unexpected bonus.

* Her orthopedic surgeon. Visited several guys when it came time to replace her knees. Picked one she liked who is also uber-competent.

Digression: Ten years ago when this guy was a middle-aged doctor knee replacements were a hand-crafted affair. Now the doctor runs the operation but a kind of CNC machine does the actual cutting, uses lasers to measure things and customize the new knees.

CNC machines cutting new knees: it's an awesome century so far.

You can apparently which consultant you see in the NHS:

http://www.chooseandbook.nhs.uk/patients/faqs/index_html#4

Also, any time I contact our local GP surgery they always ask if I want to see my usual GP or someone else.

Of course there can be unforeseen complications, but those are the exception rather than the rule. You can also have complications when you bring your car to the mechanic. Still we want to know what a typical oil refill is going to cost, and if it's going to be more expensive than expected we'd like to know what the damage is going to be so we can make an informed decision.

I don't buy that we can't handle the truth and need to be shielded from the pricing and costs structure of medical procedures. Especially because most medical procedures are purely routine matters and the hospital can just publish the average cost of those procedures. You'll then at least get a rough impression of what the price is going to be and you'll be able to compare hospitals based on that.

I'm not sure most businesses are required by law to post prices. There may be some that are, but by and large a business in the US is not required to post prices anywhere.

The terrible acting aside, this is a good way of pointing out how pricing models are totally different and specific to certain industries.

Some people can really take the piss because its standard in the industry but totally adhear to normal payment standards in another industry.

What law allows hospitals to do this? If they don't tell you the price beforehand, and they don't publicly post the prices, legally, how do you ever owe them any money?

How do hospitals collect these bills? Can the hospital sue you to collect on these bills?

> How do hospitals collect these bills? Can the hospital sue you to collect on these bills?

They just pass them onto a collections agency. Same as any other outstanding bill processing.

The law that allows them to do this is the body of laws around contracts. You sign a contract of treatment that says you'll pay what they decide you owe. If you don't sign it, they won't treat you.

>If they don't tell you the price beforehand, and they don't publicly post the prices, legally, how do you ever owe them any money?

If you ever go to an actual hospital, you'll see how absurd this question is. First, there are never any prices posted. Second, good luck even getting an answer about how much anything costs. A friend had to try three different facilities (thankfully a non-urgent matter) before he could even find a facility where they could quote a price.

It points to the absurdity of those who claim US healthcare is a "free market". It's a cartel whose hooks are WAY deeper in the political system than just about any other industry, including oil, agriculture, or telecom.

Don't like it? Then your choices are either go elsewhere or die.

It's tempting to advocate a UK-style system, but I'll need more proof that NHS is not a political tool to depopulate the opposition.

Yes, some of us septics/savages watch the PM Q-time and never a session goes by without someone in the opposition complaining about hospitals and clinics in their district closing...

The German system looks pretty good, I wonder if it could be adapted well for the US.

Interestingly, the Germans were the first to implement social insurances because they were trying to keep workers from emigrating to the US:

http://en.wikipedia.org/wiki/Otto_von_Bismarck#Bismarck.27s_...

The problem with adopting a UK-style system in the US, is that the current UK government are trying to shift it towards a US-style system and have been for a couple of decades now.

If you guys had a sensible health care system in the first place like every other civilized country then ours wouldn't have such a bad role model to try and emulate.

Why not look at statistics rather than anecdotes? The UK system costs vastly less while producing similar or better outcomes.

The UK NHS has its own peculiarities: my (Italian) mother says they're a bunch of penny-pinchers who will not do even the smallest procedure unless it's extremely and absolutely necessary. Compared to the italian system (which is almost free -- there are very small fixed charges for each procedure, they vary at the regional level and many are exempted anyway), they are quite parsimonious.

In any case, most European systems are also universal and free or almost-free. You don't need to be an advocate for the all-free-all-the-time approach to see that US people are being ripped off.

A government-run system has the same problem. When the government is running the system, if it's terrible, you have nowhere to go. Private care most likely won't be available to you either, unless you are extremely rich.

I also have a problem with the government getting even more involved in my life.

I'm not so sure this is completely the fault of Gov'ts. Healthcare services have less that -1 (1) price elasticity (2). That is to say, regardless of the price, the demand for those services go relatively unaffected. Would this be any different without Gov't intervention? Unlikely IMHO.

With Big Tobacco, "elasticity of demand for cigarettes is quite low. The amount of cigarettes purchased will remain reasonably unchanged..." (3)

(1) http://oheschools.org/ohech2pg7a.html (2) http://en.wikipedia.org/wiki/Price_elasticity_of_demand (3)http://en.wikipedia.org/wiki/Cigarette_taxes_in_the_United_S...

"Would this be any different without Gov't intervention? "

When the government gets involved in any industry, they are allowed to play by different rules (because they make the rules) making it very difficult for private companies to compete.

Septics? You should see a doctor about that.

The one item missing here is a hot-topic of mine: emergency care. Not only are emergency services as expensive as the rest of medicine, but worse than that is the providers have a legal responsibility to care for the individual, who in turn has zero responsibility to actually pay the bill.

The other missing factor is that in a lot of cases, medicare/medicaid don't actually cover the actual cost of the procedure/service being provided; this leads providers and practitioners to charge more for those with better insurance in order to keep their businesses afloat.

worse than that

Are you saying poor people should just die when they are injured?

The emergency situation is the only time it should be reasonable for Dr.s to not have to provide webbased standard billing.

Not at all. I'm just pointing out how screwed up the system is that the government requires practitioners to treat people but doesn't provide the financial resources to pay for it. I've worked in systems that basically were bankrupt repeatedly because they kept providing the services they couldn't afford.

My point isn't that the providers shouldn't be legally required to provide the care (the truth is we would and do anyway); rather, something needs to be done about how costs are distributed in order to prevent hospitals, clinics, urgent cares and 911 services from going out of business.

The emergency care trope gets repeated frequently, but the truth of the matter is that hospitals over-allocate costs to the ER, and then overcharge for ER services, and then write off the inflated charges, all to game statutory reporting requirements.

So what the public sees as loss-leading ER services pushing up costs for everyone is actually an accounting gimmick. The true costs lay elsewhere.

The initial bill is written KNOWING that it will be discounted. Prices are obviously jacked up so they get negotiated down to something reasonable, just like any scenario where haggling is normal.

I was just in the ER and got the claim forms. Price paid was about 1/10th the initial bill.

If hotels billed like hospitals, they'd offer rooms for $1000/night and settle for $100 when you flashed a Hotels Club card, which everyone would have, pay a flat rate for + deductible, and would use to the max to squeeze every penny of value out of that flat rate.

I recently had an appendectomy. It was 40k according to the hospital. My insurance negotiated 27k of that down to 3k(3k is my policy max for an appendectomy apparently) and then left me to pay for the other 13k. In the end, my insurance paid 3k and I paid 13k. The initial bill is written knowing that some people won't pay, some will get huge discounts, and others will get stiffed with the entire thing. The discount is far from guaranteed--even with insurance.

The problem is you have no idea what kind of terms that Hotels Club card gives you. I had no idea what my insurance deemed is the maximum reasonable charge for an appendectomy, how much the hospital would bill, etc. If I knew how much my hospital was going to bill I would have passed on certain procedures. For example, I would have saved $800 by not having a CT...which is actually acceptable care if you have enough clinical symptoms of appendicitis(and I did). I would have also refused an overnight stay and left immediately after the operation.

What are the ways to negotiate the hospital bill down? What leverages the patient can apply after the service has been delivered?

Step #1: call hospital billing.

Thing is, almost nobody bothers with even that first simple step.

Well it seems to me we are all in the wrong industry!

I'm sure none of these healthcare guys have to deal with fierce competition from all over the world, exponentially increasing automation, the constant threat of outsourcing, etc...

Someone mentioned how the hospital charged him $125/hour for a nurse and all she did was bring a glass of water to the patient. Try to extrapolate that situation to IT and see what kinds of crazy numbers you get.

So, why is it again that we don't just run hospitals like any other civil service (police, fire, defense), fund them with taxes, and treat the care as something that a civilized government should provide?

Having given government a monopoly on force, it would seem that we should expect it to heal as well. This is absurd.

The fire department turns up when your house is on fire, sprays water on the house, and goes home when the fire is out. Their work is well defined and self-contained.

Medicine is a completely different situation: As people get sicker, you can dump practically unlimited amounts of money on them to extend their lives by a few more days. If you're not willing or not capable of deciding who is worth treating (aka "government death panels") and don't want unsustainable government spending, the only solution is to not get into the business at all (and let insurance companies take the blame for saying that little Johnny's cancer is too expensive to treat).

Exactly. The problem with health care is that a person's life is worth as much as they're worth. It's easier to say, "I'm sorry ma'am, we can't send anyone into that burning house, otherwise, they'll be killed," than it is to say, "I'm sorry ma'am, but at best, we can do this experimental procedure with a 10% chance of extending his life for a year, but it's prohibitively expensive.

This is, obviously, and extension of the problem of those with the resources (money) not wanting their life to be weighed equally with someone who has little or no monetary value associated with their continuing existence.

Then we probably need to come to terms with losing our loved ones, because this is intractable. I'd rather have "death panels" than the current situation.

I agree. I just hope we can have panels which weigh diseases impartially. The UK did this for a while via their National Institute for Health and Clinical Excellence, measuring the cost per QALY, but now the politicians have stepped in and decided that cancer treatments are "special" and should be funded up to a higher limit -- which is really saying that they're willing to kill two people who don't have cancer to save the life of one person who has cancer.

Downvote for problems only Americans have.

Downvote for being a shithead.

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