> Sesame doesn’t accept health insurance (which also keeps prices low). This makes it ideal for Costco Members that prefer to pay cash for their health care, whether it is because they are enrolled in high deductible insurance plans, are uninsured, or simply appreciate the price, quality and convenience of Sesame.
$29 upfront rather than $25 copay + random bill for and additional $125 a month later for a 4 minute appointment sounds pretty good.
We saw the same doctor the same day, back to back. Got prescribed the same antibiotics.
I had "good" health insurance, she had none. My bill AFTER insurance was higher than her bill without insurance.
I'm really not sure the moral but it was frustrating as heck.
> We saw the same doctor the same day, back to back. Got prescribed the same antibiotics.
> I had "good" health insurance, she had none. My bill AFTER insurance was higher than her bill without insurance.
> I'm really not sure the moral but it was frustrating as heck.
The moral is that any system which introduces price opacity will gradually increase the price of the product until the price is above what the market will bear.
Look at it this way - at the point of purchase, you are buying a product with absolutely no price information, because "the insurance will take care of it". With no price information to the consumer, there is no price discovery, and without price discovery the supplier will increase prices beyond what the consumer is willing to pay.
If all medical insurances were banned, the cost of medical will not exceed what the market will bear: it can't.
But that's extreme - how about a practical and workable solution: no private dealings between medical insurance suppliers and medical service suppliers.
You have medical insurance? Lovely - you will be forced to submit the claim yourself. When you visit the medical services supplier (doc, hospital, pharmacy, etc) for non-emergency services[1], you will be liable for the bill, and so you will have to lookup what that/those particular code/codes cost/s.
In this way the cost of medical services will actually come down, to what the market will bear.
We've seen the same thing with US tertiary education - free money introduced into the system by the government caused tuition fees to skyrocket, with all the profit captured by the providers. IOW, the price rose to what the market will bear, and since the government was the market in this case, the price rose to what the government was able to pay, which is perhaps 3x to 10x what an unemployed 18 yo is able to pay.
[1] For emergency care, obviously the claim will be submitted to you by the hospital, and you can then forward that claim to the insurance. Even better would be if all emergency procedures have state-backed insurance.
Ah yes. Because I, the lay person, know exactly what all those codes mean and their actual costs.
> IOW, the price rose to what the market will bear, and since the government was the market in this case, the price rose to what the government was able to pay, which is perhaps 3x to 10x what an unemployed 18 yo is able to pay.
Strange how this didn't play out in (most of) Europe.
Why would you need to know?
Serious question - how does it help to know what all those codes mean and their actual costs?
All you need to know is $INSURANCEPROVIDER only covers $100 of a bill for $CODE. What do you care what the "actual cost" of $CODE is for $MEDICALPROVIDER?
> Strange how this didn't play out in (most of) Europe.
Because what the government was able to pay was a lot less than what the US government was able to pay, because the US government provided the money (with basically no controls on cost) and then made the student liable for paying it back. This way the state didn't actually care what the purchase price was, they were always going to get it back anyway.
My understanding is that in Europe (e.g. Germany), the tuition was paid for by the state! It's not a loan, the state is not getting that money back, and so there's pressure on the state to limit what it will pay for tuition.
Who is "you" then in this quote: "You have medical insurance? Lovely - you will be forced to submit the claim yourself. When you visit the medical services supplier (doc, hospital, pharmacy, etc) for non-emergency services[1], you will be liable for the bill, and so you will have to lookup what that/those particular code/codes cost/s."
> know exactly what all those codes mean and their actual costs.
Why would you need to know? How does it help knowing the actual cost vs what your out-of-pocket expenses?
You get $FOO as the code and $BAR as the cost. That lets the market discover, over time, which providers are charging $BAR+$EXTRA, which insurances only cover $BAR-$uncovered.
You can't have price discovery if the purchaser is not able to determine what the price is at the point of payment. If you have a better proposal for determining what the market will bear, lets hear it.
I'm not sure where you're going with this line of questions, but the impression I get from your comments are "People will find it too confusing to know how much they are are purchasing something for - let them only discover the price of the purchase after they have already bought it".
TBH, it's never a good idea to reveal the purchase price of something only after the purchase is made. There is no justification for it.
The problem with this view is that it assumes providers have relatively few SKUs and relatively static pricing, and that providers are relatively static over time. In reality:
- medical providers have an incredibly long list of SKUs, which can have adjustments (e.g. quantity).
- pricing changes frequently
- staff changes frequently. A bill is typically not a provider charging $BAR+$EXTRA, it's more like provider A working at facility B on procedure C has Price 1, but that same provider working at facility D on the same procedure has a different price. And all the prices are affected by the patient's insurance, and the specific contracts that were in place between the provider, the facility, and other parties at the time of service. (I'm simplifying this, in reality pricing is more complex).
It's entirely possible for Provider A to be the cheapest option in town (for a given patient-insurance combination) when a procedure is done at Facility 1, where they work Monday-Wednesday but the most expensive in town for that same patient when a procedure is done at Facility 2, where they work Thursday & Friday. This relationship can change frequently. Worse, this relationship can be subject to the specific service codes that end up being performed (all of these may not be knowable before the service begins).
I want to especially highlight the "over time" aspect as it assumes the relationships between any of these items are relatively static. In truth, it's entirely possible that your insurance carrier has a great deal for a given service this year, but next year has a terrible deal for that service at the same facility (possible because one of the underlying providers has changed). Second, it highlights the opacity in all of this. Even if you had the ability to digest all of the raw data, it's likely the outcome would not be very predictive at all for a given individual who needs to make a purchase today.
> If you have a better proposal for determining what the market will bear, lets hear it.
The market needs a lot more regulation. Think more like electric utilities instead of software.
In your case, they managed to negotiate such high prices that your co-pay is higher than the normal cost of the medical procedure. If you are on a Gold plan with a 20% co-pay, you can be sure that the money you paid is what went to the insurance company, while 4 times as much money went to funding healthcare!
You should be really happy about this, because this is a rule created to make sure your insurance funds hospitals, not Wall Street greed!
[1] https://www.washingtonpost.com/news/wonk/wp/2013/07/18/the-o...
It’s all a big scam.
hedge big losses with small investments, that's the idea behind insurances, isn't it?
It was even sold in a ridiculous way. “We all know health care is broken, so if we just force everyone to sign up, and give them more guaranteed income streams then it will fix itself!!”.
I don’t want to hear about how Obama actually wanted single payer or X. He knew exactly what it was the whole time.
“Medical billing” is an industry probably larger than medical care.
I fully support Costco here, insurance is a scam.
The entire idea was using the threat of losing access to Medicare $$$ to force acceptance of all ACA plans by providers in order to drive down cost negotiations for individual payers.
Large companies get to leverage large group sizes, and the idea of the ACA was to effectively turn all government aligned plans including Medicare into a single giant "all or nothing" group.
But when the courts struck that down, instead it became the exact opposite, allowing for even more division and sub-grouping across ACA plans, which drives up the end payee costs because there's little to no consequences for providers telling ACA plans to get bent.
The ACA as designed was effectively a compromise, and then the courts reversing the key compromise meant the overall result was a hot pile of crap outside of finally ditching preexisting condition lock-in (which was still a win overall, but a much more minor one).
The only such parts I know of are the mandatory Medicaid expansion and some stuff related to covering contraception. (And the individual mandate penalty was reduced to zero by Congress in 2017.)
I was not aware of any part of the ACA that required insurers to carry certain plans, apart from the general regulations it introduced on health insurance plans in general.
(The medical provider also likely won’t be able to provide accurate all-in pricing at the time of service.)
I think we're only a few steps away from patients having to place limit orders on medication like they're on ETrade.
Edit: I double-checked and now at least it gives you an "estimated price". But.. what is there to estimate? Why is there a real-time market rate for perfectly generic prescription pills? https://imgur.com/a/grNPBUB
You end up having to place the order and the charge shows up a little while later. It's never 2x or anything of the sort, but it's also bewildering that they can't tell you what it will cost.
Edit: My question is, is Sesame paying the doctors less, or are you actually paying $29 for a Nurse Practicioner/Physician's Assistant?
Allowing insurers to step in the middle of smaller, everyday health transactions by empowering them to negotiate price fundamentally screwed up the system.
There's no reason insurance should be involved in non-catastrophic or routine pharmaceutical purchasing.
The root problem is most Americans are too poor to afford healthcare at the current prices of doctors/medicines/medical equipment/liability protection/etc, period.
Also, the ideal way to use an HSA is to not use it. Every year, transfer the HSA funds to Fidelity, invest in VOO or whatever, and let it ride as long as you can. PDF all the receipts, and then pay yourself with tax free income when you finally need to.
> Fidelity offers HSAs for employers and, as of November 2018, individuals.[36] Individual HSAs have no account opening or transaction fees.[37] In a favorable review of the Fidelity HSA's features, the The Finance Buff wrote: "No other HSA provider comes close to what Fidelity offers."[38]
I would go to Fidelity.com/toa and start a transfer of assets from your current HSA. If it is an employer sponsored HSA where your employer contributes to it, then leave $25 to avoid it getting closed. But every year, move the remainder to Fidelity and invest the remainder like any other IRA.
My understanding's that direct withdraws are possible after 65, taxed as income. Does your "when you finally need to" mean only withdrawing for healthcare reasons or is there a way to transfer or withdraw without a tax hit, besides for health costs?
But pretty much everyone will incur healthcare costs as they get older, so you should be able to withdraw tax free for those. And all healthcare costs incurred by your family during your lifetime while you had an HSA are eligible for reimbursement.
Quite frankly, I do not know how auditable a 40 year old medical receipt is. Is the IRS' plan to just take everyone's word for it?
https://www.irs.gov/taxtopics/tc502
Never needed it, so don't know all the rules are, but I'd imagine the IRS gets a lot of fraud through it (since hospitals wouldn't report from their side).
I think you're not supposed to use it actually for healthcare, at least not in your young age.
Every HSA I've had[0], I just reimbursed myself for eligible expenses[1] by transferring from the HSA to my regular bank account. That amount then gets reported on line 15 of form 8889[2] the following April. If it's not an eligible expense, that's between me and the IRS—not the bank at which my HSA is held.
[0]: I highly recommend Fidelity, for anyone reading this and thinking they need a better option.
[1]: https://www.irs.gov/instructions/i8889#en_US_2022_publink379...
[2]: https://www.irs.gov/pub/irs-pdf/f8889.pdf (PDF)
Just tell me how much money I owe you and let me pay. When I find myself at a clinic, I tell them I don't want to use health insurance to pay. They just give me a bill and I give them money.
Belgium spends 11% of GDP on healthcare (https://ec.europa.eu/eurostat/statistics-explained/index.php...)
The US spends 18% of its GDP on healthcare: https://www.cms.gov/data-research/statistics-trends-and-repo....
> Also how bad are the wait times to get socialized medical care?
How bad are the wait times for not getting healthcare at all because your insurance doesn't cover it? Or because the associated costs will bankrupt you?
Middlemen can't raise the price that much; you could just go around them if so, either by not using it or by going to another country.
The US is composed of very fractured tribes, that people move in and out of throughout their lives. And US politicians are tasked with keeping taxes extremely low, and services very high, and the various tribes do all they can to give disproportionately little relative to how much they benefit.
Anyone who thinks the universal model standard in Canada and the UK is actually working has a hole in their head. The solution is a combo.
What's a "competitive healthcare market" for diabetes? Or cancer? Or childbirth?
> Anyone who thinks the universal model standard in Canada and the UK is actually working has a hole in their head.
The UK has a population of 67 million. There are half a billion patient contacts in any given year. I've yet to hear stories like "I can't afford my insulin" or "we had a child, the bill was 200k and we were also charged for holding the baby"
Same for "medication wasn't available": "my insurance doesn't cover the medication required".
The US literally has a video genre of "rationing of insulin to survive".
on average, system is good for bottom half but system is pathetic in terms of services after paying such high taxes.
The difficulty is for sudden situations like heart attacks. For these you need savings accounts and a baseline catastrophic plan.
You don't have unlimited fully equipped hospitals and operating rooms. You don't have unlimited heart surgeons. You don't have unlimited MRT scanners or labs doing blood tests.
In healthcare both the supply and the demand are inelastic. Market forces here work only for the most common and the most simple cases like nasal sprays and eye drops.
Furthermore a lot of innovation goes to increasing bandwidth of the existing doctors. See tele health.
I think you have a very limited view of what is possible.
Some of them did manage to release statements about how much they support the NHS before dying. I'd be more impressed if they lived though.
The United Nations World Population Prospects suggests current life expectancy in Australia in 2022 to be 83.79.
In fact, Australia enjoys one of the highest life expectancies in the world, ranking 8th out of 60 developed countries. That’s higher than the UK (81.65) and the US (79.05).
[ raw data source ] https://population.un.org/wpp/
So it appears that both Australia and the UK with National Health services (named differently in AU) have greater life expectancies than the US.
Perhaps it's the authors you read?
Bertrand Russell was 97 when he died.
US's lifespan is not caused by lack of access to healthcare though, that is fentanyl.
True, however Australia has a tiered health care system with a very low gap to ensure that practically the entire population has access to healthcare that they can afford in addition to national bulk pharmacy deals to cap generics for the bulk of ailments that require prescription.
For all it's warts the Australian system delivers a kind of healthcare that the US system does not .. widely available affordable treatment for the bulk of medical issues.
US (general mean both sexes) life expectancy sharply dropped as COVID spread, the most that fentanyl can be accused of is the flattening of the general slow increase between 2012 and 2018 .. even that ended and was on the increase until the USofA foot gunned its handling of COVID.
[ Historic USofA ] https://population.un.org/wpp/Graphs/Probabilistic/EX/BothSe...
[ Historic Australia ] https://population.un.org/wpp/Graphs/Probabilistic/EX/BothSe...
How do people with substance use disorders stop using substances? They use healthcare, unless they're in the US where they'll using some quasi-religious abstinence-only residential programme.
If you're talking about Douglas Adams, he died of a massive heart attack...in California, where he'd lived for years.
So, in summary, uh wot mate?
Though everyone in my family in Glasgow seems to live well into their 90s.
https://www.kff.org/report-section/ehbs-2022-section-1-cost-....
It is quite feasible that redirecting all of that to a tax-free savings account could pay for itself in no time.
That is not something any policy change can fix until far in the future. In the short term, all that is possible is deciding who gets allocated the available healthcare.
> It is not as easy as that because supply is heavily constrained
I don't think this argument works when the data shows 90%+ of the population has health insurance.
You can see echoes of this in other insurance products. Homeowners insurance, for instance: you insure against your house burning down, but you're probably better off not making a claim for non-catastrophic events, because you'll probably pay more than you would out of pocket, in the long run, when your rates go up.
Obviously, what makes health insurance especially annoying is that there isn't a transparent market for services the way there is for home repairs. Insurers work out special rate sheets with providers and quote bizarro numbers back to you. That sucks! But the underlying logic of insurance not reducing the cost of a pneumonia visit is still sound.
DME is pretty shit about getting back in touch with you unless you force them to via the doctors office.
Dropped them for Cpap.com with a script from the doctor.
What do they charge out of pocket? $800, do the insurance reimbursement yourself. Secondly, they'll call you up 15 minutes after you order and in 2 days later the machine will be on your door step. Filters here are $8 for 6. (Delhi, India was about $5 for 2 in a store with a label stamped from chicago)
Cause, y'know. It'll cost an arm and a leg to take care of that. With your insurance.
Also, if my wife has a baby at an in network hospital, and the anesthesiologist or whoever is out of network, I know that the healthcare is still going to be considered in network, and so we are still only on the hook for the out of pocket maximum. Also progress.
And if you are away from home, and happen to get into an emergency where you are taken to an out of network facility, you are still only liable for your in network out of pocket maximum, which is progress too.
Health insurance is not health care.
That being said, I'm not arguing whether everyone should be entitled to free/reduced health care - but I am making the point that insurance is just insurance; it's a hedge against an unlikely but costly event.
(Currently studying for my CPC exam)
Nowhere else would you have “insurance” which bankrupts you. How is that insurance? The point is it’s supposed to cover the whole cost for you.
It's not the $500 infection that gets you. It's the $60k knee reconstruction or the multi-million dollar cancer treatment.
It seems like medical profit motive has driven medical development too long and we could come up with cheaper, more effective treatments if medical research wasn't driven so much by profit motive.
(/someone with a very expensive condition, so don't @ me)
But even if he meant the total cost, the way insurance reduces risk through diversification is analogous to investment in a less risky index fund vs a more risky single company: beyond some minimal operational overhead, the risk reduction should be free.
Goodrx is great, but it doesn't save money for the majority of insured (for the half of the country on better-than-average plans) and it doesn't bring down costs nearly as much as you'd want for expensive medications. Cycling manufacturer's coupons for expensive medications can match or beat insurance copays when Goodrx won't. (And you'll increasingly find some insurance actually apply a manufacturer's coupon rather than cover directly. I had this happen recently with a 90-day supply of Freestyle Libre 3.)
Once in the store you open the GoodRx app and in there is a discount code that the pharm tech at the counter will enter into their billing system that will give you the listed price in the app. Oftentimes I have discovered that the pharmacies keep a list of these types of codes (GoodRx is not the only one, just the one people know about the most due to advertising) and once I show them the app they will try a couple of other codes off their list and sometimes I will get a price that is even marginally cheaper (perhaps 5%) than the GoodRx price I showed them. There’s also huge variation between places. My local grocery chain’s GoodRX price is usually less than half of what Walgreens’ price is and usually at least 25% cheaper than Walmart and Kroger
As to why I have to ask them to remove it, two reasons:
1: most people just assume insurance is always best, when it isn’t.
2: because lol USA healthcare, of course it only makes sense to do this with some of the meds I take and not others. My cholesterol meds are so cheap it doesn’t even matter whether they are insured, and some of my other meds are evergreened to hell and using insurance actually does help by a significant factor, like saving 75% or more. It’s this third class of Expensive But With Actual Competition where this GoodRX stuff comes into play. So half my meds insurance pays for and the other half I pay out of pocket. lol USA healthcare
For generics the discount cards can often make the price lower than the prescription co-pay.
Profit.
The linked blog post: https://sesamecare.com/blog/sesame-costco-partnership