Comment by frellus | Hacker News Reader

Comment by frellus | Hacker News Reader

Parent Full thread

One of the baffling things to me is lack of price transparency and incentives for consumers to make value based choices.

Example: I just got some medication I take daily forever. Insurance will only allow it to be distributed at 90 days (qty 90) and my co-pay is $30, so 4 trips to Walgreens and $120. I just got them to fill the entire 360 pills using a GoodRx coupon and paid $53. It took a but of convincing the front clerk I knew what I was doing, he couldn't add it up in his brain how it was cheeper not to go through insurance.

Now imagine managing your health was like running your car. Everytime you went to the gas station you would pay a fixed amount through insurance, but you're only allowed to gas up once every two weeks. Need car repair? I agine your mechanic calling your car insurance to try to get the work approved -- you need a brake job, and instead of costing $500 it will cost $5000, but since the mechanic is in-network they have pre-negotiated the rate to $600 and you pay that amount until you hit your annual deductible of $5000 for the year.

The system is built for manipulation, anti-competitive practices and fraud. Think about it. Who wins? Everyone except the consumer, who has been convinced its the only way to transact is through insurance, and if it were just bigger and more centralized it would certainly be more efficient so lets get a single-payer system! That will be the final nail in the coffin of our world-class healthcare in the US. There will be no more specialization, as the system will incentivize (if not demand) commoditization of skills and services.

This is one of those things that sounds really great - and would be helpful - but not have the significant impact that it might initially seem outside of prescription medication.

The reality is that price transparency already is federally mandated and you can get a list of every contracted rate for every procedure any doctor that is credentialed with your health plan will perform. They’re all available on every national payer’s directory in a machine readable format and updated every month. Startups have formed around making this data available to consumers. This has been the case for a while (well, the number of procedures was limited before, but the concept still existed). It made headlines years ago.

The problem is three-fold (there are multiple but these tend to be the most problematic):

1) It’s almost impossible to know, for any non-trivial visit, the actual procedures that will be performed. This makes price shopping almost impossible to begin with. Not only is it difficult to understand up front, it can (and does, with regularity) change halfway through the procedure - sometimes even after the fact if the procedure was improperly coded. To some extent this is just a result of an overly bloated and complicated billing machine, but it’s a real issue today.

2) Healthcare consumers at their most vulnerable (and, typically, most expensive) are not in a mental space to be price shopping for care. Savvy individuals might comparison shop before an orthopedic surgery, but nobody who just suffered cardiac arrest or was diagnosed with cancer will spend weeks finding the affordable doctor.

3) Healthcare is an intensely personal and emotional interaction. People don’t want to price shop for care even if they can and are in the headspace for it. You don’t want the budget doctor performing the bypass surgery, you want the good one if that’s an option for you.

This can and likely will change in the future. But today the system is broken much beyond price transparency.

> The reality is that price transparency already is federally mandated and you can get a list of every contracted rate for every procedure any doctor that is credentialed with your health plan will perform.

First, this just isn't true. Some providers are choosing to pay fines instead of releasing their prices. More importantly though, there's no standardization of codes, so you can't actually compare the prices.

These rates are mandated of payers, not providers (outside of hospitals), and essentially every national plan has published rates online for all providers they contract with. They are not the cash pay rates, because that is not how most patients consume healthcare.

Second, there is a standardization of codes for the most common procedures one would shop for, which is CPT. There are HCPS, DRG, and other codes as well - but they’re much less common among the types of care one would reasonably shop for in advance. A crosswalk between code sets is also possible for many procedures.

There is certainly not a standardization of the use of codes in all cases, which I alluded to in my message. It’s extremely challenging to know what codes you will receive. And placing provider malice aside, often times providers themselves do not even know what it will be before going in.

To this end, bundled episodes have become increasingly common for certain types of procedures. But it’s far from exhaustive and there’s much room to go.

In any case, the goal was never for this data to be directly used by patients. It was to expose the data, and make it available for third parties. Most of those efforts have fallen flat not for lack of data, but lack of a patients ability to reasonably engage with it for the reasons mentioned above.

You can see more about the act here: https://www.cms.gov/healthplan-price-transparency/plans-and-...

Reply on news.ycombinator.com