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Comment by rootusrootus | Hacker News Reader

Everyone blames the insurance company. But my pharmacy billed insurance 272 for a generic on the $4 Walmart list and it got paid in full. My doctor’s PA billed $440 for a 20 minute telemedicine call and it got paid in full. My insurance has never denied a medication or procedure ordered by my doctor. I think it’s not simply insurance companies that are the issue. For some reason people just feel more comfortable blaming them than admitting the doctors and other staff are massively overbilling.

Maybe we should try to fix that. They must be trying to hide other costs in those ridiculous bills to be. That’s not fair to me.

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The Affordable Care Act requires that "Insurers must spend at least 80–85% of premium dollars on health costs; rebates must be issued if this is violated." So insurers bought hospital networks, inflated the bills, and took their profit from the other side of the equation. Before you forgive your insurance company and blame your pharmacy and doctor, check first that they aren't owned by the same corporation.

Do you have any examples? I am quite confident I have never been in this situation, I have never heard of anyone except Kaiser patients (who are FWIW very happy with their service) getting this.

United Health Group is covered in "What Happens When Your Insurer Is Also Your Doctor and Your Pharmacist" - https://www.wsj.com/health/healthcare/what-happens-when-your...

There's also https://en.wikipedia.org/wiki/Centene_Corporation

You mentioned Kaiser Permanente who acquired Geisinger Health System's network of hospitals: https://en.wikipedia.org/wiki/Kaiser_Permanente

https://www.kff.org/health-costs/issue-brief/ten-things-to-k...

My extended family has been Kaiser for decades and it has plenty of faults (Bay Area region). I’ve personally had multiple severe misdiagnosis by tired over worked doctors. I’ve had massive ER bills with trivial operations. I’ve gotten damagingly inaccurate mental health care, and at times long delays to see various specialists.

The partnership of Kaiser and Reagan are largely responsible for the healthcare system America has today.

Do not give them a pass.

I think the term used to describe the imposed cost regulation is 'Medical Loss Ratio (MLR)', and the providers that own both ends of the claims transactions can use inflated costs to artificially manipulate their MLR.

Kaiser is great, until you get sick. Then it’s a nightmare, especially if you have anything complex going on.

I’m a physician that works at an ultra specialized hospital.

And I saw some chart of percentage claims denied that said KP denied the least at 7% while UHG the most or almost, at something like 39%.

Even if that were true that KP deny the least, it ends up meaning nothing if they also own the hospital who they graciously never deny claims from.

Ugh.

The gunman etched ‘Delay, Deny, Defend’ in those bullets.

UHG denies.

KP delays.

Both can lead to disastrous consequences.

Edit: And by delay, I don’t mean delay in seeing a specialist, I mean delay getting the most modern and up-to-date care. They have a tendency to practice population based treatment (and fiscally responsible), which may not be what is the most up to date. I understand it as an hospital administrator, but I can see the consequences as a physician.

Population based treatment is where nationalized care ends in

I would also add that those of us on HM are probably more likely to have good insurance versus what most Americans have access to.

Insurance carriers like low risk and thrive on people not fighting adverse decisions either because of a lack of time and resources or knowledge.

The variables matter. My insurance carrier has also never denied a claim, but I’m in more or less good health for my age, have an HSA (at a bank owned by the insurance company) with a significant annual contribution from the issuing employer, and I don’t have anything going on (at the time I write this) that would end up in medical review. And if I did have to deal with that, theres financial cushion available to me to rely on while I fight it out with insurance.

Exactly this. Me and the wife were talking about this a few moments ago and concluded that the entire health system in the US is fucked. I've seen people post itemized bills from their outpatient procedure or brief hospital stay and, to a European, it's mind boggling. People in the US are getting gouged on everything healthcare related.

Wife's position is that the free market works fine for non essentials but when it comes to essentials that you don't have a choice but to pay (water, medicine, housing, food) the market can be dangerous. Telling someone that their life saving cancer treatment comes to 500k isn't far from putting a gun to their head and saying "gimme 500k or you're dead". It's why I support ideas like the British NHS (it's not perfect but it's free), zero water charges for homes (paid through income tax, with surcharges for heavy usage like swimming pools).

> housing, food) the market can be dangerous

Housing and food are free market because they are easy to get substitutes for in most of the western world (move to a different neighborhood, buy different food). Those two categories don’t really belong with water and healthcare.

The barrier to entry to provide tap water or provide healthcare is very high.

Housing in Ireland isn't a free market. We have had a chronic shortage of housing for decades, but the influx of asylum seekers has put more pressure on it. Renters stand in lines half a mile long to view a grotty shoe-box that costs more than a mortgage. But yeah, maybe in other places it's different.

Yes, food is a free market right now, and in addition, it's subsidised (well, production is). Wait 20 years though, if climate change driven storms and floods destroy whole crops, that could change things dramatically.

> food are free market because they are easy to get substitutes for in most of the western world (move to a different neighborhood, buy different food)

In the US, a very small number of corporations own nearly all the supermarkets.

You can move all you want, it is the same stores (possibly under different brand name, but same ownership).

Grocery stores have thin margins because they have competition or threat of it.

Don’t go to a supermarket then? Use farmers markets, local butchers, and local coops if you don’t like supermarkets.

You might be surprised how hard “move to another neighborhood” can be for some.

The closest analog for a market of essential services is the kidnapping for ransom market.

You could say that insurance creates that environment, and profits from it. Insurance actually makes more money on the big bill, since they just charge whatever premiums are required to pay it plus their percentage. The bigger the better.

And insurance creates the disconnect that allows a price to have no feedback control.

They are happy to collect their income and benefit from the system they create, so they should not be granted any excuses for it's failures.

The poor insurance companies are not the abused parties here.

The insurance industry is the reason the drugs and all the other healthcare costs so much to begin with. They lobby and bribe hard to keep the US the only developed nation without nationalized healthcare and give you the illusion of free market choice while providing substandard care at inflated prices. It's regulatory capture at its worst. Their greed directly kills people every year.

That's why nobody shed a tear for that guy. His company was among the worst.

Insurance companies are a major of not the primary cause of those prices:

- they require deep discounts to put you in network, so providers increase their prices such that they end up whole after the mandatory discounts, that is why you can very often get your bills slashed to a fraction of the original if you pay crash

- obtrusive insurances means offices waste hours working on insurance instead of medical duties and many need to hire dedicated clerks

Health care billing works like a black Friday 'sale' where the price is jacked up and the 'sale' price is the same as the normal price.

Usually health insurance 'negotiates' the price down to what it should cost and then you pay the full 'true' cost.

When I had my wisdom teeth out my insurer negotiated the price down from $4k to $700, of which I paid 100%.

> Maybe we should try to fix that. They must be trying to hide other costs in those ridiculous bills to be. That’s not fair to me.

The thing is, your doctor is likely not making that much in the end. Because he needs to keep a staff of "offensive coders" who make sure that the insurance company actually pays for the correct procedures, and a couple of helpers to deal with all the paperwork.

Then they also need to deal with patients with poor insurance who can't pay. Trying to get payments from these patients is soul-crushing, and doctors typically just don't bother.

$440 for a quick call is also unusual.

> The thing is, your doctor is likely not making that much in the end.

what defines "that much" a hundred bucks? a thousand? a million? a hundred million? a hundred bilion?

That's an interesting question. Here are some answers:

> Medicare physician payment has decreased by 26% since 2001. Additionally, a recent Harvey L. Neiman Health Policy Institute study found that physician reimbursement per Medicare patient decreased 2.3% between 2005 and 2021 when accounting for inflation. And this was despite a 45.5% increase in physician services to each patient. Again, less pay and more work.

https://www.medpagetoday.com/popmedicine/popmedicine/110901

Medicare patients are not the majority for practically every doctor.

It's even worse in the non-Medicare world. There's a reason hospitals are getting rapidly bought out by the private equity.

And to give some context, UnitedHealthcare has a payday service. For doctors. To help them borrow against future claim reimbursements. At the 35% rate.

Nice, ain't it?

My family is doctors. Parents, cousins, aunts and uncles. Don’t know one user of this service.

True, the issue is pretty much the entire US healthcare “system”. But insurance companies do play a not insignificant role in that.

The primary discussion being had is about a single company using AI to make life or death decisions, and getting it wrong repeatedly without consequences.

I assume you work for a pr cleanup team and are attempting to railroad the discussion.

> I assume you work for a pr cleanup team

I encourage you to seek therapy. Life can be happier.

if the insurance company was good, wouldnt they negotiate the rest down to keep their own rates down?

Shouldn’t competition eliminate over billing? It doesn’t because there isn’t much competition due to lack of supply of doctors.

Why is there a lack of supply of doctors? Because the ama deliberately lobbied congress to decrease available residency.

We also don't honor medical degrees obtained from non-US institutions. I know several folks who were doctors in India or elsewhere, who have blue collar jobs in the US because their schooling is not recognized here.

Not every med school graduate matches for a residency in the US.

If your point is that artificially limiting supply of trained medical personnel leads to reduced access, inflated prices, and worse outcomes overall, then I'd agree.

It's a factor. I just think it would be easier to make sure there are residencies for US graduates whose training is more aligned with US Healthcare than to import foreign doctors who also require training for transition.

I'm not sure which would be easier, or if that's even a useful measure. Both seem like points of leverage to [in/de]crease supply. I think we should do everything we can do educate, enable, and employ citizens to the highest degree of which they are capable or desire. I feel similarly about putting the talent of new immigrants to work as well, and I don't see inherent conflict there. Growing the pie can mean larger shares for all.

Not all resources can be grown like pie, notably land. Economics is the study of scarcity.

Are you afraid of running out of land?

https://johnmjennings.com/how-much-of-the-u-s-is-inhabited/

Not all land is equally habitable, and there's also important things like the environment. Farmland dirt wouldn't be blowing away if there was interspersed forests to slow the wind down. I'm tired of the infinite growth cultists who are willing to sacrifice every 2nd order effect so line can go up.

> I'm tired of the infinite growth cultists

You sound like one of those Malthusian cultists. :P

Fortunately for us all, Thomas Robert Malthus was wrong in 1798 or none of us would be here today. That he would continue to be wrong today should be no surprise. Relevant criticism of his rather gloomy take on population growth abounds: https://en.wikipedia.org/wiki/Malthusianism#Criticism

It seems to me like he didn't factor in the effects of the development and widespread application of new technologies to old problems.

As an individual I'm interested in maximizing quality of life, not maximum number of lives.

And no, I am not wromg. Houston has no zoning and was able to keep growth going and build lots of new houses. Of course they did so in a flood plain. Because growth cultists are willing to sacrifice everything, even lives for growth to continue just a little longer no matter the cost.

> And no, I am not wromg.

Setting your spelling aside for the moment... You haven't said anything Malthus didn't say in 1798.

I think it's fair to say standards of living have increased since.

Malthus wrote about zoning?

>standards of living have increased since

Everywhere or just in some places? There are more slaves today than in malthuses time.

People usually cite the green revolution as the refutation of malthus. I see it as an engineering tradeoff. Every 2nd order effect was sacrificed for a single KPI. An economist would call them unpriced negative externalities.

> Malthus wrote about zoning?

He absolutely wrote about land use and the planning thereof.

> There are more slaves today than in malthuses time.

By total number of individuals, maybe (though ChatGPT seems to think otherwise). By percentage of world population, not even close.

> I see it as an engineering tradeoff.

I see some of that. I see both negative feedback loops and virtuous cycles of positive feedback. Constructive and destructive interference. I also see an incredible explosion of education, information availability, flexible automated manufacturing, advanced material sciences, driving of food calories toward $0, lifting of disease which robbed humanity of unfathomable time and energy, and on and on. I see world solar panel production supplying world electric demand sometime in the 2030s. I see us getting better at regenerative agriculture. Mars has as much land area as Earth, and I think we can go farther if we put our minds to it.

There literally aren't limits. Except the ones we place on ourselves.

>There literally aren't limits. Except the ones we place on ourselves.

This is the most delusional take I've ever seen. Limitations are built into the universe as entropy. No limits is only a locality mirage that exists only because you don't live long enough to see the limit get hit.

That being said air is free because it's a mirage, the sun powers plants and animals to continuously recycle it but once that source runs out then we hit a limit. As a local phenomena we can treat air as if it's free even though it's not.

But air is like one of the few things that are like this. The next thing, water, people pay for water. And people pay for water because there is a limit on it. On top of that the fact that we pay for everything else means that even as a local phenomena there are limits. If you think humanity has been on a continuous quest of breaking barriers and jumping over limitations, that's false. All humanity has been doing is optimization. Best utilizing what we already have to delay the impending termination of when humans hit the final limit.

> That being said air is free because it's a mirage, the sun powers plants and animals to continuously recycle it but once that source runs out then we hit a limit.

> And people pay for water because there is a limit on it.

Both exist in massive quantity in the asteroid belt. Europa has larger oceans than Earth. Your personal financial limitations aside, I was talking about what the human race can accomplish as a whole when we set our minds to it.

> All humanity has been doing is optimization. Best utilizing what we already have to delay the impending termination of when humans hit the final limit.

Final limit? Never heard of it. Is that a band name? The https://en.wikipedia.org/wiki/Kardashev_scale considers a type III civilization capturing and using all of the energy emitted by an entire galaxy. And folks have proposed larger more capable civilizations yet.

> Europa has larger oceans than Earth.

Then move to europa. I for one will stay here and enjoy the abundance of n-1.

> Then move to europa.

I'm sure humans or something descended from us will, in time.

> I for one will stay here

Looks like your limits are self-imposed after all.

As a locality phenomenon you will not live long enough to see a time where humans mine water from space. Let’s not even get to the logistics of it.

So for all intents and purposes, water is limited for you and your limited life time.

Well said.

Doctors per capita is actually up (according to wikipedia at least). So there's more Doctors available now than there used to be.

https://en.wikipedia.org/wiki/Physicians_in_the_United_State....

The types of doctors aren't evenly distributed—for a while there was shortage of primary care doctors.

Depending on where you live, it can take months to see a specialist.

It's still overall far fewer than in many other countries: https://worldpopulationreview.com/country-rankings/doctors-p...

Going up doesn’t mean anything. Compare relative amounts per capita to OTHER countries.

Hard to so around for a good deal when you're bleeding out and all the prices are hidden anyway.

How can there be competition when no one will tell you their prices?

Pick any major city in the US and tell me how an ordinary consumer can compare prices for a simple procedure like a chest xray. It’s not possible. Now how does one shop around for a cancer doctor or an ER visit?

Medicine is not a classical marketplace. Homo economicus doesn’t play his part.

How can competing doctors even afford to not tell anyone there prices if a competitor can gain a huge advantage simply by telling people there prices?

There’s not enough supply. Not enough competition such that all doctors can pull off this bs.

Last time around trump mandated that all providers publish their price lists but most providers just ate the fines instead of doing it.

Because not enough competition. The person with the cheapest price in a competitive environment obviously wants to advertise his prices.

In the case where real choice is possible, yes.

The choice is possible here. There are many doctors. Each doctor CAN display there prices. They don't want to. Why? Because there's not enough competition for them to need to.

Sometimes free market doesn't lead to competition.

UK national railway is sort of free market. The state runs the network, sells the tickets and decides the routes, but provides are chosen in open tenders - lowest price wins. They get paid for operating the route for the state-owned network.

But it then usually turns out that the only operator who can bid on the new tender for the route is the existing one. After all, they have a ready supply of trains meeting the technical spec! And if, say, the drivers go on strike demanding yet another pay rise, the providers shrug their arms and ask the state for a top up. After all, the state doesn't have an alternative either.

Free markets lead to maximizing corporate profits, but it's not a given that these correlate to a positive outcome for the society.

Right. But doctors are regulated by government and the regulation is for a good reason but it also has bad side effects.

Doctors are not part of a free market. Supply is regulated like a cartel.

I don't think you've got that right. There is an extra level:

Network Rail - the gov owned infrastructure, rails etc.

Rolling Stock - privately owned trains

Operators - lease rolling stock, employ staff, sell tickets

The problem we have is that the operators are barely profitable so always cutting quality/service because there is this other layer of private rolling stock company acting as landlords which are sucking all the profit out.

We have a similar problem with energy. There are the customer facing providers which are basically a brand and a call centre which are selling the power from energy generation companies. When they get trapped in some bad contract as a gamble on the energy market, they go bust.

It feels like a deliberate con that the customer facing providers, the brands the public knows about, keep going bust and earn public ire from their crap services but they are really scapegoats for a less visible layer of private company which are doing the real profiteering as landlords.

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