Comment by LorenPechtel | Hacker News Reader

Comment by LorenPechtel | Hacker News Reader

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Absolutely agree on the negotiated price bit. That is the root of an awful lot of evil.

I have no problem with the sale of medical debt--what's needed is sanity in the debt collection business. Combined with making one-party record the law of the land--you're automatically free to record telephone calls without notice.

Bill forgiveness as charity? No, that's counting twice. They didn't collect the debt in the first place, there is no profit to be taxed and thus you are deducting $0.

ER: Two problems here.

ERs are mandated to stabilize a patient, urgent cares are not. Thus you see people in ERs with situations that could be handled in an urgent care because the urgent care rejects them for unpaid bills. And the ER can't provide those services just as cheap--a big part of what you're paying for in the ER is potential even if it's not actually used. The freestanding radiologist books their machines as solid as can be done without too much friction. The ER needs the same machines but needs them available NOW. I've been in an urgent care over a kidney stone--they had a CAT manned and ready to go at 3am (the only urgent care in town even open at those hours even before you consider the machines--every ER needs those machines 24/7.) CATs don't cost much to run, the main cost is the machine and personnel time (operator and radiologist) and that's incurred whether it's doing anything useful or not. (And then the urgent care punted anyway. Yeah, you're right, stone, we can't deal with it, go over to the ER.)

I will also say that transport isn't always as simple as you make it out to be. Consider that stone I just mentioned--the ER was half a mile away, trivial under normal conditions. Even under those conditions I could have *slowly* walked it--except there was a major street in the way and I most definitely did not want to cross that. Is a taxi going to take the call? No. Call a friend/rideshare/ambulance.

RE medical debt sale - if you have the ability to just sell debt easily instead of having to go through the process of trying to collect it you are not incentivized to charge reasonable prices as you can overcharge and then be perfectly fine collecting much less (but still above your costs) via selling it to a third party. Any debt that is incurred forcibly or as a matter of health of the debtor should not be able to be moved around. The hospital should have some skin in the game.

Bill forgiveness doesn't necessarily target the for-profit hospitals. Not talking about debt discharge. It actually probably isn't even the right term. Essentially what shouldn't be allowed is non-profit hospitals counting discounts for low-income individuals as charity performed by hospital. The value of the charity shouldn't be sticker price but actual cost of services. Maybe that is already the case, but what I hear from randoms suggest that is why some hospitals are happy to "work" with you on your bill. I shouldn't have included "tax-deductible" in there, this is more about maintaining non-profit status.

RE ER. I don't see how keeping the ER and Urgent Care separate matters. In a combined system you would still have two sets of doctors, two sets of CAT scan machines and operators and radiologists, okay maybe not separate but the capacity for both (an appropriately reserved). In the current system you actually have more overhead from having a whole separate billing system, HR, building, landscaping, etc. Yes, the ER still needs to stabilize a patient whether they can pay or not but that becomes *cheaper* when you have a whole other pipeline to send them to. You aren't engaging a highly paid ER doctor and set of ER nurses to prescribe antibiotics to the homeless person that just came in. You can have the RN, or an internal medicine doctor do it instead in the area down the hall. If at any point that homeless person starts to code or the RN/Internal Med doc identifies something concerning, they can get them over to the ER. But again, if you are the hospital why would you do this? You can take in that homeless patient and charge them big money for some antibiotics and hopefully get reimbursed by the government. It's not like the hospital would even lose money on it, you would still charge for the urgent care services, just at the reduced reasonable price it takes to provide them plus a little more. Heck, I'm sure that an urgent care wing incorporated into an ER would beat any standalone urgent care in the business sense, you've generally got a whole waiting room full of prospective customers.. but alas.. you would cannibalize your ER "sales".

And if that cannibalization of ER sales would leave the ER unprofitable, then raise your prices! I don't think any reasonable person would be mad if you charged what it actually costs to provide lifesaving care. Insurance companies would be okay with paying real costs for the fewer cases of legitimate emergencies if they know that the much more common cases of people going to the ER for more minor things would be much cheaper. I would posit that with urgent care support you would need less ER capacity as you wouldn't have it filled up with non-emergent cases.

And yeah, it would be ideal to have them in the same building close together. Retrofitting would be hard or impossible. It would mostly be for new hospitals going forward. It all boils down to designing hospitals to be the most efficient as possible at providing care to patients, not efficiency on generating the most profits.

ER doesn't become cheaper in this case because most of the cost is the potential.

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