Show HN: What 482 hospitals charge vs. what insurers pay, from their own files | Hacker News Reader

Show HN: What 482 hospitals charge vs. what insurers pay, from their own files

billmender.com

30 pointscuratedmcp15 comments

US hospitals must publish a machine-readable file of their prices, including the rate they've negotiated with each insurer. The files are huge (one is 36GB), in four formats and often messy, so almost nobody reads them.

I built a crawler that finds each hospital's official file and pulls out 29 common services. Across 482 hospitals: a moderate ER visit is listed at a median $1,285 while insurers pay $288; a metabolic panel is listed at $207 while insurers pay $11.46.

To keep it honest: only per-service fee-schedule dollar rates count (no case rates or percentages, which cover a whole visit), each figure needs at least 3 insurers, and every value is checked against Medicare reference rates. Surgery is excluded because insurer surgery rates cover the whole operation while the list price is one line item. Each hospital page links its source file. Feedback on the methodology is very welcome.

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This feels both very depressing and very helpful. I wonder if it would be possible to use things like this to call out the most egregious examples and get them adjusted through public pressure? Maybe be able to call out specific institutions in a region as being significantly worse than their competitors?

Calling hospitals in an area "competitors" almost made me vomit in my mouth... so maybe the problem is bigger than this.

As the OP noted, and as I’ve also heard from family who paid for procedures out of pocket, asking for a “cash price” gets the bill reduced significantly. It could be cut down to 1/10 of listed price.

In one case, I think it was related to getting an MRI done, the hospital out of pocket cost was comparable to the copay with insurance. That was my moment that made me want to vomit!

List prices are entirely fictional. Nobody pays them. Their sole purpose is price anchoring for negotiations with insurers. Hospitals know they have to give 80-90% discounts to certain payers so they set them high.

There is zero value in showing them. All they do is demonstrate a dumb pricing game that could easily be ended if the GOP didn’t conflate “single-payer” with “single-provider” and scream socialism.

Moreover 80%+ of hospitals no longer charge on a fee-for-service basis but through DRG (diagnosis related groups) as part of a value based care model. So these itemized list prices are doubly moot.

Very cool. I don't know what your plans are and whether you're trying to monetize this but I think a very simple extra feature would just be to allow a natural language search for those particular rows since people may not know what the procedures are called but an LLM would: e.g.

"broken arm at red cross hospital" or something

So why do American hospitals fly the flag if they dont actually want to help their fellow Americans ?

90% of americans have health insurance… so all this shows is 10% pay more than the other 90%.

And an uninsured person is more expensive to serve. You need to track down payment and they are less likely to pay.

So why do people die for the military for free ?

I think the main mechanism is that uninsured patients will just never pay because:

1) they're poor and have no money

2) medical debts are easier to ignore than other debts that these people also have (because they're poor)

3) they're going to die much sooner than insured people

...and the hospital knows this. So the hospital charges some large multiple of what they charge insured patients so that, when they ultimately sell the debt to the debt collectors at a deep discount, they come out approximately even. If somebody is somehow enough of a sucker to pay the sticker amount, it's just a nice surprise. The other victims of this debt will either just die and never pay, negotiate with the hospital to pay much less, or negotiate with the debt collector for much less.

Would this all be simpler and better if the prices were the same for insured and uninsured people? Yes.

> 1) they're poor and have no money

I had a kidney stone several years ago. I suspected, but didn't know, and the pain was crippling (vomiting, crying in the fetal position).

I went to the ER. CT. They loaded me up with pain killers and moved me by ambulance to another hospital 15 minutes away because they had no urologist available. They took me to theater, found some infection, abandoned plans, IV antibiotics, discharged me the next morning, to return 2 weeks later for lithotripsy or otherwise.

So I came in with a kidney stone, left with a kidney stone (and stent, and pain management).

My bill for this 12 hour process was between $60-70K.

"They're poor" doesn't cut it.

This is a very common thing. And while my presentation was less common, it's still not unusual.

You're not poor if you can't afford a $70,000 unexpected bill for an ER admission, a CT, an abandoned surgical procedure and a stent and an overnight bed on a ward.

> 2) medical debts are easier to ignore than other debts that these people also have (because they're poor)

"ignore" is doing some heavy lifting. There's an element of that, sure, but remember: these had to be legislated to not affect your credit score because they're almost always events that were not poor judgment on your part, but unplanned (they're not being generated from elective or cosmetic events). And people were being penalized for having the unmitigated gall of not having, to use my example, $70K laying around, "just in case" they got sick. And those penalties have real impacts. You still need a roof over your head if you're sick, but good luck finding a rental, let alone a mortgage, with that on your credit report.

Not sure I understand the confrontational tone. I agree with everything you've posted. By calling the uninsured poor, I just mean that the system is so bad for uninsured people that anybody who possibly has the means to get even the worst health insurance is likely to do so. There are exceptions I'm sure, but I've never met anyone who walked into a period of being uninsured without exhausting every possible resource available to them first.

For the most part, to be uninsured in the US is to be impoverished.

I apologize if it came across confrontational - my intent was emphatic "angry" agreement.

I was a paramedic for 14 years, and saw more than anyone should see with people having to use the emergency system for issues that could and would have been taken care of far easier, with far less discomfort, risk, and cost, if they had access to some manner of healthcare safety net.

>90% of americans have health insurance… so all this shows is 10% pay more than the other 90%.

And what percent of all claims are summarily denied forcing the person to fight the insurance company for months or years before they actually pay for anything?

Many people would gladly pay the lower price to get past the bullshit, but instead they are set up to die.

My friend is the administrator of a small hospital (~15 beds).

He says with insurance one of the problems is that the insurance company will sometimes pay out less than the cost of the service, and there's nothing they (the hospital) can do about it.

He says they actually have a slightly better rate of payment for services for non-insured patients.

Also he said there's a serious problem with people not paying their share of the bill, when the deductible has not yet been met.

Exaclty the system is squeezing the life and time out of all Americans, until they cant pay any more.

They will be old, barely able to walk, and their entire life was consumed by paying for healthcare, and they wont even be left with memories of good times.

Thanks for shining a light on the scam!

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