The True Cost of Healthcare in the US
truecostofhealthcare.org
truecostofhealthcare.org
Example 1: A procedure costs $6,000 to be done at a hospital. It prices out patients paying out of pocket. The doctor realized that he himself gets about $700 from it. So the doctor reached out to another facility who agreed to do it for $1,800 instead of $6,000 for the exact same procedure. You can imagine how happy the doctor's patients are, particularly ones paying out of pocket.
Example 2: A patient got upset a doctor's office wanted him to pay copay. The patient got the bill and felt the doctor already got paid $1,500. When the office informed the patient that out of the $1,500 the doctor only got about $300, the patient was shocked.
Really what we need is a doctor compensation to everything else index. When we get that, we will realize the sham most of the efforts to reduce healthcare cost is. Most healthcare cost efforts focus on paying the doctor a little less, say $300 instead of $400. Problem is, bulk of the cost is not the doctor's fees. It is the cost of the bed, breakfast, Tylenol etc. We need regulation on those fees.
The real problems here especially with emergency care are that hospitals are forced to eat the cost of treating non insured patients, and that patients have no idea what something costs when they are there or if the people treating them will be covered by their insurance. Insurance companies spend a lot of time negotiating rates and making them somewhat uniform for them, but this is totally opaque to the patient. We need to make it more clear to the people being treated what things cost, and who is "in network". There have been times that I went to an emergency room "in network" and I was "balance billed" by nearly every doctor there due to them not being in network. What is a patient to do? Sit there with a book of providers and procedures?
It sounds plausible but I'd love to verify it. I have no idea what % of people in the emergency room are uninsured and what % are not in an emergency setting.
Remember that emergency rooms cannot turn people away, doctors can.
Poor people in general often don't have primary care providers -- even with Medicaid or private insurance. Reasons are varied and complex. Access is a big issue... for example, if you don't have a car, how do you get to the only doctor who is accepting new medicaid patients across town?
That problem is not unique to hospitals and emergency centers. My father runs a private practice and he can't collect payment on a double digit percentage of patients. Yet, because he is a private practice, he gets compensated significantly less than a hospital for same procedures.
I am not convinced that the root cause of high hospital cost is to make up for patients that don't pay. It seems to be a circular argument given that a decent percentage of patients can't pay because the cost is so high.
One root cause is that the Federal government (ie. Medicare) must get the best deal. If you give anyone else a better deal than Medicare, you are committing an act of fraud, and DoJ will go after you. This is known as a price floor.
Layer upon this the web of contractual arrangements surrounding different insurance providers, and you get to a place where you need to mark up the MSRP of a procedure to safely operate as a business.
The issue with poor areas having bankrupt hospitals is obviously complex. Hospitals are good for emergencies, really sick people and procedures. Not so good or profitable for primary care -- they are a lowest common denominator. You cannot afford to scale up quality outpatient medical practices if you are reliant on Medicaid to pay everything, and you can't operate small medical practices effectively and deal with all of the compliance activity that medicaid comes with.
Interesting; I don't see any obvious reason why other insurance companies couldn't do exactly the same thing by contract.
Can you charge Medicare for things Medicare makes you do that other insurance companies or individuals don't, such as billing them for time spent processing their red tape?
> Layer upon this the web of contractual arrangements surrounding different insurance providers, and you get to a place where you need to mark up the MSRP of a procedure to safely operate as a business.
Sounds a lot like selling enterprise software: corporate purchasers expect to receive a discount, so you can either antagonize them by not giving them what they expect, or mark up the price enough that you can offer "discounts" back to the real price.
Edit: The interesting thing was each doctor had an individual bill of $600 sent to me. These are still in collections. The phlegm sample cost $120 and come from a separate clinical laboratories bill.
My wife's birth control has a package value of $130/mo. Health insurance ($600 for wife, and kid), had a copay of $40 for this medication. I called the same clinic, requested generic and expressed my need to pay in cash. Instantly brought the price down to $8/mo.
I did not sign up for health insurance this year. It is a complete waste. I usually pay more than just asking for generic and paying with cash. The 'poor' clinics here have a higher quality of care and staff, and are more affordable than my co-pays.
Just to break down costs: $600/mo health for wife/kid. $7200/yr. vs ~200/mo + 1000 penalty. $3400/yr.
We're not exactly getting Xrays and CT scans on a daily basis in my household! If my wife was to get pregnant, I know most hospitals offer a specialized bundle plan for dealing with the pregnancy for a set flat rate. All check ups, ultrasounds, single doctor, etc, for $6000.
http://www.horizon-bcbsnj.com/SiteGen/Uploads/Public/horizon...
Payment for health care is composed of two parts:
You pay about EUR 867 to 1,140 directly to an insurance company PER ADULT depending on how much you want to pay yourself in case of required care.
Then there's the socialized income dependent part of the insurance that's either payed via your employer or by yourself, which, in the latter case, is 5,65% over up to EUR ~51 K.
A family of two, each with an income > 51K then pays between EUR 7,480 to 8,026 (atm USD ~10K) each year for health insurance, subsidizing insurance for lower income groups.
There are exemptions for members of certain groups (IIRC, Native American tribes and religious groups that are opposed to the concept of insurance, like the Amish). There are also exemptions for participants in "health cost sharing ministries" [0]. My family pays $135/month for what, practically, functions like a high-deductible plan [1] -- a little more expensive than just paying the penalty, but it's worth it to mitigate the cost risk associated with catastrophic illness.
[0] http://en.wikipedia.org/wiki/Health_care_sharing_ministry . There's a list of Christian health-sharing ministries at http://www.healthcaresharing.org/ ; I don't know what other religions or non-religions might have similar programs.
[1] the friend who referred me to this signed up for a no deductible option. He was diagnosed with cancer a month later, and they covered everything.
Wow. My girlfriend's birth control is $9/month, without health insurance (Target's generic Ortho Tri-Cyclen).
1. You are paying for a standing army. 1 hour of scheduled doctor time is much different than 1 hour of doctor time ready to deploy in an instant.
2. The ERs need to cover all the non-paying clients.
These two items probably feed on each other.
Emergency departments are about 1% of total health care costs. They can be a good indicator of other symptoms that are wrong (medical billing is a maze, on purpose[1]), but fixing it won't really address health care costs.
[1] http://www.thedailybeast.com/articles/2013/02/22/how-hospita...
This isn't really a sustainable plan for the nation.
Insurance companies wager paying the bill too. They say "We'll pay 60% of that $8000 ER visit."
Guess who covers 25% of that leftover 40%? In a majority of cases, the government.
(Source: My aunt has worked for a hospital performing these write-offs the majority of her 45 year life.)
I wish health insurance were more like car insurance (accidental coverage, not maintenance) and I think we wouldn't have the same convoluted pricing we have now.
* 9 out of 10 physicians would discourage their children from becoming doctors.[3] There are many reasons for this. Malpractice insurance premiums are a factor. Not the only factor.
* California physicians have the lowest insurance premiums in the country. This is directly the result of tort reform, and caps on pain and suffering payouts. His survey of physicians he knows in the area is subject to this sampling bias. Malpractice is a big issue in other states.[0] California is the model for tort reform for this reason, by not acknowledging this fact, he's missing a big aspect of the national (not just Californian) issues regarding healthcare.
* California physicians also have some of the lowest reimbursement rates in the country.
* As he indicated, internal medicine docs pay far less in premiums (as he noted) than other specialties. Surgeons pay much higher premiums. [1]
* The California Department of Insurance does a good job of keeping most premium information public. It's not a secret what your average doctor pays in insurance.[2]
[0] : https://en.wikipedia.org/wiki/Medical_Injury_Compensation_Re...
[1] : http://cl.ly/image/0m390m1F2D2D
[2] : http://www.insurance.ca.gov/0250-insurers/0800-rate-filings/
[3] : http://www.thedoctors.com/ecm/groups/public/@tdc/@web/docume...
I'm skeptical about tort reform as a panacea. However, lawsuits are incredibly expensive, and so doctors take steps that we would otherwise call economically unreasonable to avoid them.
The amount of tort reform I think is really necessary is whatever would allow me to set up a private equivalent to the UK's NHS here. If someone thinks they are getting denied care that they deserve to have, the decision needs to be very cheap to adjudicate.
Also, insurance premiums effect practices of different sizes differently. I personally think you can attribute the shift away from smaller private practice groups towards larger groups and hospitals are for other reasons. Insurance premiums are somewhat to blame, but I think the bigger driver is that many of the government mandates are too expensive (n.b. this doesn't mean it shouldn't be done) to take on for most smaller private practice groups.
I'm not sure how to respond to your comment about tort form if it get's us to an NHS like system, because I disagree that's the best way forward. But that's a topic for another day.
(I'm not advocating putting everyone into a government system run NHS-style system. Surely, though, me and a few thousand of my friends ought to be able to get together and attempt to emulate it if we wish.)
Personally, I think there could be some advantages in making a more patient-responsible system. The most expensive healthcare we have is ongoing (chronic) stuff, and most people with issues like that end up being experts on their own conditions. Why not allow them to get their own medicine and equipment directly rather than be forced to visit the doctor every N weeks to refill a prescription? Or be severely inconvenienced by being somewhere where it is difficult to obtain the right prescription for the medication they know, any sensible person knows, they need? That's silly and inefficient.
My understanding is that for all the attention it gets, malpractice insurance isn't that big a deal. But I haven't researched it very much.
Malpractice rates are a factor, not the only factor in physicians deciding where and if to practice. Just like reimbursement rates.
http://healthland.time.com/2013/02/20/bitter-pill-why-medica...
There were only a handful of actual statistics in there. The one thing he is wrong about though is that healthcare isn't "roughly 20% of the GDP", rather it's about 17.9%. The furthest out cms.gov gives yearly projections is to 2021, and even then healthcare is only supposed to be 19.6% of the GDP. And I think that might even include things like herbal supplements 'other non-durable medical supplies', I'm not positive about that though.
Source: https://www.cms.gov/Research-Statistics-Data-and-Systems/Sta...
So, the same root cause as many other problems in this country. As soon as we get the government into purchasing e.g. video games, closet organizers, computer security, vacuum cleaners, etc. we'll have the same problems with those industries we have now with healthcare, education, law enforcement, etc.
I would go for:
1) full price transparency
2) making price discrimination illegal
3) attacking the information asymmetry by providing a free, subsidized first line triage
Whether treatment is taken or the patient decides to do without it, making sure tests and diagnosis are performed could help proper self regulation of consumption
It could also be made as a public service since it seems very close to a natural monopoly (due to the subadditivity of the cost function - see for ex http://www.clt.astate.edu/crbrown/eleven1.htm - having big labs to process blood test gives economy of scales but require high fixed costs)
It could therefore be politically defensible on grounds of efficient pricing (ie pricing at the marginal cost, which requires subsidizing for natural monopolies since average cost are above marginal costs), to avoid deadweight loss.
The first line triage could then provide full price transparency (diagnosis -> probabilistic DRG), from which the patient could either decide to "wait and see", or to browse a catalog of hospital offering services (DRG -> prices) knowing the price paid would be no different with or without insurance.
At that point, it might be possible to remove all price caps and floors, and let the market work.
So basically, we could get a working market on the treatment side.
Traditional monopoly and oligopoly management (watching the HHI before allowing fusions) could then keep it that way.
I'm a bit out of idea however to have integral pure and perfect competition, at least until we get user-operable "all-in-one diagnosis devices" (like Star Trek tricoders) to remove the information asymmetry.
My last rants on this topic were posted on http://news.ycombinator.com/item?id=5261137
Why do insurance companies play such hardball with compensating private practices or medical groups? It would seem like it is in the interest of insurance companies for private practices to flourish given that the same thing done at a hospital costs the insurance companies 3-6 times more money.
Most doctors that I ask this question suggest there is a conspiracy where insurance companies are in bed with hospital. Frankly, I don't buy it. I'm probably missing something and I'd love to hear someone's take who has thought about these issues deeply as you clearly have.
For the record, my wife has gotten pretty good with the billing so I usually get paid for what I do. At first it was very painful because dealing with insurance companies has a steep learning curve in the beginning, but it's not so bad now.
It's still highly inefficient billing each insurance company for each separate patient I see just to collect the amount most people pay to fill the gas tank of their car but, that's hardly the worst problem with health care in this Country.
But at a macro level, don't you think the insurance companies have failed themselves given rise in private practices closing shop or being bought out resulting in insurance companies needing to pay a lot more to hospitals?
Edit - Given that we've got the NHS as well, losing your private coverage isn't such a big deal. It's nice to have, not a must have.
What would help too is ubiquitous electronic records management, e.g., any records from a visit with one doctor should be usable by the patient at another doctor.
Add to that cheaper testing and more AI / self-help and that should take it even further.
Lastly, kill the corn lobby and get some real sense into people about how their diet and lifestyle directly impact their health. What percentage of US healthcare costs are going towards diabetes and any related illnesses? And what percentage of that is directly related to obesity and a sedentary lifestyle?
That said, EHRs are definitely the way to go, and we'll see much more of them in the future. Once Stage 2 of Meaningful Use[1] kicks in, you'll see a bunch of hospitals scrambling to upgrade their IT infrastructure to make sure they continue to receive the bonus Medicare/Medicaid payouts they're receiving now.
1. http://www.healthit.gov/providers-professionals/meaningful-u...
One thing in common: They all suck, yet are all much better than our system.
By what measure? If you're trying to see a specialist -- say, to get a surgeon -- soon, our system is far superior, which is why Canadians routinely cross the border to take advantage of our system.
A still simplistic and incorrect but fairer appraisal would be to say that the NHS and Canada's Medicare are optimized for everyday care and our healthcare system is optimized for specialty care.
And on top of that the free market can provide extras using whatever economic model works for them.
Vermont, for example, is already ahead of the curve here.
Everybody seems to think they are smarter than everyone else when it comes to healthcare reform, but in all of the "smoking gun" articles that are posted, none of them have ever touched on this fact.
Even the new healthcare plan that passed does not address this directly, it assumes that the people who do not have healthcare will use a state healthcare exchange to get their own. I am a little pessimistic about this, and am assuming that only a small percentage of those people will do this.
Ofcourse this raises a lot of questions about responsibility. But in our society health care is making money when people are unhealthy. That is an unhealthy situation.
That said, the US healthcare system's problems go much much deeper than just single-payer vs private-public.
What he found was that the funding mechanism of health care over that time had shifted from patients paying out of pocket to government paying hospitals and government incentivized (by making it a tax write off for employers) and regulated (by preventing efficient pools of insured with state-by-state regulations) insurance.
Consequently, not only did the availability of health care go down, but the costs went up 26fold.
Or put another way, despite massive improvements in technology, medicine and productivity over 70+ years, costs skyrocketed from what you could afford out of pocket to what would bankrupt you. To put it in 2013 dollars, if you hypothesize a $100,000 surgery, in 1970[1] it would cost you $100,000, and you'd need insurance or go bankrupt, but in 1900 it would have cost you $3,846 (an amount you could put on credit cards today.)
Command economies don't work, and the change in health care over the last century has been a centralization in control. I with Obamacare this has dramatically ramped up and now there are boards to decide who gets what care based on cost measures, rather than medical need.
Whenever someone talks about the need for socialized medicine because "otherwise people would go bankrupt", remember it is the socialization of medicine that caused costs to rise to the point where people would go bankrupt.
[1] The study was originally done in the 1970s, but I'm using 2013 dollars here so you can understand how cheap things would have been.
How is this different from insurance companies, or are those what you are referring to? I'm really confused by your statement.
With regards to medical care, far too many types of care are required to be carried by insurance companies who then pass the costs to their customers. Hospitals do not get full reimbursement for all types of patients, specifically government covered patients, so they pass the costs along to groups who can and do pay. Those being individuals and insurance companies, the later nothing more than a collection of individuals.
The problem in all of these is the promise of a must-have little more if only repayment can be extended and others can be persuaded to contribute. What were luxuries become perceived as necessities. (And yes, I've said "no" to hospital tests, mortgage offers, and tuition financial aid.)
Comparing with 1900 prices is a bit of nonsense given that there was little surgery at that time as well.
Also, there are quite a few things that are inherently expensive: diabete, dialysis, cancer (things that would have got you killed in the 1900). I don't know about the US, but dialysis costs around 100-200k euros / year, diabete around 100 k euros / year in France.
I would be curious to know how much cancer + dialysis + diabete contribute to health costs. I am ready to bet it is not in the low 2 digits.
This makes your two middle paragraphs irrelevant.
If you want to just look at cancer here is a place to start: http://www.cancer.org/cancer/cancerbasics/economic-impact-of...
Much of the health care costs in America are generated by major medical issues. I've recently seen a number released by my insurance provider that said that 7% of those who use them for insurance generate 90% of the claims by dollar amount. The thing is, no one knows when they will be in the 7%.
Regarding everything about 'government' vs 'free market'.. do you feel like you're in a free market healthcare system in America? I sure don't. I feel like I have no idea what's going on with medicine and the only difference between my insurance bureaucracy and a government bureaucracy is that the insurance company is actively trying to fuck me rather than just passively doing it.
I'm not saying big government bureaucracies are great -- they're terrible. Yet every other industrialized country's disaster of a bureaucracy is miles better than our private-public system. They have the same cost issues and also have cost inflation, but it's less inflation on a lower cost.
Regarding the 7 % costing 90 %, it does not surprise me much (the figure I heard in France was something like 10 % costing 60 %, but I don't pretend for their accuracy). You need to take into account that the 7 % are not uniformly distributed (age being an obvious factor). Also, in France at least, there is no such thing as Medicare/medicaid, so the mandatory health insurance costs can't easily be compared.
Regarding the prince thing: I don't understand the argument of putting things from year X in year Y in 2013 dollars for things that did not exist at that period X. If we discover in 50 years a definite cure against say cancer, getting the price in today's USD is meaningless (how much would someone like S. Jobs be willing to have paid for it ? Much more than anything related to inflation).
I'm not sure how useful that number is, however, I'm pointing out that it doesn't add to the invalidity of his argument.
One solution that's been proposed is the increased use of HSAs + high deductible policies. That way people are paying their expenses out of pocket (for the day-to-day things at least), and are therefore more likely to shop around.
I'm not hear to argue the merits of that, but it definitely seems like an approach that might work. I fail to see how anything that takes control out of the hand of the individual will fix this problem (short of regulating the prices, which I wouldn't be a fan of).
But when you have a major health crisis, your "empowerment" is just fundamentally limited. If you get into an accident with a loved one and they're unconscious, you're not doing to be in a position to decide whether you should go to the hospital 1 mile away, that may be X% more expensive than the one 5 miles away. Your ability to price discriminate is also fundamentally limited by your own knowledge of medicine. If you have a tumor and one doctor suggests taking medicine A which costs $50,000, and medicine B which costs $5,000, is A better than B? Is it 1000% better? If it's only 2% better, unlike any other consumer product, are you trying to optimize for "value" or "not actually dying"?
There's definitely things we can do in terms of government policy to encourage more customer empowerment to bring down costs. But ultimately you have a market with unvoluntary participation and opaque pricing, which means Adam Smith can't really do his thing.
Before I used it, it seemed fine. I tend to do alot of research regarding upcoming tests/procedures and such, and so adding in an element of cost/shopping around wasn't too much more hassle.
In practice, it's been awful. I have no problem shopping around, but it's been essentially impossible to get the information I need to make an informed decision.
As an example, our primary care physician determined a procedure was needed and provided a list of specialists in the general area who were equipped to do it. So I filtered those for in-network providers using the insurance's website and then called those practices. Out of the 4: 2 refused to quote me the price at all; 1 gave me such a run-around that I eventually gave up; 1 (whose employee started our conversation with "We don't normally give this out, but Jane said I had to") gave me the price they would bill if I were uninsured. None of the 4 were actually able to tell me what they would bill me.
However, I did manage to get them to list the CPT codes relevant for the procedure, so I then called up the insurance company. Despite being able to list specific providers and the exact codes they would bill, the insurance refused to quote the member rate. The best they would do was give me that average cost for that CPT in my area which is useless if what you're trying to do is shop around within your area.
So, I don't disagree that people having a more direct link to the actual cost of their treatment wouldn't be a good idea, but until the system adjusts to provide up-front visibility into those costs, the only effect from that linkage is going to be post-procedure sticker-shock.
Because there are thousands of Canadians every year that go bankrupt because of health care costs. Your argument doesn't even begin to make sense.
Actually, there are. They go the US to get care that's not offered in Canada. The care here is about as good as former soviet bloc countries. If there was a chance that an illness such as cancer could kill me, I'd get out of Canada in a heartbeat and embrace poverty if it meant keeping my life.
Well, compared to what?
The odds of having your private health insurance rescinded in the US is also very small -- but it's quite likely among people who suddenly rack up big health care costs.
Similarly, if you compare Canada-to-US medical tourists to the Canadian population, I'm sure it's amazingly tiny. But how does it compare to the people of means who have a medical procedure denied by the Canadian system?
(I don't fault Canada for denying care in some cases. Sometimes it's not worth it. But the Canadian system would be better if people were still allowed to top off the denied care with their own dollars and didn't need to leave the country to get it.)
I could go on and on about the abuse my son received at the hands of the Canadian health care system, but I'll just say that I hate the system. At every step of the way, despite doing everything we could, my son suffered because of the system.
A part of me understands it's because it was Quebec, but Quebec is an example of how the Canadian system fails, and fails hard.
A part of me feels as if it was my fault. I should have moved sooner, when we were first lied to. But we figured if we played by the rules, things would work out. We were wrong.
So no. I'd fight tooth and nail to prevent that abuse from coming to the US. And if it did come, I'd leave. I will not let my family suffer like that again.
>> The numbers are vanishingly small
Maybe as a % of the overall Canadian population, perhaps. What about the % of critically ill? People with cancer? My aunt is an oncology nurse at one of the best hospitals in the nation, and she sees a lot of Canadians who come to the US for treatment that they can't get at home.
So yes, people with the flu or a broken arm probably aren't flocking here for care. People with serious illnesses? You bet they're coming here.
Here's a study that puts the numer of Canadians using the US healthcare system at about 0.61%: http://content.healthaffairs.org/content/21/3/19.full.html
As for that study, I'm a little concerned that they only looked at a handful of states, and this little line at the bottom:
"The authors acknowledge financial support from the Canadian Institutes of Health Research (formerly the Medical Research Council of Canada) for this research."
My guess: both your source and mine are biased and flawed, and the truth lies somewhere in the middle.
How many Americans (like Sarah Palin) are going the other way across the border?
According to one study [1], only 0.61% of Canadians are going to the US for healthcare. And you have to consider that that the Canadian government pays for much of that care in the US. I'd imagine that if things were as bad as you claim, that number would be a bit higher
[1] http://www.aarp.org/politics-society/government-elections/in...
http://www.telegraph.co.uk/news/worldnews/sarah-palin/740955...
It does not pay a dime.
Oh, yes. You try getting that through. It doesn't happen. It's something people trot out to say "see, everything is paid for" but the reality is far from different. And try to get that through for long term care.
And you want something else: "not experimental" That's not determined by the medical establishment. Rather, it's done by the government. So, even if every medical professional says otherwise, real treatments can be deemed experimental.
So no, the Canadian government does not pay for much of that treatment.
It would help if actually knew what you were talking about. There are no "boards." There is the IPAB which makes cuts to medicare if congress can't. I'm sure you are in favor of reducing this "socialized medicine" so your stated basis of opposition is nonsensical. Maybe you would prefer instead a "board" made up of people elected across the US that will make cuts to medicare instead. It's called Congress and maybe you should learn about it as I hear it has existed for a long time.
>>Command economies don't work, and the change in health care over the last century has been a centralization in control. >>Whenever someone talks about the need for socialized medicine because "otherwise people would go bankrupt", remember it is the socialization of medicine that caused costs to rise to the point where people would go bankrupt.
Milton Friedman also said that single payer system have many advantages over the system we have right now.[1] It isn't centralization of control its a broken system that has never had any reform whatsoever.
[1] http://www.hoover.org/publications/hoover-digest/article/729...
...or you just have to haggle with the hospital and refuse to pay their grossly inflated funny money prices.
I have a good friend who incurred 30K in bills for a 2 day stay related to a broken femur. He has no insurance. Since seeing his bill, which wasn't itemized at all, he's basically refusing to pay anything until he sees what he's being charged for. In response to this demand the hospital reduced his bill by about 12K, magically, and still providing no itemization.
He is still refusing to pay and only time will tell what the outcome will be. It's very clear, however, that he was grossly overcharged and that the hospital has no clue what they're really billing for. It's a game. Some people roll over, others fight.
If someone really ends up with 100K+ in medical bills after adjustments then it might actually make sense to take 7 years of 'bad credit' after a bankruptcy. No easy answers here, but it's pretty clear we're all being swindled.
My sister shattered an ankle a while back, and was billed around $40,000. Between reductions, writeoffs, and charities the hospital connected her to, she ended up only paying about $5000.
[0] http://www.chministries.org/whattodo.aspx under "general information"