Hacker News Reader

To be fair, you'll eventually die whether you go to the appointment or not.

By "eventually" I mean a cascading series of events and degradations. I won't die the day after the missed appointment, but I'd almost certainly die within the year from that specific disease. Otherwise I'd die at a presumably much later date, barring accidents and other new health issues. I'd prefer the later date.

Most people understand there's a difference between "we're all gonna die someday from something" vs. "if I don't do X within a relatively few days and do ongoing maintenance treatments Y I'm gonna die of disease Z in short order."

To imply there's not a meaningful difference between several decades' longevity vs. dead in a month isn't fair.

Depends. I don't think I have ever actually heard anybody say something like "if I don't do this, I'll eventually die", without some humorous intent. I had to read the post a couple of times to convince myself this wasn't the intention here.

Type I diabetics tend to be intensely aware of the consequences of neglecting their immediate care.

(Looking at the above, I see that I should make it clear that just I'm bringing it up as an example of a group that approximately thinks like you say.)

I run into this situation a lot:

Doctors often have a cash price and an insurance price, with the former being significantly less. I have a high deductible insurance plan, which means I effectively pay for most stuff out of pocket. So when I call, I ask them what the cash price is. I then explain my situation and ask if they'll honor the cash price since I'm paying out of pocket anyways. They always tell me no.

I mean, I get that they probably can't start discounting insurance claims because of my deductible or else they'd have to do it for all insurance claims, but it really grinds my gears that for all my insurance premiums, I essentially get the privilege of paying a higher rate.

I haven't tried it, but would it be possible to just not give them your insurance information, and pay cash? I realize then it wouldn't count against your deductible, but you could basically reserve the insurance for cases where you ended up in the hospital then. Or would that approach cause possible troubles with later coverage if something major ended up being a continuation of a visit that started initially "outside" the insurance?

This is possible, and I suggest it. You need to be one step ahead of both your insurer and your doctor, or they'll be ahead of you.

Our 'system' is broken. When will it be fixed?

That would work. It just requires some planning (which is my fault for not doing).

The problem is that my deductible is like $1300 or something. Now I don't remember the last time I spent $1300 on medical services in a year. On average, it's probably more like $500-$600 (I'm young-ish and reasonably healthy). So based on that data, I should probably get the highest deductible possible and just reserve using my health plan for catastrophic events.

But my employer only offers one level of deductible, so I can't really shop for a higher deductible. And with my employers contribution to the current plan, it's still cheaper than if I were to buy an even higher deductible plan on my own.

But still, if I have a $1300 deductible but only typically spend $600/year, I should still be paying cash. That said, I should probably be going to the doctor more than I do. I'm getting to an age where preventative care is becoming more important. I have some minor, non-life threatening issues that a doctor could probably help me out with if I was willing to go see a doctor. Under this way of thinking, I should probably commit myself to paying the annual deductible and just go to a doctor whenever I feel like it.

But it's a pain to find time for the appointment, I don't enjoy the medical "process" any more than any red blooded American man, and the whole idea of "going to the doctor just because you can" bothers me on ideological levels... so I don't go. But I keep "using" my insurance because I hang onto the idea that I "should" go. So like I said, it's just bad planning on my part.

That said, I know that's a giant whiny rant. I fully recognize that there are plenty of people who need legit medical care for serious things and can't get it, and here I am complaining that I can't find time in my day to schedule all the medical care I could ever want for $1300.

> "and the whole idea of "going to the doctor just because you can" bothers me on ideological levels"

I don't follow, can you elaborate?

One of the problems with healthcare in the US that for a long time, lots of people had insurance that would cover everything. So people would go to the emergency room over a stomach ache or schedule a doctors appointment because of a runny nose. Why not? So long as they paid the premiums, there was no incremental cost for going to the doctor. And while you're there, get some tests. Hell, get all the tests! Why not, you're not paying for them. And since the doctor knows you're not paying for them, they can bill whatever they want for them.

The net effect is that you have a bunch of people consuming excessive and over priced medical services. This means lines get longer and overall costs, especially for the uninsured, go through the roof.

On that note, I think the high deductible health plans make a lot of sense. I'm covered if something really expensive happens to me, but I still have to front the first $1300 and then another $1500 or something at a 20% co-pay. So my total exposure is only $2800, which won't break the bank if I get into a serious accident. But it's enough to make me think twice about going to the doc over trivial issues.

Some people would argue that you shouldn't have to think about cost with a doctor - if you think you need to see a doctor, then see a doctor. But that really can, and has, gotten out of control if you completely disconnect people from the price of healthcare the way US insurance has for a long time.

I used to have that view, but from what I've read more recently, the cost of doctors' visits is basically negligible in the overall U.S. healthcare picture. Almost all the money is going into major medical expenses: hospital visits, surgery, end-of-life care, nursing-home care, and chronic conditions with expensive medication. So either doubling or halving the number of times people go to the doctor for colds, by changing incentives on that front, just doesn't seem like it'll move the needle on healthcare costs.

If anything, some of the actuaries seem to think people aren't going to the doctor enough: my dad's corporate health insurance plan recently changed their policies to incentivize going to the doctor more often, by giving you a discount for various kinds of visits: you get a discount if you have an annual physical, and another discount if you have less-frequent major workups / lab tests done.

hospital visits, surgery, end-of-life care, nursing-home care, and chronic conditions with expensive medication

Any list of major costs in the medical system that doesn't include legal expenses is highly suspect.

Depending on which estimate you believe, legal expenses (including direct and indirect) account for about 1-3% of overall US healthcare costs. Not nothing, but not in the range of what we're spending on, say, end-of-life hospital care (10-20%).

Okay, fair enough. I remember reading about substantially higher percentages in the past, but googling just now turned up a best guess of 2.4%. I couldn't find any details on how they calculated the indirect nature of defensive medicine, but what they did have didn't seem to be very comprehensive.

This really doesn't make any sense to me; do you have any sources for this? Everything I've heard about problems with healthcare in the U.S. falls in line with the OP, along with:

1) People go to the emergency room precisely because they don't have insurance, and what's more, they wait until the last moment (ie, when it's most expensive to treat) [1].

2) If people were really getting so many tests done and going as early as possible, surely the U.S. would be far ahead of most other countries in terms of preventative medicine [2].

[1] - http://www.cdc.gov/nchs/data/nhis/earlyrelease/emergency_roo...

[2] - http://www.commonwealthfund.org/~/media/Files/Publications/I...

Isn't that insurance fraud? At least, wouldn't insurance companies try to call it fraud, even if a later visit had nothing to do with an earlier visit?

You are not required to provide insurance information if you would rather pay the cash price.

Why isn't this insurance fraud? If I got into a car accident and the mechanic told me it would be $7k with insurance or $4k in cash, isn't that fraud? (Note: I know mechanics do this, just curious why it's legal)

Doing what you've described would probably be insurance fraud, or at least a contract violation.

To expand on your example, the insurance company contract with the mechanic says that the insurance company will be billed the lowest advertised price. Of course, that contract also says that they will only pay $3k for the services required. The cash customer still hands to be billed the full $7k, however, or risk getting in trouble with the insurance company. That's why it's always a cash discount, and the bill will be for $7k even if they will take less (if you know to ask).

These numbers seem extreme, but they're not that far off - take a detailed look at an EOB sometime.

I'm convinced this is at least partly responsible for the rapidly increasing health care costs in the US.

I had a Doctors visit at the beginning of the year. Since I am on a HSA plan I have no deductible but rates are still negotiated. I have yet to receive a bill. This is for service rendered the first week of this year. I have received a NON BILL which denotes the costs of service and the negotiated rate having saved me money.

I am still trying to find someone to pay. Now having talked to my Doctor before I have asked the questions about rates and such. The only points that stuck with me are, negotiated rates with government providers are too low for him cover his costs, insurance companies have rates which are more favorable because they need the business, and his higher base rates are because collections is rotten to deal with.

One day I hope to pay my bill, I would have to have a collector show up but my Doctor cannot accept the payment as of yet and I legally cannot use my HSA funds for something I do not have a bill for.

How is this legal under contract law?

They extend an offer, you agree the price, you agree to buy and they sell. But they're suggesting that you buy, and consume the product, before agreeing a price?

Is it just that they don't know what's happening at the doctors? ie, they could offer a base price of $X per 15 minute appointment; $Y for writing a prescription; $Z for referring on for other tests?

Or can they not even tell you how much a basic 15 minute consultation would cost?

Like so many things, I probably could get my answer if I was prepared to fight for it. But since I have insurance, and I'll eventually pay out my deductible and out of pocket maximum, it's just not worth the fight, no matter how wrong this is.

In a way it's a very small version of someone suing me, and I settle even though I know I could win. Cost/benefit, and the game is rigged against me.

Insurance is the root of all health care evil.

>They extend an offer, you agree the price, you agree to buy and they sell. But they're suggesting that you buy, and consume the product, before agreeing a price?

Pretty much anything custom-made works like that (have you never bought bespoke furniture?) - the seller will do the work and then bill you for how much it turned out to cost. You can sue them if it's unreasonable.

Wow, really? That's impressively bad.

Over here we have a Bismarck health system (baseline coverage is publicly funded, supplementary insurances are available from the same companies for a premium), and the last time I had to go see the doctor it was free. I think I paid 15 NIS (about $4 USD) to fill the antibiotic prescription my doctor gave me.

America really needs to fix its health-care system, by now its decay has become incredibly low-hanging fruit. You have the rest of the civilized world to cherry-pick for efficient, caring health systems!

If you don't know what's going to be done during the appointment, they probably can't tell you what it's going to cost. But if you are going in for a specific procedure, you should be able to get the cost.

Call the doctor and get the procedure code. Then ask for the amount that is going to be billed and the tax id of the person or company that will be sending the bill to the insurance company.

You may need to get multiple procedure codes and talk to multiple billing departments. For example, I recently wanted to find out how much an MRI would cost. There's a fee to perform the MRI and a separate fee for reading the images. These are performed by different people, and therefore billed by different people.

Next, call or livechat your insurance company. Ask them to run a test claim. Give them procedure code(s), the amount billed, and the tax id of party sending the bill. The insurance company can then tell you what the allowed amount is, that is, how much the insurance company and the medical provider have agreed upon for the specific procedure. If you have a deductible that you haven't yet met (and the procedure isn't something covered or partially covered before the deductible, such as preventative care), the allowed amount is the amount you will be billed by the medical provider.

Obviously, this is a cumbersome process. Running the test claim took about 10 minutes in my case. This is apparently not a process that the insurance company has optimized for. But by going through the process, you are sending a signal that price transparency is important.

With MRIs, it turns out that at least one local company has recognized the value of price transparency: https://twitter.com/xn/status/311886680145666048 (They also happen to be about $400 cheaper than the amount my insurance company negotiated with a large hospital.)

It seems to me that, ultimately, such practices should be investigated and perhaps prosecuted on some legal basis. The problem is so endemic and systemic that I can't help believing some degree of perhaps illegal (and, at least, it should be illegal) collusion is in place.

One example: How can I know/believe that practices aren't widespread to deny myself and others coverage we are actually due per our contracts?

There is also widespread, systemic spreading of cost that is outside of any contract (i.e. insurance) authorizing and mandating such. Widespread enough to warrant investigation for fraud.

If the regulators weren't totally co-opted and owned by the industry, it would be rife for investigation and perhaps charges of corruption. Under existing laws -- no new laws needed.