Diagnosis: Insufficient Outrage
nytimes.com
nytimes.com
I took a trip to the ER around 10pm one evening in agonizing pain and was treated like a drug addict. I wasn't even triaged for over 2 hours (peak flu season) and everyone acted like I was just trying to score pain meds. Finally, after 3.5 hours, I was sent for a CT and only after the CT confirmed a stone was I given non-narcotic pain meds (Ketorolac) and send home to wait it out. Total time in the actual ER was ~1.5 hours (of a >5 hour trip) for a hospital administered dose of an NSAID only after a CT scan.
$4800.
Took me over 2 years to pay all of it off. It pretty much wrecked my personal finances (threats from collection agencies finally forced me to put it all on my credit card). I've been jaded about hospitals ever since.
I've also had another stone in the years since and was diagnosed with a ~$100 sonogram. And I used acetaminophen and ibuprofen to manage the pain for a couple weeks.
I'm still shocked that I had to wait so long and go through such a costly imaging procedure to justify a short prescription of a non-narcotic pain reliever.
I could go on another rant on an intelligent adult not being allowed to order a simple blood panel for self quantification.
I still have blood in the joint, but I can't get it drained because no doctor will stick a needle in without an x-ray, but those are expensive. So I'm waiting till I move out and get a full time position in a bigger city to get health care to have it fixed.
Probably going to have arthritis at 40....
Do you already have to know German or can you get by with learning the language after making the move?
Be warned, however, that you won't find anything comparable to SV in Germany. And I have to admit that there is also a problem regarding startups: The largest cluster of startups is in Berlin, but most of the money in the software biz is in West Germany. Btw, please don't get scammed by the Samwers.
Experience is definitely a plus, but probably more with the more "traditional" software companies than with the startups. Many German startups live off fresh degrees and high hopes (in the sense that they are founded by people out of the University), with all the positive and negative side-effects that this brings.
With regards to language, I'd say English and a willingness to learn German should suffice. Most of the software people already know enough English to work with them, and some corporations that operate internationally even mandate some degree of English usage. A few more rules of thumb: If the company is big or works in an innovative field, English should be all you need. If, on the other hand, it is located in a rural place or in East Germany, there might be problems.
These are of course generalizations. In any case, learning German will be helpful, even if it is only to facilitate the interactions with your surroundings outside work.
Look for something like that where you live.
They treat uncomplicated broken bones too for the same flat fee.
We here at HN know a lot about computers and programming -- even some of us for whom it isn't even our profession. We learned a lot of this stuff because it was a hobby.
Several of my real-life friends are this way when it comes to a lot of medical stuff -- despite not being in the medical profession they still know all sorts of odd things you'd expect just doctors to know just because they have been so extensively reading up on their own.
So, I guess what I'm saying is, remember the post a few months back preaching that we should 'all' learn programming? I say we should all learn more about our bodies. If and when we do, that very education will probably affect what we consume, how often we exercise, etc., ultimately improving our lives either way.
Once you are actually in a jam... trust me, you are not going to be spending your time googling for shit when you are in a bad way with kidney stones. Lobbed off a limb with your table saw? By all means, go check the internet first ...but not with kidney stones...
I was specifically looking for testosterone and thyroid previously (before starting a new training plan) and they seemed to be off limits with the providers I had located. Awesome to see those listed and a participating lab within 10 miles of my home.
I choose to fix my own car when it has small issues, I choose to fix my own computer when things go haywire (whether it's a hardware or software problem), I choose to install/fix issues relating to the washing machine & dryer, furniture, faucets, etc. etc.
To get to the point where I could fix these things I had to learn various things from others, from reading up, and so on.
I can do that quite easily when it comes to my own body too. Only in the most extraordinary of circumstances will I seek medical healthcare.
To relate this to HN: make systems that facilitate acquisition of knowledge, conducting tests, studying those tests, etc. Maybe hook the other end of the system to a database of vetted doctors in India and China who could study the test results and suggest future options?
By golly does this industry need some disruption. Please make it happen guys.
Why did you pay it then? Tell the hospital you can't pay and move on with life. If you do well financially pay it then.
> threats from collection agencies finally forced me to put it all on my credit card
I don't understand this. Why do you even answer the phone when they call? Or open the letters they send?
Just ignore them, and when you are ready to pay, then pay the hospital directly.
Completely ignore the credit collection agencies. They are utterly impotent, especially when it comes to medical debt which has no effect on your credit score.
I mean it - completely ignore them. I don't mean answer the phone, listen to the threats and ignore it. I mean utterly ignore them. You have caller ID.
Any letters get placed unopened in a box.
Hospitals can be rather unhospitable. They want their money, and they don't exactly hire the nicest/knowledgeable people. I routinely get collection calls for someone else based on this issue (who either had my number prior to me getting my phone OR the person gave them my number randomly), and I wouldn't invite them over for dinner.
Why allow them to decide what you do?
Simply ignore them.
Source? Googling for medical debt and credit score seems to indicate that it will in fact impact your credit score once they hand the bill over to a third party collections agency.
I wonder if there is a role for disputing charges on the basis of unnecessary investigations (especially in the ED setting) based on a standard of care- sort of opposite a medical malpractice suit.
But I'm in Australia and don't need to worry about having 2 years worth of debt from an emergency illness..
1) The stifling HIPAA regime that makes it almost impossible for small, potentially competitive practices to stay open without insane amounts of overhead, explaining their sellouts to larger at-scale healthcare corporations 2) The necessity to offset insanely low negotiated and subsidized Medicare/Medicaid rates with bills on the uninsured, thus bifurcating healthcare recipients into "pays too little" and "pays too much" categories with no in-between 3) The employer-provided insurance scheme--another government-subsidized program--which hides prices from consumers and incentivizes providers to hike up prices 4) Let's not forget about the inability for insurance companies to hedge risk and lower costs by selling insurance across state lines 5) Obamacare destroying any potentially new avenues for innovation by forcing the uninsured to buy into a broken system
What would happen if a doctor or hospital today started practicing medicine at affordable prices, competitively? What's stopping that from happening? If you look for what isn't there instead of what is there, you'd see how we've completely eviscerated any hope of competition, innovation or lower prices in our system.
The "moral outrage" we should have as Americans is not toward the doctors who--as even this article grudgingly acknowledges--are good people working in a bad system. The outrage we should have is toward the captured healthcare-industrial complex that has a stranglehold on our Congress and President, using its influence to send more profits its own way at the expense of patients.
High prices are not a crime. Bad policy is.
| The necessity to offset insanely low negotiated
| and subsidized Medicare/Medicaid rates
1) Government mandates the rates for procedure X to make sure that the government is getting the 'best' deal.
2) Hospitals charge insurance companies using these rates (they aren't allowed to be lower, or it wouldn't be the 'best' deal).
3) Insurance companies trim the difference between the Medicare rate and the real rate from the bill with newspeak like, "charge beyond negotiated rates," or, "over-charge of contractual limits."
It basically amounts to the hospital charging the 'correct' rate, the insurance company refusing to pay that rate, and the hospital not pushing it any further since this is all laid out in their formal agreements.
So, I'm not sure if Medicare can be said to have 'insanely low' rates, if the insurance companies end up with even lower rates. (I'd love for someone to correct me if my understanding is wrong, though)
Hospitals would be out of of business if their average revenue per procedure was equal to the Medicare rates per procedure. But that's not to say that hospitals are "losing money" on every Medicare patient, it's much more complicated.
Running a hospital is like running an airline, there are extraordinary fixed costs just to open the doors, regardless if any patients (aka customers) show up. When you have high fixed and low variable cost, if you are operating below capacity then the marginal cost to serve 'just one more patient' is low, and so providing the service at Medicare rates results in net income, all else equal.
Of course the money for the fixed costs eventually has to come from somewhere. Right now, that comes largely from private donations, and rate shifting (higher rates for the privately insured and uninsured).
Simply put it comes down to buying power. No one buys more than Medicare, so it's not surprising that they get the best rates.
It is almost as if a public option might be economically efficient.
In Aus we have a mixed public private system- everyone is treated free but if you want an elective procedure or to see a doctor of your own choice you can pay to do so. I have private health insurance and it costs me $1,500 a year (get dental and optical rebates etc, if I was to require serious treatment it would cover anything under the sun to be done my way) We have public hospital elective surgery waiting lists but the upside is people with no money can actually get the medical treatment they deserve in order to live functional lives.
I have been involved (as a medical student) in the us system- I know a little about it- and the creation of 'the medical poor' - there are probably better terms for it but basically those unable to get the treatment they need and thus unable to live their lives as functionally as possible - strikes me as sad and unjust.
BTW any comment along the lines of 'but doctors don't get paid for their services so less people will be willing to do it' - next year I will be practicing, in 4 years I can expect to be earning $150,000 and in 10-15 I will expect to be earning $350,000 inflation adjusted. More than enough for a comfortable life in my chosen specialty
As far as my rates go, I did notice almost everything, even items done at the local office, was an outpatient procedure billed by the mother hospital, at least in part. Also something I have noticed in the increase in lab work.
I am a chronic patient, I have a heart implant, feeding tube and an infusion pump that puts baclofen directly in the spinal area.
With co-pays going out of this world under this new system, we have elected to do many things at home that used to be done at the office. Changing out my feeding tube used to cost a few hundred dollars and jumped to over $6000 last fall. My wife now changes it at home. I have my Baclofen pump refilled at home instead of the office by a third party. I elected to send my heart readings over the phone instead of going into the office, except twice a year. Finally, when I make all my appointments within days of each other when possible and make them share lab results. They don't like this but I can't afford all the extra charges out of pocket. Even the monthly b-12 shot had a significant rate increase. Once again, I choose a cheaper route. The local non-affiliated walk-in clinic for the b-12 shot.
It is nice to see this article. It explains alot. At 41 with a form of Parkinson's Plus, the nickle and diming has to stop. I don't know where the $$$ is going to come from.
Another relative of mine just merged his surgical practice into the hospital system's. The overhead on his practice was getting too high, in particular malpractice insurance.
But I think it's obvious that almost no one actually wants to fix the broken system, because too many people are making too much money from it. (Doesn't that apply to almost everything in the United States nowadays? It's pathetic.) I'm happy to see the author pointing the finger at hospitals and doctors. It doesn't seem like that happens often enough. (When I say "doctors" I really mean specialists. I don't think that GPs are as much to blame.)
In the UK, after we've charged you nothing in the NHS, we'll give you the bus fare home.
1. http://www.marketplace.org/topics/world/health-care/indonesi...
However, it is worth noting that recent published statistics (for 2011/2012) show that:
"85 per cent could see or speak to a doctor or nurse within two working days compared to 90 per cent in 2009/10."
Note that this is for NHS Scotland - there actually isn't a single NHS for the entire UK.
http://www.scotland.gov.uk/Publications/2012/05/8250/3
One of the problems with the NHS is that it seems to suffer from having regular waves of (probably very expensive) management re-organisation inflicted on it in efforts to make it "more efficient" - often with non-medical managers being incentivized on performance, so they end up gaming the metrics.
Still, I think the NHS and the concept of "free at the point of delivery" championed by Nye Bevan "In Place of Fear" are still fantastically important to society the UK - though nobody claims it is perfect. Clearly the absolute best level of individual care are to be found elsewhere (probably in the US). However, when I see quotes elsewhere in this thread such as:
"I broke my knee this spring but didn't go to a hospital on my families request because the last time I broke a bone I reset it myself and the hospital still charged $8k."
Those pretty much fill me with horror/fear that anyone has to put up with that - which is precisely the reason the NHS was created.
Although specialist visits are still lagging behind the US (23 weeks for knee replacements).
Yes, the non medical managers (i.e. those annoying MPH people who make drastic irrational changes to justify their positions), we have the same problem in Canada.
You can usually get an appointment with your GP within days, sometimes the next day (depends on your local GP). In an emergency you can call them and get an appointment straight away. It's never been a problem when I needed to see a UK doctor.
The GP can decide with you if you need to see a specialist and refer you (the vast majority of people don't).
Part of the problem with US healthcare is not just that prices are insane, but that it does not provide an adequate service even given those prices. Again, a sign of a non-free market.
Since I have an HSA, I write checks to every doctor that I see. (My company buys me high deductible insurance and puts $6k into an HSA each year for my family.) When I visit my GP, it's $72 for usually 20 minutes of his time and I can get in to see him the same day. Specialist appointments are $800+ for what often feels like a more cursory conversation that I waited a month or two for. That's why I am not as quick to blame GPs. They have to rent office space and hire office staff on top of acquiring an expensive education, so the price that they charge (to someone with insurance like me, anyway) feels pretty justifiable.
I haven't found America all that much more expensive than urban India. In fact, compared to cities in India, a few things might even be cheaper. But not medicine. An eye doctor's visit costs $180, for Pink eyes! A comparable facility here would have charged me about $8.
I totally get the different standards of living and associated expenses. But medical treatment stands out so much that I can't imagine how an uninsured person could afford hospitalization or even moderately complex treatment in the US.
What I was trying to say was that I found treatment 10x more expensive in the US; while other expenses are merely higher and generally affordable.
We don't get medicine for things like pink eye, we just let it run it's course.
You really need to get a health plan if you don't have one. If you're young it might only be $100/$200 a month, even if you're unemployed.
If there was actual competition on the market, I'm sure a health service provider would find a way to perform the test for 75USD.
A not insignificant subset of people doing stress tests can enter into hypotensive shock or even cardiac arrest, the facility has to be prepared to deal with adverse effects as those reactions can be fatal.
$2000 might sound reasonable if every single patient required emergency attention, but in truth, far from it. Medical tests aren't meant to bring you to the brink of death, and are generally designed to keep you safe. It's not even worth pretending that $2k 'might' be worth it; it's just not. As for covering for insurance non-payment, isn't that chicken-and-egg? When a test costs ten times what it should? That would suggest that for each test that someone pays for, there are nine patients effectively getting it for free.
$2000 is only for uninsured patients, and as has been demonstrated numerous times results in you getting shafted when it comes to pricing. A better problem to attack is reducing the amount of stress tests given, as they're often completely unnecessary. Ontario has recently decided to stop paying doctors who give unnecessary stress tests, resulting in ~5000 fewer tests given every year.
Someone I know needed a root canal treatment, and I found out that ... it's not covered - at all - under the national system. Nor is it covered under normal insurance except for a small token amount (< $250 equivalent, and yes it will cost $2k+ here too). And there is no way to get it done quickly, which makes no sense. We're talking about a root canal here. Delaying it at the point where it hurts will make things worse FAST. WTF ?
That it's still $2k for uninsured patients is still very much the problem. It's not particularly mollifying that 'only some people' get hit with that bill. No-one should be fleeced simply because they're unwell.
I think a better tactic is to break the student cap. As long as the students remain high quality and there are facilities to train them, there is no reason to limit the number of graduates. It's basically cartel behaviour if that's happening. Doesn't solve things in the short term, though. This being said, in healthcare, there is no golden bullet. Fixing a failing system requires multitudinous tactics.
If you're paying list price you're not even trying.
My mom was told about a procedure that would have cost her $120k, in one question the price dropped to $30k. That's such an unfathomable discount that I think many people are ignorant because it sounds too good to be true. They end up thinking that it doesn't exist, there is some catch or that they probably don't qualify somehow.
Their reason was that insurance companies usually pay a predictable amount, but people paying cash frequently stop paying and get punted to collection agencies, ending up with (significantly) less money actually going to the hospital.
I'll keep asking, but it's not that clear-cut.
Anyway, while I don't know the specifics of the proton therapy centers mentioned, the assumption that a proton therapy center would just service Washington/Baltimore metropolitan areas is silly. After LLNL shut down their proton therapy center/experiment, we don't even have any proton therapy centers in the Bay Area.
Congress knew damn well what would happen when they used the force of government to compel prices for Medicare/Medicade. Insurance companies got on the ride because of size. Yet it falls to Congress to be the one to look out for the little guy but that was not their concern. Their concern was to maintain the steady flow of campaign contributions.
The ACA was more of a payoff to insurance and hospital industries than looking out for the public. The reason why most members didn't read the bill is because its contents were not important, its effect on their position was what mattered.
For years Federal law has prevented people from shopping across state lines for medical insurance. For years it has been adding elective treatments and surgeries as requirements to even the simplest policies which in turn reduced their affordability.
The solution, try to put everyone in the pool by force of law and reap the rewards of insurance companies and hospitals suddenly with more business than they had means to process.
In socialised systems, like Canada, physicians actually make more money because the government always pays so it's not a greed issue. The downside is that the government has limited funds, so the amount of beds, ORs, and advanced equipment is severely limited and wait lists are rediculous, ER times between 6-8 hours, chemotherapy wait lists of 8 months, surgeries 1 year + for the worst of surgeons. Alberta is the exception as they have rediculously deep pockets from oil revenue.
It's a trade off, this is a case of you get what you pay for. Free healthcare only works when the state has money to blow on quality care, I.e Texas with the Scottish Rite hospital.
You can't directly compare life expectancies with the US and places like France (which have free or near free healthcare) and conclude that it is just as good, if not better than America's. There are many confounding variables here (I.e their very short work weeks).
If it wasn't for A) getting the same answer for most of my ills: inflammations :p B) The doctor being very busy. C) Basic respect to not stress our medical system. One would go for the tiniest medical complain.
That, and there is a huge insurance lobby ripe with exploiting the corruption of congress and the 2 party oligopoly that keep pressure on maintaining insurer profits.
We pay significantly more by having every uninsured person come in with emergency needs rather than seeking preventative care, but the average American doesn't care, because they "deserve it" for not having a job that gives insurance. The ideology is completely backwards, but intentional on the parts of those who profit off it.
Some doctors may be profiting off this, but the principle beneficiary is private insurance companies, at least from my experiences. Doctors spend an eighth of their life learning some of the hardest science and discipline of any profession and you do want to compensate the good ones well. We need more people entering medicine, not fewer.
As much as you prefer to think of your uncle as the good guy and faceless insurance companies as the bad guy, a big part of the problem is he makes between 150% and 200% what his European and Canadian counterparts make. http://economix.blogs.nytimes.com/2009/07/15/how-much-do-doc.... Ahmdahls law makes it nearly inevitable that we'll pay doctors less if we want to reduce our overall costs.
1 http://tbd-consulting.typepad.com/healthcare_talent/2010/09/...
He might have made it all up, was living it lavishly and just lied about it, but it seems like that would be hard to hide from the extended family. He's had the same car for 8 years now, and his wife works. But he was still a general practice doctor in Augusta that closed his practice and went to work elsewhere for some reason, and if he was making a lot of money, it wasn't showing in how he was living (one house he had for 20 years).
Every country has it's own system, which range from anything between 100% government provided to mostly privatized. No system is the same. And it's not just the EU, it's the entire Western civilization outside the US.
This is extremely important, because the healthcare debate in the US is falsely framed as a choice for or against "socialized medicine", were in reality socialized medicine is a rarity amongst the various healthcare systems.
Whether or not to make quality healthcare accessible to everyone is not an ideological choice, the problem can be solved within the framework of any political ideology.
It's strictly a choice between decent healthcare for everyone or bigger profits for the healthcare industry.
Germany has compulsory health care insurance, Britain has the NHS, New Zealand has a largely free public health care system (with ACC for accident care and private health insurance for those that can afford a slightly higher level of care).
These are all "socialized" schemes of one variety or another, but they all work. You'd get funny looks framing a discussion about health care in those sorts of terms in most of those countries - and the stories shared here sound perverse to anyone in a western democracy outside of the US.
The details of how each country does it are different, but the result is the same. No insane bills to stay alive. No poor turned away or treated like second class citizens.
I have to say, of all the things I cant get my head round about the US, the health care system is the biggest jaw dropper for me. Not only is it not universal, but the people who run it make incredible profit out of it. Seems mad to me.
(1) as always, there are zillions of EUs to choose from. Reading the Wikipedia page, it actually isn't the real EU, but the EU plus (all?) members of the EFTA.
Good news is that you won't be charged bajillion dollars after you broke your hand, bad news is that you'll have to wait and suffer in horrible insanitary that is Russian polyclinic.
I have mixed feelings about our health care system. I believe, it will gradually disintegrate as doctors from soviet era get older and retire.
Not to mention, the "free market" solution doesn't actually involve consumers "voting with their wallets" and choosing the healthcare they want, but rather choosing from a very limited set of insurance options where they have no real choice or power. And the choices they are offered basically amount to a small array of socialized healthcare options: you have no control over your benefits and extremely little ability to choose a different one, but everyone pays into a large pool and costs are shared by the group as a whole so outlier costs are not overly burdensome to individuals. It is wholly baffling to me that anyone can support this system but be against socialized healthcare. Our model is socialized healthcare, but instead of being socialized across the nation as a whole, it's socialized across a particular employer or purchasing group. Does this actually give us choice? No. Go analyze your health plan "options" offered by your employer and tell me you're participating in the free market and I will laugh in your face.
I've seen friends get seriously dicked over because they filled out some insurance paperwork wrong. Ironically (and sadly), they would have been fine without insurance and just invested in a index fund.
I'm a huge fan of socialized medicine simply because I think it benefits everyone simply to have doctors gathering more data. All the stuff we know now is because people had crazy things happen to them (and most of them probably died), so it's in the public interest that people don't go off into the corner and die; rather, the health data is valuable (especially for the rich and upper-middle class who I presume would like to live longer).
Yes, you need your competitor's permission to enter the market. Its the law.
That would probably lead to what we have today - people only trust literal doctorates from top medical schools - but you could open new medical schools to placate demand, and hopefully reduce the workload required to obtain a medical license (the current 8+ years of schooling is excessive for any profession) or provide some kind of doctoral certification program outside the bounds of academia, though I have no intimate knowledge to know how you would do it.
It does become buyer beware, but it also means you would have treatment at most pay grades. Also, if it wasn't illegal to produce chemical compounds (really, that is dumb, and all the arguments of how they produce progress because of profit motive is pointless if nobody can afford the result, and the investment funds in big pharma would find other avenues to stimulate growth and research). The costs of care would fall absurdly fast if there weren't a dozen golden gates on the road to being a medical professional or medical facility, I wouldn't even mind if they just reduced the barriers, but they are too high and too plentiful right now.