Show HN: I mapped US medical prices. Save thousands by driving a few miles | Hacker News Reader

Show HN: I mapped US medical prices. Save thousands by driving a few miles

bestmedicareprice.com

488 pointsneilsharma222 comments

This has enormous impact by bringing transparency to medical procedure pricing. One could quite literally save $10-50K by opting to do a procedure just a few miles away.

Nice work. Where did you get the data for this? Is it publicly available?

Thanks. Yeah, a lot of people travel abroad to save money, but its possible to find comparable prices nearby too. Patients aren't trained to shop around with procedures though.

The Obama Administration has tried to make pricing more transparent--this particular data set is publicly available. Here it is: https://www.cms.gov/Research-Statistics-Data-and-Systems/Sta...

As someone with a disabled mother on medicaid (whom I spend tens of thousands of dollars a year on for prescriptions and care), thank you.

Can I ask why you're spending thousands of dollars on Rx and care? From what I've gathered Medicaid patients have co-pays of $3-$5 on drugs and very small office visit co-pays.

I'm not questioning your story, just genuinely curious what the extra costs are.

Not a problem

My mother is covered by Indiana's medicaid program, as she's at the poverty level but not old enough yet to qualify for Medicare. Her prescription buydown/deductible every month is $550, which I pay for. If you don't mind, I don't want to list specific medications, as it might make it easier to determine her identity. She takes medication for bone mineralization, hormone replacement due to a heart condition, a medication to reduce her blood pressure, as well as a Schedule I pain killer 3-4 times a day for pain management due to lower body nerve damage. She'll very likely have some nerves in her lower back severed in the next 6-12 months to relieve the pain.

So, her prescriptions alone cost around $5K-$6K/year. This is before her GP or specialist copays (very few providers will take Medicaid patients, so its hard to find and keep them), or a hospital visit or two. Her recent open MRI was completely out of pocket (luckily only $600 at a low-income clinic).

Thanks for sharing. I wasn't aware of Medicaid patients who had to pay those types of costs.

I guess my question is, what if a Medicaid patient in IN was truly destitute? There must be some mechanism for patients who can't afford those types of costs.

ER visits.

Seriously. An ER is required by law to treat anyone who comes in. If you really can't pay, go to the ER.

Some argue this is why healthcare costs so much because ERs have to be paid for.

No. This is wrong, yet people keep citing this.

EMTALA [0] requires the hospital to stabilize the patient, ie, make it so that it is no longer an emergency (the "E" in "ER"). If you "really can't pay" and it's not an emergency, you likely will find yourself in collections from the hospital.

[0] http://en.wikipedia.org/wiki/Emergency_Medical_Treatment_and...

I think it really depends on the hospital. Some hospitals that are in major urban centers and provide services for a large indigent population often waive all expenses.

If you go into one of these hospitals looking like you have no money, you'll likely not be asked to pay anything.

So if you go and say you are seizing, they will just stabilize you till you are done seizing then kick you out? Or at that point they will attempt to collect for the emergency care and prohibit further care until you can prove you can pay for it?

Generally yes. This comes up occasionally with cancer patients; if they have an acute issue the hospital must stabilize them, but the hospital doesn't have to actually treat their cancer.

If they are very poor, they should in theory be covered by Medicaid, which will then pay for treatment. But this requires them to actually be in a condition (mentally/physically/education-wise) to figure out how to sign up and be approved for it, since coverage isn't automatic. Afaik, even if the hospital is able to determine the person should be eligible, they can't just treat the person and then sign them up on their behalf; the person has to do it themselves, and be approved before seeking treatment.

This is one area that I think the U.S. lags behind many other developed countries in: assigning a social worker to help people in bad situations navigate the system. I've noticed that with an uncle of mine who has MS, is on SSI disability, and can't really take care of himself. If he didn't have a family member who was willing to accept power of attorney and file all sorts of paperwork and make phone calls on his behalf, he would have huge problems, because he isn't able to do that himself, and the state has not assigned a social worker to help him out.

>But this requires them to actually be in a condition (mentally/physically/education-wise) to figure out how to sign up and be approved for it, since coverage isn't automatic.

This is a tough one. I have a disabled family member who would have never been able to do this themselves.

People often claim that, but it's not a particularly credible argument. Emergency room visits account for less than 2% of total healthcare spending in the US.

http://newsroom.acep.org/index.php?s=20301&item=29928

Moreover -- ER visits with fake names. I have no moral issues, completely nothing, 0, lying and stealing from the bastards that sell $300 for a bag of saline or $40 for a pill of aspirin. I don't care that nobody pays it, I don't care what complicated laws or accounting tricks are, if that is put on a bill and sent to a person who was just sick or injured, that is wrong. It is criminal. So if you are conscious and can get way with it (don't need prescription written out just want to get "stabilized"), give them a fake SSN, name, address and fuck them.

Um this is the reason for Obamacare. People sticking other people with the bill.

People will gladly pay $500+ for an iphone but will not spend money on their own health. Yet they expect the hospital to be forced to take them even if the they can pay.

Are some hospital charges a ripoff. Oh yes. But they are also open 24 hours a day with highly trained staff ready to try and save your life even if you were doing something dumb. They are on stand by even though you pay them nothing to be waiting.

Fire fighters. Police. Both do the same job, both paid for by property taxes. Why is a hospital not the same?

> An ER is required by law to treat anyone who comes in.

They're basically allowed to make you "stable" and then send you out into the cold. They might do more but they don't have to.

unfortunately, i think its usually death.

Ok, I think I understand now. I'm guessing your Mom is slightly above the poverty line?

* For people with incomes above 150% FPL, copayments for non-preferred drugs may be as high as 20 percent of the cost of the drug. For people with income at or below 150% FPL, copayments are limited to nominal amounts.[1] *

[1]http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By...

They include her husband's income, which is only social security and an extremely small pension that barely covers their food, utilities, mortgage, and property taxes. They don't, of course, take into account his medical expenses in the income calculation.

Have you looked at programs offered through the manufacturer of her medications? Many have programs for free or low cost meds for low income people who are un or under insured.

Try here

http://www.pparx.org/en/prescription_assistance_programs/lis...

IIRC, Medicaid has some odd situations where they'll pay for nursing homes but not 10x cheaper (and better outcome, in many cases) home-health aides.

This looks like DRG data by hospital released a few months ago by CMS, so what the hospitals bill for to Medicare, although the actual payments are set by CMS. Still, charge master data is the starting point for people not on Medicare/Medicaid

What's the consumer use for this? Is it for people without insurance? From what I understand this is the rate that Medicare has negotiated from these providers. But I assume this isn't for people with Medicare, since those people are covered with Medicare. I assume the dollar values don't have much relation to the reality that an uninsured individual would be billed, since Medicare negotiates pretty aggressively for prices that "normal" people or even normal insurance plans can't get.

I'm just not understanding what you learn from this other than what Medicare gets reimbursed. And I'm not understanding how knowing that is actionable in any way for the average person.

Even with insurance your coinsurance could be up to 20%. So, for complex procedures, it is very useful to see if you can get it done some place cheaper. First example of intracranial hemorrhage, price ranges from $9,540 - $234,913. Certainly gives a lot of input to make an appropriate decision. Very unlikely that without medicare negotiation, prices will magically converge to some middle point for all of them.

Your point is a good one, but maybe a different procedure would be a better example- most people suffering from an intracranial hemorrhage aren't in a position to do a whole of of comparison shopping on where to have it taken care of.

friend got a 2nd degree burn yesterday. she waited 2h to decide if she went to a hospital because she was out of insurance... so yeah, i think she would have used this site :)

A family member who needs to find treatment for a relative could benefit greatly from this service.

I get your point, but people seem to have the ability to shop on quality!

Let's say you suddenly lose your ability to speak, you think it's a stroke, so you head to the closest clinic. They freak out because you need to go to a stroke center. People (or their family) often ask "What's the best stroke center around here? I want to go there!".

If they had the info available to them, why couldn't they include cost in that equation?

The issue is that if you have insurance, you're not paying the charge master rate or the Medicare rate, you're paying the negotiated (and likely non-public) rate for your insurer. The 20% co-insurance you pay is based on the negotiated rate.

Exactly. If this knew what my insurance company had negotiated for the procedure, and I could input my policy details to figure out what my personal cost would be then I can totally see the usefulness. But as a consumer I just have no idea at all what knowing the Medicare reimbursement prices tells me.

If I assume that the relative differences that Medicare has negotiated are similar to the relative differences my insurance company has negotiated (which I'm guessing is an invalid assumption), and if I accurately know what my policy will cover vs not cover (again, a nearly impossible thing to know given how complicated these things are), then maybe you can make a decision with this data. But the system is so complicated that I don't think that works at all by just using this dataset.

Yeah, unfortunately what CMS pays for procedures bears little relation as to what private insurers pay. It all depends on the local market for the provider. If most of the population goes to only a few providers, the providers have a lot of sway in negotiations. They will often ask for (and get) per-diem rates or percentage of charge.

If the population goes to a number of different providers, then the insurance company can play hardball and say "if you don't take this rate, you're out of our network, good luck with that". In those cases, they'll negotiate an MS-DRG + X% rate.

The reason why negotiated rates with private insurers are non-public is because it's a negotiating tool. If hospital A gets paid $5K for a heart attack and finds out hospital B a block away gets paid $7K for the same thing, the next round of negotiations will be very rowdy.

One factor that keeps these negotiated rates from becoming public is that a lot (actually, almost all) of these contracts signed between hospitals and insurers have a gag order of sorts built into the contract by the hospital. These gag orders prevent the insurer from making the hospital's rates public, and what's more, the terms of these contracts usually forbid insurers from even revealing the existence of these gag orders. Believe me, insurers would love to be able to steer policyholders towards cheaper and higher quality -- better value -- care, but these gag orders make it almost impossible for them to do so. It's an incredibly screwed up system all around, and everyone's complicit -- it's not just the insurers and other payers.

Luckily insurers have begun to find a way around this by selling bulk claim data to third parties who can analyze them and extrapolate the contracted rates on their own (a la Castlight, Change Healthcare, etc.).

True re: negotiated rate. However, the whole premise here is that there is some correspondence between this rate and the negotiated rate. If the negotiated rate is the same across the country across all hospital systems ("the magical mid point price") then this chart is not useful. I doubt thats the case.

US Patients go to south america and Asia to get treated. I don't think shopping around the country hospitals to figure out a good option is going to be a big problem. This is a good first step.

The sad part is, there is little correlation between what the hospitals have on their charge master and what they actually get paid.

A hospital with a cost of $20K for a procedure might only get paid $5K, while one with a $10K cost might get paid $8K!

In fact, the same hospital can get paid very differently between different insurance companies.

the whole premise here is that there is some correspondence between this rate and the negotiated rate

That is a plausible but false assumption. Different providers negotiate different rates. In many cases, the negotiated rate for a given provider is lower than the "cash rate" that an uninsured person would pay, but in many cases the negotiated rate it is actually much higher(!). Maybe in these cases the insurer gets an end-of-year volume-based discount that the insured (me) never gets to see.

Source: my recent experience shopping for an MRI while on a high-deductible plan.

Doesn't mean too much actually. Insurance companies have their own negotiated prices that are lower than that.

However, I think hand in hand with this you need to map outcomes data, especially for invasive procedures. Often, the reason to go to a "Big Hospital" say UCSF instead of Podunk Community Hospital is that there is often a big disparity in skill between a UCSF faculty surgeon vs. others. Or, even between different hospitals.

I'm not sure how to do this - hospitals like to hide adverse outcomes from the public, but it's really information in the public interest. Ideally you'd want some sort of index that weighs complication rates (something unexpected happening), outcome/effect measures (procedure did what it was supposed to do), with price.

Assuming this data is from the Medicare (insurance program for those >65) dataset released by the Centers for Medicare and Medicaid services earlier this year (http://go.cms.gov/1bowKJA) I have a couple of points to make:

1.) Not sure if you grabbed "charges" or "payments", but "charges" are what the providers (hospitals) billed to Medicare, and "payments" are what Medicare actually paid the providers. "Payments" would be the best indicator of "price".

2.) Regardless of whether you are using "charges" or "payments", it's pretty much irrelevant for the average person. Why? Because the patient never pays the full amount (except for the uninsured...see below).

3.) While you don't pay the full amount in most cases, you will have to pay something. However, what you actually pay varies WIDELY based on your health insurer (the "payor") and the design of the health insurance plan.

4.) Also note that every "payor" negotiates a different price, so the Medicare price does not equal the Commercial Insurance price which does not equal the Medicaid price which does not equal the price the uninsured person pays.

5.) Finally, the diagnostic/procedural terminology in this dataset is impenetrable to most people. For example, does anyone on HN know what "transient ischemia" is? And if you do, do you understand that you can have transient ischemia in many parts of your body (FTR, I'm an MD)?

Although I appreciate the effort and the clean visualization, I don't think this data is particularly useful to an individual trying to make health care decisions for reasons 1, 2, 3, 4, and 5 (and probably others that I'm missing).

The one place where this data may be useful on an individual level is in the case of the uninsured. When you have no insurance the hospital basically makes up a price (taken from something called the "chargemaster") that is way more than what commercial insurance would pay, and WAY WAY more than what Medicare would pay. Having access to this data might help an uninsured person negotiate a lower price when the hospital comes after you with a giant bill. Medicare is a pretty solid standard to compare to - i.e. "you're charging me 5X, whereas you would only charge Medicare X".

On a societal level I think this data is also extremely valuable because now you can start to analyze pricing disparities across procedure types and geographies, which is really helpful. You can also put pressure on providers who are gouging individuals paying sticker price (i.e. the uninsured), which is important given that medical bills drive the majority of personal bankruptcies.

We ran a competition on this topic recently at Health 2.0 and you can learn more about the issue and the datasets on our site. You can also view other visualizations of this very important data:

http://www.health2con.com/devchallenge/rwjf-hospital-price-t...

Transparency in health pricing is a very important topic and something you'll hear a lot more about in the future. Happy to discuss further with anyone who wants to learn more (@jeanlucneptune, jeanlucneptune@gmail.com).

Nice! Me and my friend made this app back in a few weeks ago, and here is the link.http://pricemaps.betterdoctor.com/#/

1. We used the 'Average Payment' for the actual number shown on the site. 2. Even though it's irrelevant, but it actually goes back to you by your co-pay and other expenses to you. Not 100% sure though. The point in our app is that, we want to compare the price vs quality in the US top hospitals. They actually vary a lot. 3,4 I agree. Co-pay is what you pay mostly. 5. We cleaned up the procedure names manually, and matched the procedure related specialties to the hospital specialty ranking made by US News, and it gives much better perspective to the users.

Nice to see people doing more health related stuff out there!

I like the betterdoctor price maps! Too bad you didn't have a chance to enter our competition, because you might have been a winner. By point:

1.) Good choice 2.) You need to consider co-pays as well as allowable charges, deductibles, co-insurance (if applicable), and benefit maximums. 2b.) The quality data out there sucks (hard to measure quality in HC) and is hard to find. 3.) Cool 4.) Ibid 5.) Clever

HC now is like the internet in the early 90s. Huge opportunities that will hopefully attract talented developers, technologists, and entrepreneurs.

Thanks!

Yes, we would love to take our app to the next stage by providing more comparison functionalities. One of the reason why we skipped quite a bit of the metric is that we don't want to make the users to be too much confused with choices.

This is one of the problems with the current health care system. There are too many choices, and there is no simple way to do any sort of quick decision like renting care, etc.

totally agree! my friend an me started in August on a similar mission http://www.pricepain.com - even tried YCombinator this winter but did not make it. If you checkout our /why section we collected a lot of recent articles and links on the subject

Nice! Looks pretty cool.

How did you get these data? Is there any public source for this? We are using US News Ranking & CMS charge data.

Best, developers behind the BetterDoctor PriceMaps

"My friends and I" not "me and my friends"

Yes, call me a Grammar Nazi Troll, but I see a shocking amount of this most fundamental error all over forums where otherwise intelligent, educated people discuss things.

You sound ignorant when you make the same mistakes as my 12-yo daughter. I can tell you make it because you are typing as you speak, which means you are in public, in meetings, and some day in presentations using bad English.

People will judge you by how you speak. I'm not being a troll, I'm helping you have a better future.

The rule is to use the same pronoun you'd use as if you didn't have two parties involved, right? "My friends and I did X" is right because "I did X" is, and "Me and my friends did X" is wrong because "Me did X" is obviously wrong.

Sorry guys, not a native here. I am sorry if I upset you with my poor English.

I learnt my lesson :)

It's not something we are "upset" about, and considering the level of English you used throughout the rest of your post and response, I'm not sure "not a native" is a valid excuse.

I suspect if you aren't a native, the reason you say "my friends and me" is because it's a bad habit you've picked up from natives, like typing "gonna". I think anyone who can make a sentence such as,

"We cleaned up the procedure names manually, and matched the procedure related specialties to the hospital specialty ranking made by US News, and it gives much better perspective to the users"

is far beyond making English 101 mistakes confusing objects and subjects of sentences. Actually, in 15 years of on and off English teaching, I have run into very few non-natives who have that issue, since they had to actually study it. I find you to be somewhat unique.

In any case, there are plenty of natives who consistently say write and say this, so hopefully a few of them will take it to heart.

Thanks :) I fix it then :)

It is utterly unfair to complain about errors made by non-native speakers who are making a good faith effort to communicate in English.

Why not?

It's not an attack on him personally, but ...why not?

Read the rest of his posts. He clearly has a very high level of English, and can state his ideas and opinions clearly. Yet he fell into the same shit-English trap that his friends are all in.

My complaint isn't that someone made a mistake. My complaint is that someone who knows better couldn't give a fuck to say it correctly.

This is about standards, not grammar mistakes. There's no difference between someone who speaks English at his level saying "my friend and me", and an experienced programmer not error handling his code because he's in a rush.

I don't point this problem out where ever I see it because I'm an anal Grammar Nazi; I point it out because it is slipshod, lazy, I-don't-give-a-shit attitude. It is becoming the norm among people who grew up on chat and it is garbage.

I stand by my statement; ESL students learn this in their second week of English class, and hotloo says it because he is copying his native friends on chat who speak like crap, and now he is picking up all their bad habits as well.

So hotloo, do yourself a favor and take this to heart. Some day you'll be in a suit and tie, in front of people who care about this sort of thing, and it will win land you a contract or a good job or something important you want.

Your own writing style is hardly something to use as an example of correct English. Your usage and placement of ellipsis and commas is fairly non-standard, you repeatedly use semicolons where a full stop would seem more suitable and the liberal use of dashes to form compound swear words seems a somewhat crude and overused device. On first impressions I would say that it is you who gives a less professional impression through your writing and you really are in no position to scream so shrilly from such a very high and ridiculous horse.

Why don't we just take this sidebar to Tele's native tongue, Mongolian?

I like the idea and the effort.

One thing I hate about it, though:

Again, third party javascripts are loaded in the background (Google, as usual, for example).

Come on people, you know this tracks everybody around the entire Web, stop using those scripts (is it so hard to use local js scripts? For example, find local "Web analytics" here: https://prism-break.org/).

What you're asking your users to do here is: telling Google (and the NSA, etc.) about your health problems. Not smart. At all.

Incredibly useful if you're on medicare (what the price data is based on).

For the majority of us _not_ on medicare, castlighthealth.com is solving this. It's B2B for now, i.e. Tesla pays for castlight and then its employees can use castlight to find out how much things will cost.

I just met with Castlight this week. They have a really slick tool. Other companies like Change Healthcare and Healthcare Blue Book are trying to solve the problem too (with their own B2B solutions).

..and pricepain.com

These are called cost and quality or transparency tools in the industry.

Many insurance companies have tools that can do this exact thing for their members AND apply it to your specific plan at the time of the inquiry. So you can choose based on the procedure cost and your actual cost based on your deductible and co-insurance. Not only that, the tools will also tell you about quality so you can compare based on the quality of service, cost of service and your actual cost at the same time.

Unless you can do all of these things at the same time with your tool, it leaves out critical factors for those actually searching for this type of information as it applies to them at any given time - most importantly when they are trying to make a decision.

Additionally, you only have access to negotiated rates for Medicare whereas an insurance company providing this information is going to provide as much information as they can for all of their members by displaying their negotiated rates specific to your plan.

As an HN reader, if you like this tool, go check with your insurance company and see what they already have and how specific it is for you.

This is important. Contracted network discounts may not align with Medicare reimbursement rates for providers so if you have insurance through a network you should look for a tool that can compare in-network rates for your plan as MJR suggests.

I don't know if I'm just completely retarded or hitting a bug. How do I use the "Select a Procedure..." box? Typing into it does nothing. If I click on the box (or the down triangle), it brings up a menu with only one option, which says "Select a Procedure..." and does nothing. This is on Chrome on Windows. I'm in Los Angeles, if that matters.

Oh it might be this syntax error on line 21 of index.js:

Is: query.ascending)(

Presumably should be: query.ascending();

oh sorry, I must've introduce that error when fixing other things. Thanks for the notice.

I picked one (Heart Failure with Shock with MCC) at random

http://www.cms.gov/icd10manual/fullcode_cms/P0136.html

the link shows all the diagnoses that fall in that category of DRGs. (DRGs are the packages of procedures that Medicare pays a fixed price for, simply put. If you get that diagnosis, you submit that DRG. However in this case the map from diagnosis to DRG is one to many.) Some of the average costs are only from 20-30 discharges. Do you think that makes for good math or some sort of price guide?

https://en.wikipedia.org/wiki/Diagnosis-related_group

It may highlight that the DRG is incorrectly applied by some hospitals (maybe?), but it has nothing to do with 'going down the street' for a better 'price'.

nice interface though.

We did a similar thing at BetterDoctor a few weeks ago:

http://pricemaps.betterdoctor.com/

Cool! Did you get the data from: http://health.usnews.com/best-hospitals/rankings

I'd love to talk more about how this can be taken to the next step. Can't find your contact info in your profile--mind pinging me at: neilsharma101 at gmail dot com

Yep.

We tried to compare the hospital quality with the prices.

Why don't you make it an app and give it to each doctor to give to patients?

That's an interesting idea.

These procedures look a lot more frightening when they're written in all capital letters. If this is bothersome for you too, it's an easy fix in javascript. If it were any other element I would have said CSS, but text-transform:capitalize doesn't apply when applied to select tags. Here's how to do it in JS: http://pastebin.com/cnVJwds1

You really should warn users to find the NEAREST hospital when they are having chest pain--which is one of the procedure selections.

Disclaimer: I am not a lawyer or a doctor.

Then they save your life. A week later, you receive the bill and the resulting heart attack kills you.

It's unclear how accurate this is. I searched my area for a random item (something respiratory) and there was one hospital that was $10k and another that was $30k. The $30k hospital probably has inflated prices, but not by 3x – it's also the hospital that takes harder cases. It's the hospital other hospitals send patients to. When we looked at hospitals for the birth of our daughter we looked at C-section rates. Almost all hospitals were the same, there was one good hospital, and then there was this hospital which had twice the C-sections of any other. But it's the hospital that gets the hard cases, a friend later delivered there (I think by C-section) after barely avoiding premature labor from 20 weeks to 35 weeks. Because people go there when they have medical challenges they have a high C-section rate, and generally high rates for everything.

I made a similar app at http://healthcostnegotiator.com/

I took the approach of targeting under/un-insured patients with the goal of assisting them in negotiating their health care costs to levels more similar to the Medicare payments. It is pretty difficult to shop for medical care in the event of an emergency, so my tool gives nearby, regional, and national prices for selected procedures so that the patient go into price negotiations with their care provider and hopefully get charged a lower price.

Edit: I also made a visualization of the CMS Provider Charge Data here: http://labs.coseppi.com/cms/

Excellent POC - Obamacare needs to pick this up and run with it, to provide the next level of detail, for all insurers.

Can you tell us about the technology under the hood? Ruby or Node (or whatever)? What APIs did you use? Programming-wise, what was easy and what turned out to be tricky?

Hey. The technology i used focused on speed of deployment. My DB and "backend" is all parse (I don't have a traditional backend). My hosting service is site44, which is simple dropbox hosting so i don't have to setup a server. The rest of it is just js/html/less files. I used bootstrap for the styling and jquery/google maps API for everything else.

I did do some pre-processing on the data in python to geocode the locations (ie: change the street addresses to long/lat coordinates). I used geopy to do that, and pandas to manage the data.

The total product took me three days to build and design

This is a great start, however a key thing that is missing (at no fault of the authors) is patient outcomes.

Just because a service is cheaper does not mean you should shop by the lowest bidder.

BetterDoctor's Pricemaps also include US News Rank and score which gives you a place to start: http://health.usnews.com/health-news/best-hospitals/articles...

Please please please do not shop strictly by the lowest price when it comes to your family's health. Research both the hospital and the doctor who will be doing the procedure when it comes to complex procedures.

A couple of points: There are far fewer procedures / pathologies here than are out there. At least sort the procedures / pathologies lexicographically. It would be even better if I could NLS search by the procedure.

And if you want to get really fancy, let a user search in layman's terms too (e.g. "sore throat", "mammogram", "MRI", etc.).

Excellent problem choice and great work with the solution. http://pricemaps.betterdoctor.com/, too, have done a wonderful job with their version.

May be this will also make a great phone app. If users can pre-configure a couple of medical procedures (faced in their medical history), the app can show price comparisons on the map by default at every launch. This might help addressing the concern https://news.ycombinator.com/item?id=6864945.

As a European, the need for this baffles me.

Would it be useful to have a 'show me the cheapest' button? The range in cost hints at the massive variance. The US is crazy. How does a procedure costing 4k in one place cost 120k in another?

Thanks for the feedback. My next goal is to look more into why the price varies so much.

The price spread is pretty crazy. Some hospitals have higher fixed costs or salaries depending on the geography. Also, if a hospital is more research-oriented, R&D funds are normally tacked onto the price (one of the reasons why Stanford's Hospital is really expensive).

It's hard to find quantifiable data on the breakdown of bills, but based on a great article in Time a few months ago, prices are almost entirely arbitrarily defined: http://swampland.time.com/2013/05/08/an-end-to-medical-billi...

The cost adjustments you're talking about are MS-DRG adjustments (the amount the hospital actually gets paid by CMS). From what I can gather, the numbers on the website, are cost numbers, i.e. what the hospital tells CMS it costs them (which is a number they are free to make whatever).

If you want to know why costs vary so much, starting looking at reimbursement. Hospitals are incentivized to raise their list prices because many of them are paid a set percentage.

I thought medicare reimbursement is relatively fixed, with minor fluctuations based on geography and some hospital-specific practices? Based on a rough glance at the data, it seems like medicare reimbursement is only loosely correlated with the cost numbers, so I don't know how much raising prices would increase their Medicare revenue.

Also, from what I've learned about elderly care, Medicare reimburses a care center a fixed amount ($5000/mon/patient in California) regardless of the severity of the case. I'm assuming this number varies a bit too even in the same region.

As a side note, if you click on any of the prices in the map, it'll show you medicare's reimbursement rates too. Should've made that feature more clear--it's rather important.

It doesn't. The price is set by a Chargemaster list that is drawn up by a committee. Hospitals are free to charge whatever they want above that, without any downward market forces.

Paying more sometimes means better outpatient treatment (and sometimes lower readmittance rates), but it's not a guarantor.

Nice!

Me and my friend Anders made a bit better version of this, at

http://pricemaps.betterdoctor.com/#/

Check it out!

Major joint replacement is much cheaper than Major Joint Replacement.

Yes, that was a bug.

They actually correspond to two different slugs in our database. One that has higher price is pointed to the more complicated procedures that involved multiple complications, while the other one is simpler procedure without any complications.

I'm in the midst of a heart attack, and I'm supposed to optimize cost/benefit of the area hospitals according to available data on expenses and outcomes. I invite those in favour of market solutions to propose practical responses. If Siri gives me bad advice, is Apple liable? Was I not under duress when agreeing to the 50 page (or minute) disclaimer?

Great idea, but why is this thing on front page if its not working ? I see nothing to select in "Select Procedure" menu.

I am experiencing the same trouble here, no menu to select...

sorry, the problem has been fixed

Really cool, but also not super helpful. Prices are not set. Book prices are not shared. Some prices are protected by crazy nearly anti-trust agreements (heart implants). And you have to know which procedure you want or should have for a particular condition.

But, that being said, I think it is awesome. Anything we can do to fix healthcare needs to be done.

Who cares? My insurance co-pay is the same either way, which is exactly the problem. There is zero incentive to shop on price.

Btw, nice work :)

You have a PPO plan so you pay a copay. Many people have HSA, High Deductible or Catastrophic plans where they pay out of pocket until their hit their deductible. So all of these people have an incentive to shop on price. You're just choosing to pay more in premiums for the benefit of not having to worry about the costs for care.

But this tool only includes Medicare data so it doesn't apply to any of those cases we just mentioned.

Yes, in the short term. But in the long term, your insurance premiums are decided based on the cost of your health care. So if everyone spent wisely, the premiums would go down or stop rocketing the way they have been.

True, but because you don't foot the bill aside from a relatively small co-pay, hospitals/insurance companies can get by charging more and more. This ruins it for the ~50M Americans who don't have insurance.

We'll see how Obamacare deals with it though.

Be careful comparing costs alone. Like everything else, sometimes more expensive things are better in quality. This might manifest in a different diagnosis, a longer recovery time, complications, or no difference at all. Kind of like a bandit problem because you only get one opportunity to choose.

Very cool idea. I think you should add something like select2[1] to your select input. That way when a user starts typing it could automatically start to autosuggest procedures.

[1] http://ivaynberg.github.io/select2/

Excellent design, Here are a few bugs logged for bestmedicareprice.com by 99tests

http://app.99tests.com/openbugs/?company=best-medicare-price

Medical prices are so outrageous in the US that, in theory, the medical business is a good field for startup disruption.

Real disruption, not showing prices on a page but having actual good doctors at a good price.

There is a monopoly today controlled by few.

snaphealth tries to do just that. hopefully they get more traction in 2014. Concierge doctors are all over the US as well, but its still hard to compare them or find a place that does that

Pretty cool. You could also fly to Costa Rica, if you have the time...

Cozumel/Playda Del Carmen has a significant medical tourism industry as well (dental included!). Half the price vs the US.

Eye opening... great work!

Bug: (FF 16.0.1 on OSX 10.8.5) When the "select a procedure" drop down box is expanded, wheel scrolling up/down seems to also zoom the map underneath it.

Have you looked at the Dartmouth Atlas? They've been mapping healthcare costs for the last decade. Might have some good data and inspiration for you.

Thanks for the tip. I'll look into it :)

Saw this couple of weeks ago http://pricemaps.betterdoctor.com/

Thanks for the link--haven't seen this. I think they use a different data set for the procedure prices, but I like how they also compare it to a quality ranking. I will look more into how US News quantified hospital scores.

What I think matters most for healthcare is not just price, but quality/cost. Quality is difficult to measure, but should factor in recovery speed, number of repeat-procedures, service, etc.

Thanks!

I think, when are showing some numbers, it looks much more perceivable when you have something to compare to, in our case, the top hospitals ranking from the US News.

Some more work will mostly likely be done soon to enrich the data we are showing.

Interesting. The prices listed by this tool are very different from the prices listed in the tool in this Show HN post. I wonder how their data differ?

Hi!

I went back and checked the data. If you search for chest pain, and look at Cedar-Sinai Medical Center around Santa Monica,

we are showing this piece of information.

313 - CHEST PAIN,50625,CEDARS-SINAI MEDICAL CENTER,8700 BEVERLY BLVD,LOS ANGELES,CA,90048,CA - Los Angeles,229,43714.62445,5094.71179

In the PriceMaps we made, we are showing the last value, which is the 'Average Total Payments' for the operation.

Not exactly sure if the site mentioned in the HN is using the same data.

Great first step. And pretty soon we'll have quality of care reviews--from patient questionnaires thanks to ACA/Obama Care.

I'm anxious to see those reviews. Quality of care is highly subjective and difficult to measure. Patient reviews are probably the best thing, but may be skewed on short-term or trivial aspects of the treatment, like how nice a doctor is or the wait-time. It'd need to be more on how a patient recovers over a 3, 6, etc. month period and whether or not they need to be re-treated

Can't wait to try but right now, it looks like there's something wrong with the dropdown menu: Cannot select a procedure.

The dropdown is difficult to parse, alphabetizing would help. Or at least group similar procedures together under a heading.

What do the numbers and colors of the hospital symbols mean? They do not seem to be correlated with price of procedure.

The price number in the marker is the average cost of the selected procedure at the hospital at that location.

A green marker means its the cheapest price within the map's boundaries. Red means its the most expensive.

Thanks, I will make that more clear

Example of very useful and transparent system that should be available for everyone. Keep going in this direction...

Presume you're just updating, but I'm getting a JS error on line 21

    query.ascending)(

NYT article on this a few days ago...I thought exactly about an app like this...kudos.

Have you ever thought you were having a heart attack? Flu tends to be moved by car.

This is great. Please sort the items in the drop down list. (I'm on Chrome)

This is fantastic, clear, concise, and helpful, with a simple UI.

Thanks! The goal was to shed some light on price discrepancies within the US, and not just the US vs other countries.

in this day and age of bigger monitors with larger and larger screen real estate, any and all "map overlay apps" need to be full-screenable...

Uncaught SecurityError: An attempt was made to break through the security policy of the user agent. (parse-1.2.13.min.js:1) (Hint: I block cookies.)

Nothing but a sickly looking map, and no data.

App doesn't work on safari or firefox mac

Great work! Keep it up!

Super cool. Good work.

Brilliant! Great work.

interesting idea. cant wait to see what happens next

So freaking cool.

Heroic sir.

This is cute, but it is based on a flawed premise. There are not "prices" for medical procedures and even the providers don't know what they are going to charge. Anecdata: when my wife was pregnant I asked the hospital what are the basic charges for normal obstetric delivery, since we were paying out of pocket. I got a reply in writing that it was $20k, a suspiciously round number without itemization. The baby comes and there are no complications and no anesthetic and the attending physician never even showed up for some reason. So it was in every way the cheapest possible way to have a baby short of squatting over a blanket.

Needless to say that this American hospital would not even have admitted us without a certified check in advance, so we had spotted them the $20k. Over the next six weeks I get literally dozens of bills. I get a bill from the attending obstetrician who wasn't even present. I get bills for anesthesia that wasn't administered. I get bills in total of over $31k. I was uninsured but I'm not some chump, so my attorney sent these people sternly worded letters and we held the line at $20k which I think anyone would agree is already a ridiculous price in the first place.

Point is, nobody in this system has any idea what the price of anything is. There's no rate card. It's a collective emergent phenomenon that prints invoices. Nothing more.

My question is how are they not criminally charged with fraud when this happens? I could understand if this only happens once in a while, that it isn't done intentionally, but it happens all the fucking time, so someone is clearly intentionally doing it.

If you hold a man hostage for a month or a year you go to jail for a year or two. If you intentionally overbill a man so that he must work an extra year worst case scenario you... send a sternly written letter and pay them the original amount?

WELL, if we're talking about INTENTIONALITY then yes the american medical bureaucratic system as evolved obviously singles out the uninsured and proceeds to screw them over.

If we're talking about mens rea, then I doubt it; my wager is tied to how it's in no one's incentive to care that leads to these outcomes. Medical providers are clueless and totally disconnected from administrative functions, hospital billing systems are optimized towards dealing with horrible leviathans that spew sulphur and vomit acid and all of this operates on a scale that makes makes the cost of delivering babies a rounding error.

I'd imagine someone forgot to properly code the procedures/the paperwork isn't set up to give a shit and they were simply charged the default set of procedures.

Blah blah, single payer public systems, blah blah aligning incentives around cost structures, etc. Atul Gawande has a great few articles on this.

My father is close friends with someone who runs a large hospital in Texas -- he told us that it is quite routine to overbill, and that they allow for up to 5% over billing. It's a line item in their balance sheet and they actually rely in this as a predictable revenue source.

For an industry of people who have had to spend over a decade jumping through academic hoops, and whose job seems to require a great deal of precision, it is unbelievable they lack competence in something most high school drop outs master McDonalds - namely, standardized pricing and itemized billing (not to mention customer service).

Wow, I always figured that many hospitals would overbill because they could get away with it, though I'd imagine many would go much past 5%.

I don't think it's incompetence that makes pricing variable; rather, its lack of accountability. It's hard to find out where the price tag comes from, so why not charge as much as you think you could get from each patient? If you ask your doctor for an itemized breakdown of your bill, they (may eventually) give it to. The prices are often exorbitant and arbitrary.

IMO there is a guilty mind somewhere in that hospital. After seeing bill after bill come back wrong and without blowing a whistle / fixing the problem they are obviously accepting that they are lying to a good portion of their client base.

Dispute all of it and the bill will likely be way less than 20k. I had mallet finger once and I got a bill of thousands of dollars and charge for a broken finger, then a set, and multiple check up visits.

In reality I went to the doctor once, got an xray, he gave me a splint and said don't take it off for 8 weeks. I never went back for a second visit because it wasn't needed assuming I followed the treatment of did not bend my finger for 8 weeks. I called billing and asked for an explanation and the bill went from a couple thousand to a couple hundred.

This is exactly why I get so pissed about the Affordable Care Act! We are not solving the problem of why medical care in USA is so outrageously expensive, we instead are solving the problem of how to pay for it. The problem is, once most people have insurance, there will be no political will to solve the much more complex and important problem of reducing the healthcare costs for everyone.

Incidentally, totally agree. In any hospital, all you have to do is dispute the charges and demand documentation, and all of the sudden the bill is slashed tenfold! So, basically, the system is setup to screw the uninsured americans who may not know their rights or have the ability to challenge the hospital.

Hope is that when big entities like the state or insurances have to pay the big bill, they have far superior means to enforce lower prices. That's not everything that needs to be done, but it is still useful.

They are actually pretty good at driving the prices down to something reasonable in most cases. While the headline prices are absurd, the prices actually paid by public and private insurers, whether Medicare or Blue Cross or Aetna, are much more reasonable. Not as reasonable as in much of the rest of the developed world, but the gap is not as gigantic as it initially seems.

The really big gap between the U.S. and the rest of the developed world on medical costs isn't the cost of individual procedures (once you've taken into account what insurers actually pay), but the much larger amount the U.S. spends on last-6-months-of-life "heroic care". If that were brought more in line with international norms, the overall cost-per-person numbers would be much better.

Where do you find a breakdown of the costs? Anyone have links?

This looks interesting:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1361028/

If I get table 4 right, people who manage to live past 85 years will have 1/3 of their health care spending after their 85th birthday (not entirely accurate, but a reasonable simplification).

I wonder though, even if the insurers can drive down prices, how do the insurance companies verify that they are only paying for services that are actually rendered? With the massive amount of medical billing fraud, I suppose insurance companies will invest in investigating and eliminating this behavior? Either that, or they will go bankrupt.

A telling thing: if you make world-wide health insurance it's valid for every single country other than the US. If you want US coverage the price will usually double.

ACA is a step towards single payer, which enables capitation model, vs fee for service. Meaning paying to keep people healthy vs profiting from disease. It's all about the incentives.

Medicare is already transitioning to capitation.

Meanwhile, while not ideal, ACA has already significantly slowed down the growth of costs. Amazing what just adding some price transparency can do.

I think you hit the nail on the head. I had a similar story as the OP and after complaining and looking into the price I never heard back from the hospital. In hindsight their actions reminded of highway robbery. This year with the Surgical Center of Oklahoma and the time magazine article on medical billing though a lot of information has come out. Price comparision websites like pricepain.com, clearhealthcost, bluebook of healthcosts etc, are just the beginning. It's almost like a race against the clock where either ACA's price inflation will create so much political upheaval that the single payer system hands this inefficent (non existant!) market place over to the tax-payer (which will mean ever inflating prices) or a solution like this, with dramatically visible pricing information, direct doctor pay, low cost catastrophic insurance will emerge as the saner, cheaper and higher quality solution.

> We are not solving the problem of why medical care in USA is so outrageously expensive, we instead are solving the problem of how to pay for it.

Perhaps, but to the individual, the first problem is by far the gravest. One can feel outraged if the taxpayers are paying too much in general, but that is not exactly a life or death situation like not being able to pay for medical aid.

Also: Why can't you fix both problems?

Fixing both problems is ideal, and we should do both. But, I fear, that after fixing the "how to pay for it" problem, no politician will try to fix the much more complex, and much more important problem of the very high costs. At the rate we are going, by 2021 US is expected to spend nearly 20% of GDP on health care. To address this we will need to cut the spending on last-6-months care as well as reduce procedure costs. Even if we address the latter, I doubt any one in congress has the spine to address the former.

Forcing people to pay for health insurance they don't want to drive down the cost of healthcare seems backwards. The pressure should be on insurance companies to make insurance more appealing.

At this point, it's much easier to figure out how to pay for it than it is to revamp the entire system and stop some powerful players from making as much money as they do. It's much better to have this than to work towards fixing a societal problem for decades and get no where while doing so.

That's not quite true - part of the problem is that we don't know exactly how, in the American system, to reduce the healthcare costs effectively. But I feel like I've read multiple times that the ACA funds pilot programs to try out many many different ways to change incentives to see if they help health care costs come down.

WOW just wow. Would have been cheaper to fly first class to any other country in the world and get the baby there. It's really time for significant overhaul of the health care system here in the US

Yes, in France its about 100 to 200 euros.

That's the total cost to the French medical system for a normal delivery? I find that hard to believe. In Canada that rate is a couple thousand dollars.

Or is that what the patient has to pay?

What the patient has to pay is close to zero, even with anesthesia (which is more or less compulsory -- you would have to make a big scene to avoid it) and complications.

If you want a doctor to attend (instead of simply a midwife) you have to pay him out of pocket (but if you have private insurance it might cover that too).

What it costs to the French medical system is anyone's guess. The French medical system is financed by the taxpayer. In theory, it's financed by a tax on salaries, but since it's in perpetual deficit and the deficit is covered by the state, it's in fact paid for by the taxpayer -- which is just as well, since everyone is covered.

It's a system of fully socialized medecine; there are pros and cons to such a system; it's not all good, but it's certainly not as bad as the American system (before or after Obamacare).

Difficult to say if that's the case for hospitals, since they run on public money anyway, so they could run at a deficit and it would hide the higher cost than what they charge.

But in all cases, social security pays exactly what you are billed.

In most cases you pay yourself the hospital, clinic, doctor, whatever, and social security then gives you part of the costs (depending on the procedure) and if you have one, your private health insurance gives you the rest (or less, depending on your plan, of course).

The tendency is at removing the unnecessary payment by the patient before being reimbursed, but for now this at least serves as a way to ensure you know exactly how much was paid for the procedure, and to prevent too many excesses (since, well, the patient has to be able to pay, even if he gets reimbursed).

>That's the total cost to the French medical system for a normal delivery? I find that hard to believe.

Many EU countries are trying to boost their birthrates, so the state covers most/all of it.

Come to the UK, it's free.

It's also free in Norway.

It certainly is not. It is paid for by one of the highest tax rates in the world. I currently work in Norway and pay more than 50% in income tax and social contributions - and that does not even include other taxes and excise duties like the 25% VAT, the 9USD/gallon gas price (mostly tax) or the new car tax of something like 150-200%, property taxes, road taxes, vehicle taxes, alchold and tobacco taxes...

So no, it is certainly not "free".

(And yes, people in Scandinavia stating things are "free" is a rant-trigger for me.)

And people in America stating that healthcare is not free is a rant-trigger for me.

Everyone here knows that it's not "free" but subsidised by taxes. That's what "free" means when talking about healthcare, free at the point of service, and free as equally available to everyone.

How else would it work? Are the doctors without pay and with no equipment?

It's an important point to make that even "free" healthcare is not actually free - the money has to come from somewhere, and most of it comes from forcefully confiscating it from people.

Not only that, but if you're using money, it's much easier to use someone else's money instead of your own, you just won't be too careful about how you spend it. In fact, if you've got a "limitless" supply of other people's money, you just won't give a fuck about what you do with it. This is one reason why public healthcare (and public anything) turns to shit sooner or later.

> "Not only that, but if you're using money, it's much easier to use someone else's money instead of your own, you just won't be too careful about how you spend it."

Sounds logical on paper but doesn't bear out in reality - just about every country where health care is provided via "confiscated funds" pays dramatically less for better outcomes than the USA where people are responsible for spending their own money.

The Parasite(tm) is more bedtime-story boogeyman than observed reality. They exist, but in far fewer numbers than reported, and their effects on the system far less grave than prognosticated.

This makes a lot of sense in fact, if for nothing else than the simple reason that most people really don't want to be sick or pretend to be sick so bad that they actually spend a lot of time at a hospital.. They have better things to do.

In Canada, where I'm from, most of the people I know avoid doctors and hospitals unless they really aren't feeling good. They don't want the hassle of waiting and waiting again to see specialists or get a procedure of some kind done.

The canadian socialized system is still really, really slow though for non emergency care but I never believed it was because of parasites wasting hospital resources.

>> Sounds logical on paper but doesn't bear out in reality - just about every country where health care is provided via "confiscated funds" pays dramatically less for better outcomes than the USA where people are responsible for spending their own money.

The US healthcare system is truly fucked, but serves as another great example of how people use someone else's money. That's why healthcare is so absurdly expensive there. Patients generally aren't using their own money to pay for medical services, and so, insurance companies get charged ridiculous prices behind the scenes, and the customer doesn't care. Businesses are forced to buy insurance, right?

Well, without the "forced middlemen" of insurance companies, and with customers paying for whatever services they use, you can bet your ass that health care would be massively cheaper. Competition drives quality up, and prices down.

>> The Parasite(tm) is more bedtime-story boogeyman than observed reality

I hadn't even heard of that "theory". But I bet I would have, if I were still watching Bill Maher's show.

You're right in that some parasite patients are not the problem. The whole system is.

Think about it. If you're running a hospital on a "limitless" supply of other people's money (as in, "public healthcare"), you're just not that concerned with efficiency, nor the quality of your services, because you don't have to be. It doesn't matter if your customers are unhappy, because you'll still be getting your money! .. It's blindingly obvious that this kind of system is doomed, but of course, healthcare is not socialized in order to make it better. It's socialized to make the masses dependent on the State.

So I assume you don't buy insurance, for anything ever, correct?

The norm is 36%, if you earn a lot you'll get taxed more. But your income never has a say in you wanting to have a child or not.

Is using Hacker News free?

Comparisons between countries like Norway and the US are a bit misguided IMO. It's hard to imagine that an oil rich country with a homogeneous society of 5 million people at the edge of the world can be fairly compared to the leader of the world's current Pax-Americana with a population of 300 million. Norway enjoys the benefits of being an almost-city-state as described in Antifragile by Nassim Taleb.

There is no free lunch?

There might be. The US government spends way more money per head on public healthcare than the UK (and only slightly less than Norway) and that's totally separate to all the private spending! http://www.theguardian.com/news/datablog/2012/jun/30/healthc...

Procedures are so expensive, doctors so highly paid, and insurers so profitable that the US is essentially subsidizing all that while still not providing universal healthcare.

In the UK we're both taxed less AND don't have to have private insurance due to the above. (It does have some downsides though, particularly in not being able to easily 'shop around' or get access to cutting edge/experimental medicine.. it's a bit one size fits all.)

Nobody in the United States gets access to cutting edge/experimental medicine either. Insurances just won't pay for it. They say "too experimental" and "not medically nessessary" is a reason not to pay. I am currently in a 3rd level of appeal to get my insurance company to pay for my medication they claim is "too experimental" (it isn't by the way!!!)

A top-level policy with Bupa/Pru will get you easy access to top hospitals in the UK (including London), for diagnostics at least. I just got a quote for £70/mo (it will almost double if you claim, however).

EDIT: hm, not sure about 'experimental', but top quality/teaching hospitals anyway.

Really? In Poland the state pays ~$500 and that's it. And they are not famous for being generous :)

Yes, if I had to pay 20k to just have a baby and could fly somewhere else where it's free, I'd chance it.

There might be a problem that many airlines won't let pregnant women fly past a certain number of months, for fear they will deliver the baby in the air; so maybe you have to move to the target country months in advance, significantly adding to the total cost...?

Doesn't need to be free - the very best healthcare in my country (Uruguay) would cost about five thousand dollars per year of coverage, and we're talking about something better than the average US hospital - www.hospitalbritanico.org.uy .

Those five thousand would cover 90% of the expenses involved in all steps of pregnancy (prenatal care and checkups, 4D ultrasound imaging, etc) and the delivery itself.

And living here a few months would cost way less than 15.000 dollars :)

If flying is a problem, you may drive to Canada or Mexico. Mexico has a pretty good private system that is used by the local middle and upper classes. This is from my hometown...http://www.chihuahuamedicalcity.com/

You can take quite a long vacation for 20k.

Companies, like Safeway, that self insure pay $3,000 to $5,000 per procedure. For example:

Colonoscopy: $897 Breast excision of lesion procedure: $2,569 Gall bladder procedure: $4,212 Cardiac Catheterization (no angioplasty or stints): $4,900 Knee Arthroscopy: $3,039

I wrote about it here:

http://www.quora.com/Medicine-and-Healthcare/What-are-some-o...

The CEO of SafeWay, started a company that sells this data. Unfortunately its typically only sold to companies that self insure and have ~10,000 employees. You can watch him talk about the data and the company here:

http://coe.berkeley.edu/static/streaming/gtl-conference/2009...

Wow. The average reimbursement for a non-complicated birth in most US hospitals is around $3-5K.

You are correct though, the reason why hospitals do this is because the system is entirely setup to support this kind of behavior.

Next time, try a midwife if you and your wife are comfortable with home birth. In the Denver area it runs about $3k for parental care, the birth, and post birth check ups. Also, you don't have to deal with hospitals. I had one of my kids at home with a midwife and I wish it would have been both. If you actually need one, then the midwife will take you to a hospital.

Unless you have one of dozens (hundreds?) of potential complications that can happen during childbirth and you don't make it to the hospital in time. They you've got a dead or severely brain damaged baby and a potentially dead mom. Totally worth it.

And the odds of making it to the hospital in time if you need an emergency c-section or start bleeding out are pretty slim.

Actually, experienced mid-wives are very good at recognizing problems before they become serious problems. At some point, I was running out of energy and starting to struggle. They have monitoring equipment for the baby, and checked on her first to make sure she was fine. They talked about transporting me, but decided to give me a tablespoon of honey first. It worked, and we were done with a healthy, happy outcome shortly after that.

With midwives, you actually have human attention on you during a birth, rather than doctors and nurses that drop in occasionally and can miss stuff. My hospital birth came closer to having problems because there was another emergency on the floor and no one paid attention to me for hours (when perhaps they should have).

Obviously you haven't done your research on this topic yet. The midwives are state registered and are legally bound to only serve woman who are in perfect health condition, with no complication during pregnancy whatsoever and prefer woman who had previous births without complications. Still, hospital is on standby and yes, it makes more sense if you are not 100 miles away from one.

that's exactly what we did. 12k the hospital, 6k the birthing home and the midwife charged 3k. When we asked her about the price, she "admitted" feeling "guilty". She said "it's still way too high, but I get in trouble from the birthing homes, if I charge less". Talking about "market prices". There are none (yet).

woh woh woh hold on....20k to give birth? I am amazed the US is still breeding.

"I got a reply in writing that it was $20k"

That sounds unbelievable! how can it be? it has to be a marginal case. I know at least two people that had babies in the US and barely pay anything (neither for the delivery nor for other medical acts before and after). They were PhD students or postdocs.

What I am wondering is on average how much an american pays for having a baby?

It's not an edge case: we were quoted that price a few years ago. We carry high deductible insurance, and that was before the recent US health care legislation mandated maternity coverage. (Before it passed, most insurers refused to provide maternity coverage outside of large groups, or charged insane prices, since the probability of a claim was so high.)

In the end, we opted for homebirth midwifery care, which was fantastic in every way. We ended up paying around $2k for six months of prepartum care, delivery, and six weeks of postpartum care. In the event of an emergency, insurance would've covered a hospital transfer.

It was such a good experience we did the same thing for #2, and we're planning on delivering at home if we have more children in the future.

Those people probably had health insurance and did not pay out of pocket, their insurance footed the bill. I know someone who paid out of pocket for a delivery and I think they said it was around $12K.

$20K for a normal delivery? that sends shivers down my spine. I knew healthcare is expensive, but this is insane.

Point is, you got robbed and didn't go to court for it.

>Needless to say that this American hospital would not even have admitted us without a certified check in advance

Well you ended up screwing yourself. Maybe you have never spoken to an American who didn't have health insurance and so didn't know, but, medical bills are settled later for less than half the insurance price and all hospitals have to admit you regardless of ability to pay by federal law championed by Kennedy.

>Needless to say that this American hospital would not even have admitted us without a certified check in advance.

An emergency room cannot refuse treatment to a women in labor.

http://en.wikipedia.org/wiki/Emergency_Medical_Treatment_and...

I worked at ER. No, you don't want to have a baby in ER. ER doctors are dealing with emergency situations and patients (auto accident,cardiac arrests,gunshot wounds,etc). I've seen one baby being delivered in ER, and it wasn't a good experience for the patient. Rather, you'd want proper pre-natal care and comfortable delivery room, with your own doctor. Also, ER treatments are more expensive. Way more expensive.

Wow. Next time shop around a little. We did and the hospital stay for my wife and baby was around 2800. Our doc was 2700. The anesthesiologist was a shocking 2500 though. Our doc and the hospital had to be prepaid, or else we would be charged higher rates. Some places call them "Stork plans"

"I got a reply in writing that it was $20k"

What did the reply in writing actually say?

Seems almost as if this was merely a "retainer" paid in advance against the expected cost.

Interesting data, but good to note that cheap does not equate with better in the medical field typically.

Is there evidence of correlation?

The next step would be to bring in death/complication statistics by hospital and ratings by surgeon

I would hesitate to interpret this so naively. For example, there are some vascular surgeons who take on patients that nobody else will touch. These are patients with many bad prognostic risk factors, but they will die without the surgery.

The surgeons who take these patients may end up having terrible stats, but be the most skilled if only because their mortality rate is not pushing 100%.

Comparing this statistic the way people compare gas mileage is a disincentive for these surgeons to operate on patients that need help, but are high risk.

Selection bias (by the physicians) should make that extremely challenging. You could adjust for underlying comorbidities, though that will often not give enough adjustment to make an impartial expert observer feel that it is sufficient.

Some states already do this. For example, for CABG and valve surgery, NY State publishes raw, as well as risk-adjusted mortality rates (RAMR) broken down by surgeon: (warning, PDF) http://www.health.ny.gov/statistics/diseases/cardiovascular/... (begins on pg 21)

Fun fact: Dr. Oz is in there and it even looks like he might be one of the better performing surgeons too. Another fun fact: it can be hard to draw inferences about individual providers this way; check out just how wide some of the the 95% CIs for the RAMRs are, and a lot hinges on how good your risk adjustment model is (details on pg 13).

CMS is actually doing that already (at least for hospitals).

Early next year, CMS will post healthcare quality metrics that it's collected from providers who bill to CMS. In 2015, hospitals will start getting reimbursed based on quality, which is a step in the right direction, however, it is chocked with problems (i.e. treating the best patients will advantage a hospital)

If you were a doctor, would you rather charge more, or less? What keeps you from charging the highest fees in the world? Your reputation. If you're not the best, you cannot charge the most. All of capitalism works this way.

Medical care is not really capitalism. Doctors get about the same reimbursement from any given insurance company no matter how good (or bad) they are, unless they are bad enough to get dropped from the insurance company's panel. Some negotiate for slightly better rates, but that often has more to do with the number of similar specialists in their geographic area on the insurance panel.

Insurance companies consider doctors a commodity. They only place where capitalism really applies is when patients are paying cash.

Source: I'm an MD. My specialties are forensic and child psychiatry. Interestingly, despite severe shortage of child psychiatrists, it is not reimbursed as well as some specialties that have a glut of providers (like cardiology). Not complaining, it's well reimbursed enough for me, but just making another point that it's not really capitalism.

My specialties are forensic and child psychiatry.

Wow. I bet you could write an interesting book or three. (I hope you do.)

You forgot things like consumers needing information and having a choice. Those need to be present for capitalism to work.

For fun I ask how much it is going to cost when going to my doctor. They refuse to tell me. They can't even make an estimate (tens? hundreds? thousands?) Even after seeing the doctor they can't. I pull out my card and say "I would like to pay now". I get told I have to wait for the bill. It is virtually impossible to find prices. Things are more complicated because the patient is often not the one paying directly due to the "insurance" that goes on.

This doesn't only apply for doctor visits/procedures, but even for labs where it is a known consistent product with little variability. http://www.rogerbinns.com/blog/gplus/the-first-rule-of-the-a...

A few years ago I had a ride to the emergency room. There was only one ambulance company and only one relevant hospital. The morphine in the ambulance was $27. At the hospital it was $129 plus another $75 fee to add it to the drip. Capitalism is not at play there.

Also did you know that if in most states you were going to open a hospital to lower costs you won't be allowed to? https://en.wikipedia.org/wiki/Certificate_of_Need

According to the site, for the 'Certificate of need', the main arguments seems to be following: "A number of factors spurred states to require certificates of need in the health care industry. Chief among these was the concern that the construction of excess hospital capacity would cause competitors in an oversaturated field to cover the costs of a diluted patient pool by over-charging, or by convincing patients to accept hospitalization unnecessarily."

I couldn't understand this argument. Something seems to be wrong.

The argument for CON is that if a new facility came in and charged less, then the existing facilities would have to charge more to cover the patients they lost which would adversely affect their remaining patients. So a new facility would need to show the need of non-served patients - ie that they wouldn't take away patients from existing facilities.

It is of course hogwash, but is a nice way for existing facilities to have a monopoly, prevent competition, and not have pricing pressure. Standard rent seeking/corruption that exists in the US.

If you are only doctor performing that procedure in a city... Well you get the point.

agreed. How many times have you actually shopped out a procedure by making 10 doctors appointments for checkups and quotes, typically, when they need to operate, you just go with what they say.

I don't go to the doctor much, but when I go I ask "how much will this cost?" and 99% of the time I get "hrmm... I dunno..." and a shrug.

Most doctors in rich (i.e. insured patients) hospitals have no idea. My ENT was quite surprised when I told him the charge (>$1000) for his quick look down my throat. And that was only after a lot of shopping around and negotiating on my part. And it didn't include any "treatment" - it was just to look and possibly diagnose.

I'm usually asking the receptionist or other office person - they handle most of the billing stuff, and the other response I sometimes get is "oh, we have to run it through insurance first". They just run a code, and get told what they'll get paid (apparently), not necessarily what my cost/price is.

The system is so fundamentally out of whack, and not at all 'market driven' and yet somehow... my 'free market capitalist conservative republican' friends (I have a few) are really against "socializing" medicine/healthcare. As if, somehow, what we have now in the US is a bastion of free market enterprise.

The cynic in me thinks that the conservative elite really really really enjoy having a dependent class, and ensuring people are at the mercy of private health insurance companies vs the federal or state government helps ensure that dependency in a way they can still control. But... I'm overly cynical, it's late, and my words aren't coming out exactly as I think they should. :/

This also creates an incentive to decouple the cost for the doctor from the cost of the hospital (operating room use, bed use, supplies, nurses, etc.)

You have a JS error that breaks the whole site.

Here it is:

    var query = new Parse.Query(Procedure);
    query.limit(1000);
    query.ascending)(               <---- error
    query.find({

Thanks for the notice. The change has been fixed.

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