[HN Gopher] Most hospitals aren't complying with price transpare...
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Most hospitals aren't complying with price transparency rule
Author : KoftaBob
Score : 289 points
Date : 2021-06-15 12:41 UTC (10 hours ago)
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(TXT) w3m dump (www.axios.com)
| avgDev wrote:
| US healthcare system is a joke. I have many examples but my
| recent one is pretty annoying.
|
| My cost of PT with insurance $150 per visit, cash cost without
| insurance $69 per visit. Like wtf......I get why cash price is
| lower but this needs to stop. It is getting to a point where you
| are better off with a high deductible plan and paying cash for
| minor visits.
|
| I don't know a single individual who used the US healthcare
| extensively and said "Wow, US healthcare is amazing".
| standardUser wrote:
| In the US you go to the doctor and have no way of knowing if
| you will pay $50 or $1500. I've been lied to directly by both
| providers and insurance reps about what the cost to me would
| be. Then it's on to appeals, and second appeals and so on.
|
| The entire situation is appalling, and it's even more appalling
| that people have accepted this nonsense for generations.
| hackeraccount wrote:
| There's an episode of the Econtalk podcast that covers medical
| pricing. https://www.econtalk.org/keith-smith-on-free-market-
| health-c...
|
| It is clearly coming from a ... more sympathetic to free markets
| side of the argument but I honestly believe it's interesting on
| it's own terms.
|
| It includes an explanation of the delightful term "compensated
| uncompensated care"
| Workaccount2 wrote:
| While I admit I haven't listened to the podcast (yet) I'm not
| sure how you get around that issue that the free market value
| of medical services will defacto price in the value of your
| life and health, which is infinite.
| adolph wrote:
| I think a whole universe of content could be expanded from that
| episode and I wish that more of the people commenting here
| would listen to that episode.
| standardUser wrote:
| It should be illegal to render medical services without first
| declaring the precise amount of money it will cost the end user.
|
| If I go to a doctor and they recommend a procedure, it should be
| on them (the service provider) to tell me the cost and I should
| pay it right then and there. Billing later should be strictly
| outlawed.
| acuozzo wrote:
| As mentioned elsewhere in the thread, how does this scale to
| the 10X problem?
|
| What if you have a heart attack while under anaesthesia and the
| cost of your procedure suddenly jumps by a factor of 10?
| standardUser wrote:
| This probably requires setting prices at a level that can
| absorb these less predictable costs. Would you rather be told
| you need to pay "somewhere between $2,000 and $30,000, and
| you'll find out in a couple months which one it is" or that
| you simply must pay $4,000? Most households would want the
| safer bet lest they go bankrupt and have the entire
| trajectory of their lives altered for the worse.
|
| The far better solution is of course to have a government
| program cover these types of costs.
| hirundo wrote:
| I had really bad nausea and pain, went to my doctor, who said I
| likely had a kidney stone, and the next step was to get an MRI. I
| was between jobs with no insurance and few funds, so I asked what
| it cost. The doctor had someone in his office call the hospital
| and got a quote for $1,500. I got the MRI knowing only that.
|
| A month later I got a bill for $3,500. I drove out to the
| hospital (2 hours) to ask wtf. They didn't help at all, wouldn't
| budge.
|
| So I went home and wrote them a check for $1,500, marked as paid
| in full, with a cover letter explaining my side of it. It worked.
| They cashed the check and I never heard another word. I've done
| further business there with no problem. It's well worth pushing
| back.
| cdumler wrote:
| I ended up learning this accidentally and have used it ever
| since:
|
| I knew that hospitals charge ridiculous prices at first and
| then insurance jumps in. At the time, the insurance that I was
| on seemed to have a policy of "first let the hospital bill the
| patient and see if he/she pays then we'll get in involved." My
| procedure was $3,000+. That was a joke, but it also wasn't
| wholly inexpensive. I figured I'd end up for my deductible at
| about $800 or so. Hospital sent me the bill for $3,500. I
| expected insurance to chime in, but didn't. A month went by, I
| got an other bill, only lower. I call the hospital why this
| wasn't being resolved, and they said "looks like we didn't mark
| the procedure correctly. Ignore the bill, we'll fix this."
| Another month goes by, another bill, still lower. The bills
| still come and they kept changing. Eventually, it gets coded
| correctly and insurance did their part, and I owed $600. I
| forget it about, though. I get a call on the phone with the
| hospital saying, "we're going to send you to collections unless
| we can get some level of payment on this." I ask what the bill
| is if I pay in full. She says, "Pay in full and it's $380." I
| said, "I can make that happen."
|
| The U.S. is quite corrupt like any other "third-world" country.
| Just in different places. Our places are acceptable, though
| because "deregulation" or "gun rights" or "free speech".
| knubie wrote:
| You must be joking if you think U.S. healthcare is
| deregulated. It's one of the most regulated sectors in the
| economy, which explains why it's such nightmare to deal with.
| LatteLazy wrote:
| "deregulation" needn't mean actual deregulation. It can be
| an excuse for corruption just as much as any other
| initiative.
| rundevilrun wrote:
| americans really live in another dimension
| ryathal wrote:
| Its not just heavily regulated, it's also one of the most
| indirect markets that exists. People often have no idea how
| much their health insurance actually costs in the first
| place, and they have no idea how much their insurance may
| or may not pay for any given procedure, or how much a
| procedure will be billed for, or even if a single procedure
| will result in 1-10+ different bills.
|
| Since the people giving care often have to provide care
| irrespective of ability to pay, they have no idea what
| anything costs.
|
| Since Insurance companies generally aren't paid by
| individual people that use their service, and have
| discretion in what they pay the process is as difficult as
| possible for providers and users of medical services to
| navigate.
| onetimemanytime wrote:
| >> _So I went home and wrote them a check for $1,500, marked as
| paid in full, with a cover letter explaining my side of it. It
| worked. They cashed the check and I never heard another word_
|
| I hope it ends as you say (think of collection agencies)
| baron816 wrote:
| I wonder if you could've written a check for $350 (or any
| amount), marked as "paid in full," and would have the same
| outcome. I bet either 1) no one actually looks at the checks or
| 2) $3,500 is not significant enough for them to fight for at
| all when a bunch of people are delinquent on $350,000 bills.
| MattGaiser wrote:
| Isn't this fairly typical? I had an emergency visit when I
| visited the USA once and was flat out told that the insurance
| bill was about $3000, but they could take $600 if I paid right
| away. I had out of country insurance, so had to pay upfront
| anyway, so I chose the $600 option.
|
| I was flat out offered the cheap cash settlement.
| MeinBlutIstBlau wrote:
| Part of that is why HSA's are heavily promoted since you get
| pre-tax dollars to go toward an account you can use
| specifically for these reasons. So in essence, that "out of
| pocket" money would be coming from your HSA. In practice
| however, that's not really the norm.
| danaris wrote:
| Unfortunately, I've never been offered an HSA that's not
| "use it or lose it", meaning I have to know my medical
| expenses for the entire next year during the open
| enrollment period in the fall in order to properly benefit
| from it.
| astura wrote:
| You're describing an FSA, not an HSA, HSAs are not use-
| it-or-lose-it.
|
| FSAs and HSAs are different types of tax-advantaged
| accounts with different rules, but both can be used to
| pay medical expenses.
|
| There's also HRAs too that's another different type of
| tax advantaged account and can also be used to pay for
| medical expenses.
|
| This complexity is part of the problem.
| lotsofpulp wrote:
| HSA is legally yours, and no one can make you lose it.
| What you are referring to is a health FSA, which have no
| reason to exist anymore.
|
| Any employer that does not offer HSA eligible plans is
| shafting their employees. An HSA is a 401K, but better,
| since you can withdraw without penalty at any time for
| any healthcare expenses you had at any time in the past.
| And you can invest it into anything you want (just
| rollover your funds to a Fidelity HSA every year).
| Amezarak wrote:
| This is great in theory, but HSAs are only offered with
| HDHPs, which means that every other year or so, despite
| contributing the IRS max, I spend out the entire account.
| lotsofpulp wrote:
| Assuming you have sufficient income, you should pay for
| expenses today with post tax dollars, and let the HSA
| money grow tax exempt as long as possible.
|
| The premium difference and the deductible difference
| between HDHP and non HDHP plan cancels out, generally.
| You either pay more premiums on an ongoing basis, or more
| at one time for the expense.
|
| Unfortunately, there is no getting around actually having
| a lot of healthcare expenses. But spending ~$6k out of
| pocket on healthcare every two years probably puts you a
| couple standard deviations above average spend category
| unless you are old.
| Amezarak wrote:
| Nothing too crazy. A kid one year, two minor surgeries in
| other years. Fortunately no ER visits.
|
| It has indeed been my experience that the cost of a non-
| HDHP plan is approximately the same when all is said and
| done, but I've considered going back anyway. There's
| "loopholes" in the system that you end up falling
| through.
|
| For example:
|
| - have a kid at the beginning of the year, meet your
| deductible and out of pocket, drain the HSA to do so, but
| hey, free medical care for the rest of the year and you
| can build the HSA up again, right? Nope, your division
| gets acquired, you're laid off and rehired, and your
| "new" health insurance (same carrier and deductible as
| the old) has a brand new unmet deductible.
|
| - providers demand prepayment. Fairly unusual, but it
| happens. Say you need a minor surgery. Well, the MD and
| hospital want prepayment. Both of them see you have 4K
| left on your deductible and want 4K each upfront. Don't
| worry, you'll be refunded / have a credit on your account
| by whoever files last whenever they file the insurance
| claim three or more months from now. Bonus: any doctor
| you visit in the meantime still sees your deductible
| unmet because the claims haven't been processed.
|
| - medical billing is awful. HDHPs expose you to more of
| it because more of your actual cash is in okay. Providers
| bill the wrong amounts, fail to realize you have credits
| on your account, file as out of network instead of in
| network resulting in a different discounted cash price,
| etc.
|
| IME, any health problem requiring more than routine
| doctor visit plus xray or ultrasound is going to be many
| thousands of dollars. Who knows what the median is, but
| there's a reason the total insurance premium for a family
| HDHP hovers around 20k.
|
| And yeah, I see what you're saying, but yeah, my cash
| flow is not sufficient for that. Or at least, it doesn't
| seem worth it for a potential payoff decades from now.
| lotsofpulp wrote:
| Sorry to hear, but that is a rough set of circumstances
| to be in the current US healthcare system. The first
| situation is why employers should have been barred from
| offering any compensation other than money and time off.
| danaris wrote:
| I mean, this was admittedly 10 years ago, but it was
| definitely _described to me_ as an HSA at the time in all
| the literature I had access to.
| caturopath wrote:
| That wasn't an HSA, that was an FSA (or an HRA or
| something else).
|
| FSAs (other than LPFSAs) cannot be used with HDHPs, which
| are the plans that allow HSAs.
|
| An actual HSA is your money. If you don't spend it on
| medical care, you can withdraw it when you are elderly as
| normal money.
| PaulDavisThe1st wrote:
| and tax-free to boot.
|
| I have an HSA, but I'm painfully aware of how it's just
| another boondoggle for the wealthy. I can dump cash into
| it on top of the limits for my 401k and IRAs, and pull it
| out tax-free with no limits once I turn 65.
|
| Another good example of how an idea that sounds fairly
| good on paper turns out to be another benefit for the
| rich in real life.
| caturopath wrote:
| If you aren't reimbursing medical expenses, the money is
| taxed, even when you are 65+. (It functions sort of like
| a Traditional IRA in that circumstance.)
|
| The real trick is to save medical receipts for
| years/decades and reimburse only when you actually need
| the money, paying out of pocket until then.
| PaulDavisThe1st wrote:
| What I mean is yes, indeed, it functions like an
| additional traditional IRA, gains are accumulated tax
| free, and the balance can be withdrawn in any way you
| want post-65.
|
| Does that trick actually work?
| caturopath wrote:
| > Does that trick actually work?
|
| There is no time-boxing on reimbursement, so it should.
| HSAs are only about a decade old, so no one has done the
| extreme versions of it yet, but a decent number of folks
| are squirreling away receipts and letting the money grow.
| astura wrote:
| Why wouldn't it? There's no time limit on using the funds
| and no time limit on reimbursing yourself for medical
| expenses.
|
| Kinda like a backdoor Roth, no rules prevent it, so it
| works.
| aaomidi wrote:
| Typical doesn't mean we should accept it and move on. Which
| is why we should keep talking about this and keep the
| pressure up.
| suzzer99 wrote:
| Yes it's typical. Our healthcare is basically the equivalent
| of Moroccan rug shopping. It's great.
| mason55 wrote:
| I wonder if they recognized you were from out of country and
| so they'd have no way to collect if you just left, and that's
| why they offered the cash deal up front.
| benlivengood wrote:
| The reason this works is that bad debt, sold off to collection
| companies, is worth about 3 cents on the dollar.
|
| You can get much better discounts by talking to the hospital's
| business/billing office and demonstrating difficulty to pay.
| shiftpgdn wrote:
| A "normal" business doing this at scale would be investigated
| for fraud. Yet somehow it's normal when it's a hospital.
| MeinBlutIstBlau wrote:
| It's definitely not the hospitals fault. It's insurance
| companies getting involved since paying out of pocket is
| abnormal. So when you do pay out of pocket, you're paying
| what the insurance company pays and the hospital billing
| department is most likely very apathetic to that. Since they
| operate as non-profits, they often are willing to negotiate.
| Which is most likely why they can get away with this as
| opposed to a for profit entity.
| lotsofpulp wrote:
| There was no insurance company involved in the above story.
|
| > So when you do pay out of pocket, you're paying what the
| insurance company pays and the hospital billing department
| is most likely very apathetic to that.
|
| This has nothing to do with a health insurance company.
|
| > Since they operate as non-profits, they often are willing
| to negotiate. Which is most likely why they can get away
| with this as opposed to a for profit entity.
|
| This has nothing to do with non profit tax status. Car
| dealerships negotiate too.
| xahrepap wrote:
| I think your parent is saying that the quote was given
| ASSUMING insurance. So when the bill was formally given,
| it didn't match the quote because the quote was given
| under false-assumptions (about insurance).
| lotsofpulp wrote:
| That could be a possibility, which is still completely
| the hospital's responsibility and does not involve an
| insurance company at all.
| RandallBrown wrote:
| There is always an insurance company involved with the
| prices of medical procedures.
|
| Hospitals set their prices above what most insurance
| companies will pay to make sure they get the maximum
| amount from the insurance company.
|
| When you come in without insurance, you appear to get
| screwed because the prices are extra high just in case
| some new fancy insurance comes along willing to pay more.
| Luckily, in many cases it's not terribly difficult to
| negotiate a lower payment.
|
| I'm not advocating for this system, I think it's
| terrible, but I understand how it came to be.
| lotsofpulp wrote:
| That characterization would make the word "involved"
| meaningless.
|
| If a hospital wants to set their prices high to be able
| to price discriminate, that is the hospital's choice.
|
| No one is stopping the hospital from offering the same
| low flat price to everyone.
| mynameismonkey wrote:
| >Hospitals set their prices above what most insurance
| companies will pay to make sure they get the maximum
| amount from the insurance company
|
| Tis is generally not as simple. There are two prices that
| matter to this conversation: the hospital chargemaster
| and the usual and customary rate (UCR). The two are not
| functionally intertwined. The chargemaster exists in the
| hospital back office as a legal fiction and has little to
| no relationship to anything the insurance companies do
| although yes, sometimes chargemasters may be used as part
| of the rate negotiation with insurers. UCR is governed by
| what it says on the tin, it is what the market is paying
| in the specific geography.
|
| The shenanigans kick in when the hospital tries to do
| something with the fictional difference between their
| chargemaster and the UCR, or, worse, tries to charge the
| fictional price to uninsured and under-insured
| individuals.
|
| I keep a short explainer here:
| https://jaz.co.uk/2015/10/15/hospital-retail-pricing-for-
| dum...
| kbenson wrote:
| When without dental insurance, my dentist office put me on
| a special "no insurance" price list where I got much better
| quoted prices, because they knew they weren't dealing with
| an insurance company with people dedicated to negotiating
| low rates for each specific procedure individually. They
| may not have been quite as low as insurance companies paid
| in some cases, but it was much cheaper overall.
|
| It's not like this is impossible or hard, it just takes the
| hospital actually caring about their patients enough to not
| screw them over when they don't have insurance.
| castlecrasher2 wrote:
| It's both the hospital and insurance provider's fault. In
| my opinion it's absurd that non-emergency care costs can be
| adjusted after the fact.
|
| Imagine if a car repair shop could quote you $500 for a
| fix, then after the repair is done, you've paid, and you
| get your car back, they say "actually it's $5000, and we'll
| send you to collections if you don't pay." Non-emergency
| medical services should be required to follow a similar
| model, and none of the vague "you agree to pay far, far
| extra if we don't think to tell you about it ahead of time"
| bullshit that pretty much everyone has had to deal with.
| lotsofpulp wrote:
| How is a hospital not quoting the correct price to a
| person without insurance an insurance company's fault in
| any way?
| jjoonathan wrote:
| No, the insurance companies did _not_ force the hospital to
| do this.
|
| Insurance companies deserve plenty of criticism: cherry
| picking, lemon dropping, leveraging the low feedback
| coefficient of their industry to sell one thing and deliver
| another, a failure to control long term cost growth, the
| list goes on. But insurance companies do not deserve
| criticism for _this_. This one is on the hospital, plain
| and simple. Normally this hustle would have been checked by
| an insurance company, yes, but that doesn 't excuse it in
| the slightest.
| runawaybottle wrote:
| Right, and how exactly is it advantageous to the
| insurance company's to pay a $3500 bill if it really was
| $1500 (or possibly lower). The racket on the insurance
| side is if the bill is truly 1500, which they payout to
| the hospital, but then still go ahead make back $3500 on
| the premium off the patients.
|
| I don't know who taught who to be dirty, but it seems
| like the hospitals and insurers are becoming one in the
| same (possibly the hospitals learnings from the insurance
| industry).
|
| My hot take:
|
| Insurers might be on the patients side simply because
| Americans are living longer, and maintaining the general
| level of sickness (diabetes, heart conditions, etc).
| Prices going up does not favor them when medical care is
| going up, so they are oddly on the average person's side.
|
| But for the hospitals and doctors, this is all a dream
| come true. Endless supply of patients, so charge whatever
| you want.
| lotsofpulp wrote:
| >but then still go ahead make back $3500 on the premium
| off the patients.
|
| Insurance pricing is very competitive, and health
| insurers have single digit profit margins. Most less than
| 5%.
|
| > I don't know who taught who to be dirty, but it seems
| like the hospitals and insurers are becoming one in the
| same (possibly the hospitals learnings from the insurance
| industry).
|
| The west coast has had a combination insurer/healthcare
| provider for a long time, Kaiser Permanente. It's a very
| popular organization.
| LanceH wrote:
| If the bill was $3500, the negotiated price for the
| insurance company was surely less than $1500. I had my
| appendix out, the bill was $20k, negotiated price picked
| up by insurance was $2000.
|
| Price transparency doesn't go far enough. Regular
| purchasers need to be able to get the real prices, but
| here we are and we can't even find out what the real
| prices are, much less purchase at that price.
| ddingus wrote:
| I read somewhere that insurers and umbrella entities are
| buying care entities.
|
| That way they can circumvent the care % cap
| csa wrote:
| The insurance company's profits are capped at a
| percentage of what they pay out, so (generally speaking)
| they are incentivized to maximize the amount they pay out
| so that they can maximize their capped percentage profit.
|
| Aren't they worried about costs? They just pass the cost
| on to the consumer via increased premiums.
|
| That's the racket.
|
| Insurance companies are definitely _not_ on the average
| person's side when it comes to containing costs.
| throwaway0a5e wrote:
| >Prices going up does not favor them when medical care is
| going up, so they are oddly on the average person's side.
|
| But it does favor them.
|
| If overall margins after operating cost are a small
| percentage of the money that changes hands then you want
| the most money to change hands.
|
| The insured have to buy from someone. Price and quality
| discovery takes so long that reputations don't really
| matter.
| tssva wrote:
| If you are paying out of pocket you are likely being billed
| more than what an insurance company is paying with their
| negotiated rate.
|
| A large number of hospitals are for profit and in many
| parts of the US a for profit hospital may be your only
| reasonably close choice. My experience has been that there
| is very little difference between how for profit and non-
| profit hospitals work as far as negotiation of billing.
| dahart wrote:
| I've had my local university-associated hospital knowingly
| overcharge & double-dip and repeatedly refuse to back down
| even when shown the evidence. My insurance company stepped
| in and resolved the situation by reminding the hospital
| about which billing practices are not legal.
| macksd wrote:
| No, hospitals absolutely share a lot of the blame for
| problems like this. Even WITH insurance, I've been burned
| so many times that I ask a lot of questions in an attempt
| to prevent problems and surprises. I get asked to sign
| forms acknowledging I've seen papers that they can't show
| me because they don't have them. They will refuse to
| provide care without me signing the form. Eventually I sign
| - and will later see a copy of this paper when I contest a
| bill. I will ask them what something will cost me in the
| event that my insurance doesn't cover it, and they'll tell
| me "it depends on how it's coded", and it takes time for
| them to find out how it will be coded. They will tell me.
| And then they will code it differently when billing the
| insurance. I've had bills from doctors for services
| provided at a hospital that had no record of that doctor,
| yet the doctor had copies of all the forms I signed at that
| hospital. And insurance wouldn't cover it because the
| doctor was not part of my network, even though the hospital
| proper was.
|
| Insurance companies are full of scum bags and I have my
| problems with them too, but there's plenty of blame above
| that really has nothing to do with my insurance company.
| sophacles wrote:
| Hey, wtf are you doing? Scumbags do not deserved to be
| lumped in with insurance companies - it's insulting to
| the scumbags and doesn't accurately describe how
| despicable anyone involved in the insurance industry
| truly is.
| spaetzleesser wrote:
| Don't forget that "non profit" in american hospitals often
| means a lot of profit for administrators and politically
| connected people like construction companies, test labs and
| other providers who can charge outrageous prices without
| any oversight.
| splithalf wrote:
| Unless they are Comcast. Then it's ok to work on a sliding
| scale.
| nobleach wrote:
| Or Oracle.
| Gibbon1 wrote:
| If you owned an auto shop in California and did that they
| would shut you down and criminally prosecute you.
| dcolkitt wrote:
| In many areas, the local hospital system is the major, if not
| the only, source of high quality employment. Insurance
| companies are usually cast as the villain, but they're the
| entities actually fighting to contain costs, and their profit
| margins are far thinner.
|
| Consequently the local hospital is often protected by
| regional politicians and judges. Trying to take on a hospital
| network is about as likely to succeed as going after the
| favorite hometown sports team.
| spaetzleesser wrote:
| So true! When my girlfriend had surgery a few years there
| were several occasions where the hospital sent a bill for
| things that never had happened. She called and every time
| they basically said "Oops. We'll take it off". And at least
| once they sent the same claim again a while later.
|
| It's hard to imagine any other industry getting away with
| that behavior.
|
| Another thing is the insane markups. The surgery my
| girlfriend was getting was about implanting a device my
| company is producing. I asked around in my company and after
| a while got told that our device costs usually around 30000.
| Looking at the bill the hospital charged 80000 and the
| insurance paid it.
|
| American hospitals and health insurance are a ripoff and
| fraud on a gigantic scale and it's shocking that they are
| getting away with it. The whole system is so corrupt I don't
| think it can be salvaged.
| HarryHirsch wrote:
| You talk as if haggling over prices during a medical emergency
| was normal and are proud you got a good deal.
|
| That's what normalization of deviance looks like.
| oconnor663 wrote:
| I think this is part of why the system is so hard to change.
| Because of these informal workarounds, most well-educated,
| reasonably-savvy people can navigate it and get to an
| acceptable outcome. But people with less
| familiarity/sophistication/resources get screwed badly. So
| the system only fails the people who have no power to change
| it.
| jt2190 wrote:
| It wasn't a medical emergency. He visited his Primary Care
| physician, who recommended an MRI, which was performed at a
| hospital.
|
| In the U.S. it's possible (but not widely known) that you can
| shop around for medical imaging like MRIs. (My wife has saved
| thousands of dollars doing this.) Hospitals often run these
| as profit centers so the markup is quite steep.
| jdmichal wrote:
| Yes. There are often entire offices that specialize in
| radiology and do only that.
| madpata wrote:
| He didn't haggle over the price of the procedure.
|
| He only asked how much it's going to be and was charged with
| over double what he was quoted.
| HarryHirsch wrote:
| In Britain you'd go to A&E with your kidney stone and just
| get the required treatment without haggling over prices.
| vidarh wrote:
| And if you do insist on going private for a kidney MRI, a
| quick google shows prices are in the 200-400 pound range
| ($280-$560, roughly) for MRI of the abdomen.
| f6v wrote:
| Someone is ought to bring Europe up. Yeah, you'd get it for
| free in Belgium or Germany. The wait times though... could
| anything from couple weeks to half a year.
| jrochkind1 wrote:
| I would like the citation to specifically where and when
| someone had to wait half a year for a kidney stone to be
| diagnosed and treated in Europe.
| himinlomax wrote:
| I got an MRI in France a few years back, not an emergency.
| Booked an appointment for the next day. To be fair, 30
| years ago when MRIs were kinda new and machines were
| extremely expensive, I remember there was not enough of
| them and patients and doctors complained of long wait
| times. That's not been an issue in a while.
| avh02 wrote:
| what i've found/heard in germany is this:
|
| you may struggle/it may take long to find certain things to
| get a diagnosis, but once you do, it's a ball that gets
| rolling insanely fast.
|
| 2 anecdotal examples:
|
| colleague's young child was fainting, took them quite a
| while to get through the right set of doctors/specialists
| to find out it was a brain tumor - after that was found
| though, they were scheduled for surgery the next morning.
| Operation successful, child okay.
|
| I had an appendectomy in the middle of covid: went to the
| ER unannounced at 7 p.m. - was on the table at 1 a.m. - i
| paid 50 euros (10 for each day i spent there (they kept me
| for 3-4 days "just in case")). This was quoted to me up
| front (the rate, but not the number of days) and i signed a
| document stating i understood that charge before i was in
| surgery.
| f6v wrote:
| That's all correct. The point is it's incredibly hard to
| get to the specialist at times. I was trying to get an
| appointment in Belgium, they could only offer April 2022.
| TillE wrote:
| In Germany, in the vast majority of cases, you can simply
| go to any doctor's practice (including specialists, no
| referral required) during office hours and see the doctor
| the same day, if it's urgent. They'll squeeze you in.
|
| For non-urgent appointments, yes, the wait time for
| specialists can sometimes be months.
| petschge wrote:
| Same is true in the US.
| Tade0 wrote:
| I can get an whole body MRI in Poland for ~$250 via a
| private healthcare provider and wait less than a week for
| it at that.
|
| Why is an MRI anywhere in the world $1500, or $3500 for
| that matter?
| vidarh wrote:
| Similar price in London. One provider I checked indicated
| $560 for their "platinum service" which included lots of
| mostly pointless extras, but $280 for the basic service.
|
| Private hospitals in London largely live off a split of
| offering cheap convenience or extracting money from
| foreign patients, but there are so many of them fighting
| for a small pool of patients given most people just go to
| the NHS that they have to compete hard.
| UncleMeat wrote:
| There is one major healthcare provider in my region. When I
| arrived here, the wait time for a physical was more than
| two months. The shitty US system is not giving me at-will
| service.
| vidarh wrote:
| In most of Europe you still have the _option_ of going
| private if you want that, either with private insurance on
| a "top up" basis, or paying per appointment.
|
| I don't know what the prices are in Germany, but in London
| an abdominal MRI is in the $280-$600 range. (EDIT: And you
| can usually get a same or next day appointment)
| HarryHirsch wrote:
| Prices in Germany are set by the government. If you check
| the _Gebuhrenordnung fur Arzte_ you 'll see that in
| private practice an abdominal MRI is EUR 256.46.
|
| The US are a clear outlier.
| vidarh wrote:
| Makes sense, given the prices I've seen for London and
| the prices someone quoted for Poland.
|
| Makes the US pricing in this article even more bizarre -
| in "normal times" you could literally fly to Europe for
| an MRI and save money.
| sneak wrote:
| Correspondingly, senior SWEs at startups in Germany
| struggle to earn above EUR100k/y.
| messe wrote:
| What exactly is your point?
|
| That it is worth it that people go bankrupt due to
| medical issues because it means that certain professions
| can earn 6 figures?
|
| I'm really curious. What do you think you are saying? How
| do you think those two statements correspond? Do you
| genuinely believe that if the majority of Europe were to
| ditch its public health services that salaries would go
| up and that that would be a good thing?
| sneak wrote:
| My point is that even if you have to pay market rates for
| private healthcare insurance in the US (which are crazy
| high), the overall system in the US works better for many
| HN-types because while your expenses may be much higher,
| your income is disproportionately higher (as in 2-5x
| higher).
|
| FWIW, I am a US person, resident in Germany.
| messe wrote:
| So you believe that _because you're paying only for
| private healthcare_ you're income is higher?
| petschge wrote:
| So you are saying that HN-types got theirs (the huge
| salary), so they should not care about others? Or are you
| causing them of a "I got mine, fuck you" attitude? I am
| still not sure what you are trying to say. But the fact
| that you LEFT the US that has that kind of dynamic for
| Germany, where income inequality is smaller and many
| things -- including medicine -- are more widely
| accessible makes me scratch my head.
| sneak wrote:
| > _So you are saying that HN-types got theirs (the huge
| salary), so they should not care about others? Or are you
| causing them of a "I got mine, fuck you" attitude?_
|
| Neither of those things, no. (Also, if you think of
| EUR100k as "a huge salary", you should recalibrate; in
| the industrialized world it is not.)
|
| > _I am still not sure what you are trying to say. But
| the fact that you LEFT the US that has that kind of
| dynamic for Germany, where income inequality is smaller
| and many things -- including medicine -- are more widely
| accessible makes me scratch my head._
|
| The healthcare in Germany appears to be somewhat crap
| compared to the highest level of care available in the
| US. It's an order of magnitude cheaper, though.
|
| I left the US because the US is a police state, not
| because best-in-the-world healthcare has highest-in-the-
| world prices.
|
| My comment could best be summarized as "health care costs
| should not be a major concern in your life as a SWE
| because they will be cheap (to you) everywhere, so make
| your SWE life choices based on other things". You can
| inaccurately paraphrase this as a rejection of concern
| for social justice, income inequality, or a generalized
| "fuck you, got mine" at your own peril.
|
| (FWIW, I think national boundaries are mostly irrelevant
| and unimportant, and drawing the boundary of your
| official-concern-for-the-wellbeing-of-others at an
| invisible line checkpoint to be somewhat closeminded.
| There are billions without meaningful modern healthcare
| access at all (or even clean water) so the selfrighteous
| indignation bit about the relative quality and expense of
| healthcare in two major industrialized western nations is
| sort of a silly nit to pick.)
| HarryHirsch wrote:
| Even so, medical bankruptcies are not a thing in Germany.
| johnday wrote:
| For a medical emergency? This is simply false.
| klyrs wrote:
| I live in Canada, and I've seen people put on 6+ month
| waitlists for (a) MRI after a concussion to make sure
| there's no internal bleeding (which can kill in a single
| day), (b) MRI after a stroke to diagnose the root cause,
| (c) ACL replacement surgery.
|
| Universal healthcare is great, but when you're in a
| 2-party system and one party undermines it whenever
| they're in power, the result is terrible.
| johnday wrote:
| I'm sorry to hear that, but it's not quite relevant to
| the point that the parent was making about Europe.
|
| For what it's worth, I live in the UK which has similar
| woes to how you describe Canada's two-party system.
| However we do normally get seen quickly for things which
| are a threat to life---but elective operations can take
| much longer. Mental health issues are also dealt with
| sluggishly at best.
| f6v wrote:
| Describe emergency. Sure, you'll get an MRI after a car
| crash. But you could be in this state where you're not
| dying, but still very uncomfortable. The wait list is
| pretty long then.
| KittenInABox wrote:
| Do you have studies on waiting times that you can cite
| here? Genuinely asking because I know they certainly
| exist for Canada[1] with breakdowns down to the Province
| [2] so I'm just assuming you have some proof that can be
| used to bolster your claim.
|
| 1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7292524/
|
| 2. https://www.hqontario.ca/System-Performance/Wait-
| Times-for-D...
| astura wrote:
| That's very similar to wait times as in the US.
|
| Fuck, a few years ago I had to switch dentists and I
| couldn't get even a teeth cleaning without waiting more
| than six months.
| sofixa wrote:
| For an emergency MRI? Are you insane?
|
| For reference, i got an MRI in two days for knee pain after
| i fell with a bike and the pain didn't go away after a few
| weeks ( so obviously nothing urgent).
|
| And FYI, i paid for it, iirc 60-100 euros, repaid in full
| by my medical insurance.
| f6v wrote:
| The parent wasn't saying whether it was an emergency or
| not.
| jrochkind1 wrote:
| So, yeah, there is a point on who considers what an
| emergency.
|
| They were saying they had pain and nausea, the doctor
| suspected a kidney stone. Is this an "emergency"? I have
| had a kidney stone, it is _intense_ pain. My mother had
| one, said it reminded her of childbirth.
|
| But it won't kill you, probably. You _could_ just be in
| intense pain for weeks or longer waiting to pass it.
|
| Is that an emergency? I think in probably any sane
| medical system it is. In the USA? No idea.
| __turbobrew__ wrote:
| These stories are amazing to read as a Canadian. I recently
| went to my doctor for chronic foot pain and I was into the
| MRI within a week (albeit at 3AM) and didn't pay a cent.
|
| I have received multiple offers to work in the US as a dev
| but the quality of life and safety nets here in Canada are
| more important to me than a higher salary.
| jrochkind1 wrote:
| Yup, good reminder that we're here in the US being like "We
| should be able to tell what absurd price we are going to be
| charged before we get the procedure so we can decide if we
| want to shop around and we can't even do that!", and still on
| "if only we could do that, it would be a victory!". Geesh,
| we're screwed.
| JohnWhigham wrote:
| As sad as this request may be, does anyone have a checklist or
| something of strategies to try with hospitals for bill
| negotiation?
| kingnothing wrote:
| Contact them and have a discussion with their finance
| department.
| bufordtwain wrote:
| Step 1: don't pay the bill Step 2: wait... Step 3: continue
| to not pay the bill step 4: when you've waited a very long
| time, offer a tiny amount of money
| rsyring wrote:
| FYI, there are usually non-hospital businesses that do xrays
| and MRIs for substantially less than a hospital charges. They
| usually know their fees, expect payment at time of service for
| the uninsured, and have no surprises.
|
| Example: https://priorityradiology.com/
|
| Xrays were under $250 and MRI was $600 last time my family
| needed it.
| ridethebike wrote:
| I went to hospital and they assured me my procedure was covered
| by insurance and I wouldn't need to worry about that and in
| worst case scenario insurance would contact me. Couple of days
| later this hospital sent me $400 bill. It took me several phone
| calls to get them to acknowledge that they sent it by mistake.
|
| Exactly same situation happened year later but with ~$800 bill.
|
| Although doctors and medical staff themselves are ok, the US
| healthcare system as a whole is some incompetent clown mafia.
| matesz wrote:
| I've had similar story, but this time with the IRS.
|
| Right after my university I've started pursuing startup idea
| and of course I though that I will get investors coming
| through the door very quickly so first thing I did was to
| setup a Inc. company in Delaware. There is 2 ways to pay
| taxes there - on revenue or on shares (I might got it
| slightly wrong)...
|
| After a year or so company staying dormant I was living in
| Europe already and received mail saying that I have to pay
| $150k in taxes :o
|
| I tried to call ask why I got this bill, but it was Friday,
| already closed. I didn't have a job and experience back then
| so this was horrifying. I was running through scenarios of
| having to work years to pay this off because of some stupid
| mistake (or hiding from US government for life). So I called
| a laywer who asked for initial $5000. I've met another person
| who wanted to help me for cash $2000. I though it is a joke,
| because I was barely making a living.
|
| Fortunatelly I didn't fall for that and waited until Monday.
| I called again and lady explained that they always send the
| bill for first option and we have to remember if it is
| correct or not. So at the end there was no tax to be payed. I
| immediately closed the company.
|
| What can you do...
| ridethebike wrote:
| oh yeah, IRS, they still owe me $3k. Thanks for the
| reminder :)
| jandrese wrote:
| I get sent a deceptive bill every time I use the hospital. I
| think the idea is to show you what they are billing your
| insurance (not what insurance pays in the end), but it is
| always marked as "payment due" even though the insurance is
| going to foot the bill.
| codegeek wrote:
| Yea and that's also part of the problem. Most of us ignore
| this stuff because we have insurance but this is why the
| racket keeps going. But ultimately, someone pays for it
| somewhere.
| pydry wrote:
| Incompetence isn't quite how I'd describe this.
| Gibbon1 wrote:
| There is nothing about the system that rewards competence
| on the financial side of healthcare.
|
| Billing is based on what they can force people to pay. Not
| on what services actually cost. One downside of that is
| they have no control on how much things cost.
| codegeek wrote:
| I wonder if there is any law here that protects consumers ?
| It is atrocious that a hospital/doctor/clinic can send you
| any absurd bill/amount and then it is on YOU to fight and
| prove that it was incorrect. I have done it many times
| myself.
| JJMcJ wrote:
| Most emergency room bills can get 1/2 or more knocked off just
| by asking.
| muttantt wrote:
| You over paid even with the $1,500. You could have waited a few
| months and they would have been happy with $400.
| ryneandal wrote:
| The majority of Americans aren't in a position to cut a $1,500
| check like that. That's one of the major issues here.
| throwkeep wrote:
| The majority of Americans engage in lifestyle inflation.
| That's a major issue generally.
| MeinBlutIstBlau wrote:
| The majority of americans also don't know that there is a
| concept called "saving money." I mean I understand why it is
| some people are broke and it's not their fault and I get
| that. However, I've more than encountered people living above
| their means more than I have people in poverty beyond their
| control. This is speaking as someone whose worked in banking
| for about 5 years. Too many people with FOMO end up ruining
| their lives.
| caturopath wrote:
| Note that the median net worth of an American household is
| ~120k.
|
| Obviously $1500 is a lot of money and it's not easy to come
| up with for normal folks and obviously there are millions of
| poor people, but the US is one of the wealthiest nations on
| Earth, and it's sometimes overemphasized how broke the
| average American is. Other than a few small European
| countries, the US has the highest median household incomes in
| the world, higher than any other large country like Germany,
| France, the UK, Canada, Japan, or Australia.
| KittenInABox wrote:
| Also Germany, France, UK, Japan, Canada, or Australia
| doesn't have the medical/student debt so I don't know if
| its so easy to assume that just because americans earn more
| that they pocket more.
| jrochkind1 wrote:
| > Note that the median net worth of an American household
| is ~120k.
|
| Having a net worth of $120K doesn't actually mean you can
| easily pay an unexpected $1500 bill. It might mean you have
| a house worth $100K and a car worth $10K and a retirement
| account with $10K in it, and just enough to cover your
| payments in the bank.
|
| I know there are LOTS of Americans who can't easily pay an
| unexpected $1500 bill, but I don't know if it's more or
| less than than 50% of Americans, and median net worth
| doesn't really tell us.
| sofixa wrote:
| > Note that the median net worth of an American household
| is ~120k
|
| That sounds pretty decent, but the grouped by
| age/location/education level medians are show that there
| are still a lot ( as a percentage) of people with low net
| worths in certain groups. And even then, net worth doesn't
| mean money in the bank - most people wouldn't and shouldn't
| have to sell their house or car to be able to afford a
| medical emergency ( even though i agree that if you have a
| $120k net worth, you should be able to save money on the
| side, but i wouldn't be surprised if there are situations
| where that's hard ( e.g. house bought years ago, a
| household member without a job, friend/family/only
| remaining job are in the area)).
|
| https://www.businessinsider.com/personal-finance/average-
| ame...
| gruez wrote:
| >And even then, net worth doesn't mean money in the bank
|
| According to this[1] the median family has $5k in the
| bank.
|
| [1] https://www.federalreserve.gov/econres/scf/dataviz/sc
| f/chart...
| caturopath wrote:
| > That sounds pretty decent, but the grouped by
| age/location/education level median
|
| The poster said "the majority of Americans", not "the
| majority of young Americans with less education" or
| something, so I talked about the median, explicitly
| acknowledging the presence of millions of people who are
| poor.
|
| > most people wouldn't and shouldn't have to sell their
| house or car to be able to afford a medical emergency
|
| If someone needs money from their house, they don't have
| to sell it.
|
| The median non-primary-residence net worth in the US is
| 40k. I still think it's silly to pretend $1500 is
| unthinkable for the majority of Americans like it is for
| the minority of people in America who are poorer than
| most others.
|
| > ( even though i agree that if you have a $120k net
| worth, you should be able to save money on the side, but
| i wouldn't be surprised if there are situations where
| that's hard ( e.g. house bought years ago, a household
| member without a job, friend/family/only remaining job
| are in the area)).
|
| Paying large bills is hard, especially with all the stuff
| life throws at you. I didn't mean to imply otherwise.
| jrochkind1 wrote:
| > Just 39% of Americans could pay for a $1,000 emergency
| expense
|
| > * Fewer than 4 in 10 people have enough savings to pay
| for an unexpected $1,000 expense in cash.
|
| > * The rest would have to borrow, use a credit card or
| take out a personal loan.
|
| > * While the pandemic has set back emergency savings,
| many people are optimistic their finances will improve in
| 2021.
|
| https://www.cnbc.com/2021/01/11/just-39percent-of-
| americans-...
|
| But sure, many of those could take on debt to do it, as
| the summary says, true.
|
| Medical debt is a leading cause of bankruptcy in the US.
| (No, I'm not saying $1500 alone is going to cause a
| bankruptcy.)
| anchpop wrote:
| The bankruptcy stat is that ~60% bankruptcies were
| contributed to by medical issues or debt. Here is the
| study it comes from: [0]. Many people misquote this as
| the bankruptcies having been _caused_ by medical debt.
| For example, the 60% stat includes income loss due to
| illness (40% of bankruptcies involved this). Only for
| about 30% of bankruptcies did the debtor actually say
| medical bills were a reason for the bankruptcy.
|
| This is not to say the healthcare system in the US has no
| flaws. But it bothers me that a stat which found "loss of
| income due to illness" was _more common_ among
| bankruptcies than medical bills greater than $5k or 10%
| of pretax income (~35%), constantly gets construed as
| "medical debt is responsible for 60% of bankruptcies"
| when debt doesn't even appear to be the largest factor of
| medical-related bankruptcies.
|
| And this misconception is everywhere. This article [1]
| says "The same researchers' 2009 study claimed that 62.1%
| of all bankruptcies were caused by medical bills." and
| was the top result on google when I searched
| "bankruptcies caused by medical debt".
|
| Even Bernie Sanders [2] doesn't get it right, saying that
| "500,000 people go bankrupt every year _because they
| cannot pay their outrageous medical bills_." 500,000 is a
| little over 60% of the 750,000 bankruptcies that happen
| every year, and his campaign said they were referencing
| this study. I think there's a meaningful difference
| between losing income due to not working while you're
| sick and not being able to pay your "insane medical
| bills".
|
| Also, other studies have found much lower numbers, but I
| guess they aren't as fun to quote. This is mentioned in
| the washington post article I linked:
|
| > "Based on our estimate of 4 percent of bankruptcy
| filings per year and the approximately 800,000 bankruptcy
| filings per year, our number would be much closer to
| something on the order of 30,000-50,000 bankruptcies
| caused by a hospitalization," one of the co-authors of
| the NEJM study, economist Raymond Kluender of Harvard
| Business School, wrote in an email
|
| > "This would lead us to be skeptical of the 500,000
| medical bankruptcies statistic, but that very much
| depends on how one defines a medical bankruptcy. ... An
| enormous share of households have some amount of medical
| debt, so any survey of individuals will report a high
| share of them have medical debt but this does not imply
| that the debt caused them to file for bankruptcy."
|
| Again, not saying any of this is fine, just that if we're
| talking about solutions it's probably wise to at least
| represent studies accurately.
|
| [0]: https://www.amjmed.com/article/S0002-9343%2809%29004
| 04-5/pdf
|
| [1]: https://www.thebalance.com/medical-bankruptcy-
| statistics-415...
|
| [2]: https://www.washingtonpost.com/politics/2019/08/28/s
| anderss-...
| jrochkind1 wrote:
| fair!
|
| > "Only for about 30% of bankruptcies did the debtor
| actually say medical bills were a reason for the
| bankruptcy."
|
| That would still be a lot!
|
| > ""Based on our estimate of 4 percent of bankruptcy
| filings per year"
|
| ...but 4% is a much smaller number than 30%. Is it
| actually more like 4%? I guess statistics aren't
| simple....
|
| > "An enormous share of households have some amount of
| medical debt, so any survey of individuals will report a
| high share of them have medical debt but this does not
| imply that the debt caused them to file for bankruptcy
|
| I guess I'd be interested in the average medical debt
| numbers among those filing for bankruptcy vs the average
| medical debt numbers among those _not_ filing for
| bankruptcy? To have a sense of what role medical debt may
| play?
|
| I feel safe in continuing to think that medical debt is a
| significant burden for many people in the USA (and
| therefore that "most people can afford that bill by going
| into debt" is a terrible solution), but that's a much
| more vague statement, i respect your point about being
| accurate with statistics.
| jdmichal wrote:
| Net worth is deceptive, because that's going to include
| illiquid assets such as housing. Are people supposed to
| take out a HELOC to pay their medical bills?
| caturopath wrote:
| Median net worth in the US not including primary
| residence (an odd choice considering this is many folks'
| largest asset and is easily used to pay for things) is
| 40k.
|
| It is silly to pretend like $1500 is not a possibility
| for "the majority of Americans". Certainly I do
| acknowledge explicitly in my post that there are millions
| of poor people in America.
| ticviking wrote:
| Most of which is probably in a retirement account, or
| cash value insurance policy.
| ticviking wrote:
| And most of that is likely in home equity or a 401k, not
| something liquid that can be used to pay for an emergency.
| maxmcd wrote:
| Yes, I've also heard that alternatively you can just wait for
| them to send it to a debt collector and they will happily
| negotiate with you as well.
| caturopath wrote:
| If they've sold the debt to a debt collector, don't interact
| with them at all unless they literally sue you. There's
| really nothing to be gained by paying a debt collector.
| hackeraccount wrote:
| Hospitals have incentives to have a high sticker price - it
| benefits everyone. The insurance companies negotiate to
| something closer to the "real" price. That makes them happy.
| Government through Medicaid/Medicare has a way of giving money
| to hospitals. Customers only care about the out of pocket cost
| - indeed if they happen to notice the sticker price it'll only
| be after they know what they're actually paying - so that will
| actually make them happy.
|
| There's a very small group. 5% or so of people, those who don't
| have private insurance and aren't on the public insurances -
| edicare/Medicaid/VA - . Those people are actually in a position
| where they get to see the sticker price but might have to
| actually pay it.
|
| Which sucks.
|
| But I don't see how that changes. The people getting abused are
| - despite what you might hear - are small in number, typically
| healthy and not particularly poor or old. The ACA actually went
| after those people - that was what the mandate was about - and
| tried to get them to buy a lot of insurance. More insurance
| then they wanted - and the end result was that the mandate's
| been effectively gotten rid of.
| noelsusman wrote:
| Part of the issue is that Medicare and especially Medicaid
| pay providers below cost for services. That money needs to be
| made up somewhere. Private insurers pay above cost, but they
| have too much leverage to get squeezed by the hospitals. That
| leaves uninsured patients to hold the bag. They could try to
| cut costs, but that puts them at a competitive disadvantage
| because most patients don't actually care about how much
| their care costs, they only care about how much they have to
| pay.
|
| If you're an uninsured patient who isn't in poverty then
| hospitals are going to squeeze you for as much as they can
| get away with. It's how they keep the lights on. None of this
| makes any real sense, but hospitals are just doing what they
| have to do to survive in the system we've created for them.
| zerd wrote:
| Plus out of network emergency visits, which isn't uncommon
| https://www.kff.org/health-costs/press-
| release/about-1-in-6-...
| jrochkind1 wrote:
| Good luck getting a price like this in writing in advance. I
| have not been able to get doctors or hospitals to tell me what
| a procedure would cost in advance _at all_. "So you're telling
| the only way to find out how much it will cost is to get it
| done and then see the bill?" "Right".
|
| An actually useful law might be:
|
| Before an elective procedure, they need to give you the price
| in writing.
|
| The actual price transparency law does not seem to have
| resulted in any price transparency.
| ddingus wrote:
| Medical risks and unknowns are very high, and to make profit
| metrics, they need to push all risk onto the patient.
| codegeek wrote:
| stories like this clearly prove what a racket our health
| insurance/billing system is.
| teeray wrote:
| It always amazes me when I go to the vet with my dog, I get
| an itemized bill for medical services immediately. That
| really exposes the BS of figuring out prices once they've
| sent it to insurance, months go by, and then finally you get
| a final bill. It doesn't have to be that way.
| jollybean wrote:
| It's worth mentioning this is not a fraud deigned by the doctor
| per say.
|
| They are removed from all of that, and don't care about prices.
| It's beyond them.
|
| So they just give you a number.
|
| Because there is this big 'goodwill' aspect to healthcare, the
| professions don't think about it as capitalist, but the
| hospital is actually pretty aggressive and take advantage of
| the goodwill aspect.
|
| The US needs a massive overhaul there and it's not about
| socialism or capitalism, but about simple and hard regulations.
| benjohnson wrote:
| I'm glad it worked!
|
| As I understand it, marking your check "paid in full" combined
| with the cover letter is what potentially worked for you.
| Simply writing "paid in full" on the check generally isn't
| sufficient.
|
| More info form real attorneys (unlike me)
|
| https://www.lawyers.com/legal-info/consumer-protection/banki...
| thaumasiotes wrote:
| That link doesn't support your interpretation at all:
|
| > If you try this approach on a credit card debt, it's
| unlikely to work. Why? Because you probably won't be able to
| show that the amount owed is uncertain. You'll be held
| responsible for the amount that you charged--a number that's
| likely relatively simple to figure out. On the other hand, if
| you're working with a contractor and you disagree about how
| many hours it took to finish a job or the supplies necessary
| to complete a project, you might be able to satisfy this
| requirement.
|
| The article makes no mention of a cover letter. They stress
| two things:
|
| 1. The amount owed must be subject to dispute. The hospital
| obviously satisfies that requirement.
|
| 2. The phrase "paid in full" was visible in an obvious
| manner.
|
| That's it.
| bluefirebrand wrote:
| The cover letter illustrates that the amount is in dispute
| in writing. It is likely important in order to satisfy 1.
| thaumasiotes wrote:
| No, the phrase "paid in full" illustrates that the amount
| _is_ in dispute.
|
| What you need is for the amount to be _subject to
| dispute_. See how the example they give of an invalid
| attempt to do this is a credit card bill, specifically
| because the amount of the claim is fully objective?
|
| The cover letter doesn't add anything there.
| conorh wrote:
| My wife is trying to work on price transparency at her practice
| by offering bundled rates for the surgery she does. She has
| worked with all the various providers - anasthesia, pathology,
| the hospital etc to come up with a cash rate that she publishes
| on her website for the surgery. Most of the parties are very open
| to it but also extremely worried about outliers. Patients that
| end up costing 10x what was expected due to complications. For
| her this is a minuscule risk, but in her negotiations it has been
| their main worry.
| bobduke wrote:
| Have the _providers_ buy insurance to cover those rare 10x
| cases and add that insurance fee to the cost of the procedure.
|
| The patient gets an "out the door" price and those most
| qualified (doctors and insurance companies) can argue about the
| actual cost.
|
| Even if the costs ended up exactly the same, the patient would
| not be stressed by the "surprise" bills and out-of-network
| nonsense.
| comeonseriously wrote:
| > Patients that end up costing 10x what was expected due to
| complications. For her this is a minuscule risk, but in her
| negotiations it has been their main worry.
|
| And that's probably one of the biggest reason hospitals don't
| want to talk about actual costs. If you tell someone it's going
| to cost $X for removing their appendix, but they have a heart
| attack on the table it's not going to cost $X any more.
|
| Doesn't make lack of transparency right, but in this scenario,
| I can sort of see why.
| KingMachiavelli wrote:
| That doesn't make much sense. You can have a price for
| whatever complication occurred. Does the insurance/billing
| code system not already have a method for listing
| emergency/ad-hoc complications & procedures? It must have
| that otherwise there would be no way to bill in those cases
| currently.
|
| e.g an emergency during surgery would normal get XXXX billing
| code so just publish what you charge for that XXXX billing
| code.
| fallingknife wrote:
| But a hospital doesn't do 1 surgery, they do thousands. So
| that one 10x doesn't really change the average cost very
| much. This is just an excuse by the hospital.
| SilasX wrote:
| Exactly. Every other industry in existence is able to
| package up and manage the outlier risk, but somehow, here,
| it's "different".
| loonster wrote:
| That is the entire purpose of insurance. One of the line
| items should be <procedure insurance>.
| BurningFrog wrote:
| It _does_ genuinely make it hard to price something if it
| almost always costs $3000, and very rarely $1M.
| tooltower wrote:
| Yet, this is somehow not a problem in any other country. That
| amount of outlier cost is priced in, like many other
| businesses.
| adolph wrote:
| You might be interested in the below podcast if you haven't
| already heard it:
|
| _Entrepreneur and Anesthesiologist Keith Smith of the Surgery
| Center of Oklahoma talks with host Russ Roberts about what it
| 's like to run a surgery center that posts prices on the
| internet and that does not take insurance. Along the way, he
| discusses the distortions in the market for health care and how
| a real market for health care might function if government took
| a smaller role._
|
| https://www.econtalk.org/keith-smith-on-free-market-health-c...
|
| https://surgerycenterok.com/blog/
| hackeraccount wrote:
| ha! I just put a link this to further down thread. It was a
| great podcast, right?
| adolph wrote:
| It was and I've gone back and relistened to it because it
| is such an important topic--this whole thread is people
| opining on how things are bad and how this and that should
| change--that Oklahoma anesthesiologist is going out there
| and doing something about the problems he saw in the
| economic model of medicine.
|
| Edit: anesthesiologist replaced surgeon
| dennis_jeeves wrote:
| Also mentioned in an earlier post:
| https://news.ycombinator.com/item?id=27517126
| loonster wrote:
| That sounds like something an insurance company could fill the
| void. Other industries have insurance charged for each job
| based on what the job entails. Surgery should be no different.
| ethbr0 wrote:
| The issue with US health insurance in general is that (a)
| it's not understood by the public as insurance, but rather as
| access to group rates, & (b) it's utility is proportional to
| the number of counterparties it covers (more doctors, more
| useful), which opens it up to a huge amount of abuse (doctor
| you've only done 3 transactions with over the past 5 years is
| vastly inflating fees on all).
|
| What should _probably_ happen is something akin to the
| housing market: backstop consumer insurance companies with
| re-insurers (semi-supported by the government) who buy and
| back compliant policies and providers.
|
| Allowing consumer insurance companies to bound their risk and
| offer more reasonable rates.
|
| I _think_ ACA has a provision in there for catastrophic cases
| falling off the insurers ' books onto someone else's, but
| it's been awhile since I read through it.
| prepend wrote:
| What about patients that end up costing .1x?
|
| There's risk of expensive patients but that should be easier
| born by the practice than the individual.
|
| I suggest she talk to anyone who runs a buffet restaurant since
| there are ways to plan around.
| sgent wrote:
| Most providers have a pretty good idea what the lower bound
| will be, its the upper 5% they may have no idea about.
|
| Pathology maybe usually $100 for a tissue exam, but I've seen
| a routine mole biopsy need $1,500+ (wholesale) exams after
| referral to an academic center because there was something
| off that required further workup. This happened 1 time in 10
| years.
|
| Anesthesia knows that a breast augmentation will usually be
| no less than $X, but if the patient has an anesthesia
| reaction and decompensates and needs 4 hours of one on one
| time with an MD its going to be a lot more. Very, very rare.
|
| You get the idea, its often not possible to know until you do
| the procedure. Even more when surgery is involved because
| imaging is not 100% and you may wind up with a much more
| complex procedure than you bargained for once you cut someone
| open, or a complication like a perforated bowel during
| colonoscopy, etc.
|
| Finally, most of these people don't talk to each other -- so
| the pathologist has no idea what the surgeon is charging and
| neither of them the hospital nor radiologist.
| prepend wrote:
| That makes sense that there's variability, many products
| have this. Not every single transaction needs to be
| profitable, only the aggregate.
|
| If pathology is normally $100 and yet some cost $1500 then
| factor that into the cost based on the probability. Or
| insure against it. Etc etc.
|
| These aren't novel problems to the medical space, it's just
| that there aren't normal pressures forcing them to handle
| it.
|
| Apple charges $79 for an insurance claim to replace my
| iPhone whether it costs them $1 or $1000 to correct.
| Imagine if they had an asterisk that sometimes it cost lots
| more than $79.
|
| Someone else linked to the Surgery Center of OK [0] that
| has "solved" this problem. There's a great episode of
| econtalk with Keith Smith [1] where they talk about this.
| Including examples almost exactly like how you call out.
|
| [0] https://surgerycenterok.com/
| majormajor wrote:
| > What about patients that end up costing .1x?
|
| I imagine X here is more of a lower bound than anything else
| - which is where the problem comes in with up-front pricing.
|
| It's like up-front "how long will this feature take" quotes
| from developers. Doable, but very difficult to truly
| accurately estimate.
|
| Doing this on historical data - where the range likely ends
| up more like .8x to 10x - would be the only sane way, vs
| trying to come up with it from first principles.
| ethbr0 wrote:
| And for the same reason that software estimates suck.
|
| The lower bound is quantifiable: if everything goes as
| expected, and this is all the work, then project time is
| the sum of each piece's time.
|
| But the upper bound is unknowable. If a thing that we don't
| know about happens, how long will it take to solve, if a
| solution is possible? And what portion of the project will
| it involve?
|
| But that's really a gripe about PMs not understanding
| compositions of multiple normal distributions.
| willcipriano wrote:
| I never got the impression that price differences are a
| function of billable hours but instead some vague notion of
| complexity. I don't think that 10x billed surgery consumed
| anything close to ten times the hours and materials.
|
| This would be akin to developers saying "Yeah it only took
| me 40 hours but it was harder then I thought so pay me for
| 400."
| majormajor wrote:
| My first guess for the cost of a 10x surgery is something
| like "they didn't recover smoothly so what could've been
| outpatient is now a 4 day hospital stay that involved a
| lot more people and resources."
|
| I can't say for sure, though - I've always gotten very
| detailed itemized breakdowns of all the cost, hospital
| stay vs surgeon vs anesthesia vs... but I've never
| compared them against _someone else 's_ bill for the same
| procedure.
|
| Setting aside the why of the additional expense, the car
| mechanic model is very similar: you get an estimate, then
| you get the phone call telling you the additional things
| they found out, and the new estimate, asking for
| permission to do or not do the additional things. Though
| in the case of a surgery where you're knocked out,
| getting "incremental permission" like that wouldn't
| really work. You would just have to know the range up
| front.
|
| But what if the range is so wide to be somewhat useless?
| willcipriano wrote:
| A good mechanic will tell you "it's $800 to fix the
| transmission, if the rotors are bad it'll be $1300." and
| if he finds is estimate is way off, that's his fault so
| he will take that on the chin and do right by the
| customer. Same for contractors who work on your home,
| sometimes you accidentally bid under cost and learn a
| lesson for next time.
|
| Hospital estimates in the rare case they are provided
| only seem to get revised in one direction, that seems
| like having cake and eating it too. If the high school
| drop out painter can live by his estimates, so can the
| national hospital chain full of Harvard Business School
| graduates.
| rob_c wrote:
| Thank goodness the NHS hasn't gone this route (yet).
|
| Wait I'm sorry, I thought voting Biden was supposed to fix this?
| KoftaBob wrote:
| "Hospitals were more likely to make their charge data available
| and to offer a shoppable services tool than to post negotiated
| rates or cash prices.
|
| The bottom line: "Compliance could be limited because the
| penalties for noncompliance are minimal (maximum $300 per day)
| and the costs of disclosure potentially great," the study's
| authors write."
|
| The penalty for not complying needs to be waaaay higher than
| $300/day for hospitals to start complying.
| Causality1 wrote:
| Regulatory fines should all be additive, at a minimum. 300 the
| first day, then 600, 900, etc.
| hpoe wrote:
| Ya, what ridiculousness is that. For those curious $300/day is
| $109,500, that's the cost to just shaft the IT department on a
| new employee and pay the fee and you'll come out ahead
| financially.
| jcowdy wrote:
| The fine is depressing and invalidates much of the benefit and
| work that went into passing the rule. Until the fine amount is
| increased (which I suspect may take quite some time if it ever
| happens) compliance will continue to be low without some other
| external pressure on the health systems. Are there any tools /
| organizations that are aggregating this data for consumers to
| use for comparison of service pricing? The pressure of
| consumers may be the best chance we have to drive compliance,
| but it also seems like a chicken / egg scenario where it will
| be hard to get enough consumer pressure without more than 25%
| of health systems releasing their pricing.
| duffpkg wrote:
| I wrote Hacking Healthcare, created clearhealth open source EMR,
| a decade plus managing hospitals and multi-practice groups. There
| are a couple of bad actors out there but for many of these
| organizations, though it may seem impossible to believe, they
| really haven't yet been able to coordinate all the entities
| involved to put together the list. People think of hospitals as
| monolithic entities but many are much more like medical malls
| than anything.
|
| Further for many institutions there is a plain cost/benefit. The
| maximum penalty for non-compliance is $109,500 a year though as
| far as I know 0 fines have been assessed yet. If you are a large
| institution it can easily cost many times that to put together
| and maintain this list in a compliant manner.
|
| Byzantine barely begins to describe the way medical procedures
| are billed, inpatient especially. It is not at all like a retail
| interaction. For a given patient on a given insurance program on
| a given period within a contractual cycle, the rate of charge and
| reimbursement may differ. Many contracts include a most-favored-
| nation type clause that mean when one program's reimbursements
| change then many other ones may need to be updated as well.
|
| I'm not trying to defend any of this but just point out that
| there is a lot of behind the scenes complexity to the current
| system that is easy to gloss over when it is thought of in retail
| terms.
| codegeek wrote:
| "Compliance could be limited because the penalties for
| noncompliance are minimal (maximum $300 per day) and the costs of
| disclosure potentially great"
|
| Lol what a joke. $300/day is like a drop in the ocean for most
| hospitals/clinics. No wonder no one is complying. Let's add
| Prison time to executives and see how fast they comply. I
| absolutely hate dealing with incompetent/fraud billing systems of
| our healthcare system.
|
| My steps to solve this:
|
| 1. Get rid of health insurance companies in EVERY process. If I
| want to visit my doctor for a basic checkup, let me pay cash. The
| cash price should be displayed/known in advance and I can shop
| around multiple doctors in my area.
|
| 2. With #1, get rid of crazy premiums , copays etc for most of
| these visits. Boom, u save shit ton. And no, don't argue with me
| that my employers provides great insurance. You don't want health
| insurance tied specifically to employers. You should be free of
| that.
|
| 3. Govt should subsidize the out of pocket costs for going to
| doctors . Increase a little bit of taxes for this. still a saving
| because you are saving SHIT TON of money when not paying crazy
| premiums etc. FOr those who argue otherwise, let me give you an
| example. For a family of 4, my total cost for an ok insurance is
| $2200/Month. This amount has to be paid regardless of whether I
| see a doctor or not. Then comes the copays, deductibles etc.
| Amounts can vary based on how "great" your plan is but the fact
| here is that shit tons of money is being paid to insurance
| companies for doing nothing and being a middleman. Get rid of
| this and you can add a small progressive tax instead. Will gladly
| pay that because I for sure wont pay $25,000 premiums per year
| and another $5000 in deductibles BEFORE i get a single penny from
| insurance companies. Oh and this keeps the price gouging racket
| going.
|
| 4. Let insurance companies stay in the market for "nice to have"
| procedures.
|
| Imagine if Car insurance became like health insurance. Who wants
| to argue that prices won't go up for EVERYTHING including a basic
| oil change.
| sircastor wrote:
| I agree that health insurance companies should go, but I don't
| know how we could accomplish this. Health insurance is a
| Trillion dollar industry, and that means there are a lot of
| people making a lot of money that have a lot of incentive for
| everything to stay exactly as it is.
| sithlord wrote:
| There are roughly 6,000 hospitals in the US - they sampled 100
| and concluded 17% of those were fully compliant.
|
| My question is, is that even CLOSE to enough of a sample size to
| make any meaningful statement?
| tfehring wrote:
| Depends on what you consider "meaningful" I suppose...but yes,
| as long as the sample's representative. You can do a lot with
| n=100 - unless the authors cherry-picked it would be incredibly
| unlikely for them to find 83/100 non-compliant hospitals by
| chance if there are only, say, a few hundred non-compliant
| hospitals. $ R -q -e "binom.test(17, 100,
| p=0.9, conf.level=0.999)" > binom.test(17, 100, p=0.9,
| conf.level=0.999) Exact binomial test
| data: 17 and 100 number of successes = 17, number of
| trials = 100, p-value < 2.2e-16 alternative hypothesis:
| true probability of success is not equal to 0.9 99.9
| percent confidence interval: 0.06925006 0.32125658
| sample estimates: probability of success
| 0.17
|
| Of course, there would be potential for "not fully compliant"
| to be insignificant for practical purposes (e.g. if it included
| hospitals that just missed a couple of billing codes), but
| based on TFA that doesn't seem to be the case.
| tolstoshev wrote:
| I get better price transparency at the vet than I do at any
| facility for humans.
| skeletal88 wrote:
| And where I'm from the state health organisation where everyone
| is insured sets the prices for all the procedures. If hostpitals
| want to get paid by them, then these are the prices they will be
| paid. It works, it's simple. Prices are adjusted based as time
| goes by, the hospitals make a small profit, but they are mostly
| non-profits run by the cities or universities.
| sircastor wrote:
| This is how Medicare works in the United States. The group sets
| the price and that's what Medicare pays.
|
| I recall a few years ago hearing about a company that, instead
| of getting a health insurance plan, hired a law firm to
| counter-negotiate (through legal threats) all bills down to
| Medicare prices, which apparently saved money.
| costcopizza wrote:
| Any startups addressing this somehow?
|
| Or is the regulatory framework waaaaay too favored towards
| incumbents to even fight?
|
| This shit is beyond frustrating. Healthcare could actually be
| semi reasonable if prices were as transparent as other
| industries.
| bob33212 wrote:
| The hospitals and the insurance companies do not want this to
| happen. Some politicians may want this to happen but others
| don't so the regulations are not forcing this to happen.
|
| It isn't something that software can fix.
| tolbish wrote:
| Could software help identify hospitals and insurance
| companies who are engaging in this?
| jrochkind1 wrote:
| Probably, but who would pay for it? I don't know if it
| takes software, the OP did it fine on their own.
| jehlakj wrote:
| I'd be surprised to hear successful startups with all these
| regulations
| ProAm wrote:
| Like an Uber for hospitals?
| OminousWeapons wrote:
| It is a difficult problem because there is no one price to
| show. Almost every user might be shown a different price.
|
| To my knowledge, at many orgs, insurance is actually funded
| directly by the employer; they do not contribute to a massive
| general pool along with other orgs. That individual employer
| helps set rates and coverage for their individual plan, and
| they might hire a big payer (insurance company) like Blue Cross
| Blue Shield to administer the plan that they created. This
| means that every single employer might have different payment
| rules and rates for a given procedure or item, and rates can
| also be hospital dependent or provider dependent. Additionally,
| many insurance companies require pre-approval (prior
| authorization AKA prior auth) for more expensive procedures or
| procedures / meds that are being prescribed outside of normal
| practice. This requires the provider (doctor) to call the payer
| (insurance provider), explain the situation, and see if a
| certain procedure will be covered. Before this is done, it is
| impossible to quote a price. Finally, we also have a class of
| people without insurance.
|
| So can real time price quotes be done? Maybe, but it would be a
| lot of work. The big payers do have API endpoints you can hit
| to get coverage information for a given user and I believe
| pricing data for a given procedure for that user. There are
| also clearing houses of sorts which can help you route traffic
| to the right endpoint. You would still need to get pricing data
| from hospitals which largely aren't interconnected for users
| without insurance and also deal with the prior auth situation.
| dmitriid wrote:
| Isn't it obvious that this cannot be solved by startups?
| loonster wrote:
| But it can be solved by startups: Procedure Insurance.
| AlexB138 wrote:
| It's always obvious that something can't be solved by a
| startup until it is. That's what "disruption" and
| "innovation" are.
| ryneandal wrote:
| It doesn't need disrupted, it needs to be criminalized. The
| application of capitalism in circumstances where the
| alternative is illness and/or death is tantamount to
| extortion.
| missedthecue wrote:
| So should we nationalize the farms to keep the dirty
| capitalists off of our food supply?
| ryneandal wrote:
| No legitimate rebuttal other than a whataboutism.
| Blocked.
| f6v wrote:
| The German healthcare insurance is basically run by the
| state. The healthcare is slow and far from perfect
| overall. But I didn't hear as many people complaining. I
| never paid for a hospital visit or a surgery. My only
| expenses were 10 euro/day for hospital stay that included
| free meals and 2-patient room with our own bathroom.
| jandrese wrote:
| Some kind of Expedia for hospitals? Some company that
| somehow extracts the actual price information from the
| hospitals and lets you comparison shop?
|
| Ultimately this is a technological solution to a political
| problem. It's going to be difficult to implement and face a
| lot of pushback from the entrenched incumbents.
| Sr_developer wrote:
| Wait arent you willing to put your health on the hands of the
| people who brought us Theranos, pets.com, and a DRM-laden
| juice-squeezer?
|
| "Unfortunately this transfusion cannot be given to you
| because there is a mismatch between its version and the
| versions approved in your database record. Please contact a
| representative or call our support line"
| f6v wrote:
| > Any startups addressing this somehow?
|
| With the amount of money at stake, I'd imagine organizations
| and politicians would bury any startup before you say "Seed
| round".
| mkmk wrote:
| https://turquoise.health/ is one notable example.
| arwhatever wrote:
| I would accept a life-saving medical intervention that drained
| my life savings if I were convinced that the price were
| competitive and fair.
|
| But under our current system, this could not be further from
| the case.
| epmaybe wrote:
| The price transparency rule was kind of useless already in the
| setting of most people being insured, it doesn't really tell
| people how much they are going to end up paying.
|
| I want to start a site that lets people submit their explanation
| of benefits from their insurance company and eventually lets
| people shop for insurance and/or hospital/clinic based on what
| they end up having to pay.
| deregulateMed wrote:
| 130 years of medical regulations by Physicians and it's broken.
|
| Any solution is politically impossible because the medical
| cartels can lobby(read-bribe) politicians.
|
| My only idea is for a tech company to use AI/Science to diagnose
| and treat. I imagine the physician cartel will attempt to ban
| competition, but as long as they are correct more often than
| physicians, writing is on the wall.
|
| Reminder physicians created the opioid epidemic.
| terryjsmith wrote:
| I did some research into this for my current employer and the
| challenges are pretty well laid out here: the penalties are
| minimal ($300 / day or $~110,000 per year), the data is kept in
| the invoice or billing systems, which are complex, and the
| hospitals do not want to share the truly groundbreaking data,
| which is the per-provider costs.
|
| In addition, when you Google for competitors you don't find a lot
| of them, but once you start looking at hospital websites you find
| that quite a few of them (about 50% of the ones I looked at) have
| at least a partial solution, often provided by their analytics
| company as an add-on or footnote.
|
| It does not appear there is a great market opportunity here
| unless the penalties increase (which the CMS has talked about
| vaguely, but hospitals are already asking for relief until after
| the pandemic).
| ethbr0 wrote:
| I worked in health care IT (insurance / provider side) during
| ACA's implementation.
|
| My takeaway is that Congress is technically ignorant of how
| ossified these backend systems are, but the enforcement
| agencies (e.g. CMS) are the grease between law and
| implementation.
|
| F.ex. ACA language and guidance being tweaked right up until
| the supposed "must be compliant by" date.
|
| Generally speaking, it works about as well as one might hope.
| All the stakeholders get together, hash out a reasonable
| schedule for actual implementation, and then everyone generally
| works towards that.
|
| It helps that the relationships are generally interdependent,
| and there's enough money sloshing through the system to fund
| change. So all parties generally do a fair job at converging on
| the requested changes, quicker than they'd like, but slower
| than the government would prefer. And then the few trailing
| insincere implementers start getting beat with fine sticks once
| the majority of their peers have successfully implemented.
|
| But agile, it ain't.
| terryjsmith wrote:
| I agree with everything you said. We're in the ACA space, so
| this should been right up our alley (government puts new
| legislation in with penalties to force employers to do
| something they don't really want to), but the ACA had a much
| bigger stick and a much longer runway.
|
| Starting January 2023, insurance companies and plan providers
| need to publish similar data, so to your point that might be
| the interdependency required for compliance.
|
| Obligatory these views are my own, not my company's.
| ethbr0 wrote:
| Based on what you know about the system and all parties,
| curious on any ideas you'd have to speed compliance
| (without bankrupting anyone).
|
| Would increased fines do it? Compliance bonuses [0]?
| Something else?
|
| [0] Showing a few of my cards, I was really impressed with
| the inner workings of the FEP program, from a management
| perspective. They seemed to have landed on an effective
| system of fine + incentive that strongly encouraged good
| behavior and positive results.
| terryjsmith wrote:
| TBH I didn't dig all that deep. Once you look at the size
| of the market (~6000 US hospitals, most of them in groups
| [0]), annual subscription (would need to be some fraction
| of what they would pay in penalties), percentage of
| market share you could capture (say 25%), discounts for
| groups, level of support, investment and unknown source
| systems, etc., I didn't evaluate it as a viable / likely
| opportunity, especially outside of our existing market.
|
| All of that said, if you knew the space and backend
| systems and could figure out a way to make it easy, one
| thing I did hear is that hospitals don't like to be non-
| compliant, so I think they want a solution (or this to
| just go away), it just needs to be a really minimal
| investment for them in cost and time to implement and
| maintain. The provider data coming into play in 2023 may
| be the main driver to "normalize" some of this being out
| in the open.
|
| Usual disclaimers again: my views, not my company's.
|
| [0] https://www.aha.org/statistics/fast-facts-us-
| hospitals
|
| Edit: add source.
| gigatexal wrote:
| of course not -- price in-transparency and its affects on prices
| is economics 101.
| underseacables wrote:
| There's no incentive for hospitals to provide transparency, and
| less formal doctors to worry about it. For now everyone is
| getting paid, and the only way to fix the system will be to stop
| paying many of the middle people that exist just to raise costs.
| It's like trying to change the car buying industry, there's
| simply too much money for it to improve without significant
| regulatory change. I think The transparency idea is just not
| going to hold water and will eventually be ignored or diluted.
| BurningFrog wrote:
| The leader in transparent pricing is the Surgery Center of
| Oklahoma.
|
| Their price list: https://surgerycenterok.com/pricing/
| nemo44x wrote:
| That's really great, and their prices are very reasonable to be
| sure.
| TheHypnotist wrote:
| Is $90,000 for a lumbar fusion reasonable?
| jaredhansen wrote:
| There is a lot of misunderstanding in this thread. I have a
| significant expertise on the price transparency rule and
| hospitals' responses to it, and will try to shed some light.
|
| Disclosure/source: I'm a former lawyer and the founder/owner of
| ClearCare[0], a price transparency compliance platform for
| hospitals that's purpose-built to help them solve exactly the
| requirements of this rule.
|
| I'm actively seeking someone to take it over, as I recently got a
| once-in-a-lifetime opportunity to join a plant-based bacon
| company as a cofounder, and I'm taking it. I don't want to shut
| ClearCare down, but I don't have time to focus on it since the
| bacon company is growing so quickly.
|
| I was actually pretty shocked to find so few HN-crowd startups
| tackling this. There's some competition in the market but it
| isn't very strong, and the distance to, at the minimum, a nice
| lifestyle-business that does a few hundred $k to a few million in
| ARR is pretty low. It took about a year to get ClearCare where it
| is today. The platform is written in React, uses Auth0 for auth,
| and is currently on Netlify. If you're interested in running with
| it, please reach out - jared.hansen [ at ] clearcare dot io.
|
| Also one other disclaimer: the following is an
| oversimplification. Obviously.
|
| ----------------
|
| _Background_
|
| The Affordable Care Act[1] (aka "Obamacare"), passed by Congress
| and signed by Pres Obama in 2010, required hospitals to "make
| public... a list of the hospital's standard charges for items and
| services provided by the hospital," and to update this list
| annually. The standard way hospitals met this rule was, for many
| years, to simply post a link to their chargemasters[2] - which
| you can think of as, essentially, an almost aggressively user-
| hostile data dump of opaque billing codes and amounts that didn't
| actually mean anything for patients.
|
| In June of 2019, Pres Trump signed an executive order[3]
| requiring the Dept of HHS to create new regulations that would
| more clearly codify the requirement. HHS' sub-agency CMS created
| a draft rule in September of 2019, which became final around 14
| months later.
|
| The AHA sued to block the rule but lost, and the compliance
| requirement has been live since January 1 of this year.
|
| There are many reasons the Chargemaster rate bears little
| resemblance to the rate paid by any actual patients, medicare
| reimbursement rules chief among them. Too much to go into here.
|
| So what _does_ the rule actually require?
|
| _The Rule_
|
| In short, hospitals must post two things:
|
| (1) a list of Standard Charges (i.e., the chargemaster), for
| everything. This has to include negotiated rates with each payer
| (E.g.: Blue Cross pays 7500 for a given kind of knee surgery;
| Aetna pays 562; United Health pays 812), and the cash discount
| rate, if any. One thing that's interesting about this list (and
| overlooked, frankly, by most of the providers in the space) is
| that it is described by CMS as a "machine-readable file" - and
| they give examples as CSV, JSON and XML. Historically, hospitals
| would post chargemasters often as PDF(!), sometimes XLS, txt,
| csv, god knows what all -- but CMS is trying to move toward a
| world where you can create an API on top of all of the data and
| build more of the "kayak for healthcare" tools that the industry
| has been trying (and failing) to build for so long.
|
| (2) for 300 procedures designated as "shoppable services"
| (meaning: can be scheduled in advance, and patients might want to
| shop around), a "user-friendly", "searchable" and generally
| better-designed disclosure of prices and various other
| information about the services. CMS designated 70 of these, and
| hospitals choose the other 230.
|
| *THAT'S IT.* Contrary to popular belief, especially elsewhere
| ITT, the rule does not require hospitals to provide the kind of
| price transparency you see elsewhere in life. You just have to
| post certain kinds of data in certain formats. It's not actually
| that hard, but it's pretty hard for hospital IT departments to do
| on their own -- especially IT departments that don't really
| exist, because they're at small hospitals with small budgets.
|
| =======
|
| _Misunderstandings ITT_
|
| _Myth: "The price transparency rule requires hospitals to
| explain what things cost for patients"_
|
| _Reality:_ The price transparency rule requires hospitals to
| list the "standard", or "chargemaster" price, along with the
| "negotiated rate" the hospital has reached with each payer.
|
| _Myth: $300 /day is nothing to hospitals_
|
| _Reality_ : that's true for large hospital systems maybe, but
| there are >2k small, rural hospitals that the rule still applies
| to, regardless of their tiny budgets. For these hospitals,
| 109k/year is a lot of money (incidentally: this also means that
| spending say 10k/yr on price transparency saas is a lot more
| attractive than doing nothing and paying the fine). Moreover:
|
| _Myth: the fine is the only penalty for noncompliance_
|
| _Reality:_ CMS has indicated stronger penalties will come if
| compliance does not increase, including impact on the medicare
| reimbursement rate, which is a core driver of hospital revenue.
| Hospitals do have good reason to try to comply, and many of the
| larger ones are already doing so. In fact, the data show that the
| larger hospitals are much more likely than smaller ones to be
| compliant at this time.
|
| _Myth: this is way too hard_
|
| _Reality_ : If complying with the rule meant you had to figure
| out what every patient was going to pay in advance, then yeah, it
| would be largely impossible right now, for reasons adequately
| documented elsewhere in this thread. But that's not what it
| requires. You can comply by posting a very specific, pretty well-
| understood set of information, which consists largely of a
| transform on information that each hospital absolutely already
| has.
|
| ----
|
| I started ClearCare basically the day I read the Trump executive
| order, because within an hour of hearing about it, it was obvious
| to me that either 6k+ hospitals would have to do a bunch of
| bespoke web design to comply, OR there would be a pretty
| straightforward SaaS platform that would do it for them, and that
| there was good opportunity in building that platform. I still
| believe this, and if I weren't busy taking orders for plant-based
| bacon I'd be recruiting instead of looking for someone to hand it
| off to. Call me if you want to talk.
|
| ---------
|
| [0] https://www.clearcare.io -- and there's a corporate deck
| here: https://www.beautiful.ai/player/-McFhWCjOS_FBay_aAy3
|
| [1] https://en.wikipedia.org/wiki/Affordable_Care_Act
|
| [2] https://en.wikipedia.org/wiki/Chargemaster
|
| [3] https://nationalhealthcouncil.org/blog/blog-president-
| trumps... - note the text of the order is no longer available on
| the whitehouse site, but this is a decent summary.
| dragonwriter wrote:
| > for 300 procedures [...] CMS designated 73 of these, and
| hospitals choose the other 217.
|
| 217 + 73 = 290. Somewhere, there's a mistake in these numbers.
| jaredhansen wrote:
| Yep, fixed, it's 70 shoppable services and 230 they choose.
| mindslight wrote:
| I would love to see a coordinated push by people simply refusing
| to pay hospitals' post facto billing nastygrams. AFAIK, medical
| "debt" doesn't even end up on your social credit report in the
| US.
|
| Without any up front prices, there is no contract that obligates
| payment. Instead, hospitals collect under the idea of "unjust
| enrichment" - you needed help, they provided it, and so you
| should compensate them. But that still doesn't allow them to set
| arbitrary prices the way they do ($6 for a $0.02 aspirin!), but
| only to recoup their actual costs. A few form letters that
| billing department victims could use to assert their legal rights
| would go a long way.
|
| You wouldn't pay a second post-facto bill from your grocery store
| based on some justification that "the cashier you went to didn't
| actually work for the grocery store", and we shouldn't accept
| similar nonsense from medical providers.
| CPLX wrote:
| I totally agree with the sentiment here but is this actually
| true? My understanding is that health care providers have
| legislative power and influence and have used it to actually
| ensure that a legal obligation to pay is created in situations
| like these.
|
| Is that not correct? Would they actually sue under an unjust
| enrichment cause of action, or is there statutory authority
| most of the time?
| mindslight wrote:
| I would believe that could be the case, at least in some
| states. But on that front, all of these articles about
| terrible hospital bills are doing a grace disservice by
| failing to mention those laws, so that public support can
| build against them. If _anyone_ were given the power to
| create legally valid debts out of thin air, they would of
| course abuse it. Preventing that is one of the main purposes
| of contract law.
| hansvm wrote:
| > If anyone were given the power to create legally valid
| debts out of thin air, they would of course abuse it.
|
| Which, incidentally, does exist in places. E.g., when CO
| mints a new transportation authority they give a private
| corporation oversight-free permission to set their own
| rates and penalties, enforceable by law. That's resulted in
| a long string of complaints about toll roads charging not
| just the toll, but for the first bill they never sent, an
| extra 1000% interest here and there, a fine because they
| had to "send a second bill," ....
| noelsusman wrote:
| A lot of people already do this, which is one of many reasons
| why hospitals charge $6 for an aspirin.
| mindslight wrote:
| There are other approaches to profitability besides
| committing billing fraud.
| pchristensen wrote:
| Dolt, a startup doing a version-controlled database, did a data
| bounty project and produced a huge dataset of prices for
| individual procedures at tons of hospitals:
| https://www.dolthub.com/blog/2021-03-03-hpt-bounty-review/
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