[HN Gopher] Hospitals lift curtain on prices, revealing giant sw...
___________________________________________________________________
Hospitals lift curtain on prices, revealing giant swings in pricing
by procedure
Author : paulpauper
Score : 402 points
Date : 2021-09-22 16:17 UTC (6 hours ago)
(HTM) web link (www.healthcaredive.com)
(TXT) w3m dump (www.healthcaredive.com)
| karl11 wrote:
| I bet that this ends up resulting in higher prices. Once
| hospitals know what the others are charging, it is more likely to
| cause the cheaper ones to raise their prices than it is the more
| expensive ones to lower them. Medical care is a scarce good and
| (mostly) the end consumer is not footing the bill directly,
| either for the care or the insurance.
| pulse7 wrote:
| <critic>Imagine the most advanced country in the world can not
| get their healthcare in order... Imagine one of the most
| Christian countries in the world (>75% are believers) yet they
| are not "good Samaritans" to their own people...</critic>
| twofornone wrote:
| >yet they are not "good Samaritans" to their own people
|
| The state of the secular healthcare system is unrelated to the
| religiosity of the population. Further, in some states (like
| TN), there are in fact christian organizations that do take on
| a substantial portion of the social safety net, especially for
| the homeless. Critics will say that the time limit on food and
| housing is unethical but I think its important not to create a
| permanent dependence.
|
| I'm not a religious person but the disdain which people
| commonly speak of [white] Christianity online is really
| offputting and, frankly, ignorant.
| the_imp wrote:
| I don't understand why US healthcare providers are allowed to
| charge different customers a different price for the same service
| or good.
|
| As this is clearly being systematically abused to extract the
| most wealth from patients and insurance companies, is anyone
| seeking to require healthcare providers to not provide such
| variable pricing?
| vmception wrote:
| Great, now mandate that it is viewable via API
|
| Can even use the healthcare industry standard for EHR which is
| JSON and RESTful
| nebula8804 wrote:
| In the meantime, since we have the data, this could be a good
| project for volunteers to glue together all the different
| documents from the different hospitals into a single system.
|
| These files are provided as excel documents in what I assume to
| be a (hopefully) mostly unchanging location on each site. A
| script could download all the files, match up the procedures
| and then push it to a pretty tool for everybody to use when
| comparing prices.
|
| Most enterprises have terrible dev/IT talent but when it is a
| cause as important as this, talented people tend to show up to
| provide a great solution.
| EamonnMR wrote:
| I was thinking of doing this. I even started a bit, but I
| didn't end up getting very far. I'm torn between trying to
| run it as a service and running ads or whatever, or trying to
| run it as a wiki with contributors writing ETLs for
| individual hospitals and trying to tame the data set.
| aeyes wrote:
| Even better: Mandate them to upload the data to some government
| system and let them provide a central API, transparency
| reports, ...
|
| Germany did this for gas stations:
|
| > Since 31 August 2013 companies which operate public petrol
| stations or have the power to set their prices are obliged to
| report price changes for the most commonly used types of fuel,
| Super E5, Super E10 and Diesel "in real time" to the Market
| Transparency Unit for Fuels.
|
| https://www.bundeskartellamt.de/EN/Economicsectors/MineralOi...
| sxg wrote:
| Have JSON and REST been meaningfully adopted in healthcare? I
| thought most things still used the god-awful HL7 with hopes of
| migrating away.
| topspin wrote:
| HL7 FHIR is a counterpoint. A comprehensive, well specified
| REST API based on JSON.
| EamonnMR wrote:
| As mentioned upthread, faxes are still in use.
| samstave wrote:
| When I was working in healthcare, I found out that hospital
| groups negotiate their own Code prices with each carrier
| individually.
|
| So one group will have one rate with Blue Shield vs what another
| hospital will have.
|
| Its absolute bullshit.
|
| ---
|
| If youre mandated to have insurance - then procedures should be
| regulated to a set cost regardless of who performs the procedure.
| pkaye wrote:
| Another thing is Medicaid pays below the cost of care so that
| is balanced by the private insurers payments. This is why you
| see many county and rural hospitals struggling because the
| private hospitals have taken the cream of the crop private
| insurers. First step is the make sure hospitals are not
| drowning in covering for costs of Medicaid and uninsured
| patient care.
|
| This Frontline documentary talks about this issue.
|
| https://www.youtube.com/watch?v=UVvEkeH4O8o
| jjoonathan wrote:
| Alternative spin: Medicare/Medicaid are the only insurance
| that is any good at keeping prices under control. Everyone
| else in the medical industry is in the city, bilking people
| who have money. Expanding medicare/medicaid will help us
| slowly bring costs down, more in line (PPP-adjusted) with the
| rest of the developed world.
| scheme271 wrote:
| This will probably help a bit but in an emergency people don't
| have the time to compare prices. And with US health care, it just
| takes one accident that sends you to the ER and where someone
| that's out of network performed a procedure to end up with a bill
| that's tens or hundreds of thousands of dollars.
| vmception wrote:
| Its just the first step
|
| To shock and awe into future laws
| hanniabu wrote:
| The whole out of network aspect in hospitals is ridiculous
| arcticbull wrote:
| Yes, in a single-payer environment everyone is in-network.
|
| Every doctor in Canada providing covered medical services is
| in-network.
| mistrial9 wrote:
| I was told by a cancer patient in the US, who is a Canadian
| citizen, that specialized equipment and certain tests are
| not available in the entire system, or months-long wait
| times.
| pessimizer wrote:
| Not all treatments are statistically useful. In the US
| you can get anything you can pay for, even if it costs a
| million dollars and hasn't been shown to have any
| beneficial effect. In a national system you make
| statistical decisions based on cost and effectiveness.
| arcticbull wrote:
| Medical bankruptcy is the most common form of bankruptcy
| in the US. I would say that for the massive portion of
| the US that is un-insured, under-insured or faces
| bankruptcy in the event of a medical procedure that
| substantially any tests and equipment for them are not
| available.
|
| Canada has some of the best cancer survival rates in the
| world, and is substantially identical to the US. [1]
|
| Further the US tends to skew towards early detection
| without a commensurate increase in survival rates, which
| means 5-year numbers in the US are higher than elsewhere
| in the world but it does not necessarily translate to
| lower mortality.
|
| [1] https://www.ctvnews.ca/canada-gets-high-ranking-for-
| cancer-s...
| SamuelAdams wrote:
| Yes but emergencies are the exception, not the norm for most
| hospitals. Most hospitals make 40-60% of their revenue on
| elective surgeries, ie things that can wait 2-6 months. So
| patients have time to shop around.
|
| Source: currently work at a big hospital in IT.
| pessimizer wrote:
| Emergencies are the norm, not the exception, for most people.
| Elective surgeries are mostly the well-insured and the
| wealthy. Poor working people go to the hospital when it hurts
| so bad that they're missing work, and when they miss work
| they don't get paid.
| 1123581321 wrote:
| That is old information. In the US, your deductible and copay
| have to be the in-network price in emergencies, and balance
| bills from the provider will not be allowed in emergencies
| starting next year (and you can already usually get the balance
| waived with sliding scale charity etc.)
| maxerickson wrote:
| You don't pay up front in an emergency, so people can consult
| the information and ask questions before they do pay. They can
| call their insurance company and ask why they pay more than
| average. And so on.
| [deleted]
| nradov wrote:
| A recent federal regulation which implements the No Surprises
| Act of 2021 should reduce some of those abuses by hospitals.
|
| https://www.cms.gov/newsroom/press-releases/hhs-announces-ru...
| weberer wrote:
| I'd imagine that prices will now plummet simply due to the fact
| that prices are now transparent and real competition can
| actually exist.
| folkhack wrote:
| The other big conflict here is that I'm not an expert and I'm
| not about to turn down services if recommended to me by an
| expert in a field which I have no experience.
|
| I get the whole "do your research", but often it's in areas in-
| which I have no real capability - especially with healthcare.
|
| ---
|
| > And with US health care, it just takes one accident that
| sends you to the ER and where someone that's out of network
| performed a procedure to end up with a bill that's tens or
| hundreds of thousands of dollars.
|
| Agree. And to add, all it takes is one procedure that your
| insurance company doesn't want to cover to put you into literal
| billing hell for months on end. My point being, even with price
| transparency they can just chose not to pay even if they're
| obligated (and they do this). If there's _any_ way they can
| weasel out of paying they will.
|
| I'm still 100% in support of price transparency in healthcare
| however... there's just so much broken with it and I've lived
| through the hell.
| quadrifoliate wrote:
| > I get the whole "do your research", but often it's in areas
| in-which I have no real capability - especially with
| healthcare.
|
| Oh the system has answers - just happen to be high enough at
| your company, or the spouse of someone who is.
|
| > While a benefits expert at a mid-sized company may create a
| narrow network, an executive's spouse, for example, may want
| to go somewhere not in the network. "And there's a pillow
| talk that happens. And the next thing you know that hospital
| is in the network," Ladd said.
|
| This whole "employer provides your healthcare" thing we have
| going on in the US is just nuts.
| MarkSweep wrote:
| There is a little bit of good news here from the omnibuss
| budget passed at the end of 2020. Search for "NO SURPRISES ACT"
| on this page:
|
| https://congressionaldish.com/cd227-coronabus-health-care/
|
| "Starting on January 1, 2022, any health insurance company that
| provides "any benefits" in an emergency department can not
| require pre-authorization of those services or deny coverage
| because the emergency department is out of their network. If
| emergency services are provided out-of-network, there can not
| be any limits on coverage any more restrictive than what would
| be covered by an in-network emergency department and the out-
| of-pocket costs can't be more than they would be in-network.
| Out-of-pocket payments at an out-of-network emergency room must
| count towards in-network deductibles and out-of-pocket
| maximums."
| missedthecue wrote:
| Emergency care accounts for just 2% of healthcare spending.
|
| https://www.politifact.com/factchecks/2013/oct/28/nick-gille...
| drunner wrote:
| And yet: _Using a conservative definition, 62.1% of all
| bankruptcies in 2007 were medical; 92% of these medical
| debtors had medical debts over $5000, or 10% of pretax family
| income._
|
| https://www.amjmed.com/article/S0002-9343%2809%2900404-5/pdf
| lolpython wrote:
| That is not a useful statistic here. We are talking about an
| individual's financial obligations in a medical emergency. A
| $10,000 bill is not 2% of an individual's yearly spending.
| loeg wrote:
| You're missing the bigger picture. It's worthwhile
| improving transparency around the vast majority of
| healthcare needs/spending. ER costs are also a problem, but
| it's an orthogonal issue. Don't let the perfect be the
| enemy of the good.
| lolpython wrote:
| No, I don't oppose hospital price transparency. My
| comment was basically a procedural one. Saying that ER
| visits are 2% of nationwide costs does not meaningfully
| address the toplevel poster's concerns.
|
| > ER costs are also a problem, but it's an orthogonal
| issue.
|
| It's natural to want to discuss this orthogonal issue,
| and the solutions to the two issues are not mutually
| exclusive.
| seaourfreed wrote:
| Hospitals rig the economy. They intentionally break price
| comparisons, patients able to decide-before-buy, pricing
| pressure, and a million ways to rig prices.
| FirstLvR wrote:
| My third world country has better regulation than this
| pc86 wrote:
| Why is it that insurers in the US are seemingly the only industry
| where the person _paying the bill_ can a) negotiate it _after
| services are received_ ; and, b) just decide not to pay it if
| they don't want to?
|
| Hospitals should set a price for a procedure. There will be some
| variability of course as people need more or less anesthesia,
| identical surgeries can take longer to perform (=== more
| OR/surgeon time === more money), etc. But a $22-102k like in the
| article is absurd. Insurance companies should be required to pay
| whatever the hospital price is provided it can be justified.
| There should be specific courts to handle these disputes until
| the industry realizes it isn't special. Regardless, the onus
| shouldn't fall on the patient. Outcomes should be limited to: 1)
| Insurance company pays without complaint; 2) Insurance company
| doesn't pay, is sued by hospital, and is ordered to pay by the
| court; 3) Insurance company doesn't pay, is sued by the hospital,
| prevails in court, and hospital adjusts accordingly, eating 100%
| of that loss.
|
| But, we'll likely just stay where we are now where people pay
| $100 for Tylenol PM and insurance companies get out of paying
| claims because one person out of 12 in the OR were out of network
| and they're all contractors.
| gfodor wrote:
| It will be fun to watch people be positive on this until they are
| reminded who we have to thank for it.
|
| Edit: CNN hasn't forgotten, notice the obvious negative spin,
| with literally zero argument of how this may be beneficial:
| https://www.cnn.com/2021/01/04/politics/hospital-price-trans...
| SavantIdiot wrote:
| You mean Bill Clinton in the early 90's? It was part of the
| Clinton health care reform. But maybe you're not that old. ;-)
|
| Every president has pushed for this except Bush Jr.
|
| Glad it finally happened even if it was under who I consider to
| be the worst president* in the last 100 years of US history.
| Doesn't mean I need to thank him. If you were being tortured in
| a Mexican cartel prison, would you thank the torturer for
| giving you glass of water?
| mardifoufs wrote:
| Thinking that trump is the worst president in the past 100
| years just betrays either an insane privilege[1] or just
| ignorance. You realize the hundreds of thousands of lives
| lost directly or indirectly in the war on terror, a war
| almost completely engineered by the Bush administration, are
| actually real right? They were people with hopes, plans,
| dreams that were all wiped out, and for a lot of those who
| are still alive they are condemned to live in a cycle of
| violence caused again by the war on terror and it's ripple
| effects. If you compare that to what trump did in his 4 years
| and come up with the conclusion that hey, it wasn't as bad &
| Donald truly is the worst president... Then I don't even know
| what to tell you.
|
| I'm Muslim and I've grown up my entire life with that war and
| its consequences in the background, especially since we
| mostly consumed arabic media. I've thankfully not been
| affected directly, but man do these takes completely
| discredit the side that keeps pushing them instantly for me.
|
| We are at a point where even the notoriously neocon hawkish
| republican party and their voters are a lot more willing to
| acknowledge just how horrible those people were, yet
| democrats have no problem completely rehabilitating the old
| neocon crew because hey yeah they killed people but at least
| they were... Polite about it? I get that it's unhinged
| crusading politics and we just have to paint the adversary as
| the worst person ever to feel the rush of being morally
| superior but when you are at the point where you defend
| George W Bush to own the magahats, maybe take a step back and
| reflect on what you are doing.
|
| The worst part is that now that bed has been made and
| apologism for those neocons became a mainstream talking
| point, everyone is just doubling down because admitting that
| trump isn't actually even close to being worst would be to
| admit that maybe the hysteria to score political points
| didn't warrant sweeping under the rug 2 enormously
| destructive wars.
|
| [1] as in the privilege of not having ever been affected by
| the war on terror. Which in turn leads to pretty
| insignificant events like being concerned about the
| presidents tweets or feeling that you are part of some sort
| of feel good #resist movement for 4 years just registering as
| being more impactful than a region getting destabilized far
| away
| SavantIdiot wrote:
| That's a fair criticism, although you really pulled out the
| big hyperbolic guns. Insane? Not really. And you continue
| to make personal attacks even in your footnote. But hey,
| it's an internet discussion board, I'm guilty of the same.
|
| The guy broke democracy and started a trend that IMHO will
| inevitably break the US. There's no stopping the
| nihilistic-right's rise fueled by an uneducated white
| minority bent on revenge via politics for their oppression
| at the hands of those they vote for. This nihilism, meaning
| its not that side A is correct or side B is correct: there
| is no "correct". That's worse than two pointless wars,
| IMHO, and it springs directly from Trump. A fountainhead of
| corruption the likes of which modern democracy has never
| seen. And I stand by that.
| mardifoufs wrote:
| Yet that white minority is more willing to stop bombing
| non white across the world. It's a bit unreal but it's
| the truth. You ought to realize that you are also coming
| from an imo pretty... White-democrat point of view right?
| And my argument is exactly that a segment of the country,
| mostly white, went to such a extent to get revenge on the
| 2016 election that they sided with literally everyone
| they used to hate not even a decade ago. I'm sorry but
| how is that for nihilism? Your arguments are again very
| philosophical, but in a way just dismiss the destruction
| of an entire generation of Iraqi (and Syrian, by ripple
| effects) because a nihilistic trend of your political
| opposition rising? I'm sorry but come on! Like you are
| exactly doing what I was critizing in the first place.
| "those people may have died, and that region may have
| been hopelessly destabilized but at least Bush (who
| literally was elected by the supreme Court which makes
| this even more ironic) wasn't nihilistic?". The guy that
| came up with you are either with us or you are with the
| terrorists?
|
| Of course it's worse than 2 wars you have never been
| affected by. The entire USA had a complete meltdown over
| allegations of Russians rigging the elections, _without
| any American casualty_. In fact I 'd bet that one of the
| reason you are saying trump broke democracy is probably
| related to those allegations. But when the US is
| destroying entire countries it's no big deal? I hope you
| can see the cognitive dissonance there or at least why
| your point of view is very very white centered. And
| that's without even getting into how the democrats
| attacked the integrity of the elections for years,
| rightly or wrongly yet I don't see how that didn't
| directly undermine trust in democracy. It was a dance-a-
| deux, and if trump ends up breaking democracy down the
| line it's not because one side pushed against it. My
| point here is that no matter how you look at it, the
| entire thing is related to partisan politics not a
| righteous crusade that couldve somehow justified arguing
| that 2 desastrous, decades long wars were in fact less
| important/bad.
|
| But that's all unrelated. Look, I'm not American, not
| white and not Christian.to me it boils down to this. I
| don't think anything is more cynical and cold than to
| publicly downplay and rehabilitate a figure that caused
| so much more pain and suffering because that would score
| points. That's it.
|
| I really didn't want to come off as insulting you,
| honestly. And I get that some things can't really be
| expressed in a non offensive way (even if that's not the
| intention) when it comes to heated subjects like this.
| That's why I'm not going to touch on some of your other
| points. Again, it's not because I'd have insulted you
| otherwise, but because I don't know how to express what
| the war on terror felt like from the "inside" without
| inevitably sounding hyperbolic.
| SavantIdiot wrote:
| > I'm sorry but come on! Like you are exactly doing what
| I was critizing in the first place.
|
| Shit. That's an excellent point. Thanks for making me
| realize it. I'm being absolutely glib about 1M+ deaths.
| Yeah, that's totally privilege. My bad. I'll go think on
| that for a while. Yes, I'm a white liberal and I haven't
| been called out this succinctly and correctly in a long
| time. I responded like shit because I got angry, my
| apologies. Thanks again.
| mardifoufs wrote:
| Hey this is actually really nice to read, and no matter
| what you end up concluding I think it's good to just put
| things in perspective.
|
| I totally realize it's harder to get the whole picture
| for a lot of people who weren't really affected or
| involved, just like it is harder for me to relate to
| let's say the current Ethiopian civil war and it's very
| harsh effects on the local population since it's so
| detached from my every day life. Even as a Muslim , I'd
| probably have been oblivious to the war on terror if it
| wasn't for my parents being very into Arab politics and
| the family tv always tuned to Arabic news. Growing up
| with daily reports of bombings, suicide bombings, mothers
| crying on TV, and just footage of destruction everywhere
| is what made me realize and process how much misery was
| brought upon so many people. it got to the point where
| the opposite of the normal media sentionalism happened
| and a few dozen people dying in a suicide bombing/drone
| strike barely made it in the news. the weird part was
| that it somehow was never ending.from the invasion of
| Iraq, to the insurgency to the Iraqi surge to the afghan
| surge to libya to Syria to Isis to... A bit of very
| relative peace now? I think everyone would've felt the
| same if they were in the same situation I think. Even
| many Arabs and Muslims in the US don't fully realize that
| either. Cheers!
| 93po wrote:
| I also really hate how much people ignore the actions of
| other presidents and hyper focus on one mainly because of
| the massive amount of consent manufacturing by mainstream
| media. Hundreds of thousands of people are dead as a result
| of other presidents, and a lot of those were women and
| children.
| neither_color wrote:
| I think it's sad that you can end a sentence with Bush Jr and
| then not call him the worst president in the next sentence.
| My vote for worst president in living memory is the guy who
| started two pointless trillion dollar wars, the latter of
| which took 20 years to close up in a humiliating retreat, but
| that's just me. This is not a defense of he who isn't being
| named here btw.
| tormlop wrote:
| You seem upset.
| mullingitover wrote:
| I mean, that's nice, but I'm not going to fall all over myself
| thanking the people who have fought viciously for decades to
| maintain the current profit-driven health care system and block
| single payer health care. It's like an abusive spouse who, out
| of the blue, brings you flowers and chocolate.
| gfodor wrote:
| Wasn't really my point. My point is that you should expect to
| see all kinds of mental gymnastics around answering the
| question of if this is a positive change or not.
| dehrmann wrote:
| Biden doesn't run his mouth when he shouldn't, but foreign
| policy with China and along the southern border are essentially
| the same as under Trump, and the Afghanistan withdrawal
| alienated some NATO allies. Biden is carrying over more of
| Trump's policies than you'd expect.
| disgruntledphd2 wrote:
| Presidents come and go, but the Blob is eternal.
| cwkoss wrote:
| It is funny/depressing to think how different our country
| would be today if Bernie had been the 2016 dem nominee.
| jimmygrapes wrote:
| The most depressing thing is that it likely wouldn't have
| changed much. Congress (of which Bernie is still part of
| and has been for decades) is the one with the power to
| make these changes, the President is just the
| scapegoat/hero.
| trixie_ wrote:
| I'm not a fan of the guy, but this is probably the most
| important/good thing he did with his presidency. Price
| transparency is the most fundamental first step to driving down
| health care costs. Once people get a taste of it, it will drive
| even more, better and accurate data. Start real conversations
| about costs and open the door to measureable improvement
| through innovation.
| mullingitover wrote:
| Price transparency is a pointless shell game designed to keep
| everyone strung along on the entrenched, failed system. When
| you're having a heart attack, the last thing you're doing is
| shopping around for the best prices on heart attack emergency
| treatment.
|
| The free market has no place in health care, because in the
| hands of the free market the first thing that will happen in
| a life-threatening emergency is for you to transfer 100% of
| your wealth to the party that has 100% of the leverage.
| twofornone wrote:
| >When you're having a heart attack, the last thing you're
| doing is shopping around for the best prices on heart
| attack emergency treatment.
|
| This is a tired, nonsensical argument. The vast, vast
| majority of medical procedures are not last minute
| emergencies. Furthermore, with price transparency you will
| clearly be able to evaluate which hospitals may or may not
| be generally in your price range and choose a default to
| visit for an emergency (assuming you're not carted off in
| an ambulance).
|
| More importantly, this will absolutely force competition
| and some degree of price correction.
| xur17 wrote:
| I agree that it's pointless for emergency surgery, but
| there are plenty of other cases where a consumer could shop
| around (colonoscopy, ACL repair, etc), and I'd argue these
| are actually the majority rather than the minority of
| cases.
|
| To me it comes down to - if we are going to pretend we have
| a market based system for health care (that's what we say
| we have now), we need pricing transparency to have any hope
| of it working.
| pessimizer wrote:
| > I'd argue these are actually the majority rather than
| the minority of cases.
|
| For well-insured middle-class people. Poor working people
| _only_ get emergency care
| codegeek wrote:
| I think forcing hospitals to at least list something is a
| good start. It won't be perfect but it will make people
| more aware of how hospitals and insurance companies are
| working usually to screw people when it comes to billing.
| Any transparency is a good thing whether it is perfect or
| not.
| bjt wrote:
| Not all health care is heart attacks. "Health care" is a
| huge bucket containing everything from buying a bottle of
| cough syrup to the heart attacks you mention.
|
| For life threatening emergencies, I'm with you. Let's fund
| that care through the state.
|
| But excluding the market from everything is not the answer.
| The problem with using insurance for all these non-urgent
| things is that insurance _distorts_ the market and price
| discipline goes out the window.
| mullingitover wrote:
| We don't have to reinvent the wheel. Other countries have
| solved these problems. They have better health care than
| we do. It's measurable, it's been measured, and no
| surprise, they have flat-out superior outcomes. They are
| _dramatically_ more efficient. Our market focus is a
| cargo cult.
| weberer wrote:
| What market focus? Prices were completely opaque until
| just a few months ago. Any economist on the planet will
| tell you that would lead to awful outcomes for everyone
| except the powerful healthcare lobby.
| mullingitover wrote:
| Yes, we have a thoroughly regulated, negotiated,
| contractually obligated system. You can't have a true
| "free market" in health care without some truly egregious
| outcomes because when people are in health crisis they
| will pay _anything_ to stay alive, and we already know we
| won 't countenance the (let's call it what it is)
| extortion that the free market would produce in those
| scenarios. Because we want to _feel_ like it 's a free
| market, because free market economics is a cargo cult
| when it comes to health care, we get the worst of both
| worlds.
| gfodor wrote:
| There is no silver bullet. Your absolutist perspective
| undermines your argument.
| mullingitover wrote:
| On the contrary, there is, the problem (for some) is that
| it is indeed a _bullet_ and the people getting
| (figuratively) shot are the ones who, under this system,
| are getting very fat on the inefficiencies. They 're able
| to use their illicit wealth to exploit our very broken
| system of government to maintain their rent-seeking
| successes.
| gfodor wrote:
| No system is perfect. If the US had a universal
| healthcare system, it would suck in many ways. People do,
| after all, travel to the US for medical care. My point is
| that there is likely a better local optimum out there
| than the one you suggest, and coming off as if the
| problem of healthcare is "solved" is news to people under
| any system who are suffering due to its inefficiencies or
| inequities. For example, I live in the US - I have CF and
| have been taking a drug for more than a year that is
| extremely effective. It has yet to be approved in some
| universal healthcare systems, likely due to its high cost
| (given the small patient population and its extremely
| high R&D costs.) This is literally killing people who
| would be alive had they been able to access the drug.
| mullingitover wrote:
| There may be edge cases, but on the whole if people in
| the US had the health care systems of the UK, France,
| Germany, Japan, or pretty much any other developed
| country, they would _riot in the streets_ if the US
| system were suddenly forced on them.
| gfodor wrote:
| lol dead people as "edge cases" - frame this one up - own
| it.
| mullingitover wrote:
| Nothing funny about it. It's grim, but it beats dead
| people as the _default case_. We have a lower life
| expectancy in the US than _Cuba_ , a nation with a GDP
| per capita of 8,821 USD. A country where the average
| person's annual wages wouldn't buy them half of a ten
| year old used Toyota Corolla has better health outcomes.
| We have people begging bystanders not to call them an
| ambulance when they're grievously injured, because they
| can't afford it.
|
| So yeah, there are a handful of people out of thousands
| where this system works great. We shouldn't optimize the
| entire system for hundreds of millions of people for
| these edge cases.
| gfodor wrote:
| You've set up a nice little fallacy for yourself in the
| form of declaring people you don't care about as "edge
| cases." I'm glad you're acknowledging that your original
| claim of the problem of allocating heathcare for people
| is not "solved" though.
|
| Let me cut to the chase: a better system is probably one
| where competitive market forces are leveraged to drive
| down (actual) costs and drive up innovation where it is
| an optimal strategy, and social program-oriented
| solutions are deployed when that is the bad, unethical,
| impractical or suboptimal approach, with an overarching
| mechanism to regulate over time the transition from the
| former to the latter. If you remove the incentives that
| come with a free market for healthcare, it comes with
| benefits and costs. Stop acting as though it is cost
| free. It isn't.
|
| I never took issue with your claim that healthcare in the
| US has problems which are solved through universal
| systems. I took issue with your claim that universal
| systems are a panacea that solve all relevant problems,
| and the implication that trying to hill climb to a better
| optimum is not worthwhile to improve outcomes.
| mrguyorama wrote:
| How many people died last year in the NHS because they
| couldn't get health care?
| bjt wrote:
| Not sure how you get reinventing the wheel from my
| comment.
|
| What I described would move us in the direction of the
| countries you're talking about.
|
| I have lived in the UK, and seen doctors through the NHS.
| I have bought cough medicine at the chemist, and no it
| was not state-funded. I have visited patients at NHS
| hospitals where you are one patient sharing a room with
| 20 others in the same ward. I have talked to people on
| the waitlist for months to get surgery.
|
| I still think the UK system is better than ours in the US
| for urgent care. I don't want anyone to be financially
| ruined because of some unforeseeable accident or
| emergency.
|
| But I maintain that "health care" is way too big a
| category to be absolutist about using or not using free
| market principles in it. There are parts of health care
| where markets do not make sense. There are other parts
| where they do.
| mcguire wrote:
| Even a blind squirrel finds a nut once in a while.
| rootusrootus wrote:
| Our system is so byzantine. I prefer to go to Kaiser, if
| possible, for no other reason than everything is in-network by
| definition. The only reason I don't have Kaiser right this moment
| is my current company only has one Kaiser plan, and it's a
| Cadillac plan -- zero deductible, zero out of pocket maximum, and
| so it has a fairly high premium (whereas the PPO plan I'm using
| has a premium essentially zero, the company pays almost 100% of
| it). Which brings me to something else I loathe -- that my health
| coverage is related to my job. Dammit, I don't want to change
| doctors when I change jobs.
| Someone1234 wrote:
| Local hospital released this as an Excel spreadsheet
| (Chargemaster).
|
| They have a column called "Uninsured cash price." These prices
| are <25% of the insurance "discount" prices, but the really
| amusing thing is that this column was set to 0 size so that when
| you download the Excel sheet you have to know to auto re-size all
| the columns, or you cannot see it.
|
| And, no, I don't think this was by accident as they have updated
| this Excel spreadsheet several times and only that one column is
| always set to 0 size.
| 5faulker wrote:
| It's like that "display:none;" thing in CSS.
| snarf21 wrote:
| This is why we need reference based pricing. You can't charge
| more than 1.2 * Medicare and if you pay cash, you get the
| Medicare price. This change alone would remove 25+% of
| unnecessary bloat from the US system.
| nickff wrote:
| > _" This change alone would remove 25+% of unnecessary bloat
| from the US system."_
|
| Where do you think the money is going? Insurance companies
| are not as profitable as you might think, drugs are not a
| massive burden on healthcare expenditures, and many hospitals
| are non-profits. The truth is that most of the money is going
| to staff wages; if you want to reduce healthcare spending,
| the only way to do it sustainably is to increase the numbers
| of doctors and nurses, so as to drive down their salaries
| (but this is not a popular option).
| alex_smart wrote:
| >the only way to do it sustainably is to increase the
| numbers of doctors and nurses, so as to drive down their
| salaries
|
| Getting the hospitals to accept a price ceiling which
| forces the issue _is_ another way to do it.
| rsj_hn wrote:
| Yes, but supposedly the author was referring to a way to
| lower prices while maintaining an equilibrium of supply
| versus demand.
|
| You can always lower prices by fiat proclamation, but
| then you have shortages and wait lines as hospitals go
| bankrupt and shut down, which will hit rural areas
| particularly hard.
|
| If you want to lower prices _and make sure that everyone
| gets served_ , you need to be a bit more sophisticated
| than just cutting hospital revenue in half and washing
| your hands of the consequences.
| alex_smart wrote:
| >supposedly the author was referring to a way to lower
| prices while maintaining an equilibrium of supply versus
| demand
|
| They were trying to solve the problem by increasing the
| supply of doctors into the system. The other proposed
| solution was taking the approach of reducing the supply
| of money into the system. Neither are contradictory to
| "maintaining an equilibrium of supply versus demand" but
| both are trying to move where that equilibrium is by
| adjusting the supply of two different things. So however
| you define "while maintaining an equilibrium of supply
| versus demand" either they were both doing it, or both
| weren't.
|
| >then you have shortages and wait lines as hospitals go
| bankrupt and shut down, which will hit rural areas
| particularly hard
|
| Sure, that is what happens if you only fix the prices in
| certain states and not others, which incentivizes the
| doctors to move from states that have such price ceilings
| into states that don't. That is why the only possible way
| to implement that solution is nation-wide.
|
| >If you want to lower prices and make sure that everyone
| gets served
|
| I don't see why lowering the price nation-wide would
| reduce the supply of doctors. What are the doctors going
| to do? Migrate? But no other large economy has doctor
| compensation as high as the US. So as a country, you are
| only competing against yourselves.
| kazinator wrote:
| > _many hospitals are non-profits._
|
| That can't possibly be true of a hospital that charged
| $3000 for something on Tuesday, and $53000 for the same
| thing on Friday.
|
| (Under reasonable assumptions like that Tuesday wasn't done
| at a $25K loss relative to breaking even; why would such be
| the case? And that they are busy with procedures, not
| simply doing a way overpriced procedure once every few
| weeks, and then just burning through cash in between that
| time.)
| BurningFrog wrote:
| PSA:
|
| Non profits can be as greedy as any other organization.
|
| Typically the money goes to wages for the leadership
| rather than profits to the owners.
| lostlogin wrote:
| > Non profits can be as greedy as any other organization.
|
| The term 'non-profit' is one I find hilarious. With the
| smoke and mirrors of accounting and standard insurance
| company behaviour it can mean anything.
|
| The directors can get bonuses, the cars can be upgraded
| and the conferences/holidays can get more impressive.
| It's surprising that 'non-profit' doesn't generate an
| eye-roll in more people.
| kazinator wrote:
| Yes; basically it's just a classification combined with
| an accounting strategy.
| nickff wrote:
| The most famous (infamous?) example of this was the
| Hughes Medical Foundation.
| nickff wrote:
| Very few hospitals do cost-accounting, so they don't even
| know how much things cost; this results in the
| inconsistencies you see in prices.
|
| From Wikipedia:
|
| > _" In 2003, of the roughly 3,900 nonfederal, short-
| term, acute care general hospitals in the United States,
| the majority--about 62 percent--were nonprofit. The rest
| included government hospitals (20 percent) and for-profit
| hospitals (18 percent)"_
|
| https://en.wikipedia.org/wiki/Non-profit_hospital
| kazinator wrote:
| If you don't know how much things cost, how can you say
| you're doing accounting?
|
| If you're doing accounting you have a ledger which
| balances down to the penny, and the expenses are spelled
| out in there with concrete amounts.
|
| This is why that judge, as noted in the article, rejected
| the argument that the cost of an X-ray can be unknowable.
| nickff wrote:
| Cost accounting consists of more than just balancing a
| chequebook to the penny; you need to attribute expenses
| to specific procedures, which can get a bit tricky. It
| requires discipline and cooperation throughout the
| organization, which would likely be a huge change for
| hospitals (as I'm certain doctors would be loathe to log
| their time like lawyers do).
| kazinator wrote:
| OK, so if my company knows how much it's spending on
| toilet paper for the washroom, but doesn't know exactly
| which departments are wiping how much ass, then we are
| not doing cost accounting though we are tracking the bulk
| expense properly in the ledger. We are not able to answer
| the question of how much toilet paper is required to
| operate our marketing department, for instance.
| nickff wrote:
| Widely used supplies like that are usually just put into
| a general overhead account, sometimes specific to a
| department.
|
| Healthcare companies would need to attribute things like
| depreciation of equipment (MRIs & CAT scanners for
| example), as well as doctor and nurse time (outside of
| operating rooms). These things are generally not tracked
| accurately, and many professionals are indignant at the
| idea that they could be.
| jeffdn wrote:
| A substantial portion of the money spent on wages at
| primary care physicians offices is on staff to negotiate
| with insurance companies. At a previous employer, where I
| worked closely with many primary care physicians offices,
| it was not uncommon for there to be three or more staff
| members working entirely on billing. That is ludicrous.
| snarf21 wrote:
| You are forgetting about all the brokers and all the staff
| at the insurance companies whose jobs is to negotiate
| different prices for procedures with different doctors.
| Most brokers charge 5%. Additionally, this change would
| cause a loss of some clinical jobs. A lot of the urgent
| cares would no longer be profitable and would have to get
| shutdown. Additionally, all these changes would ripple in
| other ways. Some providers may start offering sub Medicare
| cash prices to attract business. There is no reason
| healthcare costs needed to go up 6% per year and the main
| reason it does is that it can.
| coredog64 wrote:
| If you accept Medicare, you cannot legally charge
| _anyone_ less than the Medicare price.
|
| I won't say always, but Medicare price is usually
| marginal but not profitable. I.e. if you've got an empty
| bed, Medicare is better than nothing, but you wouldn't
| actively try to fill beds at sub-Medicare rates even
| without the hassle of dealing with insurance companies
| eganist wrote:
| > increase the numbers of doctors and nurses
|
| and tort reform to manage the lawsuits to enable lower
| malpractice insurance costs.
|
| and a scheme to drive down med school pricing. Maybe more
| competition? Enabling more MD and DO schools? There are
| <200 medical schools (both MD and DO schools) in the US.
| nradov wrote:
| Tort reform only helps a little. In fact several US
| states have already implemented major tort reform and
| their healthcare costs aren't significantly lower.
| Doctors still tend to practice defensive medicine and err
| on the side of doing too much rather than too little.
|
| The current bottleneck in producing more physicians isn't
| medical schools but rather funded residency program
| slots. Every year some students graduate from medical
| school but are unable to actually practice medicine
| because they don't get matched to a residency program. We
| need Congress to increase funding.
|
| https://www.ama-assn.org/press-center/press-releases/ama-
| fun...
| DaveExeter wrote:
| >and tort reform to manage the lawsuits to enable lower
| malpractice insurance costs.
|
| A great insurance company talking point! The purpose of
| 'tort reform' is to increase insurer profits.
|
| We need more medical malpractice lawsuits, not less!
| iratewizard wrote:
| Medical errors cause an estimated 250,000 deaths in the
| United States annually.
| programmertote wrote:
| I didn't downvote you and in fact, I agreed with the fact
| that a significant portion of the exorbitant healthcare
| prices in the US can be traced back to administrative
| bloat, MBAs who are in the management and to a degree, the
| significantly-higher-than-OECD-average salaries of the
| doctors in the US.
|
| Having said that, your belief that many hospitals are non-
| profit might not be as simple as it looks from the outside.
| I recently read an insider writing something about it on
| Reddit: https://old.reddit.com/r/SelfAwarewolves/comments/p
| ruk4x/the...
|
| Hope that gives you an additional viewpoint regarding the
| "non-profit" label of the hospitals.
| wintermutestwin wrote:
| >administrative bloat
|
| I'd love to know how much money is spent by hospital
| admin staff dealing with the insurance industry.
| nickff wrote:
| I completely agree with that user's statement:
|
| > _" The end result is a privately-owned hospital that
| operates as a non-profit on the books when it is anything
| but that... American doctors and hospital executives are
| printing money using the backs of their patients as the
| die. They take in millions per year in compensation that
| was given to them by people who worked hard and fell on
| bad times. It is one of the most shameful forms of
| exploitation in modern history."_
|
| I'm just unsurprised, as that is consistent with my view
| of many (most?) non-profits. I also think that the
| executive pay component is a smaller share than that
| Redditor seems to.
| CPLX wrote:
| > Where do you think the money is going?
|
| To the millions of people making a living in the health
| care system that have no actual role (direct or indirect)
| in improving the health of patients.
| rsj_hn wrote:
| I think this is far too facile. It's like saying half
| your taxes go to government waste. I mean sure, OK, but
| how do you get rid of government waste? So far no one has
| been able to do it. So this is really an unwillingness to
| engage in the problem, which is absolutely endemic in the
| current discourse.
|
| The key problem is that 20% of our GDP goes to
| healthcare, and similarly 20% of our population is
| employed in healthcare provision. This isn't just people
| sitting around doing nothing. It's nurses, doctors,
| administrators, etc. If you want to reduce healthcare
| costs in half, so that it is only 10% of GDP, then expect
| to throw 10% of the population out of work. That will
| include nurses, doctors, EMT personnel as well as
| administrators. Sure, you can try to shift that and fire
| a bit more administrators than nurses, but you will soon
| discover that's about as easy as eliminating government
| waste.
|
| This inability to address the core issue arisies from
| people approaching these difficult problems in
| administration and systems science from a facile moral
| point of view. "it's wrong!" they say, to be given a big
| bill for a snake bite. Well, OK, it's wrong. But that
| same attitude will tell you "it's wrong" to fire a hard
| working nurse, or to reduce the pay of a doctor, etc. So
| now you are left with boogeymen like greedy insurance
| companies and fat cat CEOs. This is like the person who
| insists on a tax cut funded by reducing government waste.
| It's not a serious proposal. And what we have in the US
| healthcare debate is two sides, the first side is just
| lying and obfuscating (that is the side opposed to
| reform) and the second side is so bound in the chain of
| moralizing that they are unable to make any serious
| proposals. They can only go after the fat cats, and not
| the nurses. Thus their proposals will never work.
|
| Same thing for education -- you need to fire most of the
| university staff and reduce the pay or fire many of the
| teachers. Same thing for all the difficult problems in
| life where we complain that things cost too much. It is
| not shadowy fat cats that are causing these problems, it
| is too many people employed in the provision of services
| who are earning too much. Ordinary professionals. The
| biggest problems of modern life are that professionals
| have too much power and are extracting too much from the
| society as a whole. Whether it is hospital workers or
| government workers or teachers, the issues of
| skyrocketing costs and bureaucratic bloat are very
| similar across these areas, and they cannot be solved by
| getting rid of shadowy fat cats or employees that "do
| nothing".
| CPLX wrote:
| > So far no one has been able to do it.
|
| But that's the problem with your argument. Of course
| people have done it, nearly every developed country has.
|
| > If you want to reduce healthcare costs in half, so that
| it is only 10% of GDP, then expect to throw 10% of the
| population out of work. That will include nurses,
| doctors, EMT personnel as well as administrators.
|
| No, it won't. I'm talking about eliminating the positions
| that would only exist _because_ of the private insurance
| system. Which is a _massive_ amount of dead weight loss.
|
| It's not remotely hard to understand conceptually, I mean
| EVERY dollar that's devoted to arguing over insurance
| bills is completely wasted. As are all the dollars spent
| on insurance advertising and marketing, and so on. Every
| dollar paid back to health care companies as dividends,
| or used for stock buybacks.
|
| That's a _lot_ of dollars.
|
| Every time this argument comes up people in the US start
| talking about it like "Oh yeah? Sure but what's YOUR
| solution then smart guy? Stumped you didn't I?"
|
| Um, no. My solution is the NHS. Like you can go there and
| look at it I swear it's a real thing, they have buildings
| and everything, just book a flight to London and see for
| yourself. Or, in US terms, Medicare for all, which is
| also a real understandable thing that exists, except for
| the "for all" part.
| rsj_hn wrote:
| To believe that administrative overhead would
| significantly reduce healthcare costs is just obviously
| false. We spend 20% of GDP on healthcare and UK spends
| 10%.
|
| Total spend is employees * average salary per employee.
|
| Let's take a look:
|
| * For doctors, there are roughly the same number, ~2.8
| per 1000, but US doctors _earn three times_ as much as UK
| doctors[1]. 294K /year US versus 66K/year (UK).
|
| * The US has twice as many nurses[2] per 1000 people
| (17.4 per 1000) as the UK does (9.8 per 1000), and the US
| _pays its nurses much more_. The US pays 77K /year for an
| RN and 112K/year for an PN and 181K/year _average salary_
| for a nurse anasthesologist[3]. Nurses in the UK earn
| about _1 /3 less_, a total average of 33K/year[4]
|
| * The US has 315K pharmacists (not assistants) or roughly
| 1 per 1000, whereas the UK has 43K or .65 per 1000. US
| pharmacists make average of 140K/year[7]. UK pharmacists
| make an average salary of 58K per year[8].
|
| * The US has 23,200 microbiologists (earning 69K/year).
| The UK has 490 (earning 52K/yr)
|
| * The US has 40 MRI machines per million. The UK has 6.
|
| * Now let's generally talk about staffing. The US employs
| 20 million healthcare workers with a payroll of 1
| Trillion (2018)[5] an average wage of 70K (and median
| wage of 42K/year). These is occupational data from BLS
| (https://www.bls.gov/ooh/healthcare/home.htm), so you
| can't complain about insurance employees at hospitals as
| being included.
|
| The UK has 1.3 Million[5] in both hospitals and clinics
| counting both NHS and Independents, with an average
| salary of 24.7K/year.
|
| That means, relative to population, that the US employs
| 60 per 100,000 healthcare employees while the UK employes
| 20 per 1000. We have triple the number of healthcare
| workers and our health care workers earn double what the
| do in the UK.
|
| Now let's talk about this enormous waste in insurance
| that will make healthcare affordable if only we got rid
| of it. Total insurance overhead in the US is 7% of
| healthcare expenditures[8]. So if we reduced it to zero,
| we would pay 7% less. Whoppee.
|
| Thinking that you can keep paying doctors and nurses
| triple and have so many more staff and keep their high
| wages but merely with insurance reforms reduce healthcare
| spending by half is so wrong I am amazed I even need to
| say it. It's a terrible, misleading, evasive non-answer.
|
| What we need to cut are salaries and employment. If you
| don't acknowledge that, then you are not a serious
| participant in this discussion because you are refusing
| to acknowledge that this problem has tough trade offs.
| You are not going to solve it by "cutting waste".
|
| ---
|
| [1] https://revisingrubies.com/us-vs-uk-doctors-salary/
|
| [2] https://www.healthsystemtracker.org/chart-
| collection/u-s-hea...
|
| [3] https://nursinglicensemap.com/resources/nurse-salary/
|
| [4] https://www.bls.gov/opub/ted/2020/number-of-
| hospitals-and-ho...
|
| [5] https://digital.nhs.uk/data-and-
| information/publications/sta...
|
| [6]
| https://www.census.gov/library/stories/2020/10/health-
| care-s...
|
| [7]https://www.salary.com/research/salary/benchmark/pharm
| acist-...
|
| [8]https://uk.indeed.com/career/pharmacist/salaries
|
| [9] https://time.com/5759972/health-care-administrative-
| costs/#:....
| topkai22 wrote:
| The NHS/UK isn't cheaper (just) because of insurance
| related dead weight though- they also just pay everyone
| less.
|
| The US Government estiamtes the total adminstration and
| health insurance expenditure cost $288B in 2019. Total
| health consumption was $3.69T. Thats about 7.5% of total
| health spending. Even if you assume a 2 or 3x multiplier
| to the effect of eliminating insurance companies you
| STILL don't get US healthcare spending on a GDP basis in
| line with international norms.
|
| Insurance companies are awful, but they alone are not the
| cause of American's health care spening problems.
| kingsloi wrote:
| I'd love to look up uninsured prices and compare them 1-1 to
| what I was charged for my little girl's 2 week ICU stay
| https://kingsley.sh/posts/2021/two-weeks-in-the-icu-as-a-bab...
| avs733 wrote:
| You inspired me to look at the local hospital we just delivered
| our first child at.
|
| They release 'standard charges' which as far as I can tell
| means 'the range of charges for this particular diagnosis based
| on past data' as an excel file.
|
| But the price list is a text file delimited by pipes (vertical
| bars... |) which just seems unnecessary. They also do nothing
| to define the variables or column names they use...so that's
| nice.
| mulmen wrote:
| Pipes are commonly used as delimiters in healthcare settings
| [1]. A quick quack suggests Python, Javascript and Perl
| ecosystems have HL7 parsing libraries available. I assume
| most languages do.
|
| [1]: https://en.m.wikipedia.org/wiki/Health_Level_7
| batty_alex wrote:
| Yep, probably an HL7 message. In the case of vertical bars,
| pretty sure it's HL7v2
| KarlKemp wrote:
| Except they usually call them "tubes".
|
| (Can't find the original source, but it goes "Cant breathe?
| Put in a tube. Can't pee? Tube. Can't poop? Tube. Bleeding?
| Tube. Infection? Tube. Heart attack? Tube.")
| slownews45 wrote:
| God, I used to work in medical billing, and people would
| think these file format issues were some kind of scheme. NO
| they are not. They deal with the obvious problem that
| clinicians are NOT always programmer friendly, and will put
| things like tabs in case notes, will use commas etc. At some
| point you use a delimiter that is much less likely to be used
| - | - is one of those, not a lot of clinicians use it and you
| can say, please don't use this.
|
| A surprising amount of stuff (at least medical billing side)
| can be flat file moves, especially if you are billing into
| lots of different systems.
|
| And yes, the idiot new person with a phD says, just quote
| every field with a ". Great - you program all this up, along
| with the required escape sequence handling, and then escapes
| for escapes. \ and / get used a fair bit sometimes already
| and we are dealing with tons of systems.
| [deleted]
| lostlogin wrote:
| > God, I used to work in medical billing, and people would
| think these file format issues were some kind of scheme.
|
| I think it must be at this point. The hot garbage that is
| medical data formats (HL7, in particular) and the ways you
| can break it as a user, unknowingly and silently. It's
| incredible that a format this bad has hung around this
| long.
|
| It's not ok that users can type certain characters into a
| field and break the system.
| NortySpock wrote:
| Sometimes medical procedure names have commas in them.
| Instead of text qualifying them, it can be faster to write
| code that uses a different semi-standard delimiter.
|
| It sucks, but, like, I don't really blame people for being in
| a hurry to fix a problem.
| jolmg wrote:
| Or they could be using a legacy system that exports data in
| that format from times before CSV was
| invented/standardized.
|
| For example, SCO Unix's Informix SQL's `UNLOAD TO <file>
| SELECT ...` queries output in a format that's very much
| like what avs733 describes, only that the values aren't
| separated by pipes, they're terminated by them, so every
| record ends with a pipe character.
|
| If that's the case, there's unfortunately no built-in
| option to get it to include column identifiers in the
| report. :(
| mulmen wrote:
| If it's HL7 (likely) the format is more complex than just
| a CSV anyway. There are multiple separators for different
| purposes.
| batty_alex wrote:
| > But the price list is a text file delimited by pipes
| (vertical bars... |) which just seems unnecessary. They also
| do nothing to define the variables or column names they
| use...so that's nice.
|
| They likely just exported the prices as HL7 from their EHR
| system and used Excel's built-in delimiter support, then
| called it a day
| lostlogin wrote:
| > HL7
|
| And there is the problem.
| EForEndeavour wrote:
| This is the GDPR cookie popup annoyance equivalent of
| requiring hospitals to disclose their chargemasters, but not
| spelling out that the published data should be reasonably
| human-readabale. Malicious compliance.
| KarlKemp wrote:
| Oh but, if you read slightly between the article's lines,
| you'll notice that the law does require both human- and
| machine-readable publication.
|
| The machine-readable part is mandated here: https://www.fed
| eralregister.gov/documents/2019/11/27/2019-24...
|
| As a taste of how specific this is: (5)
| The file must use the following naming convention specified
| by CMS, specifically: <ein>_<hospital-
| name>_standardcharges.[json|xml|csv].
|
| And here's the consumer-readability requirement for 300
| "shoppable' services: https://www.federalregister.gov/docum
| ents/2019/11/27/2019-24...
|
| They aren't always quite as stupid as people make them out
| to be, these lawyers.
| EForEndeavour wrote:
| From your second link:
|
| > c) Format. A hospital has discretion to choose a format
| for making public the information described in paragraph
| (b) of this section online.
|
| This is how you get Excel files with certain column
| widths set to zero. All it has to be is searchable, free,
| public, and updated regularly.
| folkhack wrote:
| And this can really cause issues for people who are insured
| because if an insurance company decides not to cover something
| (very _very_ common, even in-network) then the inflated price
| is what you end up getting billed for.
|
| That is until you call the hospital and find out there's all
| sorts of "sliding" prices etc...
|
| I had a procedure billed for one of these drastically larger
| "insured" codes which got denied based on the nature of the
| procedure from the insurance company (apparently too new of a
| procedure at the time, however common now).
|
| It all got worked out in the end but what I realized was that
| hospitals are largely subsidizing the cost of the uninsured by
| over-billing the insured folk's insurance companies. We've set
| the American healthcare system up to be a cat and mouse game
| where those in need are represented the least.
|
| Best insurance here is "don't get sick"
| mywittyname wrote:
| > if an insurance company decides not to cover something
| (very very common, even in-network)
|
| Which is why hospitals charge higher prices to insurance
| companies.
|
| Insurance companies often blanket deny every single claim
| made against them. This forces the hospital revenue cycle
| department to have an appeals nurse review just about every
| procedure done in the hospital, and justify its use. This
| almost always results in a "discount" for something by virtue
| of a care provider not justifying every action they take.
|
| Revenue cycle management departments used to be small, about
| 1 per 1000 hospital employees. Today, they are so big - and
| make so much money* - that hospital systems are spinning off
| their revenue cycle management companies for billions of
| dollars. Private equity firms have been acquiring in this
| space like mad since about 2016.
|
| * Really, they are actually getting the money that is already
| owed.
| mabub24 wrote:
| > Best insurance here is "don't get sick"
|
| Recent New Yorker article looking at the "Costa Rica
| model"[0] raised this point as well. America, by contrast to
| Costa Rica, has a very weak public health sector and
| infrastructure, and this leads to a real weakness when
| focusing on preventable illnesses and issues.
|
| [0]: https://www.newyorker.com/magazine/2021/08/30/costa-
| ricans-l...
| folkhack wrote:
| Yeah I read that too - just cherry picking here:
|
| > All adults have tests and follow-up visits to prevent and
| treat everything from iron deficiency to H.I.V. It's all
| free. If people don't show up for their appointments, she
| makes sure their team finds out why and figures out what
| can be done.
|
| It's common sense why they have better results and outcomes
| than we do here... Our system is optimized for capitalistic
| profit. I've got insanely good insurance and I still have
| no idea how screwed I am if I go to the doctor or
| especially a hospital. Although I've only had one major
| billing snafu years back I have real anxiety about going to
| the doctor here.
|
| And hell, even if I go my PCP is going to be stuck in an
| "all or nothing" mentality where it's either OTC or getting
| in their own conflict with my insurer... ie: "If I can't
| justify this test with your insurer..."
|
| ---
|
| Costa Rica's model is better than America's. The reason for
| this is because it's not optimized for profit, it's
| designed from the ground up to optimize for patient
| outcome.
| fidesomnes wrote:
| > Our system is optimized for capitalistic profit.
|
| We got a real astute analyst here. I am curious what your
| first hint of such a fact was?
| Thlom wrote:
| In a well functioning health care system screenings like
| that is actually of debatable value as it generates a lot
| of false positives and un-necessary procedures.
| hellbannedguy wrote:
| "I realized was that hospitals are largely subsidizing the
| cost of the uninsured by over-billing the insured folk's
| insurance companies."
|
| 1. You have to back up claims like this.
|
| 2. I imagine for-profit Insurance companies would love to
| blame their prices on the uninsured.
|
| 3. Many poor people actually have insurance in the USA. Even
| if they don't apply for it, insurance can be applied for
| after the fact.
|
| 4. The wealthy, and the poor are usually covered by
| insurance. It's the middle class that needs attention. They
| have insurance, but it's not great.
|
| I still don't belive our healthcare costs are due to the
| uninsured. Oh yea, every hospital has a fierce Billing and
| Collections department.
|
| They are allowed to go after your assets if you can't pay
| your bill, and they do. Obamacare gave patients some rights,
| but hospitals blatantly abuse the regulations.
|
| The right to collect in municipal court was never taken away
| from hospitals.
|
| In my local newspaper, it's not uncommon for a hospital to
| sue a patient over a bill, and put a Judgment lien on the
| patients assets.
|
| They claim they only do this as a last resort, but bankruptcy
| due to medical bills are still the number 1 reason people end
| up in federal court (Bankruptcy).
|
| Your protections under a bankruptcy are not great either.
|
| There are many hospitals that forced a former patient to sell
| their home (homestead exemption needs to be higher. In TX,
| they can't touch your primary residence.). under a
| bankruptcy.
|
| In CA, for example, the primary home gets a $250,000
| protection. (Look up that last figure. I know it's very low
| in CA, and needs to be raised to at least a million. You have
| a $600,000 home. You are only protected by $250,000 of it's
| worth.
|
| So in America, if you do get sick, and can't pay all your
| medical bills, you have no protections. These for-profit
| medical companies will come after you with more zest than an
| unpaid credit card. I think CC companies are less aggressive.
| EvanAnderson wrote:
| > if an insurance company decides not to cover something
| (very very common, even in-network) then the inflated price
| is what you end up getting billed for...
|
| Is there any reason why this kind of windfall shouldn't be
| illegal? I realize it isn't, but is sure seems like it should
| be.
|
| I was stuck with a charge from a doctor for 7x the price my
| insurance would have paid. My pre-ACA insurance refused to
| cover the procedure and I ended up on the hook for the
| inflated price. The doctor wouldn't negotiate and demanded
| the full fee. Neither the doctor, nor I, knew this would
| happen until the procedure was already done.
|
| It feels like an agreement, to me, when the practice takes on
| a patient knowing who their insurer is. I feel like the
| reimbursement rate that insurer has negotiated, regardless of
| whether the insurer ultimately covers any procedures, should
| act as a cap for the fees charged to the patient. It feels a
| lot like negotiating a contract, except that one party gets
| to unilaterally change the amount of consideration. How does
| that fly?
| brandall10 wrote:
| There are services you can use which will negotiate the
| rate back down to the neighborhood of what the insurer
| pays. They won't negotiate with you specifically, you have
| to retain one of these services to negotiate on your
| behalf. They have direct access to usual and customary
| charges insurers pay per region.
|
| Was in a similar situation as you were, but unfortunately,
| what I'd have had to pay was still too much as it was
| clearly fraud on the part of an outpatient clinic - one
| side, the clinic, was approved by my insurer, the other
| side, the surgery center, was not, and they willfully lied
| about this distinction. I threatened a law suit and they
| demurred.
| KingMachiavelli wrote:
| I've had this thought as well. If insurance is negotiating
| with the provider then that should be the final say. What's
| the point in negotiating if the patient gets charged the
| difference?
|
| I believe this is called 'balanced billing'. Some states
| prohibit it under certain conditions but it seems either
| the government or insurance should be prohibiting this
| practice.
| elliekelly wrote:
| > It feels like an agreement, to me, when the practice
| takes on a patient knowing who their insurer is. I feel
| like the reimbursement rate that insurer has negotiated,
| regardless of whether the insurer ultimately covers any
| procedures, should act as a cap for the fees charged to the
| patient. It feels a lot like negotiating a contract, except
| that one party gets to unilaterally change the amount of
| consideration. How does that fly?
|
| You aren't exactly talking about "balance billing"[1] but
| you'll be pleased to know the No Surprises Act[2] tries to
| address this situation with required cost (estimate)
| disclosures in advance of a procedure and capping the out-
| of-network amount that can be charged in the event of an
| emergency where there can't advanced disclosure. The HHS
| recently promulgated regulations[3] under the Act but the
| compliance date is January 2022. For some reason I _think_
| there is at least one (maybe two?) other proposed rules in
| the works but I can 't recall what they address and I can't
| seem to find them.
|
| Edit: The other proposed rule is relating to air ambulance
| services[4]
|
| [1]https://en.wikipedia.org/wiki/Balance_billing
|
| [2]https://www.congress.gov/bill/116th-congress/house-
| bill/3630...
|
| [3]https://www.hhs.gov/about/news/2021/07/01/hhs-announces-
| rule...
|
| [4]https://www.healthaffairs.org/do/10.1377/hblog20210913.5
| 7633...
| jjoonathan wrote:
| Insurance has the worst moral hazard: the winning strategy
| is to sell a product that pretends to cover your customers
| but actually doesn't. Your customers give you money for
| nothing and they will only realize it once in a blue moon.
| You can probably buy off the few who are capable of causing
| actual blowback, and if that doesn't work just rebrand.
|
| Until everyone becomes a contract lawyer capable of
| devoting weeks to insurance shopping every 6 months, the
| only good insurance market is a heavily regulated one, even
| though heavy regulation comes with its own gigantic bag of
| worms.
| wuliwong wrote:
| Insurance isn't inherently a moral hazard.
| fragmede wrote:
| Inherently? No, just under capitalism.
| folkhack wrote:
| I know that any anti-capitalism comments get immediately
| downvoted here but yeah...
|
| The privatization of healthcare is a conflict of interest
| which is a product of our hyper-capitalistic society. You
| can't make a profit center out of human services without
| dehumanizing it in the process - the very nature of
| profit/capitalistic societies means someone has to lose
| and I see no place for these interests in healthcare or
| education.
|
| Edit: yep - expected that. Maybe someone argue as to why
| privatization (which is a product of capitalism) isn't a
| conflict of interest in regards to healthcare?
| nybble41 wrote:
| Private health care is _adversarial_ (so you have to look
| out for your own interests) but this does not
| automatically imply a conflict of interest. It may
| _become_ a conflict of interest if you get your advice
| about which tests or treatments to undergo from the same
| health care provider who profits from you taking that
| advice, but this is something which you have control
| over: Get your advice from one place and have the work
| done somewhere else, just as you would for e.g. home
| inspections.
|
| It's not as if public health care doesn't have moral
| hazards of its own, including conflict of interest. The
| system may officially be non-profit but the interests of
| its workers and administrators (profit-oriented or
| otherwise) do not necessarily align with those of the
| patient.
| wuliwong wrote:
| >the very nature of profit/capitalistic societies means
| someone has to lose
|
| If by 'profit/capitalistic societies' you mean those
| allowing for voluntary exchanges between its people, I
| would disagree. As an adherent to the subjective theory
| of value, I think it is common that both parties in an
| exchange would consider themselves 'winners.' [0]
|
| [0]
| https://en.wikipedia.org/wiki/Subjective_theory_of_value
| folkhack wrote:
| I'm in the Jim Camp school of thought where, in
| negotiation, there is no "win-win" situation.
|
| https://www.forbes.com/sites/jimcamp/2013/03/11/revisitin
| g-w...
|
| The reason I am firmly in this school of thought is that
| I've made the absolute mistake of a decision to try for
| "win-win" situations in a capitalistic society,
| specifically in regards to contract negotiations and
| ultimately pricing/billing.
|
| When I'm making sure that the person on the other end of
| the table "wins" I'm putting myself at a capitalistic
| disadvantage; and - if both parties "won" then didn't
| both ultimately lose?
|
| I get your ideal, but when money is involved I find that
| the "win-win" is very much that: just an ideal. And,
| anecdotally over the years I've found many business
| experts write on the topic of why "win-win" is a losing
| position which validates my position on this.
| nybble41 wrote:
| > if both parties "won" then didn't both ultimately lose?
|
| No, because even in a capitalist society "winning" is
| defined by each party's relative improvement over the
| state they would be in if they didn't come to an
| agreement and make the trade--not by some absolute
| measure of whether they did better than the other party.
| A "win-win" is simply an agreement where both parties are
| better off for making the trade. This is the usual state
| of things when both parties are free to accept or decline
| and there is no deception (fraud) involved, since both
| parties need to accept the agreement and they will only
| do so if they believe that doing so benefits them. In
| rare cases one or both parties may be mistaken about the
| benefit, but they know their own business better than
| anyone else and are best positioned to judge the expected
| value of making the trade based on the information
| available at the time.
| alex_c wrote:
| What is the definition of "win-win" that you are against?
|
| I'm not familiar with Jim Camp, but the term is vague.
| The linked article to me mainly seems to argue that:
|
| - the side with a better BATNA has more negotiating power
| (yes, of course) and
|
| - a negotiator should avoid agreeing to a bad deal out of
| desperation (yes, of course - but not always easy to do)
|
| I'm not sure how the concept of "win-win" specifically
| plays into it, so I think this is where definitions are
| useful.
|
| To me, win-win doesn't make sense for transactional
| negotiations where there is only one dimension (usually
| price), but CAN happen for more complex negotiations with
| multiple dimensions where each dimension has different
| value to each party (price, time, volume commitments,
| etc...)
| opo wrote:
| >...the very nature of profit/capitalistic societies
| means someone has to lose
|
| The last time you bought milk did you lose or did the
| grocery store? The last time you paid money for a hair
| cut, who lost there?
|
| The extreme regulation of all aspects of health care that
| has developed over the last century has improved some
| problems and created other problems - the problems
| specific to healthcare have little to do with the "the
| very nature of profit/capitalistic societies"
| folkhack wrote:
| > The last time you bought milk did you lose or did the
| grocery store?
|
| There's way more people involved in that supply chain
| then me and the store. This is an over simplification.
|
| Outside of the obvious answer of "the cows" - factory
| farming has been destroying my home state causing huge
| problems in rural America. Also - the environment. Big
| time the loser there is the environment for literally any
| bovine farming.
|
| > The last time you paid money for a hair cut
|
| When I was getting my hair cut professionally I tipped a
| $20 because I knew the gal cutting my hair working at the
| midwestern mall Regis Salon was making jack-all. I knew
| this because I worked at Geeksquad with her boyfriend,
| eventually husband. If I were not to tip well she would
| be at-risk for making minimum wage for that hour - and
| since you can't support yourself on minimum wage I see
| that as her losing.
|
| I've always tipped my butt off because I know without
| that they lose.
|
| ---
|
| So yeah - sorry... I anecdotally do see losers in the
| situations you described. I don't have to look hard to
| see them.
| opo wrote:
| >Big time the loser there is the environment for
| literally any bovine farming.
|
| Factory farming probably does cause externalities that
| aren't addressed. People could choose to buy from grocers
| who only source from smaller farms but there isn't as
| much interest in that due to price sensitivity.
|
| >...and since you can't support yourself on minimum wage
| I see that as her losing.
|
| Even in the case where you didn't tip, she likely would
| have preferred having the work than there not being a job
| available at that location.
| sk00tmer wrote:
| I have to agree with you for the most part, as a
| Canadian, I know our healthcare system is flawed, deep
| systemic problems, problems I'm not even familiar with.
| However, we don't have to deal with any of these price
| lists or copays or pre-approvals or debt (inside the
| scope of hospitalisation) I've even heard arguements that
| many of the pitfalls stem from privatised aspects. I'm a
| fairly capitalist person, but there is something awfully
| and fundamentally wrong about a society that monetizes
| well-being and health.
| OrvalWintermute wrote:
| > However, we don't have to deal with any of these price
| lists or copays or pre-approvals or debt (inside the
| scope of hospitalisation) I've even heard arguements that
| many of the pitfalls stem from privatised aspects
|
| Many of the current US medical problems
| (bureaucratization of medicine) actually evolved out of
| massive government regulation with debatable value. EMRs,
| ICD/coding, the bureacracu that eats up 25% of your
| doctor's day? It is mainly for insurance companies and
| Medicare/Medicaid.
|
| https://healthncare.info/history-healthcare-insurance-
| united...
|
| > I'm a fairly capitalist person, but there is something
| awfully and fundamentally wrong about a society that
| monetizes well-being and health
|
| All the medical providers
| (doctors/nurses/therapists/techs/PAs/etc) do not work for
| free, and there is a significant logistics and technology
| tail in providing medical services at huge scale.
|
| If you really want to go after waste in medicine ask the
| following questions:
|
| (1) How much are the nonclinical hospital mgmt &
| insurance executives paid?
|
| (2) What is the ratio of clinical to non-clinical
| personnel?
|
| (3) Why is the US subsidizing the vast majority of the
| medical research, and drug profits for the entire world?
|
| These are serious questions because, as my nearby
| regional hospital group was firing hundreds of nurses
| during COVID, their CEO was collecting millions.
| ipaddr wrote:
| Aren't insurance rates regulated meaning if they payout a
| smaller amount than expected the rates will go down next
| year?
| saalweachter wrote:
| Now; I think the "medical loss ratio" requirements were
| one of the most important features of the ACA.
|
| One of the worst offenders from the before-times was an
| insurance plan targeted at college students that had a
| _10%_ MLR.
| munk-a wrote:
| I wonder how MLRs interact with subsidies, backroom deals
| and manufacturer rebates - if an payer can inflate their
| MLR by double paying for a medication - but then they get
| a rebate back for half the cost they paid will MLR
| tracking catch that?
|
| Payers often get incentivized to promote certain drugs
| via manufacturer kickbacks and I wonder if this system is
| also used to run around MLR requirements.
| kristjansson wrote:
| To save those looking it up: medical loss ratio is the
| fraction of premiums an insurer spends on actual
| healthcare expenses. 10% means 90 cents of every dollar
| paid in premium goes to admin/profit/etc.
| [deleted]
| monocasa wrote:
| So that encourages greater payouts more or less synced
| with greater premiums in order to increase year over year
| real profits.
|
| And given that the payouts are very nearly a function of
| how hard the insurance company can negotiate, they can
| simply choose to call off the negotiations when they
| reach their target amount.
| joshAg wrote:
| Only to a degree because policies basically always have
| an upper limit on coverage.
|
| If the payouts are dropping because there's a massive
| reduction in claims, then there's a pretty decent chance
| that paying the policy maximum on each claim still won't
| be enough.
|
| Plus, profits don't come directly from the premiums
| anyway. They come from the investments the insurer makes
| with the premiums. So sure, they can try to convince
| policy holders to increase coverage which allows them to
| charge a higher premium, or they can work on their loss
| modeling and investment strategy to better predict their
| actual loss ratio (which means they can have less money
| in reserve and more money in investments) or get better
| returns on the investments. And those 2 are usually a
| better use of resources since increasing coverage means
| an individual conversation with each policy holder.
| That's a lot of human-hours compared to the modeling and
| investing.
| monocasa wrote:
| > So sure, they can try to convince policy holders to
| increase coverage which allows them to charge a higher
| premium
|
| Or they just stone wall and increase premiums anywhere
| they can until they hit targets. Like at a previous job I
| had at a 250 employee company where premiums went up
| $150/m one year because the previous year had two
| families had a kid get (very different kinds of) cancer
| out of the blue. You'd think that shopping around
| would've helped in that case, but the word got out
| somehow to the other insurance companies and they were
| giving us similar quotes.
|
| The power relationship is very very tilted in the
| insurance company's favor and they can more or less
| dictate terms.
| lotsofpulp wrote:
| >You'd think that shopping around would've helped in that
| case, but the word got out somehow to the other insurance
| companies and they were giving us similar quotes.
|
| Employers are welcome to purchase healthcare.gov plans
| that are not allowed to price based on pre existing
| conditions:
|
| https://www.healthcare.gov/how-plans-set-your-premiums/
|
| If an employer wants to self insure and restrict their
| risk pool to only their employees, then they have to pay
| for it.
| monocasa wrote:
| > Employers are welcome to purchase healthcare.gov plans
| that are not allowed to price based on pre existing
| conditions:
|
| Which are stupid expensive for anyone much above the
| poverty level.
|
| > If an employer wants to self insure and restrict their
| risk pool to only their employees, then they have to pay
| for it
|
| A 250 person company wasn't self insuring or restricting
| their risk pool to only their employees. They wouldn't be
| negotiating premiums with an insurance company if they
| were self insuring.
| lotsofpulp wrote:
| If they were not restricting their risk pool, then how
| would a couple kids with cancer affect the company's
| premiums? The costs would be distributed across a much
| larger population.
|
| When I was shopping around for health insurance for my
| businesses, the premiums were the same as what they would
| have been individually on healthcare.gov. Kaiser has a
| good report showing the costs are not that different
| based on firm size:
|
| https://www.kff.org/report-
| section/ehbs-2020-section-1-cost-...
|
| The cost of healthcare is pretty predictable, and spread
| over a sufficient population converges to the same
| numbers. Only option I can think of is people were
| thinking that the employer reduced their portion of
| healthcare they were subsidizing, and so people thought
| premiums were going up since the size of the portion they
| were expected to pay went up? Most people do not really
| know to look at box 12 code DD of their W-2 to know what
| is happening with their healthcare insurance premiums.
| monocasa wrote:
| Because the premiums even for the larger risk pool can be
| negotiated with the insurance company. And if you suck at
| negotiating (like our HR), then you can accept at face
| value the arguments the insurance company makes about how
| much you're costing them, and how they'll just drop you
| if you don't accept higher premiums.
|
| And I'm going to guess that your businesses had very,
| very few employees? To the point of not being worth
| negotiating with from the insurance company's
| perspective?
|
| And Kaiser isn't run like most insurance companies.
| lotsofpulp wrote:
| Kaiser is short for Kaiser Family Foundation, which
| compiles nice reports about healthcare in the US. Using
| their reports does not have anything to do with Kaiser
| the company. Although their insurance side is similar to
| any other health insurer.
|
| >And I'm going to guess that your businesses had very,
| very few employees? To the point of not being worth
| negotiating with from the insurance company's
| perspective?
|
| Yes, but that was my point about businesses being able to
| just buy the health insurance plans available on
| healthcare.gov. Earlier you mentioned the healthcare.gov
| plans were:
|
| >Which are stupid expensive for anyone much above the
| poverty level.
|
| But the data does not support that. Average annual
| employer sponsored insurance is $7,675 for single PPO
| coverage in 2019:
|
| https://www.kff.org/report-section/ehbs-2019-summary-of-
| find...
|
| And average lowest cost monthly gold premium on
| healthcare.gov is $516 ($6k annual) in 2019:
|
| https://www.kff.org/health-reform/state-
| indicator/average-ma...
|
| So employers can probably save money going to the
| healthcare.gov plans, albeit with higher out of pocket
| maximums probably. But at least a couple kids with cancer
| would not throw off the premiums.
| folkhack wrote:
| > Like at a previous job I had at a 250 employee company
| where premiums went up $150/m one year because the
| previous year had two families had a kid get (very
| different kinds of) cancer out of the blue.
|
| It's bad enough that I've heard office gossips complain
| about other employees leveraging their healthcare turning
| into higher premiums the year after. Like, as evil as
| complaining their coworker's kid got cancer.
|
| When employees go through big health events it's hard to
| keep it under wraps in a work environment... especially
| in this "race to the bottom" society we happen to live
| in. You can bang on about privacy all you want, but
| people talk.
|
| I guess I'm shocked it happened in an office of ~250 as
| I've always seen it happen at much smaller places.
| lotsofpulp wrote:
| >It's bad enough that I've heard office gossips complain
| about other employees leveraging their healthcare turning
| into higher premiums the year after. Like, as evil as
| complaining their coworker's kid got cancer.
|
| That is how it would have to work if the employer wants
| to restrict the risk pool to the company's employees.
| After all, money has to come from somewhere.
|
| But employers are welcome to participate in
| healthcare.gov plans where the risk pool is much larger
| (across the whole state), and where individuals in the
| company cannot be solely blamed for increases in
| healthcare costs:
|
| It's bad enough that I've heard office gossips complain
| about other employees leveraging their healthcare turning
| into higher premiums the year after. Like, as evil as
| complaining their coworker's kid got cancer.
| [deleted]
| nradov wrote:
| The Affordable Care Act (Obamacare) eliminated lifetime
| coverage limits. There are also limits of the minimum
| medical loss ratio.
|
| Unlike property and life insurers, medical insurers
| generate very little income from investments. Premium
| revenue comes in at about the same rate as claims are
| paid out. They don't have large reserves to invest. And
| most large employers are self insured anyway, so the
| "insurance" company just acts as a claims administrator.
| joshAg wrote:
| The parents in the thread don't specify medical
| insurance. They're talking about a moral hazard in all
| forms of insurance.
| Retric wrote:
| Only up to a point, they still accept or recheck claims
| arbitrarily to get closer to their targets. Worse they
| have incentives to decrease efficiency by increasing
| paperwork etc.
|
| Private medical insurance in the US is a horridly
| inefficient system. Separating the claims process from
| insurance companies hands might help, but their
| incentives are never going to line up with consumers.
| dllthomas wrote:
| > Worse they have incentives to decrease efficiency by
| increasing paperwork etc.
|
| Money spent on paperwork comes out of the same pile as
| profit. The MLR cap preserves incentive to reduce
| paperwork, wherever premiums and payouts sit.
| Retric wrote:
| Not internal paperwork. Think in terms of industry wide
| collusion not a single insurance company. If lobbing or
| an industry group can drive up healthcare costs via say
| paperwork or regulations then every health insurance
| company is "forced" to raise premiums and as the maximum
| profit per premium ratio is fixed that also increases the
| total possible industry wide profit.
|
| Of course insurance companies are also in competition so
| they have individual incentives to keep premiums cost
| competitive.
| lotsofpulp wrote:
| This is not remotely true.
| joshAg wrote:
| for admitted policies, usually yes. But it's not just
| that the rate for the next year goes down. Premium
| payments have to be refunded too.
| joshAg wrote:
| Payouts and premiums aren't where the money is in
| insurance. It's in the return on investments the insurer
| makes with the money they hold in trust. From an
| insurer's point of view, the best market isn't one with
| no payouts, but one where there is a highly predictable
| amount of payouts, because the better they can predict
| how much they need to payout, the more aggressive they
| can be with their investments.
|
| Yeah, there's a decent amount of regulation around
| payouts to protect the consumer, but it pales in
| comparison to the regulations around making sure that the
| insurer has enough liquid assets on hand, that the total
| valuation of their assets (ie investments) remains large
| enough, and that they're charging a minimum amount of
| premium for the risk that they're taking on.
| monocasa wrote:
| > It's in the return on investments the insurer makes
| with the money they hold in trust
|
| ...sourced from the premiums. When they pull in more
| premiums, they have more money to invest.
| joshAg wrote:
| No, it's sourced from the initial capitalization of the
| firm and then realized returns that are reinvested. You
| can't offer insurance until you're capitalized enough to
| handle claims on the same day the policy takes effect.
|
| Ideally the premiums will cover payouts and day-to-day
| business expenses, so the invested money can just keep
| being reinvested, hopefully into longer term and more
| aggressive investments. The premiums and payouts get
| rolled into underwriting profit/income. And that can
| eventually get rolled into new investments.
|
| Here, look at state farm for 2019[1].
|
| Their underwriting gain was $777 million on $65.2 billion
| in total premium. Their investment income was $5 billion
| with a net worth of over $100 billion, which is more than
| 6 times larger their underwriting premiums.
|
| Their profit ratio for underwriting is like 1.2% because
| they're not trying to maximize that profit. A large
| reason they're not trying to maximize it is that for
| admitted policies, there's usually an upper limit to how
| much aggregate premium can go to anything other than
| paying out claims (eg: [2] and [3]).
|
| So for an insurer, they don't want to set themselves up
| to depend on premiums to fund the investment arm because
| 1) there's an upper limit on how much aggregate premium
| can go towards anything other than claims 2) there's no
| limit on how much aggregate premium can go towards
| claims, 3) growing premium haphazardly can result in less
| money available for investing due to other regulations
| that limit risk and require a certain amount of liquidity
| for claims.
|
| [1]: https://newsroom.statefarm.com/2019-state-farm-
| financial-res... [2]: https://www.law.cornell.edu/regulat
| ions/california/10-CCR-Se... [3]:
| https://consumerfed.org/press_release/auto-insurers-
| reaped-n...
| monocasa wrote:
| The seed comes from initial investment, but if premiums
| weren't a major component of growth they'd just be an
| investment firm.
|
| They don't have control over investment returns for the
| most part, so premiums are the only avenue for growth
| that they can do something about.
| [deleted]
| jjoonathan wrote:
| Yes, in a well-regulated insurance market the winning
| business model isn't deceit. That's the point of the
| regulations.
|
| Deceit can take many forms, and I'd argue that
| undercapitalization is actually one of them. "There's a
| trap clause on page 23 of the telephone book contract" is
| only the simplest strategy an insurance company can use
| to lemon-drop. "We ask our customers to do an impossible
| information wrangling task and only review the paperwork
| if they get cancer, so that we have an excuse to drop
| them" is a slightly more evolved form. Loading up
| sacrificial business vehicles with risk and using
| bankruptcy to discharge obligations is the most advanced
| form of deceit-based insurance business models, because
| it provides plausible deniability. "We just tried to
| compete a bit too hard!" they can claim, even if they
| knew in their hearts exactly what they were doing: the
| age old practice of selling insurance that you had no
| intent of making good on.
|
| Fortunately, we have a long record of historical evil
| tricks to draw on when crafting legislation, because I
| absolutely stand by my claim that the natural incentives
| (the ones that happen without careful legislation) in the
| insurance industry are overwhelmingly bleak, both on an
| absolute scale and relative to other industries.
| joshAg wrote:
| I'm not saying it's not because of regulations. I'm
| saying it's not just the regulations on payouts and the
| regulations on payouts probably aren't even the most
| important, because all the regulation in the world around
| ensuring the insurer can't skip out on payouts will do
| nothing for "Oops we invested badly and have literally no
| money with which to pay your completely valid claim".
|
| The payouts regulations are still good and necessary
| because that's way better than requiring people to find
| out the hard way through shitty claims processes and
| denials and word-of-mouth reputation, but they're in no
| way sufficient.
| jjoonathan wrote:
| I'm not sure we disagree. We just allocate the benefit of
| the doubt differently.
|
| > "Oops we invested badly and have literally no money
| with which to pay your completely valid claim".
|
| It's 100% possible for this to be a genuine mistake. I'm
| sure that it happened as a genuine mistake more than
| once! However, it is also possible to do this on purpose:
| load up a business vehicle with increasing amounts of
| risk and extract as much of the premiums as one possibly
| can before it explodes. If this is done intentionally, it
| is exactly the same hustle as selling policies that one
| doesn't intend to make good on, it just uses a different
| mechanism to shirk the obligation.
|
| Every company that does it on purpose will say that it
| happened by mistake, of course, and just as I am certain
| that it has happened multiple times as a genuine mistake,
| I am certain that it has happened multiple times on
| purpose.
|
| Undercapitalization is the evolved form of the "sell a
| trash policy" hustle because it provides almost perfect
| plausible deniability. It makes sense that the greatest
| legislative effort would be spent heading it off.
| TeMPOraL wrote:
| > _From an insurer 's point of view, the best market
| isn't one with no payouts, but one where there is a
| highly predictable amount of payouts, because the better
| they can predict how much they need to payout, the more
| aggressive they can be with their investments._
|
| Isn't the latter a strict superset of the former? No
| payouts is an _easily predictable_ number. And for
| nonzero amount of payouts, the less those payouts sum to,
| the more money remains for continuous investing.
| joshAg wrote:
| No, they're not a superset. You can have events with a
| very low probability and very little variance, events
| with very low probability and very high probability,
| higher probability with low variance, and high
| probability with very high variance.
|
| Here's some random numbers,say for a hypothetical 100,000
| hypothetical year long policies low probability, low
| variance: E(total claims) := 20, V(total claims) := 1 low
| probability, high variance: E(total claims) := 20,
| V(total claims) := 20 higher probability, low variance:
| E(total claims) := 20,000, V(total claims) := 10 higer
| probability, high variance: E(total claims):= 20,000,
| V(total claims): 10,000
|
| Premiums don't usually make their way into investing for
| a bit. They're used to cover claims and then business
| overheads and then even dividends first. First they go to
| claims, because there's usually regulations to prevent
| price gouging that require insurers to refund premium if
| the ratio of aggregate premium : aggregate claims gets
| too high (the regulation is on a state by state basis in
| the US). Then any remainder goes to any other outlay
| first, so that the invested money can be/stay invested
| into longer term investments. Only if those outlays can
| be completely covered by the premium (and i'm skipping
| over a few things like regulations regarding various
| levels of liquidity for different risk levels and other
| stuff) then yeah it can make its way over to the actual
| investment fund. But in general the business model for
| insurers is that underwriting profit, limited as it is by
| regulations, is primarily used for actually running day
| to day operations and isn't a reliable source for being
| turned over to the investing side. The investing side is
| primarily using the initial capitalization of the insurer
| and the returns from earlier investments.
|
| One way of looking at insurance is that the insured is
| actually buying an option against the insured's
| capitalization with very limited exercise clauses, but
| the the insurer pays out exercised options with the money
| from other purchased options contracts.
| haliskerbas wrote:
| Reminds me when my dentist charged me $50 for a cup of
| fluoride (nothing too special about this fluoride).
|
| I asked why they said it would be covered. They said when
| they checked with insurance it says it's covered, but for
| my age or whatever it's not actually covered.
|
| So then I said why is it my fault that you gave me
| something you said was free but actually wasn't because
| your check wasn't thorough enough?
|
| They said they already spent it so someone has to pay...
|
| In the end I didn't pay for the fluoride after hours of
| argument.
|
| Next year at a different dentist, same situation. I learned
| my lesson and just paid for the damn fluoride. Land of the
| free, home of the brave!
| lotsofpulp wrote:
| The dentists peddle that nonsense because it is almost
| all profit for them. Insurance will not cover it because
| there is no strong evidence that it helps, assuming you
| are brushing your teeth regularly, have access to
| fluoridated drinking water, and otherwise have healthy
| eating habits.
| kube-system wrote:
| Just take all of the money you'd otherwise spend on
| dental care and put it into a savings account or FSA.
|
| I've never seen a dental insurance plan that actually
| makes financial sense. Most of them place significant
| limits on expensive and unlikely care, and cover routine
| care with little or no cost sharing. Insurance is a
| highly inefficient way to pay for expected expenses.
| lotsofpulp wrote:
| Dental insurance via employer is mostly just a way to pay
| for dental healthcare via pre tax dollars.
| kube-system wrote:
| And FSAs do that without the insurance company overhead.
| lotsofpulp wrote:
| Yes, the only downside I can think of is if you have an
| HSA (which anyone that can afford max out of pocket limit
| should), then you generally cannot have FSAs also unless
| they are Limited Purpose FSAs and then it gets too
| complicated for my tastes. I generally do not like the
| concept of FSAs period, being employer owned, and having
| to use up funds by the end of the year and all.
| kube-system wrote:
| Agreed. I only put money in an FSA that I know I am going
| to use. But for my routine cleanings/xrays/etc, this is
| pretty easy to calculate.
| knicholes wrote:
| I never pay for this.
|
| "No cavities again! Would you like a flouride rinse?"
| "Why would I do that? I have flouride in my mouth rinse
| and my tooth paste." "Well, ours is a higher
| concentration that I paint onto your teeth." "Didn't you
| say I had no cavities?" "Well, yeah." ".... so what I'm
| doing seems to be working without your rinse" "Well, it's
| only $16" "My flouride rinse has the exact same active
| ingredient as yours and costs $5 for an entire bottle."
| And it just goes on and on.
| hamburglar wrote:
| Yes, our medical/dental insurance industry has encouraged
| the attitude of "cost doesn't matter, because it's free
| to you (oh and besides, you can't put a price on your
| health, can you, you cheapskate?)" which just serves to
| constantly let prices grow out of control. This is an
| instrumental part of how our healthcare costs got so
| high. It also is why it's laughable to think of medical
| care as a free market: you can't even find out what
| things cost before you buy most of the time. Not to
| mention that when you are in need of care, you often
| don't have the luxury of shopping around.
|
| What we really need is for people to stop thinking of
| insurance as a big blanket you buy that reduces the price
| of things to zero. That's not what insurance is for.
| Insurance is supposed to be a system where you still pay
| for the cost of the good, but that buffers it for you so
| when you get an outlier cost, it doesn't break you. It
| doesn't make the costs of things go away. On average, you
| should end up paying a little more than the cost of your
| healthcare by purchasing it through an insurance plan. A
| high deductible plan does this: you actually pay the cost
| of all your healthcare up until a certain point out of
| pocket, and if you reach a certain amount (which is
| pretty high, but significantly less than the premiums on
| a low-deductible plan), the insurance takes over. This
| makes you actually aware of the prices of things and is
| healthy. Not to mention the insurance is a hell of a lot
| cheaper.
| ben0x539 wrote:
| I don't think consumers budgeting can realistically be
| the control on the growth of healthcare costs. For one
| thing, people's budgets vary too wildly.
|
| Healthcare should simply be "free", ie budgeted into the
| operation of a modern society, like infrastructure costs
| and education.
| wins32767 wrote:
| How effectively can you actually shop for medical care?
| Providers lobby against public measures of effectiveness
| so basically only payers have enough data to actually
| judge who is effective and people scream when their
| doctor choice gets restricted for any reason.
| weaksauce wrote:
| > Is there any reason why this kind of windfall shouldn't
| be illegal? I realize it isn't, but is sure seems like it
| should be.
|
| because our senators and congress critters are all on the
| buy for really cheap... it's not even hidden. something
| like medicare for all is the thing that _makes sense_ but
| has a hard time finding traction because the people that it
| will negatively impact have the means to buy those
| politicians out.
| [deleted]
| throwaway0a5e wrote:
| <deleted>
| folkhack wrote:
| There's police around hospitals constantly and if they get
| a whiff that you have a fake ID they're going to be talking
| to law enforcement sooner or later.
|
| Also this isn't going down to your corner liquor store and
| flashing your drivers license... that thing is going to get
| scanned etc.
|
| ---
|
| Actual protip: If you're uninsured and need care they
| legally can't turn you away at an ER. They have to provide
| the healthcare to get you stabilized regardless if they're
| going to be able to bill for it or not... which ironically
| this is a _big_ part of why the insured end up subsidizing
| the uninsured at the hospital.
|
| Also, if this ends up being you - don't sign anything until
| you're in the right mind to sign something. They're going
| to try to pin you to bill your ass off one way or another
| and if you're half way through a heart attack or something
| do not sign _anything_ until you can 100% understand what
| you 're legally agreeing to.
| throwaway23438 wrote:
| I've often wondered what would happen if you went to the
| ER, carried no identifying documents, and just refused to
| identify yourself. Just hope nobody recognizes you there.
|
| Giving a fake name is fraud, and people have been
| arrested for doing that at the ER. (Fuck America.) But I
| don't know that there's any legal obligation to give
| _any_ name at all. If you don 't give them a name, you're
| not lying to them, and oops, looks like they don't have a
| way to bill you. As you note, hospitals are legally
| required to provide emergency stabilization without
| regard to ability to pay.
|
| I suppose the hospital could try to call the police, but
| AFAIK the police cannot compel you to identify yourself
| without reasonable suspicion that you have committed a
| crime.
| texasbigdata wrote:
| I believe legally they have a duty to provide care.
| throwaway23438 wrote:
| Yes, that's my understanding. So wouldn't refusing to
| identify yourself be an effective way to avoid a bill,
| without the criminal exposure of giving a fake name or
| ID?
| kube-system wrote:
| People show up at hospitals _physically unable_ to
| identify theirselves all of the time.
|
| https://www.npr.org/sections/health-
| shots/2019/05/07/7207022...
|
| Hospitals that accept medicare do have a legal obligation
| to stabilize patients. But we're talking 'stabilize' as
| in 'you're not dying'. If you're alert and capable enough
| to be arguing with people and you're not a psych danger,
| you're likely stable enough to legally be thrown out on
| the street.
| throwaway23438 wrote:
| I'm aware of that. That's different from refusing to
| identify yourself to avoid paying money to the healthcare
| racket.
|
| The discussion here is whether there is a legal
| obligation to identify yourself. If there is such a
| requirement, it would apply to someone who is fully
| capacitated but refusing to identify themselves. It would
| not apply to someone who is unable to identify themselves
| due to incapacity, because such a person obviously lacks
| any criminal intent.
| kube-system wrote:
| There is no legal obligation for you to identify yourself
| to any businesses that I'm aware of. Most businesses will
| refuse you services if you refuse to cooperate in paying,
| to the extent that they are legally able to do so. I
| think you can expect that a hospital met with this
| scenario will complete their obligations under the EMTALA
| and nothing more.
| throwaway23438 wrote:
| Even with identification, healthcare systems usually will
| not do more than they're required to under EMTALA. The
| hospital will provide intensive care to the uninsured DKA
| patient, since they're obligated to do so under EMTALA,
| but they will not provide that patient the insulin and
| other care necessary to prevent them from needing ICU in
| the first place, since it's not yet an emergent
| condition.
|
| If there's no risk of criminal exposure, even insured
| people should start doing this. Hitting hospitals with
| uncompensated care under EMTALA is one of the few points
| of leverage we have to fight back against these
| murderers. Hospitals are, by and large, not innocent
| parties in this -- several hospital groups are even
| members of the Partnership for America's Health Care
| Future terrorist group, which bribes politicians to fight
| Medicare for All.
|
| It would bring me great pleasure to get to tell a
| hospital to go fuck themselves and to quit bribing
| politicians to fight M4A if they want to get paid next
| time.
| kube-system wrote:
| If I'm dying, I want the best care I can get. I'm not
| about to argue with someone trying to save my life to
| make a political point to an ER doctor who didn't have
| anything to do with it in the first place. And I'm
| certainly not about to risk my own health outcomes by
| withholding the insurance that I paid for to help me in
| that exact scenario.
| throwaway23438 wrote:
| Oh, I wouldn't be arguing with the ER doctor. I'd be
| arguing with the billing murderers, like the one that
| comes in to shake you down for money while in the ER bed.
| fidesomnes wrote:
| No, let's "fuck you," instead.
| [deleted]
| luxuryballs wrote:
| That last sentence would be a great opener to the explanation
| of what insurance is, it's not healthcare, insurance is
| something you don't want to have to use. Healthcare is just
| healthcare, you can buy it from all sorts of places in
| various forms without billing to insurance.
|
| Just like how car insurance is not a mechanic.
| jrochkind1 wrote:
| >> They have a column called "Uninsured cash price." These
| prices are <25% of the insurance "discount" prices
|
| > And this can really cause issues for people who are insured
| because if an insurance company decides not to cover
| something (very very common, even in-network) then the
| inflated price is what you end up getting billed for.
|
| That doesn't sound like an "inflated" price? 25% of what
| insurance companies are billed for?
|
| I'm confused. I'm not sure y'all are talking about the same
| things?
| wswope wrote:
| He's saying if you go in as an insured patient and get
| denied for a procedure by the insurance company after it's
| been performed, you'll get a bill from the hospital for the
| insurance-negotiated rate, not the uninsured cash pay rate.
| You can generally talk the billing department down to the
| cash pay rate, but that requires having a lot of meta-
| knowledge of how American healthcare works.
| jrochkind1 wrote:
| omg, I see what you mean. Confusing as heck.
| jweir wrote:
| Anytime I have a procedure, imaging, anything I ask for the out
| of pocket price. You can save a lot of money doing this
| especially imaging.
| m0ngr31 wrote:
| My local hospital offers a cash discount of nearly 50% if you
| pay at time of service.
| bazooka_penguin wrote:
| That sounds pretty unreasonable. Most people can barely stay
| on top of payments with a payment plan, let alone paying
| everything upfront
| phkahler wrote:
| That's why they're so eager to get the payment upfront that
| they'll give a heavy discount. Apparently a lot of people
| have trouble keeping up with their bills.
| Clubber wrote:
| Especially after a major traumatic event that requires an
| ER or hospital stay and especially if that bill is 5 or 6
| figures.
| toomuchtodo wrote:
| File a complaint with Health and Human Services [1]. It is
| clear they are not acting in good faith. Take snapshots of the
| URL with the Internet Archive for notarization [2].
|
| [1] https://www.cms.gov/hospital-price-transparency/contact-us
|
| [2] https://web.archive.org/save
| Darkharbourzz wrote:
| Thanks for posting this. I just looked to see if my local
| hospital had prices available. They have a webpage set up,
| but they give you a dummy link! Outrageous! I will absolutely
| be making a complaint.
|
| I'm also going to post a review online, since poor reviews
| seem to get attention from them.
| Someone1234 wrote:
| I actually might, the wording on this page:
|
| https://www.cms.gov/hospital-price-transparency
|
| Does say "provide clear, accessible pricing information"
| which I would argue this is not.
|
| edit: Filed a complaint.
| splistud wrote:
| Fantastic. In return I will review my locals and see what
| they report.
| toomuchtodo wrote:
| I genuinely appreciate that you took the time to do so.
|
| EDIT: Thank you all for your efforts.
| elihu wrote:
| It can go the other way too. Some hospitals will charge
| uninsured people much more than they would charge the insurance
| company for the same procedure.
| rhacker wrote:
| What's hilarious about that - is this:
|
| Instead of giving a hospital your insurance info, say "you
| don't know if you have it, the last one expired" - even if you
| have insurance they couldn't prove you did "know you had it".
|
| Then get the bill in the mail.
|
| Submit the bill to your insurance company.
|
| Bill gets paid.
|
| Hospital doesn't get to inflate.
| tobr wrote:
| Reminds me of that time I exported a bunch of strings to Excel
| for translation. Was very confused when I got surprisingly
| short translations back.
|
| Turns out the translator didn't know you could resize the rows,
| so they had only translated the first few words that happened
| to be visible in each cell.
| gameswithgo wrote:
| Excuse me. But fucking cunt asshole motherfuckers, we should be
| lining the people who are intentionally deceiving the public up
| against the wall, they are causing people to DIE.
| lostlogin wrote:
| Would a local news outlet publicise this?
| ed25519FUUU wrote:
| I would think hospitals like people paying the cash price?
| avs733 wrote:
| Things they would love more:
|
| Accepting the cash price after billing the person for the
| full price and writing off the difference.
| Someone1234 wrote:
| They make less that way. If they know you're insured they
| won't allow you to pay the cash price, only the much higher
| negotiated price.
| kindle-dev wrote:
| But someone told me insurance companies are bad and are
| stiffing those poor, struggling doctors and hospitals.
| bazooka_penguin wrote:
| Everyone says that. But it's pretty clear that healthcare
| services themselves just cost an obscene amount of money
| no matter who's paying.
| marcellus23 wrote:
| Just because hospitals are also evil doesn't mean
| insurance companies are not.
| jjoonathan wrote:
| Every head of the insurance/drug/provider dog points at
| the other two heads when somebody accuses it of being the
| problem.
| lotsofpulp wrote:
| Voters not wanting to pay for comprehensive care for
| everyone is a 4th head. The current system of healthcare
| is great for allocating different amounts of healthcare
| to different classes of people, so that it is great for
| 20 to 30% of people, okay for 20%, and not good for 50%,
| and that is why it persists.
|
| There is no reason Medicare should be restricted to those
| over 65, or why Medicaid is implemented differently (and
| reimburses providers more poorly than Medicare). Or even
| Tricare. We have at least 3 different taxpayer funded
| healthcare programs specifically so not everyone can get
| access to equal care, but so that various classes of
| people can get healthcare proportional to their political
| power (which usually scale with money, but also votes in
| the case of old people).
| long_time_gone wrote:
| ==We have at least 3 different taxpayer funded healthcare
| programs specifically so not everyone can get access to
| equal care==
|
| Add in CHIP and the VA (Tricare). We've taken every
| vulnerable part of society (older, poor people, poor
| children, injured veterans) and given them government-
| paid, universal healthcare. This is around 100 million
| people.
|
| Everyone left over is thrown into the private insurance
| pool. These people are typically working age population
| (18-60), making them both the richest and the healthiest.
| This is around 200 million people.
| lotsofpulp wrote:
| >given them government-paid, universal healthcare
|
| This is meaningless if the quality of healthcare is not
| the same. There are numerous hurdles placed for various
| different people to get the healthcare, effectively
| restricting access to healthcare itself.
| long_time_gone wrote:
| No doubt. I wasn't trying to comment on the quality or
| access, just a point on how we have "solved" the
| healthcare problem over time.
|
| Taxpayers cover the neediest, leaving the healthiest to
| for-profit insurers. The healthiest have no incentive to
| make sure the programs for the neediest actually work or
| are accessible.
| lotsofpulp wrote:
| Oh yes, I agree with you. I remember how pissed people
| were when ACA caused their premiums to go up, because
| they were now subsidizing everyone who used to simply not
| get healthcare.
| pessimizer wrote:
| > Voters not wanting to pay for comprehensive care for
| everyone is a 4th head.
|
| M4A is overwhelmingly popular, at points taking
| majorities of _Republicans._ Also, the US government
| already spends as much on healthcare as Britain and the
| NHS; US healthcare is just allowed to cost twice as much.
| lotsofpulp wrote:
| Maybe now, but it was not true in 2009/2010 when ACA was
| being hashed out. As I saw it, lots of people said they
| wanted everyone to get healthcare, but when the chips
| were down, there was lots of balking at costs.
| OrvalWintermute wrote:
| > There is no reason Medicare should be restricted to
| those over 65, or why Medicaid is implemented differently
| (and reimburses providers more poorly than Medicare). Or
| even Tricare. We have at least 3 different taxpayer
| funded healthcare programs specifically so not everyone
| can get access to equal care, but so that various classes
| of people can get healthcare proportional to their
| political power (which usually scale with money, but also
| votes in the case of old people).
|
| Medicare/Medicaid reimbursements are insufficient to
| support most medical practices. Tricare is for military &
| their families. Most active duty military are young &
| extremely healthy compared to the general population.
|
| Medicare/Medicaid combined are the largest single item on
| the federal budget. More importantly, they are still
| growing in costs because of an aging population, and are
| heading towards 30% overall of the federal budget [1]
|
| Tricare operates as an employment perk. Medicare has a
| cap on benefits, but is effectively mandatory for 65+,
| and medicaid operates as a payor of last resort, after
| folks have run out their lifetime benefits on medicare.
|
| However, an argument in favor of your suggestion is that
| the vast majority of medical resources are spent on the
| last 2 years of life, often for terminally ill patients
| with a ton of co-morbidities that are at death's door
| anyways. Most medical spending happens in the latter part
| of life [2]
|
| > 25% of Medicare's annual spending is used by the 5% of
| patients during the last 12 months of their lives [3]
|
| [1] https://www.americanprogress.org/issues/economy/repor
| ts/2010...
|
| [2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1361028/
|
| [3] https://www.acsh.org/news/2018/09/28/true-cost-end-
| life-medi...
| nradov wrote:
| Medicare reimbursement levels are sufficient to support
| most medical practices. They charge more because they
| can, not because they have to. If reimbursement levels
| are cut then they'll find ways to improve efficiency, and
| then cut salaries.
|
| Is there a reason that US doctors should get paid
| significantly more than their peers in other developed
| countries?
|
| https://www.medscape.com/slideshow/2019-international-
| compen...
| OrvalWintermute wrote:
| > Medicare reimbursement levels are sufficient to support
| most medical practices.
|
| Big Nope.
|
| Most practices have fairly fixed costs:
|
| Medical malpractice
|
| Facilities rent, or mortgage
|
| Front office
|
| IT & EMR
|
| Privileging/Credentialing
|
| Practice
|
| CME/required education
|
| The only highly variable cost is physician compensation,
| and considering the limited availability, this will
| merely cause the retirements and limited access to
| specialists.
|
| Perhaps you have some evidence to support your
| extraordinary claim?
|
| I'll provide evidence to the contrary, based on Hospitals
| _and_ practices refusing to accepting Medicaid [1]
| patients, or, not accepting /limiting medicare
| patients[2], [3], [4]
|
| The simple fact is, there is a limited supply of
| physicians, and many of them don't want to practice the
| higher volume, 5 minutes per patient, 5 minutes for notes
| x 12 hours a day type of practice. Not only is the higher
| volume more dangerous for the patient, it is also more
| risky for the medical provider, both in terms of quality
| of life, and also, the risk of an error, or inadequate
| information exchange.
|
| [1] https://www.reliasmedia.com/articles/147019-when-
| hospitals-r...
|
| [2] https://www.investopedia.com/articles/personal-
| finance/10021...
|
| [3] https://www.verywellhealth.com/doctors-accept-
| medicare-insur...
|
| [4] https://www.hlc.org/news/more-physicians-no-longer-
| seeing-me...
| OrvalWintermute wrote:
| > They make less that way. If they know you're insured they
| won't allow you to pay the cash price, only the much higher
| negotiated price.
|
| This is not correct for all practices
|
| My wife's practice (of plastic surgeons medical providers
| only in a reconstructive practice 75%, cosmetic 25%,
| attempting to be in-network with every insurer, with
| administrative front-office doubling as billing, and
| dedicated personnel for resubmits) vastly prefer cash
| paying because they get the money right then, and they
| don't have to haggle with insurers around things like pre-
| authorization, billing, etc. Insurers regularly make
| physicians go through the ringer to get an pre-
| authorization for a vital surgery. Even worse, insurers
| will ask for a "peer to peer" and then have some
| underqualified medical provider understand what a board
| certified surgeon is doing, based on a complex diagnosis,
| and not understanding the actual surgeries or procedures
| involved. Insurers will forget pre-auths, and then reject
| billing, and they have a whole bunch of shady practices
| around, even with in-network practices for cancer cases.
|
| So much of this price transparency stuff is a _giant
| racket_ because it helps insurers, and not the actual
| medical doctors, PAs, NPs and other medical providers.
| However, it is medical insurers & Payors which are driving
| all the paperwork (Horrible EMRs, ICD codes, pre-auth,
| auths, etc) along with growing the tsunami of
| administrative personnel)
|
| Insurers try to use being out-of-network to reject medical
| bills, so they use it as a weapon vs practices/hospitals,
| very effectively unless it is an emergent case (medical
| emergency).
|
| What is completely missing from this conversation is who
| this benefits, who this harms, and how insurers exploit the
| status quo.
|
| Cash paying customers should always be the cheapest option,
| since there is little overhead for them.
| intrasight wrote:
| There is a loophole in ACA specifically for this. A
| loophole that you can drive 20% of all Americans through
| (That's roughly the percent I've heard).
|
| https://www.nytimes.com/2020/01/02/health/christian-
| health-c...
|
| https://www.nytimes.com/2016/12/10/opinion/sunday/should-
| i-l...
| mullingitover wrote:
| > These prices are <25% of the insurance "discount" prices
|
| There are some clever insurance companies whose entire model is
| "tell the hospital you don't have insurance, get the cash
| price, pay it with this debit card we give you."
| derwiki wrote:
| Is it illegal to state you don't have insurance when you do?
| Or is this product not considered Insurance in the legal
| sense?
| scohesc wrote:
| They could be running as a "health spending account" where
| you can spend the money on whatever you want provided it's
| health-related. You don't technically have "insurance" but
| you're insured.
| travoc wrote:
| Health care consumers are absolutely free to pay providers
| directly even if they carry insurance coverage.
| toomuchtodo wrote:
| It's not insurance. They're "fixed indemnity plans."
| Sidecar Health is the one I'm familiar with.
|
| https://www.brookings.edu/blog/usc-brookings-schaeffer-on-
| he... (Fixed indemnity health coverage is a problematic
| form of "junk insurance")
| Y_Y wrote:
| I do this. Once my insurance company got upset that my
| procedure was so expensive and rang the hospital. The
| hospital immediately tripled the price. The insurance
| became even more upset and asked me to fix it. Still much
| cheaper than the equivalent procedure in the USA.
|
| It's not illegal here, but in any case nobody asks, I just
| tell them I'm paying cash.
| mullingitover wrote:
| I don't think it is. Sidecar Health is doing just fine on
| this model[1]
|
| It's pretty perverse that you, an insured person, would
| have to _lie about having insurance_ because the provider
| would charge you _more_ for being insured.
|
| [1] https://cost.sidecarhealth.com
| stonemetal12 wrote:
| The same goes for pharmacies. Walmart advertises $4
| generics. If your insurance has a $25 drug co-pay, then
| they will charge you the full $25.
| rpmisms wrote:
| Not technically "insurance", these are cost-sharing
| companies. Often religious due to Obama's brilliance.
| loeg wrote:
| They are required to have some shared religious belief to
| be exempt from the ACA.
| lotsofpulp wrote:
| Is there evidence that Obama wanted those religious
| exemptions and bullshit cost sharing plans? I would be
| willing to bet that was a concession to other politicians
| in Congress in order to get ACA passed.
| [deleted]
| rpmisms wrote:
| I'm thankful the concession was made. The lower price of
| cost-sharing made it possible for my parents to keep
| eating while providing for the family.
| rconti wrote:
| That's great until the church decides your parents are
| sinners and refuse to cover anything, and have no
| consequences for stealing their money.
| rpmisms wrote:
| They're not church-run organizations. This is
| reductionist, inaccurate, and I would go so far as to say
| bigoted.
| good8675309 wrote:
| People voluntarily join health sharing groups. They are
| run by non-profits, some of which have no religious
| affiliation.
| nickff wrote:
| The parent comment never said anything about President
| Obama's desires regarding the Affordable Care Act, just
| that his 'brilliance' resulted in this outcome.
| loeg wrote:
| You're probably thinking of "healthcare ministries," which
| are not insurance (they're scams).
| hartleybrody wrote:
| > (they're scams).
|
| citation or story?
| 0xcde4c3db wrote:
| https://www.buzzfeednews.com/article/lauraturner/christia
| n-h...
|
| They're not inherently scams, but a major reason that the
| "premiums" are lower is that they have hardly any legal
| mandate to actually provide anything, which comes as a
| surprise to some members who are denied reimbursement.
| Their authority to deny "coverage" (scare quotes because
| that's not, technically, what they provide) is huge. In
| particular, HCSMs frequently deny reimbursement on the
| basis of conservative religious morality. Got an STD
| while unmarried, or cheating on your spouse, or just in
| an open marriage? You can't ask your good Christian
| neighbors to pay for that. Drug addiction or mental
| illness? The cure is more Jesus. Abortion? Not even to
| save your life. You get the idea.
| good8675309 wrote:
| If you agree to a contract and then break the terms of
| the contract why would you be surprised when things
| aren't covered? It's the same thing with insurance
| companies. Also, many of these examples are broad
| generalizations that may apply to some but not all of the
| health sharing groups out there.
| rconti wrote:
| Here's a good start.
|
| https://openargs.com/oa497-christian-health-sharing-is-a-
| sca...
| good8675309 wrote:
| I think instead of using a blanket statement and calling
| them all scams, the OP should have said that some are
| scams. That goes for pretty much any service out there.
| Here's a site with over 900 reviews of different health
| sharing communities. Some there are clearly scams by the
| terrible reviews.
|
| https://healthsharingreviews.com/
| loeg wrote:
| > some [healthcare ministries] are scams. That goes for
| pretty much any service out there.
|
| Not really? Which of the highly regulated healthcare
| insurers do you feel are scams?
| monocularvision wrote:
| I personally know several families that are a part of these
| co-ops and they have had incredibly expensive things fully
| paid for. What makes you call them a scam?
| good8675309 wrote:
| Scams? They paid for my $6000 colonoscopy which caught
| early cancer, my daughters stitches, my wife's allergy
| specialist, my son's rocky mountain spotted fever, etc.
| etc. $500/mo for our family of 5 and we've been on it for
| nearly 10 years. But yes, please tell me more how this
| service that is way cheaper than insurance, is a community
| of people helping each other, and covers way more than
| insurance, is a scam.
| lowkey_ wrote:
| Can I ask what service you use? I'd be interested in
| checking it out.
| good8675309 wrote:
| Sure, I use Samaritan Ministries. I've tried other health
| sharing groups but Samaritan has been the best
| experience. They also have the best tech platform with
| the best user experience that I've seen. Samaritan is for
| christians but there are other health sharing groups that
| don't have that requirement.
| DaveExeter wrote:
| > $6000 colonoscopy
|
| Six grand to shove a camera up your butt? That's the real
| scam!
| svmegatron wrote:
| Can you elaborate on this? My gut agrees with you 100%, but
| I can't puzzle it out.
| rhacker wrote:
| No, this technique works with plain old insurance companies
| too. It's just that no one does it because they mistakenly
| give the hospital their insurance info - because, guess
| why? They ASK.
|
| Also, healthcare sharing ministries are not scams. However
| they are simply not guaranteeing payment. It sounds like
| the truth of it is that the "guarantee" of payment is what
| makes traditional insurance expensive. Is that worth it? I
| think that's up to each individual.
| michael_j_ward wrote:
| Please provide an example or two.
| nums wrote:
| I studied this years ago for years. My summary:
|
| - a mandated MLR of 85% means the insurance companies have zero
| incentive to reduce the cost of items. In fact, their toplines
| and real (non%) profits increase as healthcare gets more
| expensive.
|
| - industry profitability for insurance companies is around 3%.
| So, their overhead is around 15%-3% = 12%. They have an incentive
| to do their job cheaper. This pales in comparison to the 85%
| cogs.
|
| - the small company cfo (me) has negative incentive to get
| involved in my employees' healthcare decisions. In fact, even
| being aware of cancer, pregnancy, etc. can be used against
| management in an employee lawsuit. No thanks. We just accept the
| situation and pay the bill.
|
| - huge companies that can afford to self-insure can do it as they
| can firewall healthcare information from employment decision
| makers.
|
| So, who in this system is going for cheaper healthcare:
|
| - employees ... no
|
| - insurance companies .. no
|
| - healthcare providers ... no
|
| - business paying the bills ... no
|
| This bullshit billing structure is the tip of the iceberg. We
| have no freemarket incentives to keep down the cost of healthcare
| (i.e., carveout for high deductible insurance plans). Why would
| we expect otherwise?
| noelsusman wrote:
| I've worked in healthcare my whole career and you hit the nail
| on the head. Costs keep going up because nobody involved in
| healthcare has an incentive to make it cheaper, including the
| patients. We've designed a system that is doomed to fail and
| nothing short of tearing it down will fix it.
| flowerlad wrote:
| The solution is to make the consumer participate in driving
| costs down. One employer I know of has an excellent solution to
| the problem: Make employees pay 100% of the bill up to a
| certain amount, such as $6000. That's a large amount, but the
| employer then contributes a large amount to your Health Savings
| Account (HSA), such as $4000. This amount is for you to keep
| regardless of whether you have any health bills or not. (This
| money can be used for medical expenses only, but can be used
| any time, including after retirement). So the maximum you will
| spend out of pocket per year is $2000. How does this encourage
| the consumer to scrutinize and control medical expenditure?
| Because the first $6000 of medical spending in a year is "your
| money". This is money you'd be able to keep in your HSA if you
| didn't have any medical expenses. This gives the consumer a
| strong incentive to reduce costs, question charges, avoid
| unnecessary services, and so on.
| r0m4n0 wrote:
| Seeing the price range you pay is interesting, but I'm not sure
| what we are supposed to do with it.
|
| My wife had her prenatal anatomy scan a few months ago at
| Stanford medical, $11000 for a 1 hour ultrasound. I personally
| was on the hook for around $500 and insurance paid $10500.
|
| End of the day, what say do we have as consumers? How did the
| insurance company negotiate a rate of $11,000? Does the insurance
| company really care when every year they can just increase
| premiums and shrug and go "costs are going up! sorry!"
|
| It feels a lot like a pyramid scheme, at some point the gravy
| train has to stop
| cmollis wrote:
| healthcare insurance is the best example of a state-sponsored
| scam I've ever seen.. and it just continues unabated. I can
| guarantee that almost no one involved in that transaction
| actually knows what the per-unit cost for a 1 hour ultrasound
| actually is.. and when I say 'cost', I mean how it costs the
| hospital. Health insurers, hospitals, doctors are so awash in
| money they probably can't believe they're still getting away
| with it after all this time. Just look at all of the new
| hospitals and care facilities that are getting built. You don't
| do that if you're 'squeaking by'.. Hospital lobby is full of
| shit. You can probably trace all of this back to the HMO model
| where insurers began to add a lot of distance between the
| caregivers (i.e. doctors, hospitals, etc) and the patients.
| Like wall street did (with basically every financial
| instrument), they add layer upon layer to the cost chain, which
| adds an equivalent number of money-takers, to the value
| proposition. Insurance companies amortize the total cost across
| their subscriber base and 'poof', you've got our ever
| increasing health premiums. Just ridiculous and so obvious..
| but since they're 'doctors' and 'care givers', we automatically
| just assume they're not motivated by profit and therefore
| beyond reproach...um, wrong.
| GordonS wrote:
| Holy shit, that's just insane!
|
| Here in the UK we paid for a prenatal scan and NIPT a few years
| ago (this was in addition to free NHS scans at our local
| hospital), and IIRC it was PS200!
| itisit wrote:
| The insurance most definitely did not pay $11,000 USD. They
| paid a percentage of an adjusted figure, and the balance was
| passed on to you. Billing and payment amounts usually differ by
| an order of magnitude.
| r0m4n0 wrote:
| Oh yea they paid it. Negotiation for rates happens before you
| pay coinsurance. I've called them and discussed it all. They
| send a $10000 check.
|
| Odd part was in this case, we had a follow up ultrasound for
| another $2500 for a second hour after they "saw something
| odd" and it turned out to be nothing. Second hour had billing
| codes that were 75% less for some reason.
|
| https://imgur.com/a/Ffmt8YT
| itisit wrote:
| Wow, that's an absurd disbursement, even if the procedure
| might have been done out-of-network. Glad everything turned
| out okay. The administrator should have taken you out to
| celebrate. :)
| kwere wrote:
| So deducibiles are a sham?
| jonathan-adly wrote:
| I am one of the people responsible for making these lists. The
| fact that the general public as well as journalists think this
| data is accurate in anyway is really funny. This an exercise of
| futility that only increases the overall cost and provides job
| security for me :)
|
| No one working in a hospital knows how much do we acquire things
| for, or how much we get paid for doing things in advance. And
| only like 8 people can tell you that information 3 months after
| the fact.
|
| Take the simple exercise of figuring out cost/revenue of an
| aspirin administration.
|
| Cost depends on: 1. Are you an outpatient/Obsveration v.
| inpatient v. ED? 2. Are you on Medicaid? 3. Is the hospital a
| part of GPO organization or not? 4. Is contractual obligations of
| GPO includes/excludes Aspirin?
|
| Reimbursement depends on: 1. Insurance 2. Group which you are
| under the insurance from 3. Contract language whether its a
| fee/service or bundled 4. Is the visit covered or not 5. how the
| visit/procedure was coded (most important and opaque factor)
|
| Everybody in the know, knows that these lists are a joke, but no
| one can prove it.
| clavalle wrote:
| >And only like 8 people can tell you that information 3 months
| after the fact.
|
| It's like that in every large organization. But it turns out
| businesses are pretty good at tracking costs, no matter how
| complex.
|
| Besides, the specifics of any single case don't matter all that
| much. The variation can be smoothed out given enough data and a
| few common points of comparison.
|
| But all of this is asking the wrong question...not 'how much
| does this cost now?' which is hopelessly mired in historical
| cruft but 'how much would this cost if done efficiently?'.
|
| I wonder if the VA has open books...if not, they should.
| garettmd wrote:
| I think the issue here is that the system that has been setup
| is so dysfunctional that there is some validity to the phrase
| "the cost is unknowable".
|
| But prior to this regulation, it was extremely difficult to
| even ascertain just how dysfunctional it all was. Putting it
| out in the open means more accountability for providers and
| insurers. Which in due time means more regulation :)
|
| Which is how it goes when an industry misbehaves for so long.
| Eventually the public will get fed up, and demand that changes
| be made. This is just one step on that journey.
| karmelapple wrote:
| Exactly this, though I'd like to point out that word
| "misbehaves."
|
| Many people may not see the medical cost world as misbehaving
| at all. It sounds like healthcare companies, from drug
| manufacturers to hospitals, are charging what the market will
| bare.
|
| The inelasticity of the products and services for sale are
| what allows this market to become so out of whack. I don't
| need an iPad that badly, but I do need to have these drugs to
| have a good quality of life.
|
| I'm glad we're taking these steps on the journey of making
| costs more transparent and understandable. And perhaps
| putting into law what we the people think is a reasonable
| approach to charging for life-saving treatments, rather than
| "whatever the company can get away with."
| garettmd wrote:
| I see what you're saying, but much of the factors driving
| the "misbehavior" is due to companies being in-cahoots with
| each other on creating convoluted pricing schemes,
| kickbacks with various parties, and muscling through
| legislation that favors healthcare providers and insurers,
| to the detriment of patients.
|
| It's true that this can all be explained in economic terms,
| but it's true in the same sense that the behavior of
| warlords can be described by economics.
| earksiinni wrote:
| > Take the simple exercise of figuring out cost/revenue of an
| aspirin administration. [...]
|
| In your opinion, is this something that could be exhaustively
| modeled in software? What would the bottlenecks be? I'm
| guessing probably the biggest is the fact that the necessary
| data isn't digitized, or if it is, it's not easily accessible.
| colejohnson66 wrote:
| I'd've assumed that it's all done by software that takes into
| account all the factors, but I wouldn't be surprised if it's
| a step-by-step guide in a physical book. (Hospitals are
| horribly outdated with technology)
| jonathan-adly wrote:
| Yes. It could be. The bottleneck is selling it. Healthcare
| has lots of problems that can be solved with software. The
| bottleneck is always making a business case and selling to
| hospitals which is a nightmare.
|
| So long as a shitty excel sheet with inaccurate data fulfills
| the regulatory requirement, you will find a lot of trouble
| getting people to pay money for it.
| earksiinni wrote:
| Alas, this makes sense.
| jonahbenton wrote:
| Pricing in general for any non commodity is the same kind of
| statistical joke.
|
| That said, these price lists are an attempt to turn healthcare
| service delivery into commodities. Transparency, yes, but the
| lie is that healthcare is a market.
|
| The alternative is nationalized care where all sorts of
| financial flows that now are optimized for profits, are so
| optimized no longer.
|
| Most people living under and working for a nationalized system
| tend to like it. Most who live under or work for a commodity
| system tend not to, except for those positioned to receive
| profit flows.
| satronaut wrote:
| You're in charge of literally saving lives but you can't handle
| something as standard as cost estimation? How can you joke
| about that? Figuring out the cost to the hospital in terms of
| materials and labor should be standard.
|
| Example, an x-ray. You know you need to pay an x-ray tech
| X$/Hour and after doing 1,000's of x-rays, a hospital should
| have it down that somebody with a broken leg will require N
| hours (maybe .5, maybe 1.5) to setup and take the x-ray. x-ray
| film costs HAVE to be known. the x-ray machine life time and
| number of shots should be known. Then do something like a 30%
| surcharge for admin fees and boom, x-ray cost.
|
| Every other industry estimates this way, what makes a hospital
| different?
| jonathan-adly wrote:
| Because the broken leg could be a gun shot wound, or an
| alcoholic who fell down and now is withdrawing, or a
| geriatric patients who is abused at home or a person who fell
| due to side effects of drugs with alternatives, or a cancer
| patient with bone metastases.
|
| No one gets an x-ray for a broken leg then leaves with their
| foot broken. Even assuming that you are just trying to figure
| out the cost of an x-ray - there is a radiologist involved
| (unless you want to read it the x-ray on your own) and how
| they bill is a whole total beast!
| njovin wrote:
| I'm not following why any of that matters to the cost of an
| x-ray. If there's a gunshot wound and there needs to be a
| nurse attending to the patient while the x-ray is being
| taken, the nurse is an extra cost, separate from the x-ray
| and the x-ray tech. The cost of the x-ray itself shouldn't
| change.
| satronaut wrote:
| I'm talking about the x-ray, nothing more and nothing less.
| If they have a broken foot and need a cast, the cast should
| be an estimatable line item based on where it's broken,
| age/gender/size of the patient, and materials used. If a
| doctor has put a cast on 1,000 broken feet on men aged
| 12-16, they should have a very good idea of the material
| and time it will take and the number of nurses or whatever
| else they need to put it on.
| somethingAlex wrote:
| But we are just talking about an x ray here. Estimating the
| price of a radiologist per hour is not hard.
|
| It shouldn't be this difficult to price x rays at a per
| hour or per shot basis.
|
| Pretty much every industry has variability in their jobs.
| Sometimes they eat some money and sometimes they make more
| based on what actually happens during the job fulfillment.
|
| No one expects (or should expect) hospitals to literally
| know the amount of parts and labor for every single x ray
| they could perform. However, like literally every other
| business, they should know rates and tiers such that on
| average they make money. Then, disclose that.
| silverlake wrote:
| To be fair Boeing doesn't know how much an airplane cost.
| satronaut wrote:
| There's R&D, and then there's the actual manufacturing.
| Sure, prices go down after a while, but you can track costs
| accordingly.
|
| If you know (because you have blue prints) that the
| materials will cost 1,000,000 to build the plane (because
| your suppliers gave your price quotes), you can have a very
| good idea of what that plane will cost before putting it on
| the assembly line.
| merpnderp wrote:
| You forget that the x-ray is propping up about 50 admin job
| positions that don't directly generate revenue. The army of
| compliance, insurance, billing, etc etc etc employees have to
| get paid somehow.
|
| But hopefully this price transparency helps us ask the
| question of why does an x-ray have to pay for a ton of
| positions which have nothing to do with x-rays, and how do we
| correct this situation.
| satronaut wrote:
| You could say the same about any other service work. If I
| have the internet guy come out there's probably 50 admin
| job positions that bill for that time too. Internally they
| bill the installation department. Hospitals are just
| complaining to make it seem more complicated than it
| actually is.
| sushid wrote:
| I think you made the biggest argument for requiring these lists
| in the first place.
|
| For your simple exercise, it seems like we need to have that
| breakdown for those four different factors (and have that
| explicitly listed). Then we can figure out why the cost for a
| $0.22 jumps to $20 for those with insurance but $12 when paying
| cash. I agree it probably is a huge plus for you and your job
| security. :)
| tibbon wrote:
| Can you say more about why the information process isn't
| automated, allowing for easier and faster determination of
| these things?
|
| Doing it manually seems rife for error and to be awful toil
| gwright wrote:
| I think the point of making the lists public is to provide
| information that can lead to iterative improvements. I'm not
| sure it will do that but I'm a bit more confident that it is a
| necessary first step.
| minsc__and__boo wrote:
| I thought the lists were a red herring for the problems with
| privatized healthcare - i.e. look at how complicated pricing
| is, not how it is being complicated by for-profit middlemen.
| elliekelly wrote:
| One interesting aspect of the No Surprises Act regulations
| that would seem to support your claim is the three hour
| required waiting period for non-emergency same-day
| procedures. The waiting period is ostensibly to prevent
| patients from feeling rushed or pressured into agreeing the
| price but the "long wait" boogeyman is another common red
| herring in the healthcare discussion and the three-hour
| wait seems unnecessary. The wait applies only in non-
| emergency situations so logic would follow that if the
| quoted price were too high the patient could leave.
| MetaWhirledPeas wrote:
| > Reimbursement depends on: 1. Insurance 2. Group which you are
| under the insurance from 3. Contract language whether its a
| fee/service or bundled 4. Is the visit covered or not 5. how
| the visit/procedure was coded (most important and opaque
| factor)
|
| But this list doesn't care why the price was charged. It only
| needs to know, bottom line, what amount of money changed hands
| for the procedure?
| jimbokun wrote:
| > The fact that the general public as well as journalists think
| this data is accurate in anyway is really funny.
|
| If they are inaccurate, these hospitals should be sued into
| oblivion and replaced by trustworthy, competent organizations.
|
| > Cost depends on: 1. Are you an outpatient/Obsveration v.
| inpatient v. ED? 2. Are you on Medicaid? 3. Is the hospital a
| part of GPO organization or not? 4. Is contractual obligations
| of GPO includes/excludes Aspirin?
|
| > Reimbursement depends on: 1. Insurance 2. Group which you are
| under the insurance from 3. Contract language whether its a
| fee/service or bundled 4. Is the visit covered or not 5. how
| the visit/procedure was coded (most important and opaque
| factor)
|
| Your convoluted process should not be the patient's problem.
|
| Write an app that allows the user to input their provider and
| group, and search for the procedure to get a price.
| dougmwne wrote:
| At this point, I think your colleagues' nihilistic humor is
| totally lost on the American Public. Your flippancy is a strong
| argument for legislative reforms of the healthcare industry.
| someguydave wrote:
| if most patients were paying cash with no insurance such that
| hospitals had to compete on price all of these items would
| somehow become clear
| kurthr wrote:
| That neither the people prescribing/providing the product, nor
| the customers/insurers can ever know the price before they are
| billed, shows that this is not a market, or certainly not
| anything like a free market.
|
| The real scam is that the health insurers have convinced people
| they "fight for lower prices", when in fact they collectively
| profit from price hikes and the annual marginal increases fuel
| their growth as well.
| phkahler wrote:
| >> Cost depends on: 1. Are you an outpatient/Obsveration v.
| inpatient v. ED? 2. Are you on Medicaid? 3. Is the hospital a
| part of GPO organization or not? 4. Is contractual obligations
| of GPO includes/excludes Aspirin?
|
| Those considerations aren't part of what anyone calls cost. How
| much does the hospital pay for aspirin? How much do they pay
| someone to administer it to a patient? That's cost. If it's
| very complicated to determine what the patient or their
| insurance pays, well that's part of the problem.
| garettmd wrote:
| This. It's telling that people working inside this system
| operate on a totally different set of rules for how to
| determine basic things like the cost of some input.
| throwthere wrote:
| You're making the reasonable-sounding (but incorrect)
| assumption that the cost to the hospital of a drugs is the
| same for every patient. It's telling how people on the
| outside have no idea how complex the system is, as if
| there's one simple way to cost an item (hell, there's not
| even one simple way to cost an item with GAAP accounting
| for a widget). These lists are kind of worthless in the
| current iteration, but they'll hopefully get better with
| more targeted intervention.
| garettmd wrote:
| How does the cost of a drug change based on who is
| consuming it? That's like saying the cost of a loaf of
| bread changes based on who is buying it.
|
| The _price you charge_ for the bread might change, but
| the _cost_ is the same regardless of who is purchasing
| it. There 's a difference between varying costs of an
| item based on accounting methods, versus varying costs of
| an item due to who is buying it. There seems to be huge
| disconnect here between people working in healthcare, and
| pretty much everyone else.
| throwthere wrote:
| The hospital's drug cost is the price the distributor
| charges it. That price varies for each individual
| patient. It's turtles all the way down.
| thesimon wrote:
| Why does the distributor know the identity of the
| patient?
| 6gvONxR4sf7o wrote:
| That doesn't change the question though. It just changes
| who it's posed to.
| jimbokun wrote:
| That needs to be made illegal tomorrow.
|
| Heck, sounds like there could be a Civil Rights Act case,
| if prices impact people differently based on race or sex
| or other protected class.
| dougmwne wrote:
| This reads like straight up corruption and extortion.
| There could be no other reason to do this than to milk as
| much money as possible out of people who have no
| alternative.
|
| You should absolutely be testifying before Congress, not
| before HN.
| learc83 wrote:
| This is exactly what happens when a monopoly produces
| extremely price inelastic goods. If it's not illegal, the
| monopoly will attempt to charge each customer as much as
| they can afford.
| karmelapple wrote:
| I wouldn't call it worthless at all, because of the rest
| of your last sentence. It provides a starting point.
|
| We need to start setting the expectation of transparency
| for some small subset of info to get further
| transparency. Change takes time, as much as we'd like it
| to drastically improve overnight for real life and death
| situations like medical prices.
| callmeal wrote:
| >You're making the reasonable-sounding (but incorrect)
| assumption that the cost to the hospital of a drugs is
| the same for every patient.
|
| Why shouldn't it be? How hard is it for a hospital to
| project their annual aspirin/paracetamol/? usage and
| budget for it?
| mwerd wrote:
| Easy.
|
| Now try it at a rural critical access hospital for
| rattlesnake antivenom with a short shelf life, so it
| usually expires unused. They are required by law to stock
| it or they cannot have their emergency room open.
| Estimate the revenue generated from treating the one
| patient who needs it every other year, and by the way,
| you have 9 contracted payers with different rates and you
| don't know which one, if any, the patient will have.
| Rinse and repeat for every other drug required to provide
| "critical care". Maybe layer on infusion of exotic
| chemotherapy drugs or monoclonal antibodies to treat a
| new pandemic virus.
|
| It's not easy.
| jonathan-adly wrote:
| The cost of the aspirin depends on these things lol. Look up
| 340B.
|
| There is a drug called Oncaspar. It's >$16,000 for one
| patient, and 5 cents for another (acquisition cost). Same
| drug, widely different acquisition cost.
| EForEndeavour wrote:
| The more I read about US healthcare, the more confused I am
| about how it's grown _this_ perverse for this long. Prices
| are hidden (until the government forces them into the
| open), but they 're badly distorted anyway by perverse
| incentives, which all seem to ladder up to the root cause
| of providing healthcare for profit.
| Notanothertoo wrote:
| Thank the private free market.. /s it goes this way
| because the government involvement. If anyone else in
| another industry attempted the same thing they would be
| sued for fraud.
| danShumway wrote:
| When two pills coming from the same company are being made
| at the same time on the same machines, then they both
| _cost_ the same. It 's pretty obvious that the patient
| status changes nothing about that. However, the hospital's
| acquisition cost is variable because you're further down
| the supply chain and you're seeing the exact same kinds of
| arbitrary behind-the-scenes price swings that this article
| is talking about.
|
| It sounds like within the industry, hospitals are facing
| the same problems as consumers, and they need more price
| transparency from _their_ suppliers as well. Hopefully
| increased requirements towards hospitals to explain their
| pricing will lead to hospitals demanding slightly more
| transparency and slightly more consistency from the other
| companies they work with.
| [deleted]
| fragmede wrote:
| Under capitalism, a thing's cost to manufacture has
| nothing to do with the price of that something.
|
| Read that again and work through your objections. Ideally
| something's price is higher than its cost so the company
| can make a profit, but there are so many obvious
| exceptions that its nice, but not necessary. Thus, who
| _cares_ how much the pill coming down line costs to
| manufacture, unless you start hacking into the free
| market and set price controls, and say that
| pharmaceutical companies are only allowed to make 20%
| profit (or however much), Martin Shrekili 's play, of
| buying pharmacutical companies and simply raising prices
| of drugs, is a legal move under capitalism, no matter how
| reprehensible that move may be.
| nybble41 wrote:
| Under capitalism, with that kind of price difference,
| someone else would move in and start manufacturing the
| same drug and selling it for less to gain market share.
| That's competition for you. Or if no one else wants to do
| the job you could just make it yourself. Cost and price
| are indeed two different things, but competition keeps
| the prices of goods down to a relatively low multiple of
| their manufacturing cost.
|
| Unfortunately what we actually have, between patents and
| other monopolies the government has instituted on drug
| manufacturing and distribution, is nothing like
| capitalism.
| learc83 wrote:
| >Unfortunately what we actually have, between patents and
| other monopolies the government has instituted on drug
| manufacturing and distribution, is nothing like
| capitalism.
|
| You could replace patents with trade secrets and have
| many of the same problems (along with some others).
| danShumway wrote:
| Eh, technically yes, but that's not really what I'm
| talking about. The way we use the word "cost" varies
| depending on the context, and I'm responding to a
| specific usage of that word. I'm not making a broad claim
| that drugs need to be sold at cost, I'm making a claim
| that drug costs are not so highly variable that coming up
| with a consumer price needs to take days of research
| after a procedure.
|
| jonathan-adly is making the argument that the inherent
| "cost" of drugs is itself highly variable for hospitals,
| and that means it's normal and expected that hospitals
| should not be able to tell patients the price of
| procedure before it happens. I'm arguing that the "cost"
| of the drugs is not actually that variable, that
| hospitals are just downstream of another part of the
| industry that is engaged in the same price-hiding
| behavior that hospitals are engaged in.
|
| Of course, under Capitalism "cost" doesn't determine
| price, the market determines price. But I would also
| point out that under Capitalism, signing a contract
| usually involves the terms of that contract being made
| upfront. Pretty much every other industry in America has
| figured out how to put a price tag on the products they
| sell, and I'm not sympathetic towards the medical
| industry just because up until now it's never _needed_ to
| learn how. Apple sources its components from
| manufactures, those manufacturers could change their
| prices someday. But Apple still puts a price tag on
| iPhones, and because it needs to put a price tag on
| iPhones it 's incentivized to form long-term contracts
| with suppliers and to demand a level of consistency in
| the prices its suppliers offer.
|
| Hospitals haven't needed to do that in a long time.
|
| Price transparency is an important part of most
| industries under Capitalism, and the medical industry
| hiding behind variable "cost" as an excuse to avoid
| pricing their products shouldn't be something we
| tolerate.
|
| Martin Shrekili's practices (as abhorrent as they might
| be) are a different conversation. I think that price
| limits and price transparency are two very different
| issues.
| learc83 wrote:
| >But I would also point out that under Capitalism,
| signing a contract usually involves the terms of that
| contract being made upfront.
|
| There's nothing inherent to Capitalism that prevents
| variable priced contracts.
|
| >Pretty much every other industry in America has figured
| out how to put a price tag on the products they sell,
|
| Maybe for mass produced products they have, but certainly
| not for custom work. You aren't paying for a product but
| for a custom service. Paying a doctor to fix your body in
| many cases is more complex than paying someone to build a
| house, a bridge, or a piece of software. You won't even
| get an upfront price for something as simple remodeling
| your kitchen. A contractor estimates that it will cost
| $20k and then finds that a leak in your attic completely
| rotted some of the framing, now it's $50k. A builder
| starts digging the foundation to your house only to
| discover a huge boulder that has to be moved.
|
| There are parts of medicine that could be made more
| transparent, but there is an inherent complexity that
| makes complete or even mostly complete price transparency
| impossible.
| danShumway wrote:
| > There's nothing inherent to Capitalism that prevents
| variable priced contracts.
|
| Definitely not the norm though, and it is inherent to
| Capitalism that price transparency is an important part
| of creating an efficient market.
|
| But sure, it's not a _rule_. A lot of common things in
| Capitalism aren 't rules, but they're still often signals
| of a healthy market.
|
| > You won't even get an upfront price for something as
| simple remodeling your kitchen. A contractor estimates
| that it will cost $20k and then finds that a leak in your
| attic completely rotted some of the framing.
|
| A contractor will not however replace the framing and
| then charge me after the fact. They'll discover the
| rotten framing, inform me of the new conditions and the
| new price, and then let me decide. A good contractor will
| walk me through that process.
|
| > but there is an inherent complexity
|
| Not in the places that we're talking about. The kind of
| complexity and guesswork and change in procedure you're
| talking about is not present in the situations that
| jonathan-adly discusses above. The inherent complexity of
| fixing someone's body and the inherent variability of
| what drugs/procedures will be necessary to do so is a
| good explanation of why pricing a surgery or an entire
| hospital visit is very difficult. But it is not a good
| explanation for why hospitals have claimed that the price
| of a single x-ray is "unknowable".
| learc83 wrote:
| >Definitely not the norm though
|
| It most certainly is the norm when purchasing complex
| custom services.
|
| >A contractor will not however replace the framing and
| then charge me after the fact. They'll discover the
| rotten framing, inform me of the new conditions and the
| new price, and then let me decide. A good contractor will
| walk me through that process.
|
| If a surgeon could keep your chest open on an operating
| table while they walked you through the process this
| analogy would work.
|
| >a good explanation of why pricing a surgery or an entire
| hospital visit may be difficult. But it is not a good
| explanation for why hospitals have claimed that the price
| of a single x-ray is "unknowable".
|
| jonathan-adly has done a great job explaining why drug
| prices are difficult to calculate upfront.
|
| As for the price os a single x-ray. I'm sure the average
| cost of a single x-ray could be calculated. But how much
| is that worth when the entirety of the hospital visit is
| going to be a variable cost? If you're only interested in
| a single x-ray, there are already outpatient imaging
| clinics that will give you the upfront cost.
| danShumway wrote:
| > It most certainly is the norm when purchasing complex
| custom services.
|
| An x-ray is not is not a complex custom service.
|
| > But how much is that worth when the entirety of the
| hospital visit is going to be a variable cost?
|
| This is the exact same argument that hospitals used to
| use against itemized pricing, and yet it turns out that
| requiring hospitals to give itemized bills on request has
| pretty solidly been a good thing for consumers.
|
| There are a huge number of reasons for this, not the
| least being fostering competition and putting natural
| pressure on the market to justify its prices helps it
| become more efficient, and these kinds of opaque systems
| will almost always naturally lead to inflated prices.
| There's little reason to believe that up-front price
| transparency for individual itemized procedures and drugs
| wouldn't also be good for the same reasons.
|
| At the very least, this would help with the _many_ health
| decisions that consumers make that aren 't happening
| during life-threatening situations. Most of the time that
| I get an x-ray, most of the time when I'm being offered
| pain medication, most of the time when I'm making
| decisions about whether or not to opt for anesthesia
| before a procedure, I'm awake and not in danger of
| immediately dying.
|
| It really doesn't make sense to keep leaning on the most
| extreme life-or-death situations as a defense for why a
| hospital can't walk me through the price differences in
| several different brands of pain medication. But sure,
| we'll make an exception for surgeons operating while a
| patient is literally unconscious during a time-sensitive
| procedure. Most health visits (and the vast majority of
| all preventative care procedures) do not fall into that
| category.
|
| > jonathan-adly has done a great job explaining why drug
| prices are difficult to calculate upfront.
|
| Let's make this simpler. johnathan-adly says:
|
| > The cost of the aspirin depends on these things
|
| Here's Rite-Aide's page that comes up when I search for
| an aspirin: https://www.riteaid.com/shop/medicine-
| health/pain-fever-reli...
|
| Why is it that Rite-Aid can give me an upfront cost for
| an aspirin, and a hospital can't? 340B is a rebate
| system, it doesn't force doctors to avoid talking to
| patients about the baseline price differences between
| comparable off-the-shelf name-brand and generic drugs.
| learc83 wrote:
| >Most health visits, and the vast majority of all
| preventative care, does not fall into that category.
|
| The kinds of easy issues you're talking about don't need
| to happen in a hospital. You can already go to an
| outpatient imaging clinic for an x-ray, a dermatologist's
| office to have a mole removed, or an urgent care to
| suture a laceration.
|
| If you need emergent care or you want an elective
| procedure that requires a hospital stay, you're into the
| realm of custom services with variable pricing.
|
| >This is the exact same argument that hospitals used to
| use against itemized pricing, and yet it turns out that
| requiring hospitals to give itemized bills on request has
| pretty solidly been a good thing for consumers.
|
| Has it? Has it driven down prices? Has the demonstrated
| value been worth the cost? Or has it just pushed
| hospitals into creating longer bills with more creative
| items and charges. Creative line items like $500 for
| aspirin perhaps?
| danShumway wrote:
| > The kinds of easy issues you're talking about don't
| need to happen in a hospital. You can already go to an
| outpatient imaging clinic for an x-ray, a dermatologist's
| office to have a mole removed, or an urgent care to
| suture a laceration.
|
| Even better: clearly the market has proven that it's
| _possible_ to offer these services with transparent
| pricing. Why can 't hospitals keep pace?
|
| This also raises the question why preventative care often
| falls into the same category. Lawyers have a predictable
| billable rate, personal physicians and doctors often
| don't. Most scheduled hospital procedures require
| multiple consultations and planning before the procedures
| take place. Most of that stuff is not transparently
| priced.
|
| There's no reason why a hospital shouldn't be able to
| figure out the cost of minor anesthesia _before_ a
| scheduled minor surgery. That 's not a surprising part of
| the procedure, that should be something that's fully
| negotiated with insurance and disclosed to the patient
| beforehand so they can decide.
|
| > Has the demonstrated value been worth the cost?
|
| Yes, absolutely, you can find tons of stories online
| about people negotiating smaller bills because itemized
| bills turn out to include services that they never
| requested (and in some cases services that were never
| even actually performed). If you talk to experts about
| managing personal health costs, pretty much all of them
| will tell you to always request an itemized bill after
| you visit a hospital or doctors office.
|
| It's also absolutely worthwhile _because_ you 're seeing
| creative line items like $500 for aspirin that prove that
| the costs of the services aren't being based on market
| rates. That's really important information because it
| opens the door to other questions like "why are these
| prices what they are", and "can you tell me in advance
| before you give me a $500 aspirin?"
|
| I mean... you're saying this is the norm in complex
| industries, it absolutely is not. Complex industries are
| complex because they don't know up front what they'll be
| billing you for. That's not even remotely the same thing
| as "we think your stay should cost $5000 for reasons we
| can't disclose, so I guess we'll jack up the aspirin cost
| after the fact to try and prevent anyone from questioning
| us."
|
| It is extremely worthwhile to put hospitals in a position
| where they have to answer consumers why an in-patient
| aspirin is priced so much higher than the market rate for
| the drug. I don't know if this is your intention, but
| what you're implying when you say that the itemized bills
| aren't accurate is that hospital pricing isn't based on
| any kind of competitive or visible market rate, or even
| anything objective at all. Which is a pretty bold claim.
|
| Other industries with high-variability pricing exist, but
| they're not just making up numbers completely out of thin
| air after the fact and then lying about line items to try
| and justify that cost. _Hopefully_ hospitals aren 't
| doing that either. But if they're not, if they are
| actually basing their prices off of the combined prices
| of the services they provided... then we gotta ask about
| that $500 aspirin, because that's a weird price.
| mwerd wrote:
| Not trying to be rude but he already told you the answer.
| You really should look up 340b. It's a federal program to
| rebate drug costs for certain types of patients and is a
| legal form of price discrimination. When you provide a
| drug in a healthcare setting, it can be a very different
| price depending on who receives it, because the federal
| government has the 340b program.
|
| Your argument about cost to manufacture isn't relevant in
| the same way that the marginal cost of a flying one more
| passenger on an airline isn't relevant. We all pay
| different prices for airline seats. Hospitals pay
| different prices for the same pharmaceuticals.
|
| There are a lot of smart people working in healthcare. A
| lot of people go into the industry thinking they know
| better and wash out. See the latest Berkshire Hathaway +
| JPM + Amazon failure.
| danShumway wrote:
| What's preventing the hospital from at least telling me
| the baseline price without 340b rebates and then listing
| those rebates separately? Does the hospital even _know_
| the baseline price without 340b rebates? If not, doesn 't
| that strike you as a problem?
|
| > Hospitals pay different prices for the same
| pharmaceuticals.
|
| Right, that's exactly what I said:
|
| > It sounds like within the industry, hospitals are
| facing the same problems as consumers, and they need more
| price transparency from their suppliers as well.
| Hopefully increased requirements towards hospitals to
| explain their pricing will lead to hospitals demanding
| slightly more transparency and slightly more consistency
| from the other companies they work with.
| mwerd wrote:
| They have the transparency to supplier costs but it's so
| variable and granular that it's not meaningful to
| discuss.
|
| Drugs in a clinical setting are priced on a per unit
| basis (which might be per mL), usually with a flat markup
| over cost. In practice, that can mean a patient getting
| IV drug treatment could receive two different charges for
| the same drug in the same day. If it's a hard to find
| drug and they deplete batch 1 from supplier A, then
| administer batch 2 from supplier B, the cost per unit
| could change by multiplies.
|
| Using the earlier airline example, it's like trying to
| say what the cost of a generic flight is. The answer is
| always going to be it depends.
|
| Combining that kind of cost structure with a transparency
| requirement means you get unusable, and as parent
| commenter mentioned, laughable results. It's not
| malicious compliance driving this garbage price
| transparency, it's a fundamental misunderstanding of how
| the healthcare system works.
| danShumway wrote:
| > They have the transparency to supplier costs but it's
| so variable and granular that it's not meaningful to
| discuss.
|
| Right, so again, exactly what I said:
|
| > It sounds like within the industry, hospitals are
| facing the same problems as consumers, and they need more
| price transparency from their suppliers as well.
| Hopefully increased requirements towards hospitals to
| explain their pricing will lead to hospitals demanding
| slightly more transparency and slightly more consistency
| from the other companies they work with.
|
| jonathan-adly suggests that it's laughable to assume that
| a hospital could get a predictably priced supply of
| aspirin from it's suppliers. And I'm sorry, but no it's
| not. Everybody else has figured out how to do this. The
| market has already proven that it is possible to
| predictably price an aspirin tablet for consumers before
| you hand it to them.
|
| If hospitals can't do that, then it signals that either
| something is very wrong with how they operate, or (from
| the sound of things) something is very wrong with their
| supply chains.
|
| The value here is in asking _why_ hospitals can only
| provide laughable answers to a question that other
| segments of the health industry have been competently
| answering for decades now. I 'm not saying it's
| necessarily the hospital's fault. I'm saying that
| something is pretty clearly wrong with their model for
| sourcing even generic drugs, given that they are one the
| only parts of the health industry that has this problem.
| mwerd wrote:
| Can't speak to aspirin specifically, but I think
| generically you're pushing a false assumption. It is not
| easy for the rest of the health industry to provide
| stable pricing of drugs, especially for the types of
| rarer drugs that are administered in inpatient care
| settings. Go click around GoodRx drug prices and tell me
| how stable even generic drug prices are. There's a post
| here on HackerNews every 6 months about the outrageous
| cost of insulin, one of the most commonly prescribed and
| readily available pharmaceuticals (within a lot of
| variation depending on patient needs).
|
| It's complicated. You're oversimplifying it.
| karmelapple wrote:
| Drugs typically have a pretty in elastic demand. Whether
| it costs $16000 or $0.05 for a pill, the end user -
| whether a doctor or a patient - will simply figure out a
| way to pay for it to alleviate the pain, symptoms, and
| perhaps to avoid dying.
|
| Seems like 340B (I hadn't heard of this before, thanks!)
| may have been created with recognition of this
| inelasticity.
|
| If we can limit prices this way, all it would take are a
| few more laws to put more price limits in place.
| fragmede wrote:
| Sort of? As we're seeing with the pandemic, a not
| insignificant portion of the population is _so_ used to
| healthcare being utterly inaccessible that animal
| medication seems like a reasonable alternative. That
| $16,000 pill isn 't getting to patients, people are
| simply dying without it instead, going to faith/crystal
| "healers" instead.
| xyzzyz wrote:
| There is much more elasticity than you think. Most
| medicine is not about "not dying". Here is an example: I
| get heartburns pretty often. I take a heartburn medicine
| omeprazole daily. It's an over the counter drug, costing
| something like $0.3/dose. If they bumped the price to
| $16,000 I would just stop taking it, and started getting
| regular heartburns again. These suck, but I lived with
| them before finding this drug, and wouldn't pay tens of
| thousands of dollar annually to get rid of them.
| earksiinni wrote:
| > The fact that the general public as well as journalists think
| this data is accurate in anyway is really funny. This an
| exercise of futility that only increases the overall cost and
| provides job security for me :)
|
| People are literally dying out here from administrative bloat
| and you're joking about job security. Your comment comes across
| as cavalier and even a bit callous.
|
| With that said, I respect the systemic and historical
| complexity of the problem and don't mean to suggest that you
| personally are the problem. I understand that you're pointing
| out the Kafkaesque futility from within the trenches; I think I
| get where you're coming from.
|
| May I suggest that you rephrase your critique next time in a
| way that would communicate empathy so that we might in turn
| empathize with your situation? If these spreadsheets are feel-
| good window dressing (not that I agree), then state your case
| and let's stop wasting time on them. What do you think should
| be done instead?
|
| Let us improve things together.
| danShumway wrote:
| Requiring hospitals to make these lists may help the situation
| improve.
|
| > No one working in a hospital knows how much do we acquire
| things for, or how much we get paid for doing things in
| advance. And only like 8 people can tell you that information 3
| months after the fact.
|
| This is the problem. There has to be prolonged pressure put on
| multiple parts of the system until it will start to optimize in
| different directions.
|
| A nontrivial part of _why_ no one knows these things in the
| hospital is because nobody has to know these things, the entire
| system (not just the hospital but the surrounding insurance
| system, the billing systems, the vendors, etc) is used to not
| needing to care about these things.
|
| So these lists, as imperfect as they are, increase that
| pressure a little bit. Ideally, seeing the price fluctuation
| and seeing the reactions of doctors to these lists will prompt
| more in-depth questioning[0] from regulators, judges, and
| consumers. The fact that the lists are a joke is why they're
| not a joke. People need to be publicly reminded, again and
| again, over and over, that the way health procedures in the US
| are priced are generally broken, often arbitrary, sometimes
| opportunistically exploited, and almost always unnecessarily
| complicated.
|
| The more obvious that becomes, the more attention that other
| parts of the system will get.
|
| [0]: https://www.healthcaredive.com/news/baffled-judges-price-
| tra...
| the-pigeon wrote:
| I think this is the best argument for these lists that I've
| heard.
|
| Forcing this stuff out into the light helps the system get
| fixed. This is a pattern I've seen in internal tools
| development for businesses over and over. When my solution
| increases visibility into a problem, suddenly people start
| solving the problem without my help.
| IMTDb wrote:
| The spirit is here is that you should _fully open_ all those
| factors and _fully open_ how they influence the cost paid by
| the patient. Make an excel sheet, a web app, an API, whatever.
| But let people know and simulate the cost - include _all_
| required factors.
|
| If the prices you charge differ from the prices provided by
| your open data platform, or if some factors are omitted from
| the open platform, you should get a lawsuit on your hand - and
| lose it.
|
| If your excuse is that building the open data platform is too
| complex and expensive because too many variable are involved,
| explain how you were able to build a reliable system internally
| - and open that one.
|
| If you cannot do that as well, you know it's time to rethink
| your pricing model, in order to simplify it.
|
| The end goal of the regulation is to push as many health
| institution as possible to reach the conclusion that they
| really need to rethink their pricing model.
| jonathan-adly wrote:
| There is no internal reliable system. Healthcare in the US
| uses faxes.
|
| People here thinks that their local hospital is Google, while
| in reality it's a badly managed/badly funded 100 year old
| non-profit organization full of middle managers who just
| learned how to use their email.
| mchusma wrote:
| I think if your point is "the system is broken today",
| basically everyone agrees with you.
|
| If your point is "it is not possible to have transparent
| pricing", that seems also insane.
|
| IMO we should pass a law that says if you can't give people
| transparent upfront pricing, you can't bill them at all.
| The idea that you can "figure out a price later" seems
| absurd.
| jonathan-adly wrote:
| It is not possible to have transparent pricing in the
| current broken system.
|
| It's like trying to put a bandaid on an arm that met a
| chainsaw. Not really a good first step and a waste of
| time. The solution is to go to the OR, and give him a new
| arm. The more bandaids and time you waste, the worse it
| is.
| EamonnMR wrote:
| By demanding transparent pricing (and other aggressive
| policy, like say not being able to bill patients without
| them seeing a price and agreeing) might we force the
| system to replace itself? Because these companies are
| very good at complying with regulations, but the
| regulations allow them to use faces to communicate
| because most of the regulations are designed to keep most
| of the system compliant.
| batty_alex wrote:
| > 100 year old non-profit organization full of middle
| managers who just learned how to use their email.
|
| As someone who works in the industry, you gave me a hearty
| chuckle - well done, too true
| 6gvONxR4sf7o wrote:
| It seems like in 2021, doing better than faxes is pretty
| reasonable. If things like that are legitimately the
| significant barriers today, then doesn't that suggest it
| should be very easy to get them fixed?
| rootusrootus wrote:
| I'm not sure how useful these lists are when hospitals are not in
| competition. In many areas that aren't a major metro, you may
| only have one hospital you can even choose, and the law prevents
| new hospitals from opening without permission. This 'market' is
| the very definition of inelastic.
| spaetzleesser wrote:
| Full openness is a good first step to make this insane system a
| little better. Next step would be for hospitals to quote the same
| price for the same procedure no matter if or where you are
| insured. I can't think of another business where prices are
| different by hundreds of percent for different customer groups.
|
| Also get rid of the whole in and out network system.
| breckenedge wrote:
| I like the idea of getting rid of in/out of network. Both
| recent administrations have taken steps in this direction.
| novok wrote:
| Psychologists want to charge $200-$250/hr, but insurance only
| reimburses $120-$160/hr. You might think these are high
| prices, but chargeable hours isn't hours worked for
| psychologists, since they have to do notes for every meeting,
| manage the business, appointments, etc, which reduces their
| total take home to something below $200k/yr, which is below a
| typical bigtech Eng II with only a couple years of
| experience, potentially not even going to college if they are
| clever and self motivated enough. While a psychologist has
| gone to school for 10 years and paid for it.
|
| It's gaps like that that lead to the entire in/out network
| split.
| breckenedge wrote:
| FWIW I pay mine in cash from my HSA because he doesn't
| accept _any_ insurance due to the headaches involved
| getting reimbursed.
| minsc__and__boo wrote:
| That's fair but for people without HSA they should still
| file a claim against maximum out of pocket.
| LurkingPenguin wrote:
| > You might think these are high prices, but chargeable
| hours isn't hours worked for psychologists, since they have
| to do notes for every meeting, manage the business,
| appointments, etc, which reduces their total take home to
| something below $200k/yr, which is below a typical bigtech
| Eng II with only a couple years of experience, potentially
| not even going to college if they are clever and self
| motivated enough.
|
| Silicon Valley/big tech is not the center of the universe.
| How is what "typical" engineers at big tech companies make
| relevant to a discussion of what psychologists and other
| medical professionals make? Are you suggesting that the
| medical profession is doing battle with big tech for
| (future) workers?
| novok wrote:
| Any ambitious and smart enough American who wants to make
| a high income in exchange for working hard at prep has a
| choice of jobs they can go into. Many people who go into
| medicine are not necessarily the most passionate about
| medicine, but want a high paying, prestigious job.
|
| So yes, it does effect the supply of future and even
| current psychologists and doctors. Supply is dictated
| partly by cost of that supply vs the demand in dollars
| for it, and the cost and barriers to med school and
| licensing is a big factor of supply costs.
| LurkingPenguin wrote:
| > Any ambitious and smart enough American who wants to
| make a high income in exchange for working hard at prep
| has a choice of jobs they can go into.
|
| I suspect that the number of people who are driven solely
| by money and prestige is smaller than you believe, but
| even so, careers in different fields aren't fungible for
| the simple fact that even ambitious and smart people
| aren't universally capable of excelling in any field they
| choose. A top heart surgeon, for instance, wouldn't
| necessarily have the ability to be a top software
| engineer, even if he or she tried, just as a top software
| engineer wouldn't necessarily have the ability to be a
| top heart surgeon.
|
| > So yes, it does effect the supply of future and even
| current psychologists and doctors.
|
| Do you have any hard evidence indicating that the lure of
| big tech jobs is reducing the number of individuals who
| are pursuing careers in psychology, medicine, law, etc.?
| A study perhaps?
| Sevii wrote:
| Yes, all high paying careers are competing with each
| other for ambitious workers.
| toast0 wrote:
| Networks are a double edged sword. They're a pain to use
| (especially for things where network facilities have non-
| network providers or network providers steer you towards non-
| network accessory care like labs and what not), but network
| agreements are also a way that insurers control costs.
| Forcing insurers to cover every provider means insurers can't
| exclude overpriced providers.
| bcrosby95 wrote:
| Yep. These agreements cut out some ridiculous fees some
| might try to charge.
|
| E.g. when my wife had surgery, the hospital tried to charge
| $20k for the surgery room and $20k for the recovery room.
| Our insurance pointed out that by their agreement they
| aren't allowed to charge for use like that.
|
| Instantly cut the hospital portion of the bill from $49k to
| $9k.
| spaetzleesser wrote:
| That's the insanity. You are the same person, same
| procedure, everything same but somehow the hospital can
| reduce its bill from 49000 to 9000. That is just not
| normal for a business like a hospital where they have a
| ton of fixed costs (unlike a software company where
| delivery of their product often costs close to zero so
| they can easily give rebates). This seems to indicate
| that the 49k is an insanely high price with very high
| profit margin.
| aqme28 wrote:
| Completely agree with your point, but I want to point out that
| a lot of businesses (most?) adjust pricing based on the
| consumer group.
| [deleted]
| twistedpair wrote:
| Ever heard of coupons, rebates, bundles? All ways of adjusting
| pricing based on consumer price sensitivity.
| gwbrooks wrote:
| It's not as pervasive, but a good deal of consulting work is
| priced, at least partially, by the size of the problem you're
| solving rather than the labor required to solve it.
|
| That can lead to price discrepancies similar to (although
| perhaps not quite as severe) as what you see in healthcare.
| mullingitover wrote:
| > Next step would be for hospitals to quote the same price for
| the same procedure no matter if or where you are insured.
|
| After that, decouple health care from employment.
|
| Finally, fully excise the connection between health care and
| ability to pay.
| [deleted]
| AptSeagull wrote:
| There are 6000 hospitals, 20% for profit businesses, 17 of which
| are publicly traded. They write off procedure costs to some
| degree. The amount written off is so widely variable and
| lopsided, the IRS or the SEC would have a nearly impossible task
| of determining what is true. I'm curious, do hospital CFOs sweat
| the risk of IRS discovery that write offs are artificially
| inflated if/when the data becomes easily known and calculable?
| How many years and how many procedures were written off to which
| extent? To what end did asymmetric data play in avoiding taxes or
| violating SEC regs?
| elpakal wrote:
| Just spent last night in an Urgent Care watching my youngest
| child get stitches (closest thing around for miles). Can't wait
| to see how that bill plays out, hopefully one day I can see how
| their prices compare to larger hospitals and such.
| aaron695 wrote:
| > Hospitals lift curtain on prices
|
| *Trump lifted curtain on Hospital prices
|
| But lets not get to far into reality, it'll hurt the sheeps
| brains. It's good the actual article acknowledged it further
| down, I assume because it's not a conventional media site.
|
| It's a good initiative. Contrary to Goodhart's Law, the pop
| Internets deadhead goto, quantifiable data is what we need more
| of.
|
| Parallel to Goodhart the attempts at cleverness to find fault
| currently are also lame. Bugs will be fixed, obscuration's will
| be removed and hopefully hospitals being forced to improve
| internal processes current CEO's just don't care about.
| TomK32 wrote:
| Got three plates and a few screws put into my smashed hip last
| year, cost me 120 Euros for the stay.
|
| I'm in Austria, obviously... The only thing wrong here in Austria
| is there's still more than one health care insurance (one of
| regular employees, quite a few on federal and state level and one
| of self-employed) and there's a separate one for accidents (AUVA)
| and almost all of them are just playthings to the power hungry
| and greedy government.
| [deleted]
| javier10e6 wrote:
| US Insurance Aetna President Karen Lynch Compensation 2020: 7.33M
| https://www.comparably.com/companies/aetna/executive-salarie...
| Ferengi Rules of Acquistion #87 : A friend in need means three
| times the profit
| literallyaduck wrote:
| Contact your state legislators and ask them to put large fines
| which go to the patient if they are discriminated against for
| their insured status.
| codegeek wrote:
| I am willing to take some time and build a publicly available API
| of this. I care so much about this issue that I would build this
| db at my own cost and hope it truly helps people. if anyone wants
| to join forces, feel free to send any suggestions.
| dpayonk wrote:
| There is obviously a ways to go to create a system where price
| transparency is feasible, but I'm very interested in how the
| community might think it would affect the value based healthcare
| industry with respect to total cost of care management and
| bundled services? You cannot always look at a service in
| isolation because of complications on episodes like joint
| replacements or the impact of chronic conditions over the
| longitudinal total cost.
| q-rews wrote:
| You're right, my estimate for a short surgery in a private Thai
| hospital last Monday was "10k/11k THB excluding fees." I walked
| out of the hospital 2 hours later having paid 9.1k THB (270
| USD) painkillers included.
|
| Estimates are fine, it's just that they don't benefit US
| hospitals. Stop justifying them, they're scamming you.
| folkhack wrote:
| > You cannot always look at a service in isolation
|
| But in the American system it's setup that you must. This is
| the whole "coding" thing that you hear people refer to which is
| taking a procedure and breaking it into individual codes that
| can be used in billing you/your insurance.
|
| This was addressed in the "Methodology" section of the article:
|
| > Data was collected for three services, determined by specific
| codes.
|
| ---
|
| > I'm very interested in how the community might think it would
| affect the value based healthcare industry with respect to
| total cost of care management and bundled services?
|
| You mean... releasing pricing for individual codes.....?
| Finally showing that hospitals will bill different prices for
| the same code based on the patient's insurer...?
|
| I read the article and all I got was that hospitals are
| releasing pricing information under the Trump mandate. I'm not
| sure what you're positing for an "effect" here as the effect is
| literally just transparency in hospital billing?
| nradov wrote:
| The US healthcare system is slowly moving away from the fee-
| for-service model and towards a value-based care model. Under
| that model, providers bear much of the financial risk. They
| might receive a single bundled payment for a joint
| replacement including all follow-up care, with penalties for
| failing to meet clinical quality measures. Or they might
| receive a flat per-patient per-month fee to completely care
| for people.
| OrvalWintermute wrote:
| >Under that model, providers bear much of the financial
| risk.
|
| Actually, practices currently bear the risk already,
| because they are subject to reimbursements unless they are
| cash-paying. Remember, the patients are regularly not the
| bill payors - the Payors are actually insurance
| companies/medicare/or, rare HMOs out of the area.
|
| > They might receive a single bundled payment for a joint
| replacement including all follow-up care, with penalties
| for failing to meet clinical quality measures
|
| Certain medical interventions like cancer treatment or
| joint replacement may require a long tail of treatment,
| counseling, physical therapy, aftercare, global periods,
| etc.
|
| The applicability of that is fairly limited since many
| things do not trigger a global, and don't fit into this
| definition.
| folkhack wrote:
| Good faith - not trying to be a bastard...
|
| I've heard rumblings of this too but every time I've
| interacted with healthcare it's still the same coded system
| that you see in regards to the chargemasters etc... even as
| recent as-of a few weeks ago this was the system in a
| modern hospital in a large west coast city.
|
| So, two things:
|
| 1. I think we're on the coded system indefinitely, or at
| least that's only what I can expect given recent experience
|
| 2. Even if we were to implement this, providers and
| insurers will still fight like cats and dogs because
| there's just too much money to be made here that I can't
| imagine the same problems won't manifest itself in a
| "bundled payment" system. I would actually expect this to
| make matters worse. Often when you bundle something it
| obfuscates and confuses the value of the individual
| "things" in the bundle - the middlemen will do everything
| they can to extract margin from this. I'd personally like
| to stay with codes to maintain transparency through having
| an auditable receipt of known services directly tied to a
| fair price.
| nradov wrote:
| Procedures will always be coded using a terminology
| system like CPT4 / HCPCS / SNOMED CT regardless of the
| payment model. The issue isn't coding but rather who
| bears the risk.
|
| Bundled payments give providers the freedom and financial
| incentive to find innovative ways to efficiently deliver
| high quality care. No one benefits when hospitals have a
| separate line item charge every time a nurse administers
| a pain killer over the course of a hospital stay.
| folkhack wrote:
| > Bundled payments give providers the freedom and
| financial incentive to find innovative ways to
| efficiently deliver high quality care
|
| Until someone financially incentivizes a higher quality
| of care I don't expect to receive it, especially by a
| bundled pricing model.
|
| > No one benefits when hospitals have a separate line
| item charge every time a nurse administers a pain killer
| over the course of a hospital stay.
|
| And as someone who's been billed insane amounts for
| things like OTC painkillers I disagree with this so hard.
| I have zero, and I mean _zero_ , confidence that they
| will not continue to overcharge me. When everything is
| individually coded then at least a patient can go back
| and "look at the receipt"...
|
| In my adult life I realize that almost everything is
| weaponized against _me_ (the patient) in healthcare. I
| cannot expect in good faith that removing the line items
| from the receipt will help me in any way. In America, I
| can only expect this to hurt me or I 'd be an idiot.
|
| Sorry to disagree, but there is no way that bundled
| pricing is going to serve the patient better as it makes
| auditing services rendered much much harder. As someone
| who's had to get into the weeds on this stuff between
| insurer, hospital billing, etc. I can only imagine that
| bundled pricing would have made my life more difficult as
| it really did come down to the codes.....
| topspin wrote:
| "You cannot always look at a service in isolation because..."
|
| The medical industry is adept at excuse making and impeding
| change. If we wrap ourselves around every conceivable axle then
| nothing will be achieved. As it is providers and payers already
| employ elaborate coding systems to represent work and ascribe
| costs. Step one is to kick open that door and make this
| transparent. Should the result prove inadequate to sufficiently
| represent every imaginable nuance then the medical industry can
| engage in the necessary rework under that pressure.
| leetcrew wrote:
| sure. any given procedure has a happy path and many different
| ways it could go wrong and become much more expensive. you
| can't really predict what it will cost for an individual. but
| after performing the same procedure hundreds or thousands of
| times, the hospital ought to be able to figure out a standard
| rate that (statistically) covers its costs. I don't see a good
| reason why a large organization with tons of cashflow shouldn't
| be able to quote a price up front after taking any pre-existing
| conditions into account.
|
| of course, we might not like the prices they quote if forced to
| do this, but it would at least be better than rolling the dice
| every time.
| mkr-hn wrote:
| Hospitals didn't "lift curtain on prices." They were forced to do
| so. Accept no framing that allows them to appear heroic or
| selfless.
|
| https://www.cms.gov/hospital-price-transparency
| supperburg wrote:
| There is debate about healthcare nationalization.
|
| As always, that which lends itself to regulation via market
| should be private and that which does not should be nationalized.
| So which one is medicine?
|
| Medical care that is needed suddenly and urgently must be
| nationalized because the consumer of this care doesn't shop the
| market and therefore the market is not capable of regulating its
| participants in that case.
|
| Medical care that planned ahead of time, not urgently needed or
| otherwise allows people to shop the market should be private.
|
| But this is not the issue. Whether or not medicine of one kind or
| another is private or public doesn't matter as long as the
| medical establishment is corrupt and inefficient. Corruption and
| inefficiency are possible in both scenarios. Too few people in
| the public appreciate that it is the massive corruption and
| inefficiency of the medical establishment that is the cause of
| America's healthcare problem. Doctors are in hundreds of
| thousands of dollars in debt by the time they wear a stethoscope.
| Hospitals are charging ten dollars for an aspirin. Patients can
| sue and cause material damage to medical practitioners even if
| the medical practitioner did nothing wrong. The system is broken.
| It doesn't cost 300k to train a fucking doctor. It never did in
| the past and it doesn't now either.
| dundercoder wrote:
| The csv from my local hospital is 247MB. Still going on 3 mins
| trying to open it.
| donatj wrote:
| Around 2012 before my wife and I were married, we both got
| pneumonia. I was insured through my employer, she was uninsured.
|
| We went to urgent care at the same time on the same day, saw the
| same doctor and got prescribed the same drugs.
|
| About a month later when the bills came, her bill with no
| insurance was somewhere in the $160 range. My bill _after_
| insurance was nearly $300.
|
| I'm still peaved about this.
| deadmutex wrote:
| Was there any difference in ability to sue the provider in case
| things went wrong?
|
| I heard that sometimes they ask the uninsured to sign away the
| ability to sue the doctor and get lower prices in return. I am
| not too sure about details, this is just hearsay.
| donatj wrote:
| I remember she did have to sign a lot of paperwork. I have no
| idea what it contained however.
| karmelapple wrote:
| And that's because the product you were buying had a
| completely inelastic demand. You might have died if you
| didn't get treatment.
|
| Perhaps allowing healthcare providers to incentivize things
| like this is... not great? Because we'll sign pretty much
| anything if we're sick enough.
| r00fus wrote:
| Did you have a HDHP (high deductible plan)? In that case, you
| have no co-pay or anything until your deductible is used up.
| Employers typically contribute a good amount towards this
| deductible (or even more than) using an HSA.
|
| It's still crazy that the bills were so completely divergent.
| codegeek wrote:
| That's not the point. Your explanation is exactly what the
| issue is. Why is cash price cheaper than insurance price ?
| And in that case, why do we even need insurance for most of
| these visits.
| city41 wrote:
| I think the problem is, it's insurance. I pay $1200/month
| for my ACA insurance as I am a freelancer. Those with full
| time jobs pay a similar amount, just indirectly. In a given
| year, if I am healthy and need minimal medical care, then
| my insurance puts me way behind financially. If I have a
| sudden medical emergency, it can really save me. That is of
| course, assuming the insurance company will honor their end
| of the bargain which is another matter altogether.
|
| I don't want health insurance. I want health care.
| omgwtfbyobbq wrote:
| In my view, the amount you pay for stuff before you hit
| your deductible is just another type of premium. If the
| cash prices you can pay for what you reasonably think your
| care will be in a year are less than your deductible, then
| it can save you a little money to do that. If you happen to
| be wrong, you'll have still have to pay for your
| deductible.
|
| I pay for a specific medication OOP with goodrx because
| it's not covered by my insurance, and paying for it through
| them would be nutty ($1600/year versus $90/year). But other
| things I just lump in b/c I use a fair bit of insurance
| every year.
| r00fus wrote:
| Make no mistake, I think the entire health insurance
| industry is a meat grinder for profits and we should move
| to single-payer like most other affluent countries.
| mooreds wrote:
| If you are interested in this topic, I found this podcast to be
| enlightening: https://www.econtalk.org/keith-smith-on-free-
| market-health-c...
|
| Basically, there's a surgery center in OK which posts every price
| online and doesn't take insurance. A surgeon who works there
| talks with the host about how it works and the nuttiness of
| health care pricing in America.
___________________________________________________________________
(page generated 2021-09-22 23:01 UTC)