Hospitals lift curtain on prices, reveals giant swings for hips, knees and more

https://www.medtechdive.com/news/hospitals-price-transparency-spotty-compliance-swings-price/596593/

by theonlyklas • 5 years ago

254 267 5 years ago

wdn• 5 years ago

Only in US that we don’t know the price of the health service we are redeeming.

When I go get my car fix and I would go around to get an estimate for multiple body shop even if it is under insurance. But when it come to health care, you ask them for a cash price, they said they don’t know.

darkwizard424• 5 years ago

They will outright REFUSE to give you a quote...forget out-of-network, even IN network?!

This is so astonishing cause you would assume they have NEGOTIATED the rate given its in network so there is little variability in what can be charged by the doctor and what can be thrust upon the customer. ex. if you charge $100K more than other in-network doctors, good luck, cause the insurance company is only paying the doctor $5,000 no matter what and the customer will be on the hook for X% of that (outside of deductible and other math required to quote a price)...

maxerickson4• 5 years ago

They bill based on the procedures done and might not have that information until after the fact.

I'm not saying it's a good way to do things.

Opening a price list, it looks like one hospital charges ~$5000 for a knee replacement without major complications, and then the matching price for one with complications is $30000.

So how do they quote that when the complications can be unpredictable?

Which of course just says that maybe people shouldn't be put in the situation of trying to figure it out for themselves.

PragmaticPulp2• 5 years ago

They have to reveal their prices now. It's part of a bill that the Trump administration passed in 2019: https://www.cnbc.com/2019/11/15/trump-releases-rule-requirin...

From the article:

As of Jan. 1, hospitals must publicly reveal the negotiated rates reached with insurers for services, a landmark shift in the sector notoriously opaque when it comes to pricing. The data offer a peek behind the curtain, exposing prices long kept a secret.

The catch is that they can't guarantee what services you'll receive. If you have complications after your inpatient surgery, the price is going to be higher than the estimate due to additional services.

emkoemko• 5 years ago

how is that legal? you are telling me you won't know how much sometime costs until you have to pay for the service? is that not illegal? reminds me of Chinese scam of foreigners where women lure men to restaurants on the take and give you a massive bill at the end telling you it does cost that much but since you can't read Chinese its your fault.

mindslight2• 5 years ago

I feel like 80% of the healthcare logjam would be fixed if providers were required to 1. charge uniform prices for all payers and 2. present patients with written estimates based on said price schedule ahead of any non-emergency services, thus forming an actual contract.

Note that mechanics don't particularly know what they're going to have to do to any given car before they really get into working on it. Yet the market functions perfectly fine with estimates, agreements on hourly rates, phone calls for decisions on surprise situations, etc.

dumpsterdiver• 5 years ago

I'm not disagreeing at all (I'm not familiar enough with the system to disagree), just curious about your reasoning on uniform pricing for all payers?

The reason I'm curious is because using your car analogy, if I was a barely competent mechanic then management would probably be fine letting me perform oil changes, but when a classic Rolls Royce comes in with all original parts, management isn't going to let me touch that, right? They'll need to call in the big guns, whose rates are definitely higher than my "oil change" rate. I know that doesn't directly map with how medical procedures play out. I guess my real question is when and how does that balance out?

BeetleB2• 5 years ago

But when it come to health care, you ask them for a cash price, they said they don’t know.

As with everything, "it depends".

You often can get an idea from your insurance company, who will often provide you with what's called the "usual and customary" rates for a given procedure (in-network). Depending on the procedure, though, it may be hard to pin down. The procedure you want may actually consist of 3 things, and you need to look at all 3 up.

Also, if you call some private practices, and if it's a standard procedure (ultrasound, etc), you will often get a quote if you tell them you'll pay cash without involving insurance (some people ask for the "uninsured rate"). Often that will be less than the insurance negotiated rate. The down side is that whatever you pay will not count towards your deductible.

hoka-one-one• 5 years ago

According to the law they have to provide a price list, you're probably just asking for the wrong thing. No one's going to go through the price list and translate what you're looking for into medical jargon. My experience has been that you can usually find a list of direct-to-consumer prices online.

Spooky232• 5 years ago

Only in the US among developing countries do you care.

My experience getting a COVID vaccination was eye opening. I walked into a large facility, provided ID, was asked screening questions, consulted with a provider about a medical issue and got the shot.

I work for an employer with a legacy PPO. I suffered a back injury, had a major surgery and 8 weeks of physical rehab. My out of pocket was a few hundred bucks. I didn’t lose a days pay because of sick leave at half pay and short term disability insurance. The people I was in rehab with were losing jobs, selling cars, facing complete ruin.

The lack of ethical standards and focus on profit over the general welfare of the people is gross.

1cvmask• 5 years ago

In other countries you can see prices before making a decision. Funny that this a (sticker) shocker to us still today.

PragmaticPulp2• 5 years ago

That's what this article is about. The prices must be revealed now:

As of Jan. 1, hospitals must publicly reveal the negotiated rates reached with insurers for services, a landmark shift in the sector notoriously opaque when it comes to pricing. The data offer a peek behind the curtain, exposing prices long kept a secret.

WalterSear2• 5 years ago

I called UCSF's price transparency hotline earlier this week, to find out the price of some Xrays, because my insurance - the best plan that I was offered - won't even cover the first $2,000, and then half the cost after that. The pricing transparency hotline told me that they could not give me a quote until I made appointments for the procedures.

I called the Xray department. Apparently, they don't set appointments as Xrays are a walk-in procedure.

After almost two hours on hold and being handed around, I found someone who was able to tell me that the Xray billing department could provide me the information, provided that I was able to get an exact list of the Xrays that my doctor required. They could see my doctor's referral on their screen, but apparently, I still needed to reach out to my doctor and get the information from him, if I was to provide it to the billing department.

I messaged my doctor four days ago. He hasn't replied. Given that he squeezed me into his schedule at the last minute, and he usually replies to my messages after 10 pm, or during the weekend, it's clear that he's overworked, and I don't want to be an additional burden on him.

The last two weeks have been agony, and I haven't even been able to start to pursuing a diagnosis. This current week has also involved a lot of rage.

I've come to the conclusion that the system is so egregiously predatory that everyone involved - even those who are working within the system to ostensibly help me (such as my doctor) are ultimately culpable, since they are propping up the system.

bootlooped3• 5 years ago

I was once told by a pharmacy tech that they couldn't tell me the price of a vaccine until after I got it.

koolba2• 5 years ago

Which pharmacy? In my experience with all the majors they have standard price sheets for vaccines.

bootlooped3• 5 years ago

This was maybe 8-10 years ago, but I think it was a Kroger.

JoshGlazebrook• 5 years ago

"And I can't determine if I can pay you until after I know the cost"

bootlooped3• 5 years ago

Or "I will reveal the price that I pay you for the shot only after you give me the shot"

tzs• 5 years ago

When I take a prescription from my Kaiser doctor, covered by my Kaiser insurance, to the Kaiser pharmacy, and ask them how much it will cost they cannot tell me. This is completely ridiculous.

supernova87a• 5 years ago

Isn't one of the problems that the price of the total procedures are so different from the component parts / equipment / time, because different providers (and insurers) lump in different categories of cost with different methodologies of billing for overhead items? Or allow different costs to come in?

Such that even if you tried to comparison shop across 2 hospitals, you can't really tell whether that is the "all in" cost of what you want to understand?

Or is it that even for the same exact procedure, two patients might be billed differently because of what insurance each allows in particular? Or is it even further, price discrimination? Or because the hospital has agreements with the insurer for other costs to be billed for on the side, complicating the issue?

lupire• 5 years ago

Yes to all of this. That's the problem.

benmaraschino2• 5 years ago

Yes, this is a part of the problem. This is also why it’s hard to interpret the results of studies like this.

Without knowing more about the methodology, it’s possible that a lot of the apparent variation in cost arises from different ways of paying for the same thing. Take a joint replacement surgery—the surgery itself will generate claims for both the surgeon and the hospital, and maybe also the anesthesiologist. Each of those claims could be counted as a bill. But there’s also the initial clinic visit before the surgery as well as the aftercare and rehab, which also generate their own bills. What’s more, some payment models bundle all of those costs into one bill for the entire episode of care. (See how there’s no range listed for the procedures performed at Kaiser?)

The problem arises when you try try to compare those individual claims to the episode of care bills. You can’t, because they’re basically apples and oranges. But if you’re not aware, that can make it seem like there’s more variation than there really is. Don’t get me wrong, though, there is way too much variation in what we pay for health care, but it’s important we measure it precisely.

axlee• 5 years ago

I thought "free markets" where supposed to facilitate fair value discovery?

elevenoh• 5 years ago

Look at Canada, we're spending tax $ on health care per capita each year, yet wait times & outcome success has plateued.

This is about more than 'free markets', it's arguably more about regulatory capture by the major entities in health care.

The health care industry is hand in hand with education as top of the 'scam index' industries.

Yet criticism of health care is relatively 'off limits', and there's low competitive incentive to correct/draw attention to this.

'e.g. you're evil for wanting more efficient health care: why? doctors/nurses are already overworked & efficiency will mean jobs cuts of those at the lowest rung'

prostoalex2• 5 years ago

It does for less regulated markets, which is why you get those promotional mailers with promotional prices on LASIC or teeth whitening.

Medical lobby benefits from high barriers to entry, suppressed competition (from foreign doctors or medical tourism companies able to fly their customers abroad) and opaque pricing. Uninformed consumer forced to shop locally is rarely able to extract best pricing.

You can look at the annual fear-mongering fairs where medical lobby has been attempting to insert itself as a rent-seeker into kidney dialysis services in California. It's not like those industries are run by altruists, but on TV concerned serious faces in white coats would tell you in alarmist tones how those centers are run without professional supervision and people with no medical training, but when you vote properly, some [highly paid] individual with medical credentials would make things so much better [albeit more expensive in the long run].

techrat2• 5 years ago

Funny how it's only when regulation is involved that it begins to pull back the curtain.

ClumsyPilot• 5 years ago

Ah another believer in infinite wisdom of free markets without regulation.

This is a true believer, few people suggest we need no regulation in healthcare.

How far are you willing to go, should we remove fire safety and return to the fun days where entire cities burned down like in the great fire of london.

Should we deregulate the nuclear industry and let the market decide which reactor design is best and who should be allowed to enrich uranium

KoftaBob• 5 years ago

Yup, which shows that the healthcare system in the US is not even remotely a free market.

christophilus2• 5 years ago

There hasn’t been a free market in US medicine in a long time.

Clubber• 5 years ago

Healthcare is an inelastic demand service. Also a free market requires an informed buyer. Lack of price transparency coupled with inelastic demand makes it highly resistant to traditional market forces. You've got other forces working on it like high barrier to entry to be a healthcare service provider, high upfront costs for equipment, very heavy (expensive) regulation, higher likelihood of legal costs, etc.

It's like food. If you're starving, you'll do or pay whatever you have to to get nutrients.

knightofmars• 5 years ago

You are absolutely correct. Healthcare drives towards monopoly for the very reasons you describe.

datavirtue4• 5 years ago

Because it was not a free market. Hospitals had the insurers by the balls, set the price, and forced them into secrecy contractually. It WAS a huge factor in Healthcare prices.

throw1231231238• 5 years ago

The last thing I would call the healthcare market in the us is a free market.

EliRivers• 5 years ago

Slightly relevant historical aside; when Adam Smith was thinking about his famed free markets, it wasn't government regulation that he wanted them to be free of. They were to be made free BY government regulation and enforcement. What some markets seem to have become (such as this US medical market) are the self-same unfree markets that Adam Smith believed were so damaging.

I for one would not be too upset to see the government hold a gun to the metaphorical heads of various bodies and organisations and tell them that they'd better start delivering a free market pretty damn quickly. Given a political class in the US that seems so obsessed with "free markets" (they're mostly not, of course - it's just sloganeering bullshit to enable weakening of protections and increased screwing over of everyone but the ruling classes), sure is a shitshow of captured, unfree markets.

randyrand• 5 years ago

The developing world often has a rather free market, and the prices are just that, cheap.

In the US, it’s the most regulated service we offer.

1. the supply and instruction of doctors are regulated

2. the supply of hospitals are regulated (often by other hospitals!)

3. service for insurance is regulated

4. pharmaceuticals are regulated

5. physical medical tools are regulated

6. hospital facilities are regulated

avgDev• 5 years ago

The US healthcare system is just a completely broken mess. When things go smooth, you are lucky! However, when you have a major procedure, life event or sickness things can get messy quick.

We had a child 10 months ago, billing was screwed up by the hospital, then by insurance and we are still in process of getting it resolved. I have now spent at least 8 hours on the phone.

I had a surgery, called insurance and verified it was pre-approved and in-network. After procedure I receive $22k bill. I was young and did not care about my credit back then and never paid. 5 years later I received a new bill, for $300 as the provider sued the insurance company.

I hate going to the hospital and AWAITING a shower of bills. This grinds my gears SO hard. Every hospital stay and bills just keep coming for a few months.

As someone who likes to budget and plant expenses, I just cannot stand the US medical system. I never know how much a simple wart removal my cost. $100 or $2000? I'm happy to have good insurance, don't require to use the medical system a lot and have enough money. However, if you are extremely ill you seriously need to move to a "FIRST" world nation or have a good insurance with low max out of pocket. However, you still are going to deal with bills like its your full time job.

kshacker• 5 years ago

It is not a 'broken mess'. It is an 'engineered mess'. The difference is in intent.

danaris2• 5 years ago

Framing it this way is probably inaccurate, and if inaccurate, unhelpful.

From decades of observing the system, it seems extremely unlikely to me that it was deliberately engineered to be this way. Rather, different parts of it grew and changed organically and the parts and changes that benefitted moneyed interests in power stayed, while those that did not were discarded.

It does not take a deliberate will behind something for it to be pulled toward this sort of inequality, and presenting it as if that's what's happened suggests that if we could only defeat the Evil People who "engineered" it this way, we could make it better. It's a very compelling idea, and it makes for a nice dramatic narrative, and humans love good stories.

Unfortunately, it's not the case. In order to make it better, we need to take a good, comprehensive look at many aspects of our systems of economics and government, and redesign them deliberately and with a strong intention to inhibit the flow of money upward from the 99% to the 1%. It's hard, it will take a long time, the people with the most wealth and power will fight us every step of the way, and there's no silver bullet, but there's also very little that's more worth doing.

ArtDev2• 5 years ago

It's a racket and that is why the industry does everything it can to avoid having to adhere to basic capitalism.

There is no other industry like it except, perhaps, the mafia.

missedthecue• 5 years ago

Who is making the profits? Most health insurance orgs, mine included, are not for profit. BCBS, Kaiser, Wellmark, etc

wincy• 5 years ago

Our first daughter was born right as the hospital was changing ownership. They billed the c-section as a natural birth. Cool. Then a year later they called and told us we had to pay the full cost because they’d messed up the paperwork. My wife said that was their problem and she wasn’t going to pay. The hospital maternity ward closed down, and the bill vanished and has never shown up on our credit report six years later, so that’s cool I guess. Telling people you won’t pay and to gleaned you alone works sometimes.

I was unemployed for our second daughters birth (I started a new job a week after she was born) and her birth and subsequent care was all covered by Medicaid. So I guess the best financial decision is to time job changes for births, which really shows how messed up the system is.

bluedino• 5 years ago

Forget the hospital, let’s talk doctors office. I saw a PA for barely ten minutes, I got a $326 bill.

When my wife takes our baby in for a visit, we wait 2-4 hours and get a $200 bill for a routine visit. We get charged if we cancel an appointment with notice or late.

They are always fumbling around with bills. Pay $150 at the visit and get a $80 bill in the mail, and then they bring up a $60 charge from last time.

civilized2• 5 years ago

Once I paid a bill that came the usual 3-6 months after the appointment. A few months later they send me a check in the mail for the same amount as that bill. Then a few months after that, another bill for the same amount as the check.

quasirandom• 5 years ago

bpodgursky• 5 years ago

I don't mean to blame you, but for the sake of anyone reading this -- you could absolutely have negotiated this down with the hospital by pleading financial hardship.

I'm not trying to justify the system overall, but please don't take a $150k bill at face value, if you can't reasonably afford to pay it.

christophilus2• 5 years ago

I just got a $3k bill in the mail for my 6 month old son’s delivery. This is about 4 months after they incorrectly billed us for part of it.

I have the money, but am thinking of fighting it even though it’s such a small sum.

Either their accounting is incompetent or fraudulent, but either way, I’m annoyed enough to push back. I suspect they are trying to fleece as many people as possible to make up for the 2020 budget hit they took.

pxeboot2• 5 years ago

I disputed essentially every bill after my first child was born. Magically, every one was reduced by a substantial amount.

There were literally made up charges they admitted to billing everybody for, but can waive if somebody's insurance doesn't cover it.

No idea how they get away with this stuff. Every hospital in America must have some very good lawyers on staff.

websites2323• 5 years ago

Always always always challenge it. In the American medical system is that the first bill is a first position. Expect to negotiate down, even with insurance, by at least 20%.

It’s time consuming, and confusing, and people will fob you off. But it’s necessary unless you want to get taken for a ride.

Rickasaurus• 5 years ago

Similar here. Had a baby 9 months ago, the doctor took the insurance, but it turned out later the hospital didn't. Bill was over 100K and it wasn't covered at all.

jjeaff2• 5 years ago

I knew about that little caveat/scam going in. So I spoke with hospital billing and confirmed that the hospital did accept our insurance. But I also discovered that any other doctor that works on you during the birth will bill separately and will need to accept your insurance.

I asked the hospital who the anesthesiologist would be and they said they had no way of knowing because you use whoever is on duty when you give birth.

So there was literally no way to figure out if all of the birth would be covered. And it turns out, the anesthesiologist that happened to be working that day was not accepted on our plan. They billed us for $4k (even though he botched the epidural, causing us to need an emergency c section.)

We had to decline to pay it a few times before they said they would work it out and accept the lower amount from our insurance.

fractionalhare2• 5 years ago

Holy shit. Did you pay it? What the fuck...

banana_giraffe2• 5 years ago

I have good insurance through a major company. My SO tripped, and hit their head on a curb on a busy road. I wasn't there, but by happenstance an EMT was there, witnessed the event, and came to offer aid. The EMT was concerned enough my SO ended up going to the hospital.

Several scans, and a few hours later, my SO was discharged.

I then got to spend something like 30 hours on the phone over the course of a couple of months fighting a bill for around $100k because of a typo during the admissions to the hospital.

That's bad enough on the face of it, but there were real Kafkaesque moments. Like where I was explaining to the insurance company that this was not an automobile incident just because there were cars nearby, not once, not twice, but five times, once with a form that asked for pictures of the intersection and made me describe why cars would be stopped at a red light.

tomrod3• 5 years ago

Always ask for the billing and procedure codes, also known as DGN, ICD10, and CPT/HPCPS

Medical transcribing has a high error rate.

tornato7• 5 years ago

That's awful. I hit my head in Thailand and went to the hospital, excellent experience I was in and out in 2 hours, got CT scanned and fully examined by a specialist, then left with a USB drive of my brain scans all for $180 out of pocket.

cameronh90• 5 years ago

I went to an optician for a routine eye test, and they detected something severely wrong with the appearance of my retina and called an ambulance thinking I had a brain aneurysm.

Several hours and CT scans later, I was informed my brain was fine and I just have a strange retina, and will need annual follow up.

I've been sent a letter every year since, inviting me back to the hospital, and every year they tell me it's still fine.

So far I've paid £25 for the eye test (which I completed at a later date!) as I do not get my eye-tests subsidied by the NHS. However my employer reimbursed me for that too...

javiramos• 5 years ago

Funny that you mention wart removal. I once got a $450 bill for wart removal cryosurgery. “Cryosurgery” meant a one second spray of the wart with liquid nitrogen. Outrageous.

Black1012• 5 years ago

The US healthcare system is just a completely broken mess.

That's why I got hospitalization-only insurance as soon as Trump allowed it... Obama-care was a joke... except for the pre-existing condition clause, maybe.

jjeaff2• 5 years ago

There is a very valid reason that hospitalization only insurance was not allowed.

The whole point of requiring everyone to get insurance is so that you don't have just the sickliest and oldest people getting insurance. Insurance is meant to spread the risk amongst everyone who pays premiums.

Additionally, not having insurance for primary and non-emergency care will make it much less likely that people will even end up in the emergency room. (No checkups, no outpatient)

Even worse, having emergency room coverage only encourages people to use the emergency room more often than they should.

Though I wouldn't expect our last president to have much of a handle on economics and business, considering his track record. Either that, or he was purposely trying to destroy the program (he was, but it was probably both reasons).

0xmohit• 5 years ago

The mess is by design.

Goldman Sachs asks in biotech research report: ‘Is curing patients a sustainable business model?’

<https://www.cnbc.com/2018/04/11/goldman-asks-is-curing-patie...>

agumonkey2• 5 years ago

‘Is curing patients a sustainable business model?’

this is some quote...

what's next: "people, what is their true ROI.."

JamesBarney4• 5 years ago

Should we be upset that people can't afford to provide cures we don't want to pay for?

When I work, I get paid. I expect pharmaceutical companies feel the same way.

And if you look at how the world dealt with the hep c cure, it was pretty much trying as hard as possible to pay as little for a cure because the cost was front loaded.

joshspankit5• 5 years ago

The providers should get paid every month that you’re in excellent health.

Imagine how many cheap cures we would “suddenly discover”.

astrange3• 5 years ago

Someone said something somewhere is not actually evidence of anything. Also, the answer is "yes", because new patients are always being born.

Geezus_42• 5 years ago

Like when you go for a normal doctor's appointment, pay on your way out the door and the other get three bills in the mail "because they didn't know how much the insurance would cover when you paid". I have great insurance, this is pure bullshit.

phreack• 5 years ago

In a moment of levity, check out Dogen's dramatization of having a child in Japan as a westerner.

https://m.youtube.com/watch?v=Rl5WSGs5bGs

davidw• 5 years ago

When I lived in Italy, I once went with private care for a thing I wanted taken care of same day. I called, and they told me all the prices. I think I paid something like 120 euros out of pocket for a chest X-ray and consultation with an ENT specialist.

The US health care system is so screwed up.

iagovar• 5 years ago

It's like that in Spain too. If it's complicated you get an appointment, and an estimate afterwards.

ArtDev2• 5 years ago

In Thailand, the hospital lobby has printed brochures with all the prices. It reads like a menu.

I can't wait to return there and be a medical tourist again! The facilities and level of care was superior to my local dive of a hospital that is chronically understaffed.

The hospital president make $980k while currently the nurses are on strike.

19962• 5 years ago

The US healthcare quality is bad, regardless of how much you pay, period.

For knee problems, like you I went to SE Asia as a medical tourist. I was provided with a taxi waiting for me at the airport, a translator who stayed with me at all times, a dedicated hospital administrative assistant for more complex issues like obtaining a copy of my exams, having them send to the doctor of my choice, obtaining the CV of the doctors so I could decide on the best one etc.

But the best was the fine dining options, as I do not like hospital food.

And when I was tired of the hospital and decided an hotel would be better for my mood, the doctor I had selected visited me in my suite, every day - with a nurse. If I wanted anything, I still had the translator the rest of the time.

It's not even a question of costs - that quality of service is just not available in the US, except maybe outside of some VIP setting where it may be shiny but the healthcare is mediocre (friends strongly recommended against such options)

Years later, I no longer have to care about costs, but I still won't go to a US hospital.

thesimon• 5 years ago

Same goes for Germany. The prices for doctors are fixed, so you can kinda look up how much a treatment would cost.

flemhans2• 5 years ago

I remember people in Germany being upset that you have to pay €10 for a consultation.

AndrewKemendo2• 5 years ago

Has anyone aggregated hospital cost data yet or is it something that is only there if you ask for it? Are there hospital APIs for this?

Not that they are mutually exclusive, just that I wouldn't imagine a pricing service exists yet if it's just manually gotten.

mklauber1• 5 years ago

Take a look at this: https://www.dolthub.com/repositories/dolthub/hospital-price-... It's not a nice interface, but it's raw pricing data for 1400 hospitals.

AndrewKemendo2• 5 years ago

Awesome thanks!

BeetleB2• 5 years ago

A cautionary note: Don't assume that the low price is "what it really costs". It often happens that hospitals lose money on negotiated rates with some insurance companies, and have to find other ways to recover that money (e.g. high prices for other procedures).

So the lower rate in the Chicago hospital of $4613? Quite possible the hospital is losing money when they bill that rate.

zuhayeer• 5 years ago

Always thought it'd be cool to have a levels.fyi for different operational costs across various hospitals (obviously insurance and different coverage makes it a bit complicated and tricky but would still bring a lot of transparency across the board)

cm2012• 5 years ago

I've been ignoring surprise medical bills for 10 years, at least $10k worth altogether. None have reported to credit bureaus yet so I will continue to ignore letters.

agumonkey2• 5 years ago

I had a funny interaction with accounting, not for medical services but import.

I got billed extra taxes like 100$ (for a 80$ item), even though the seller said price included import fees to my country, so I bounced complaint emails all around to say no. After a while they stopped responding. Then 6 months later, lawyer official letter comes in. Threats of legal action.. I do the same email bouncing to them. After a while I suggested I paid 20$, the guy handling my case asked me to confirm that, a week later they sent me a new bill with 100$ fees and 80$ rebate.

There's no ground in their actions, at any point some dude can edit the documents and consider the issue resolved.

rscho6• 5 years ago

People here comparing medicine with car mechanics don't have the slightest idea of what they're talking about.

The US system is in the hands of the administrators. Not docs, not even the govt: administrators, usually belonging to a behemoth (private) company that has immense and intrinsic lobbying power due to the nature of the industry. There can be no shortage of buyers. Well, admins wanting to earn more just have one thing to do: reproduce by complexifying the system. Private healthcare is a garbage fire.

tdeck• 5 years ago

That's not entirely true; doctors have massive political and financial power. The AMA is run by doctors and has consistently lobbied against government funded healthcare for more than a century. They killed FDR's and Truman's proposals and lobbied hard against Medicare and Medicaid in the 1970s.

rscho6• 5 years ago

Docs have power over their own turf (losing ground to admin every day that passes). They incidentally absolutely do not have power over the billing scheme in it's entirety, especially since healthcare juggernauts like Kaiser have appeared. Today, docs are really a small part of the problem but people stay fixated on them both because of envy and because docs are used as strawmen by big healthcare, whose stakeholders have every reason to reduce docs into slavery. Docs use the AMA to avoid being converted into Amazon warehouse workers? Big surprise.

refurb5• 5 years ago

No, it’s not private healthcare that’s the issue, it’s the absurd layer of regulations that were developed over the past 70+ years. Typically some inefficiency was addressed with regulation that just created a new inefficiency.

To give you a good example - 340b is a govt regulation that requires drug manufacturers to give a 23% discount off drugs to hospitals that treat a lot of low income patients. Great idea right?

Well, that just incentivized hospitals to buy up standalone oncology clinics, fold them into the hospital and then capture that sweet 23% margin on drugs without actually using it to help low income patients.

As a result there are almost no community oncologists now, they almost all work for hospitals and good luck starting your own clinic now.

Good intentions that just made the problem worse.

rscho6• 5 years ago

In my book, the problems begin as soon as the healthcare system is required to be lucrative. And don't tell me not-for-profit hospitals are not lucrative. It would be even worse without regulations. Care providers would illegally organize into cartels (which is of course already happening) and going to see the doc would then really just be like bringing your car to the garage, with all the 'niceties' that go with that. I don't expect to convince any free market proponent, since to really grasp what I mean by all that those people would have to experience the private system from the inside (as I do). Private interests are very much the problem. Healthcare should be a public service.

narrator• 5 years ago

Kaiser is the only non-broken part of the U.S healthcare system. They have never sent me a bill for a surprise out of network anything. Out of network doctors don't work there. All doctors are on salary. You get one bill from one company. No wonder they have been growing like crazy in California.

CGamesPlay• 5 years ago

They have sent me a bill for non-preventive services which should have been billed as preventive (aka free), but to their credit I was able to get them to refill with a not-too-tedious phone call.

dilyevsky• 5 years ago

Kaiser is amazing. Other than no surprise bills that you mentioned they also have your full history that is accessible to all doctors and to you. Also no scammy $200 new patient copays etc

throw1231231238• 5 years ago

Kaiser is popular and 'a' model of care, but do note that it is extremely limited in coverage and is one of the most draconian in respect to providers.

They hire people right out of medschool with the offer to pay their entire student debt if they stay with them for 8 years. They have massive burn out.

wbl• 5 years ago

Kaiser promptly volunteered to perform several minor surgeries I would have spent months hunting down preauthorization for other places. It was almost scary how efficiently they bumped me up to the right person with me having to do almost nothing to arrange it.

disabled3• 5 years ago

Yeah, if you have a rare disease, which 7-8% of the general population collectively has (there are about 8,000 or so rare diseases), for example, then you are totally screwed if you have an HMO. Rare diseases are difficult to treat, frequently involve multiple systems of the body, often require many off-label non-FDA approved treatments, and require specialists that are often in niche fields of medicine.

Gravityloss3• 5 years ago

Hmm is that kind of a contract legal? What happens if a person leaves after four years?

ironmagma• 5 years ago

To say they work is a bit doubtful. Because they are both the insurance and the doctor, there is an incentive for them to find nothing wrong with you.

refurb5• 5 years ago

The incentive is the opposite. Kaiser gets a fixed premium from its patients no matter how much or how little care they get.

refurb5• 5 years ago

Kaiser is an integrated provider - both the medical care and insurance so any billing, approvals are all internal.

The only issue I’ve heard is mental health care which is apparently quite lacking at Kaiser.

kelnos2• 5 years ago

Kaiser members I know who have needed mental health care have found that part of their system to be atrocious.

Sure, maybe the billing part of it is still great, but the care itself is not.

ryanbrunner3• 5 years ago

From the perspective of most of the world, having to limit yourselves to medical care that's provided by a particular company seems very broken. (unless I'm misunderstanding how Kaiser works).

I can just go to whatever walk-in clinic, urgent care provider or emergency room I need, depending on the severity and get treatment (I do try to go to my GP if possible, but I have many options if that's not practical for some reason).

leetcrew3• 5 years ago

From the perspective of most of the world, having to limit yourselves to medical care that's provided by a particular company seems very broken.

from the perspective of some people in the US, this is exactly what socialized medicine looks like, except you can't change the company.

Balgair• 5 years ago

I agree, Kaiser is very very good for the US. However, they tend to be more of a 'standard' care kind of thing. Like, broken arms, colds, pregnancy, all good under Kaiser. But harder things like cancer, ALS, Parkinson's, it's a lot tougher for them to get you the right treatment. This, unfortunately, I know about as people close to me had to leave Kaiser to get dealt with.

That said, Kaiser is still my gold standard for the US.

benlivengood• 5 years ago

Healthcare is such an asymmetric market that there will never be enough information for patients to price things accurately.

It's like if every road we drove on had a different toll every time we travelled on it, and we didn't quite know what the total would be (or what construction projects you might encounter along the way) at the end.

It's made worse by the high value people put on their health and their low knowledge of healthcare in general.

I worked in a hospital for 13 years, most of it on the billing and medical records systems. There was a single project I recall that tried to do price estimation for patients up front. It worked best for lab draws because a fixed number of vials were drawn for a finite number of predetermined tests. Anything beyond that involved human judgement at the time of service:

A doctor decides which X-ray views they want taken after seeing an injury, and may need to order more after the first results, and the radiology tech has some leeway in how they actually perform the imaging. A choice between X-ray, CT-scan, and MRI is pretty much an order of magnitude difference in costs between each, and determining whether an injury is bone, soft tissue, organs, etc. may require any or all of them.

Surgery is wildly unpriceable. The number of shots of anesthesia will differ for weight, metabolism, actual length of a procedure, and individual reactiveness to the medication, and the anesthesiologist may need additional medications to stabilize a patient's vitals. Each surgeon is making similar decisions as they go along; all of it has a cost and some tools/medicines are pretty expensive but no good surgeon will have price in mind during surgery; they'll use the best available method.

The article wants to blame insurance companies for price variation but that's a bit of a red herring. Every clinic and hospital does different numbers of various procedures and has different patient demographics so outcomes and severity will vary. ERs and cancer treatment are notorious cost-centers, whereas radiology services and outpatient procedures are the money makers. Hospitals and clinics have no choice but to pick and choose a set of services each year to raise or drop the prices for even before negotiating with insurance companies on actual reimbursement. Medicare and Medicaid also reimburse at (even lower) fixed rates so hospitals are always balancing costs for the number of commercially insured patients against government insured patients. Hospitals can't refuse emergency service to anyone, so they're also forced to eat the costs if they don't play the pricing game to cover ER and subsequent treatment costs.

The whole thing is a terrible mess and socialized healthcare is the solution.

maxerickson4• 5 years ago

CT scans in India cost ~$100.

US prices for imaging aren't based on the cost.

datavirtue4• 5 years ago

This was a key thing that needed to happen for a long time. Insurance companies had no bargaining power with hospitals and price opacity helped secure that leverage for the hospitals.

This is the only sensible thing I can recall to emerge from the Trump administration and it is a much bigger deal than most people realize.

datavirtue4• 5 years ago

I mentioned that Trump accidentally did something good and got downvoted to zero. Same comment without Trump mention gets up-voted. Interesting and disturbing.

datavirtue4• 5 years ago

Happened again. What a lovely community.

torgian• 5 years ago

Meanwhile in developing countries, health care is hassle-free and low cost.

I spent 24usd for an invasive procedure and meds in Taiwan. I’m honestly happy I left the States years ago because I’d probably be in debt at this point.

kelnos2• 5 years ago

Taiwan isn't a developing country.

yhoneycomb• 5 years ago

Yea wtf lol

Honestly, by many measures Taiwan is more advanced than the US.

swayvil• 5 years ago

There is only one local dentist that will take my broke person's insurance. And they are notorious for messing up people's teeth.

And I think I have a cavity. Dang.

primitivesuave2• 5 years ago

I'm the technical cofounder of a mid-sized healthcare startup, and when I start explaining hospital administration to people, I start with this - every person working in your hospital or clinic has no incentive whatsoever for you to emerge healthier. The only goal is to maximize the ratio between the amount your insurance is willing to pay, and the amount of care that is provided.

In the case of joint replacement, each insurance provider has negotiated a fixed block payment for all costs related to the surgery. If the surgeon makes a mistake, or the patient doesn't follow along with physical therapy, or something goes wrong for whatever reason, the care provider is financially responsible for any corrective actions on the procedure. This means any complaint in a follow-up visit is usually met with some kind of platitude to make you go away, like "here is a prescription for some pain medication, let us know if the problem persists". There is no incentive to do any scans or tests, since this would eat into the profits that the hospital has made on this patient.

For certain GI surgeries, patients are instructed not to eat solid food for a week or two after surgery. A certain percentage of people ignore these instructions and end up in the hospital ER requiring another surgery. In the last couple years, providers of these treatments have learned how to bring that percentage down by hammering post-op patients with daily email/SMS messages to ensure they are educated about their procedure. These systems were not put in place by someone at the hospital who wanted patients to be better informed, they were put in place because someone noticed that percentage and calculated how much money the hospital could be saving for each percentage point in reduced readmission.

I have heard good arguments against Medicare-for-all, but I have never heard any logical argument to defend the status quo.

Spooky232• 5 years ago

In helping with a family member struggling with a very serious medical condition, the only incentive I’ve been work is the stick.

The Medicare incentives to kick patients out of rehab is very effective, to the point that it’s a cruel game for families operating under the mistaken assumption that healing is a goal.

In the hospital, the only urgency outside of acute/intensive care that I saw was when my family member was readmitted due to incompetence on the part of the hospital, and ended up costing them thousands of unremimbursed dollars.

RIDDLERTHIS• 5 years ago

I worked on the tech-side of healthcare informatics with researchers and healthcare economists. What you say is correct. The cost/benefit ratio of hospital admittance and hospital stays has been quantified to an alarming degree. Not that we shouldn't be looking at such costs, but I feel as though it should involve some level of humanity. The other, often overlooked angle of healthcare in the U.S. is the dynamic at play between for-profit and non-profit hospitals. Both of which require and actively seek profit of course. As others have stated - we need a complete overhaul of the healthcare system here. Something that would require a Teddy Roosevelt-esque stature of a man (or woman) to get started.

bitdizzy2• 5 years ago

It won't be a great person who saves us.

fineIllregister• 5 years ago

I'm not following your example. I don't want to end up in the ER requiring another surgery. If the provider can do something such that I can avoid that, I feel that's healthier.

So the provider "hammers" me with reminders which makes that less likely to happen. Sure, they might not be doing it out of the kindness of their hearts (I've worked in a hospital and many people definitely do want patients to be healthier, but that's neither here nor there), but it seems like they're "incentiv[sized] for you to emerge healthier."

ianai• 5 years ago

It’s the counter example that makes the point. The only reason it seems a better outcome is coincidence.

sircastor• 5 years ago

I think the point being made is that a patient’s health is a adjacent to the effort the hospital administration is putting in. The incentive isn’t “keep the patient healthy”, it’s “keep the patient from costing us money”

gregsq2• 5 years ago

My mother lives in country australia and had pancreatitis it seemed. Hospital, cat and mri’s, spent a week in hospital, sent home, returned after pain returned. More tests, it was decided she should be sent to a larger regional hospital for biopsy. Flew by Lear jet, drove by road home I guess about three hundred miles. Advise was a Whipple procedure. I wasn’t inclined to agree for reasons I won’t go into. I declined before second opinion from brisbane world class surgeon. He agreed. Flown commercial to brisbane. More mri’s and cat scans. Acinar cell carcinoma suspected. No need for full duodenectomy. Hospital stay and operation. After care and so on. Total cost zero. I live in the US. Healthcare here is a grift. The wife did medical billing, mostly reconciling and working all the codes. It’s a complete mess

aantix3• 5 years ago

“Total cost zero”.

The cost is never zero. Doctors, nurses, don’t work for free. Infrastructure isn’t maintained without money. It comes from somewhere.

Gatsky• 5 years ago

Yeah it’s pretty good. You can walk into any hospital in Australia and they’ll just look after you and try to do their best to help you. You won’t be asked to pay anything, except maybe some pharmacy fees. Novel concept. And there is also the private system if you want alternatives.

Problem is, I don’t think it’s going to last. The ageing population means health costs will spiral, and health budgets will consume an unsustainably large proportion of revenues.

Fomite2• 5 years ago

The infection control people do, because those won't be reimbursed.

disabled3• 5 years ago

I start with this - every person working in your hospital or clinic has no incentive whatsoever for you to emerge healthier. The only goal is to maximize the ratio between the amount your insurance is willing to pay, and the amount of care that is provided.

This is the gist of American healthcare.

A good read from someone who had a medical crisis, from a series of medical errors, is "Our Malady" by Timothy Snyder. He took great notes in his personal diary when the whole ordeal occurred and was able to trace back the errors, unlike most people. He also nearly died. He is a renowned American historian who is a scholar of European history, and particularly of eastern European history.

Anyways, the third leading cause of death in the US is believed to be preventable medical errors (you can also google "3rd leading cause of death preventable medical errors" and find other sources which corroborate the findings of this peer-reviewed journal article): https://www.bmj.com/content/353/bmj.i2139

When it comes to longevity of the human lifespan, as in life expectancy, by country, the US is about to soon mirror Croatia (I am a dual US|EU [Croatian] citizen). You know, that war-torn eastern European country that went through a nasty war in the 90s. Anyways, I am proud of my country, I mean Croatia. But, as Americans, we should be ashamed.

U.S. life expectancy will soon be on par with Mexico’s and the Czech Republic’s: https://www.washingtonpost.com/news/to-your-health/wp/2017/0...

(non-paywalled version: https://archive.md/3EpBi)

Anyways, there are countries with national health insurance ("socialized medicine") and there are also countries that have universal health insurance coverage (guaranteed issue health insurance, which you are required to have under law).

From an access perspective Germany is very similar to the US, and has universal health insurance coverage. Switzerland has a system closer to what we have in the US, with respect to both access and privitization, and they do not seem to be having the problems that we have in the American healthcare system.

Just some food for thought...

LocalH• 5 years ago

It's almost like certain things should be exempt from the "profit first" mentality that is pervasive in capitalism.

bane2• 5 years ago

The U.S. healthcare system cannot be fixed. Period. Full-stop. The only solution is to nuke it from orbit, pave it over, and start again. It's very easy to point the finger at the conservative party as the one who's screwed it all up, but the other parties are not really putting forward models for successful healthcare systems.

If one were to sit down and try to create the most absurd approach to healthcare that guaranteed high cost and poor outcomes you couldn't come up with the idiocy that our system has become. It's completely untenable, a failure at every single level from medical school to funeral services. The fact that there are so many smart people working in healthcare defies belief in the absolute fucking disaster it is.

Even in the interaction between health providers and insurance companies, the billing practices have moved so far beyond fraud and are so widespread that nobody can even comprehend or describe how fucking broken just that one part of it is.

Without getting into details, the healthcare industry is absolutely mortified of a law that requires them to provide patients expected costs before care and to publicize those cost for comparison. I can't believe that some startup hasn't glassdoored billing practices yet by patients simply uploading screenshots of their bills when they get them.

note we just went through a bizarre medical experience where surgery was billed out at a total of something like $70k, the "negotiated" price was more like $7k, and we payed out of pocket something like $700.

At one point the insurance company turned down the bill from the surgeon, who promptly simply submitted a bill from a "surgical assistant" who we never met or knew existed for the exact same dollar amount which was also denied, and then resubmitted the original bill which was approved and promptly "negotiated" to 10% of the original bill amount in the end. In the meanwhile we had absolutely no idea if we owed $30k for this bill, $30, $300, or $300k. No idea at all.

It beggars belief that congress, who is mostly made up of people who are obviously experiencing their own medical journeys, can't put together some easily bipartisan approaches to price visibility.

zie3• 5 years ago

Senators and congresspeople get their own very high quality insurance. They have no incentive to fix it, their own health care is world-class.

bane2• 5 years ago

That's too easy an answer. They get basically the same options for health insurance as other federal employees. And that insurance is not materially different from the insurance you'd get from any other major employer.

pxeboot2• 5 years ago

Many companies maintain VIP lists to provide better service to celebrities and politicians. When a senator calls Comcast, they are not talking to the same call center the average customer is.

mbg721• 5 years ago

Having high-quality insurance doesn't really fix the issues with US healthcare; you can still go broke with decent insurance, and the billing only gets screwier the more middlemen are involved. (Congresscritters' real insurance is that if their particular claims were denied, it would be newsworthy.) We know that our healthcare system is messed-up, but we're wary of socialized medicine because we've seen failures everywhere that Washington has been involved so far. The middle-class expects a result not like some well-run Nordic paradise, but more like what we already have, only with more forms and longer waits.

nitwit005• 5 years ago

The U.S. healthcare system cannot be fixed. Period. Full-stop. The only solution is to nuke it from orbit, pave it over, and start again. It's very easy to point the finger at the conservative party as the one who's screwed it all up, but the other parties are not really putting forward models for successful healthcare systems.

I wouldn't say the Republicans are fully responsible for the state of things, but they can't seem to agree within the party on a basic concept. I recall John Boehner saying he laughed at Republican promises to swiftly repeal the Affordable Care Act, commenting "Republicans never ever agree on health care". And, well, he was proven right.

If you can't unite your party on a big fix, then the only thing you can pass is some sort of limited fix, which tends to just add more complexity to the whole thing over time.

primitivesuave2• 5 years ago

I agree with your initial sentiment completely. I joined my current cofounders (from medical/business backgrounds) for a health tech startup, sold on the dream of saving lives with technology. If my CEO didn't play the game by the absurd rules that are in place, I wouldn't have enough financial incentive to swallow my idealism and stick around.

My point being, there are plenty of smart people in this system building cool features and chalking it up as progress, but we don't have any power to institute any kind of fundamental change. No healthcare leader will ever acknowledge the flaws in the system, because the people who get promoted up the bureaucracy are the ones who know how to play the game. The people at the top are the champions of collecting the maximum amount of money for the minimum amount of care.

gremlinsinc• 5 years ago

What about an intra-hospital alliance of sorts, basically build a software platform that covers billing/etc and turns your local hospital into the insurer.

You pay 5% of your income for example. If you're traveling they pay the other hospital, either at the normal ins. rates or the rates that hospitals...

Example: All the hospitals in utah join. I live in a small town with 45k people.

Only hospital in the county, which is about 60k people.

So the hospital gets 60K * 5% of income - Medicare/Medicaid who would be billed normally.

They get this monthly so they could budget their bills by this income.

Anyone traveling who gets sick in their location the hospital they are subscribed to pays their bill. Hospitals in the network all agree on pricing schemes that are fair so there's really no gouging or alternative prices. Since the payee is other hospitals and they could be on the other side of the price for patients it makes sense to make it reasonable.

Localities could require all residents move to a hospital as insurer model to make the system more streamlined. A tech provider would create software / erp that automatically does the billing so basically you replace billing people on both sides of insurance.

There's probably a lot of small quirks I'm unaware of... but this seems like it could work the larger (multi-state/all 50 states) the network as a whole they could even have significant power to bring down drug prices and equipment purchases for MRI machines/etc as basically a big union of healthcare providers.

Primary care physicians would basically get a "cut" of the subscription monthly + co-pays.

You could pick your "regular" Dentist, PCP, Eyecare, and other "centers" you go to at least a few times per year, and they could divy out funds to them on a recurring basis for the same goal of creating MRR for small healthcare providers locally.

disabled3• 5 years ago

Remember this. This is actually a very good reason to emigrate from the US, even if you have to pay US taxes for life.

If you look at the predicted life expectancy of an American in 2045 for example, you would know it is time to be "making plans". You would also know that the price differential on salaries between America and other places in the world as a person in STEM is not worth the payoff long-term. Plus, you cannot put a price on your health. This is just one eerie statistic, for example: Medical error—the third leading cause of death in the US https://www.bmj.com/content/353/bmj.i2139 You cannot evade a statistic like that by going to the "best hospitals" or by receiving the "best healthcare" in America, or by having "good insurance".

By the way, I did become a dual US|EU citizen over American healthcare, as somebody who is chronically ill with 2 rare immune-mediated neurological diseases affecting my peripheral nervous system, plus type 1 diabetes (autoimmune and insulin dependent).

yibg• 5 years ago

The system is working very well, just not for people you think it should be working for.

tim333• 5 years ago

The medical part of the healthcare system - doctors, hospitals, the machines that go ping[0] - seem ok. It's the financial side - insurance billing and so on that needs nuking.

Talking about bombing stuff Wikipedia has:

Charles Webster, official historian of the NHS, wrote in 2002 that "the Luftwaffe achieved in months what had defeated politicians and planners for at least two decades."

[0] https://youtu.be/arCITMfxvEc

nunie123• 5 years ago

I can't believe that some startup hasn't glassdoored billing practices yet by patients simply uploading screenshots of their bills when they get them.

I believe this is what Sidecar Health is working on: https://sidecarhealthinsurance.com

QuantumGood• 5 years ago

I had to check myself out against doctor's wishes after a serious heart incident. They kept sending doctor after doctor in to "consult"—each one adding a huge fee to the final bill. The hospital's "billing assistant" was NEVER available, after days.

I became informed on additional tests they considered doing, and eventually arranged for related tests outside the hospital to determine if the tests they were going to do were necessary. They were not.

Bill was just under $60,000, ~$8,000 deductible, paid the deducible in one lump sum and negotiated a 25% discount. A partner at a medical firm told me they are only paid 75%, so it made sense to him that I could negotiate a 25% discount.

BadassFractal• 5 years ago

Another example of how bananas the system is: when I go to order prescription refills through my health care provider, it is currently unable to tell me how much it's going to cost me. You're expected to say "Ok, charge me whatever these cost" and then, I suppose, call customer support if you don't agree with the price you were charged that day.

I don't know if there's some kind of a "price of the day" marketplace calculation that needs to happen for the provider to find out the current prices, but that's pretty odd. It's like buying stocks or a Dungeness crab dish at a restaurant.

mattmcknight• 5 years ago

A simple change- providers offering the same transparent price to all patients would make things so much simpler. (and by this I mean different providers could charge different prices, but one provider can't charge different patients different prices.)

It removes the whole in-network/out-network scam. It removes the whole process of negotiating prices with insurers.

Transparent pricing is the baby step in this direction that reveals the problem. The hope was that it would at least provide negotiating power for payers when they see what the other payers are getting. Let's just take the next step and make them commit to pricing ahead of time.

alexanderdou• 5 years ago

I work in the space (specifically, on the Payer/Health Insurance Co side) and this is my current bugaboo

From best I can gather, there are a handful of High-Level issues. But for the sake of brevity, I'll highlight what I think is the biggest:

The data requisite to make a confident estimate lives in many different parties' databases. To make an estimate, you would need: (1) Full List of Procedures and Services to be done (keywords here: CPT and ICD codes); (2) Contracted Rates between Payer and Provider; (3) Patient's Deductible, OOP Max, and Plan Benefits; (4) List of which services require Pre-auth

(1) lives with the Provider

(3) and (4) live with the Payer

(2) lives in between, but is also a huge problem because it's a many-to-many sort of relationship (many Payers have many contracts (e.g. annually re-negotiated contracts) with many Providers)

Hospitals lift curtain on prices, reveals giant swings for hips, knees and more

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