I analyzed hospital price lists so you didn't have to

https://www.dolthub.com/blog/2022-07-01-hospitals-compliance/

592 388 4 years ago

anonu• 4 years ago

Toothless law. What article writer should do is just shame the hospitals who don't comply. Tweet at them and make it known.

ceeplusplus• 4 years ago

It really is a toothless law, the hospital probably makes more surplus profit from price discrimination in a single week than their entire fine for the year. The damages should be increased 100x.

causality0• 4 years ago

In my fantasy world there's a full-on constitutional amendment demanding that any monetary fine must meet or esceed the profits gained by breaking the law.

amluto2• 4 years ago

I would advocate a more direct form of damages: a hospital that does not comply may not charge more than the minimum over all hospitals in a 500 mile radius for any procedure. A hospital that does charge more and is caught must refund double the difference. Furthermore, no contractual provision may penalize patients for attempting to seek that double refund, and a class action lawsuit to recover the difference that actually goes to trial recovers triple instead.

Hospitals will comply immediately :)

yborg• 4 years ago

Not only that, but it costs money for the hospital to make the chargemaster available, deal with people asking about it, etc. If the fine is really just $900K, if I was a hospital CFO I'd pay that every year without a second thought, or even work up a service charge to add to all hospital billing a la the "Federal Access Charge" AT&T puts on phone bills so I can get people to blame the government for $15 Motrin tablets in the hospital.

mancerayder2• 4 years ago

What's more toothless than tweeting? Words don't hurt the pocketbooks all that much, especially of hospital groups.

A NYT article about the hospital I'm not even certain does very much.

mgleason_3• 4 years ago

Interesting to read that only 33%-50% of hospitals comply with the law and post their prices. If there's one thing this country needs to do it's demand transparency everywhere.

Especially our government. Spending. Salaries. It all needs to be public.

khuey• 4 years ago

Especially our government. Spending. Salaries. It all needs to be public.

A lot of it is. In California for example you can go look up any public employee's compensation at https://transparentcalifornia.com/

pengaru4• 4 years ago

W T F

https://transparentcalifornia.com/salaries/2021/gateway-comm...

screye• 4 years ago

What's up with those million dollar benefits ? What could they possibly be spending those on ?

softwaredoug2• 4 years ago

Especially our government. Spending. Salaries. It all needs to be public.

This is especially useful for valuable gov't employees that want to negotiate a higher salary :) Totally fine by me, but just be aware you may not realize the second order effects. The primary people that care may actually just be the employees for pay fairness

d4mi3n• 4 years ago

The US government is the last entity that should be playing games with salary negotiations. The G payment schedules are well established and can be updated. If they need to figure out other ways of providing a salary, they can update the existing schedules or make a new set that is also publicly available. If I’m paying taxes to provide a salary for a federal employee, I want that to be recorded, publicly accessible, and for there to be a controller somewhere accountable for how they money is allocated.

vlovich123• 4 years ago

What is the penalty for non compliance?

pc866• 4 years ago

CMS just fined some hospital $900k. So it's not nothing.

cheschire• 4 years ago

https://www.fedsdatacenter.com/federal-pay-rates/

A fairly searchable database of individual salaries

cycomanic4• 4 years ago

Reading this thread and watching the US news in general, transparency is pretty far down the list of things the US needs.

rinze• 4 years ago

What a strange concept, "hospital price".

nwienert• 4 years ago

There’s always a price, you just may not pay directly.

hunterb1233• 4 years ago

Why? What do you think pays for the "hospital cost"?

(That's not to say there aren't MANY opportunities to reduce the price and cost, starting with complying with the law to post prices, which many hospitals don't adhere to because the current administration isn't enforcing the EO)

beeboop2• 4 years ago

Pretty sure he's just writing commentary on the US not having a single payer healthcare system

petilon• 4 years ago

Spoken like an American. In other countries where healthcare is not paid for by the government, the prices are readily available.

Here are some examples:

https://www.ktph.com.sg/patients/hospital-charges

https://www.sgh.com.sg/patient-care/visiting-specialist/char...

refurb8• 4 years ago

I was going to say. Singapore has universal healthcare and they want all patients to have “skin in the game”.

So even if you’re destitute you need to pay something within your means, even if it’s $5 for a hospital stay.

Someone1234• 4 years ago

When High Deductible Insurance was introduced the supposed concept was to "give employees a stake in their costs, and therefore lower them for both employer and employee."

However, even today doing so is very challenging, and before laws like this it was essentially impossible. There's no way to shop around American healthcare, with the system itself working against you at every turn (e.g. doctors prescribing named brand, and you not be allowed to switch back to generic without another $100+ appointment).

You can try calling and getting quotes, but they'll just waste a bunch of time and then give you a RANGE with no assurances. Even getting the quote requires your doctor to write up the entire work-order, which itself can get pushback, and or cost money.

Then you have random things like for-profit life flights, which are automatic bankruptcy machines. Imagine one minute driving down the road, then suddenly waking up in a hospital, and then getting billed $80K for just the trip to get there let alone your hospital treatment or recovery. And insurance doesn't cover it.

Aside but all ambulances around me are "out of network" and don't work with insurance at all. So I guess I should shop around by moving cities..?

mancerayder2• 4 years ago

I believe some states regulate that better than others. At the least, some prevent 'surprise bills' where the provider selected is out of network while the referer is in network. That's just not fair when you're unconscious or suffering.

bbreier• 4 years ago

It's complete nonsense even when you're conscious and fine!

maxerickson5• 4 years ago

CMS took administrative action this year to try to improve those situations:

https://www.cms.gov/nosurprises/consumers/new-protections-fo...

javajosh3• 4 years ago

So I guess I should shop around by moving cities

No, the solution to most social ills in America is to simply not be poor. If you are poor, stop it. Then you don't have to worry about any of this. Consider abortion, a procedure now outlawed in many US states. If you're not poor, you can just pay to travel to another state or country, have the procedure, do some sight-seeing, and come home. The law has no de facto effect on you. Same with every aspect of healthcare. So, just don't be poor and you'll be fine. (Even better if you are connected to the wealthy and powerful in your city & state. It is very nice indeed to be a VIP in an American hospital, court, or anywhere else.)

GiorgioG• 4 years ago

The other solution is simply not to be sick. If you're sick, stop it. Welcome to America.

leeoniya• 4 years ago

cancer treatment costs can make anyone poor. just sayin'

cyanydeez2• 4 years ago

Or don't be racist and rebuild the social safety net

Americans desocialized because of equal rights.

JumpCrisscross3• 4 years ago

the solution to most social ills in America is to simply not be poor

American healthcare works well if you have money and better than anywhere else in the world if you have money and a chronic condition. If you get in an accident, however, particularly while away from your posh neighbourhood, you’re getting the same overworked, hyper-indebted surgeon as the homeless man. (If you’re a billionaire or head of state, that’s different, but that’s different everywhere.)

gumby• 4 years ago

No, the solution to most social ills in America is to simply not be poor. If you are poor, stop it.

Those people deserve it. I mean, some people chose to be born to wealthy parents; if you were too lazy to do that why should I have to reward your laziness by paying to look after you? Really, some people can be so selfish!

It is very nice indeed to be a VIP in an American hospital

My gf had a life threatening illness and went to Stanford hospital. They gave her the special blanket just for Stanford Faculty so she'd get the VIP treatment. Which in practice meant nothing. Thankfully she survived; now I wonder if I should be glad or not that VIPs get the same shitty health care there as everybody else.

spaetzleesser2• 4 years ago

"No, the solution to most social ills in America is to simply not be poor. If you are poor, stop "

In healthcare not being poor is sufficient. You actually have to be quite well off in order to not worry about cost.

flatline• 4 years ago

I think the abortion case is more problematic than this. The laws raise a high barrier to entry, not just financial, but logistical and social. You can leave to get an abortion if you have the money, but there will be a fine on you, and you have to make travel arrangements for a very uncomfortable medical procedure. Poor people still have other, riskier options available.

nostromo• 4 years ago

the solution to most social ills in America is to simply not be poor

No, the solution is to be either poor or well off. The lower middle class are the people that have the most to worry about in the US healthcare system.

briHass• 4 years ago

doctors prescribing named brand, and you not be allowed to switch back to generic without another $100+ appointment

I'm not sure this is that common, unless you have an adversarial relationship with your doctor. It's actually the opposite: in most states the Dr. must write DAW-dispense as written or 'name brand only' to get the expensive brand. Otherwise, the pharmacist can and will substitute a generic if available.

I've always found docs to be very willing to work with you on budget issues. If there's a similar med that is available in generic where their original recommendation isn't, they're happy to switch.

legitster6• 4 years ago

Fun fact, your pharmacist is allowed to change your prescription in some states! Try asking them if there are cheaper generics.

shusaku2• 4 years ago

Aside but all ambulances around me are "out of network" and don't work with insurance at all. So I guess I should shop around by moving cities..?

That’s rather disturbing, and from a purely pragmatic point of view, you might consider raising a fuss with your employer…

IncRnd• 4 years ago

The Pharmacist is a doctor and can offer the generic version. They do that regularly. There is no need to go back to the original doctor you saw.

closewith2• 4 years ago

That depends on your state and country. It's certainly not universal.

hotpotamus• 4 years ago

I feel like if your response when I ask you the price is, "I don't know", then my response is, "well then I don't know if I can/will pay that". A friend of mine with limited means says his medical plan is just to go the ER and give them a fake name - he came up with it after suffering a head injury (pool cue to the head) and being unable to remember the details of his treatment. I don't think it's a good system, but it seems to be the one we've got.

ethbr0• 4 years ago

For reference, the legal grounding of this is EMTALA: https://en.m.wikipedia.org/wiki/Emergency_Medical_Treatment_...

Which basically summarizes as "EDs that accept payments from Medicaid are required to at minimum stabilize all patients, regardless of their ability to pay or several named statuses."

oneoff786• 4 years ago

When High Deductible Insurance was introduced the supposed concept was to "give employees a stake in their costs, and therefore lower them for both employer and employee."

Funny, I always thought it was just squeezing every last penny out of customers without letting them feel like they didn’t have health insurance for big ones

duffpkg3• 4 years ago

The primary cause today of doctors prescribing name brand medications without the ability for substitution of generics is a form of institutional stupidity. EMR prescribing systems are driven by a common "formulary" that has an entry for each drug and defaults. Often the people that define formularies are a weird mix of technological people that don't know anything about the drugs/medicine and medicine people that don't know anything about the technology. The checkbox for the formulary entry that defaults to "allow substititions" is not properly set or is defaulted to disallow them.

Also this reminds me of one of the more evil things I have ever seen in healthcare. Practice Fusion gave doctors a "free EMR" because it was being paid by opiate pharmecuitcal companies to create an electronic EMR workflow that intentionally increased unecessary opiate prescribing. Absolute evil in my opinion.

https://www.justice.gov/usao-vt/pr/electronic-health-records...

jjoonathan2• 4 years ago

institutional stupidity

If you are a hospital, and you are shopping for an EMR to maximize revenue, is that a feature or is it a bug?

Evil, yes, stupid, no.

colordrops• 4 years ago

give employees a stake in their costs, and therefore lower them for both employer and employee

The idea wasn't to get people to shop around, at least in my opinion, but rather to not use healthcare altogether unless absolutely necessary, because they feel the cost of the services more when they pay for the directly.

bsimpson3• 4 years ago

I broke my foot recently. Calling around and asking for quotes ranged from a straight up "I don't know" to "Here is the cash price. We won't know your HDHP insurance price until after we bill them, which could be good for you or could be bad. It will probably be bad, because there are more middlemen."

I tried paying the cash price. They inadvertently billed my insurance anyway. Turns out, I actually saved like 33% using the insurance price ($180 vs $120 for an xray + analysis).

They said the only way to get a copy of the x-ray was to pay $5 for a CD. None of the computers I still use have a CD reader.

The whole system is such a clusterfuck. I understand the aversion to giving a governmental bureaucracy more control (esp over something as important as healthcare); however, it's hard to imagine a worse way to pay for care than what we have now.

dheera5• 4 years ago

I just got billed $5000 for a routine echocardiogram at Stanford, and in the process of fighting it. My insurance is supposed to cover preventative care 100% (not even a copay). They billed $18000 total (yes, for a 1-hour ultrasound) and insurance is leaving me to pay $5000.

This is about the 6th time this has happened. It's always 15+ e-mails back and forth, then threatening lawyers, then they back off.

I'm wondering if it would be faster if I just take it directly to a small claims court. I am insured and it is preventative care, so I believe I'm entitled to pay nothing. Advice welcome.

MomoXenosaga• 4 years ago

People don't want universal healthcare because then all the poors increase waiting times. But then they complain when healthcare is expensive?

pc866• 4 years ago

Hospital IT systems are incredibly locked down, especially from a network perspective. And DICOM images (the format things like x-rays are stored in) are very large, and not readable by most image readers. I honestly don't know if there are even free DICOM readers out there, but there probably are.

CD is honestly the easiest way for them to send the images to you, because you can give them to any doctor and they can load them within minutes. For the hospital to send them directly to another hospital would literally take weeks (at a minimum) of back and forth between two overworked and incompetent IT teams.

lelanthran3• 4 years ago

"Here is the cash price. We won't know your HDHP insurance price until after we bill them, which could be good for you or could be bad."

This is the reason that non-emergency healthcare is so expensive - the purchaser does not know the price of something at the point of purchase.

This results in the price being significantly higher than what the market can bear.

When consumers are informed and can force suppliers to compete with each other, prices go down to exactly what the market can bear.

Emergency healthcare is a different beast, but will probably also decrease if non-emergency healthcare prices was left up to the market to set.

dham• 4 years ago

Broke my finger and did the whole CD thing to. I accidentally laughed on the phone when they told me what I had to do. Felt a little bad. I had to drive to the urgent care to get the CD and then drive it to the orthopedic specialist days before the appointment. As I was driving I just thought to myself, here is everything that's wrong with the medical industry, synthesized in a 700Mb metallic disk I'm holding in my hand.

hnburnsy• 4 years ago

I belive that ACA plans must cover out of network emergency services.

throw1231231235• 4 years ago

HDP is definitely in the right path, but you need to get rid of many layers of bureacracy and paperwork. Need an absolute de-reg.

It's not going to happen, so the most likely scenario is innovation will be coming from fringe services.

CarbonCycles2• 4 years ago

Me and my colleagues (actuaries by training) ran some very interesting what-if scenarios based on our companies insurance packages, and every single scenario indicated that going with the highest deductible (or HSA) was more cost effective for the employee...the employer (with the insurance companies) had stacked the deductibles and cost structure to shift the risk from the company to the employee.

And the medical providers (not the insurance company) will always have discounts on their procedures...just have to ask for them. Makes one wonder how steep the mark-ups are.

eek2121• 4 years ago

Love the post, however, your description of the problem leaves me wondering...did we work together?

social_quotient2• 4 years ago

Why can’t insurance companies post the actual price they are paying and being charged by the hospital with proper billing taxonomies. They seem like they probably have these things well ironed out since they actually deal with various hospitals whereas hospitals only deal with themselves.

bliteben• 4 years ago

There is no actual price. Its rent extraction. They can change how much they charge you for 18 months.

social_quotient2• 4 years ago

I’m guessing you’re serious. Can you link me to more info on this specific thought?

shad0wfax• 4 years ago

The health insurance companies are now required to publish this and in fact the rule went into effect July 1 2022.

Look up price transparency by CMS (the data will be published in this format: https://github.com/CMSgov/price-transparency-guide)

Note: the data being published by payors in machine readable format (MRF) is MASSIVE - terrabytes of data. Example: https://transparency-in-coverage.uhc.com/

throw1231231235• 4 years ago

Because they don't know it yet. They audit and review each claim a an office sends, which starts a negotiation process to see if each claimed item by the physician was warranted and done properly. All that information is codified then into a level of visit, which changes the amount it will be payed out.

It is grotesquely complex, but the core issue here is that patients want to consume their healthcare through insurance, because it is tax advantaged. Thus it is impossible to make a cash business that would cut through all this bullshit for the majority of healthcare.

zxexz2• 4 years ago

Congress has been considering transparent, prior authorization legislation in the realm of CMS. I don't know much about it, but they did publish an RFI recently[0]. I hear it has bipartisan support (that's obviously hearsay, but a lot of this recent healthcare legislation that has been passed has not been divided along party lines, AFAICT)

[0] https://www.federalregister.gov/documents/2022/01/24/2022-01...

lotsofpulp8• 4 years ago

Insurance companies have always given out prices. I have been able to type in CPT codes online and my insurance tells me the price on a map of all the providers in network in my area.

Before that, you could call and give them the code and they would tell you the price.

The problem is the doctor will not give you a code, and sometimes that makes sense since they do not know what they will be seeing or doing, so they cannot know the code in advance.

But I have also had doctors not give me codes for completely preventative services, which makes no sense.

remflight2• 4 years ago

I hate Trump and am glad he was voted out, but you have to give him his dues.

This is 100% his doing, through executive action. The Dems could have done this but never did. It’s just another example of how neither side of the aisle is truly on your side.

system2• 4 years ago

All politicians are crooks. Left or right, doesn't matter. They are both accepting bribery under "lobbying".

ipnon• 4 years ago

This seems like a perilous line of thinking: If all politicians are crooks, then we should get rid of politicians. Without politicians, we either have anarchy or dictatorship. Politicians don't seem so bad at that point.

refurb8• 4 years ago

So when EFF goes and talks to their Senator to ask (“lobby”) for privacy laws you call that “bribery”?

arwhatever2• 4 years ago

As I understand it from news articles a few months back, the Biden administration was letting the enforcement of Trump’s healthcare price transparency law really slip.

And it was severely under reported.

Recommend sending Biden a message (I guess via whitehouse.gov) that you’re tracking this issue.

legitster6• 4 years ago

The price transparency rule was actually an ACA provision. It just got tied up in legal limbo for a long period.

It was finalized during the Trump administration, but in no way should he get 100% of the credit.

remflight2• 4 years ago

No that’s not what happened. Obama came up with a toothless proposal and once ACA was passed he didn’t push further because he didn’t want to piss of the AHA.

So it languished for 6 years with no movement. Trump came in a added it with an executive decision, and it was then that there were legal challenges that were denied. And that’s how we got here.

Like I said, Trump is the worst president of all time but give him his dues when he deserves them. This is one of them.

nomilk• 4 years ago

CMS's price transparency law, which requires all hospitals to post their prices online in a single, machine-readable file

Whoever got this legislation through deserves a pat on the back.

thedougd• 4 years ago

Many hospitals and providers are ignoring it, perfectly willing to eat the fine, if it ever comes.

cgb223• 4 years ago

I wonder if one could automate finding the hospitals that don’t do this and filing a complaint that leads to a fine

like patent trolls for a cause

ars3• 4 years ago

Whoever got this legislation through deserves a pat on the back.

That would be Trump.

majormajor• 4 years ago

Trump's administration offices finalized the rules on how it would work, but the law was part of the Affordable Care Act, so it would be the Democratic congress and presidency of the Obama era.

Per https://www.sihd.org/affordable-care-act-price-list-2718-e and others

One wonders what took so long, of course.

legitster6• 4 years ago

It was part of the ACA, but hospitals tied it up in court for a long time.

humanistbot• 4 years ago

Thanks, Obama!

refurb8• 4 years ago

It was Trump through a regulatory change by HHS.

https://www.forbes.com/sites/joshuacohen/2020/11/06/on-healt...

legitster6• 4 years ago

A chain of clinics recently opened in our area that post all of their prices online.

We almost exclusively go there now for everything. Even if they are occasionally more expensive (briefly, until the normal UC would send their surprise bills), it's just so much easier to pay up front.

Thankfully we have an HSA and it's our money.

lotsofpulp8• 4 years ago

If you can afford to pay for it with post tax non HSA money, then investing the HSA funds in a Fidelity HSA and letting them grow is the ideal maneuver.

Pdf your healthcare expense receipts and reimburse yourself from the HSA 50 years in the future completely tax free.

robocat2• 4 years ago

HSA for those who are “international”: https://en.m.wikipedia.org/wiki/Health_savings_account

cycomanic4• 4 years ago

That's insane! Goes to show again that the solution in the US is "be rich" and then you'll be given additional benefits.

thenerdhead• 4 years ago

Only way to get hospitals to abide is to complain. It’s quite sad as a person who wants to get care about an issue in their health and needing to bounce between the insurance quote and the hospital costing quote.

You shouldn’t have to do napkin math to know how much it’s going to cost you in worst or best cases for simple visits, procedures, or devices/drugs.

This is a positive change as you can now ask directly and hold parties responsible for a transparent price. No more ranges or “estimates”. It’s been slow rolling, but I did have success when complaining recently to my local hospital. I just hope that the fees for ignoring this start to become hefty enough to change the healthcare industry’s behavior.

rootsudo• 4 years ago

Nitpick, but, anyone else have issues reading the article? The grammar usage seems "off."

Content is excellent, but the writing feels off.

duffpkg3• 4 years ago

Wrote Hacking Healthcare for O'Reilly, created ClearHealth/HealthCloud open source EMR, managed health systems for 15+ years, blah, blah, blah.

It is very good there is are the transparency regulations. It is worth briefly explaining some of the reasons why many facitilities are having a hard time complying. There are some bad actors, absolutely true. However "Hanlons Razor" -- never attribute to malice that which is adequately explained by stupidity -- definitely applies.

Many health systems are a lot more like "medical malls" than they are single monolithic enterprises. Lots of health systems use really, really old technology and also a lot of it from a company called "Epic". Epic does what it wants, when it wants and there is basically nothing anyone can do about it. There is rarely one central consistent mechanism and source of truth for pricing data because it gets generated from a complex web of different entities, systems, and processes. Herding all those cats is why it can take a health system a long time to comply. And also why a fine of even a million dollars can be small potatos vs the cost of actually complying in a timely manner.

Just one facet, MUMPS is a widely used technology which you probably haven't heard of and which very few technologists understand. Lots of people are struggling to create new code to meet the new regulations using 1970s era technology including MUMPS.

Another, a lot of health systems have been around a really long time. The insurers they work with also, (since the 1960s at least). They have Electronic Data Interchange EDI relationships built on the standard called 837. Business logic that surrounds pricing and billing is often buried in 50 years of tech debt. Everyone is deathly afraid of making too many changes too fast because when those systems break the money stops flowing and a health system will literally go insolvent. People still have hard physical lines connected to Medicare mainframes.

This is a similar situation to other regulated industries like banking, airlines, etc. Modernization is hard, time consuming and very expensive. These regulations are a good driver for all that, but it takes time. Having been in some of these boardrooms there is not typically a cartel of evil executives figuring out how to screw patients. A lot of the time it is a group of relatively normal people trying to hold up a technological and business process house of cards with chewing gum, paper clips and hope.

Disclaimer: I have been involved with the development of some of the fee schedules and health systems mentioned/criticized.

z3ugma• 4 years ago

You’re right about the comparison between airlines and systems like SABRE and healthcare.

You are mischaracterizing MUMPS which is now called M and has been updated many, many times since its invention and has a robust standard library of functions from M vendors.

tooltower• 4 years ago

You've touched on regulation being one source of this problem. But do you think prices will become more normal if regulations disappeared? What do you think is different between the US health care regulatory structure, vs. those in other countries? Can we have the same desired effect with regulations that are easier for hospitals to follow (so as not to be dependent on Epic)?

duffpkg3• 4 years ago

It's really convenient to cherry pick parts of "healthcare" or the "healthcare system". The thing is, it's 20-25% of our entire economy, so it's really hard to make meaningful comparisons to other countries and their distinct economic systems, in my opinion. To compare you end up having to get into labor, education, taxation, political systems, etc. The most obvious thing is that the USA is a federation of states and with regard to healthcare the federal government has relatively little direct power (but a lot of money). I think the transparency regulations are an excellent small step, I think that there is a little bit of disconnect in regards to timeframe. It will take several more years to see how that plays out.

Regulation is one piece but ultimately dysfunction stems from huge differences between what different constituents want from a healthcare system and what they want it to be (and not be). People hold extremely different views about it. Depending on your circle and where you live you may not realize just how far apart your thinking is from people in other circles and places. Creating palatable compromises between those groups has proved almost impossible and so a lot of what we have in lieu of a compromise occurs by default and accident.

gavinray• 4 years ago

Interesting to read mention of MUMPS

I'd never heard of it -- until I was at an afterparty at last year's AWS ReInvent and started talking to an older couple near us over some drinks.

The guy was well to do and had been in technology a long time. We had a great discussion where he told me about things like MUMPS and other tech I'd never heard of.

When they left, his wife gave me his name. Looked him up, it turns out he was C-Suite at a company nearly everyone has heard of (but is not known for being a tech company).

Makes me wonder how many billions of dollars are being pumped into tech I wouldn't recognize the name of.

viraptor• 4 years ago

I heard of Mumps for the first time from tdwtf. https://thedailywtf.com/articles/a_case_of_the_mumps

BeetleB2• 4 years ago

Back when I was leaving school and looking for a job, I came across Epic and MUMPS.

From what I read, MUMPS is actually very performant. Although other companies use it, Epic is the giant. Epic was considered a decent company to work at - good reviews, good work/life balance. The downside is mastering technologies that no one else would value. Or so everyone thought. The reality was that if you become well versed in MUMPS and the Epic stack, a lot of hospitals would pay good amounts of money to you - a lot more than what Epic paid.[1] The only catch was that Epic had a 1 year non-compete clause.

At the time I considered them, they were starting to develop stuff with Visual C++ and .NET, so there was a chance you'd learn more transferable skills.

Fun story: The first time I encountered them at a career fair, I knew nothing about them. I was a grad student. At the booth, they asked me my SAT and GRE scores and were crazy impressed, and immediately booked me for their "entrance exam". At the time (perhaps even now), all candidates had to do a written exam - they'd arrange for the university to conduct it. The exam was mostly assessing logical skills, etc. No advanced material.

I didn't know anything about Epic at the time, and was extremely turned off by anyone being so easily impressed by things like SAT scores. I didn't bother to go through with it. I was studying an advanced degree, and wanted to work for a place that was not so superficial.

Fast forward a semester later when I really needed a job. I researched Epic and it actually didn't feel so bad. I felt I would easily ace their logic exam. So I applied to them. This time, though, they made me do an online behavioral screen first. The type where they ask questions like "Are you more of a X or Y?" where you feel you're neither X nor Y. Apparently I flunked that test and they didn't invite me to take the logic test. Bummer.

[1] Not FAANG level money, but still a lot more than industry average, and a relatively cushy job with you being treated as "the expert".

smolder2• 4 years ago

The difficulty of fixing and improving these systems is frankly overrated. It has more to do with penny pinching and profiteering that they haven't modernized. I don't mean a rewrite in JavaScript either, I mean sensible engineering, which many people are ready to do but not paid to do, because it weakens the upwards money vacuum the finance cabal wants to maintain. Progress isn't profitable enough according to the Excel spreadsheet.

diob• 4 years ago

The irony of attributing the free market healthcare disaster we have here to regulation. Things are plenty regulated in Australia and other socialized countries and they have none of the crazy billing / coverage issues we have. It's frankly, bullshit.

throw1231231235• 4 years ago

Progress isn't profitable enough according to the Excel spreadsheet.

It's precisely the opposite. Its a racket but its not for profit. If you made a health care service that didn't have any of this cruft and just provided great care, it would not be used, because it would not be compliant with insurance, and employees would not get the tax benefit of using it.

If it were for profit, it would work better.

BeetleB2• 4 years ago

The difficulty of fixing and improving these systems is frankly overrated. It has more to do with penny pinching and profiteering that they haven't modernized.

Eh, I'd rather listen to duffpkg, with his extensive, real world experience in health tech, than a random comment.

FWIW, a former coworker of mine spent a few years at a health technology company (also worked with MUMPS), and legal compliance was the number one hurdle to modernizing. It was expensive, and created a huge drag.

gricardo99• 4 years ago

Exactly. IT, software, systems, etc… are viewed as a cost center. Hospitals aren’t in the business of selling software. How do you increase profits (or get yourself promoted, a bigger bonus)? One way is contain or reduce cost centers. The incentives are stacked against overhauling antiquated systems and modernizing, at least until the issue is forced by major business disruptions or regulations.

kelnos• 4 years ago

Right, and the fact that they are in this mess of tech debt in the first place is because they've cut corners and pinched pennies over many many decades. We shouldn't just nod our heads and be all like, "ah yeah, that's annoying, no way it could be helped". I'm so tired of companies continuing to be short-sighted about technical debt. Clearly it's been that way for more than 50 years, and we continue to validate this sort of behavior with understanding and extending deadlines.

Fine these people out of existence and let someone competent (if such a person exists) pick up the pieces and start anew.

Ekaros• 4 years ago

On other hand looking at experiences here the projects to change these systems seem not to go well... So there is also not promise that things will get better...

jamra• 4 years ago

I was in the physical therapy space for over 15 years. The penny pinching that comes from healthcare giants towards their software vendors are dreadful. It prevents any serious software engineering from happening. One customer billed over a billion dollars in a year to Medicare through our software and paid us $1M that year. I'm still not certain that we didn't take a loss to take that client.

Passing around financial data on SFTP drops is something that irked me. Having the total not add up from the line items is also pretty ridiculous. The systems in place are all about edge cases that have formed over decades.

Software engineers are not invited to the discussions in a lot of these companies. The area is gate kept by healthcare people, which tend to be people who don't know how to do technical writing or planning.

Our company wasn't a huge one. But the huge ones looked to me as run by accountants. If you can't establish an income stream for them, they won't even talk to you.

mapt• 4 years ago

All you need for progress is a sensible regulatory environment.

"Some of you may not be in compliance. We start you off at a fine of $1. For every month this continues, the fine doubles."

All you need for a sensible regulatory environment is a complete overhaul of how your society works, starting with a campaign finance & congressional staffing system that isn't built on implicit corruption.

ineptech• 4 years ago

Everyone is deathly afraid of making too many changes too fast because when those systems break the money stops flowing and a health system will literally go insolvent.

Isn't this the desired outcome, that such organizations go broke? And let their assets, employees and customers go to some other organization that isn't saddled with technical debt?

peyton• 4 years ago

The code looks like this:

``` I X?1.N1"H" S X=X3600,%H=$H,@("X=$P(%H,"","",2)"_Y_X),%=$S(X<0:- 1,1:0)+(X\86400),X=X#86400,%H=$P(%H,",")+%_","_X G RT D DMW G 1^%DT:'% S @("%H=$H"_Y_%),%H=%H_","_$P($H,",",2) RT D TT S %=$P(%H,",",2) D S S %=X_% I %DT'["S" S %=+$E(%,1,12) Q:'$D(%(0)) S Y=% G E^%DT PF S %H=$H D YMD S %(9)=X,X=%DT["F"2-1 I @("%I(1)*100+%I(2)"_$E("> <",X+2)_"$E(%(9),4,7)") S %I(3)=%I(3)+X ```

I mean, I can see why reimplementing could be scary even with org churn.

mschuster91• 4 years ago

When modernizing processes becomes too hard, it is almost always a sign for the processes being way too complex and needing a complete overhaul.

US healthcare billing certainly could benefit from a massive simplification, and the reason of the success of neobanks/fintech is the same: they always started from green fields and didn't have to fight internal politics battles to change a data entry mask.

el_jay• 4 years ago

Interesting, thank you. One remark:

Modernization is hard, time consuming and very expensive. These regulations are a good driver for all that, but it takes time. Having been in some of these boardrooms there is not typically a cartel of evil executives figuring out how to screw patients. A lot of the time it is a group of relatively normal people trying to hold up a technological and business process house of cards with chewing gum, paper clips and hope.

It bears questioning how, in ”the richest country on Earth”, something as important as a hospital ends up held together with spit and twine.

Inside this richest country, the richest individuals and companies have been capturing ever-larger shares of GDP. Perhaps instead of growing private fortunes, this money could have gone towards modernising these regulated industries?

stickfigure2• 4 years ago

It bears questioning how, in ”the richest country on Earth”, something as important as a hospital ends up held together with spit and twine.

In less rich countries they use paper records, which are worse. Everything is held together with spit and twine.

techdragon• 4 years ago

The problem is that it was built by the last 50+ years of technology and regulations. The system is a product of its upbringing. A company could starts out with noble goals of doing better and slowly year by year sink into this morass and become just another “part of the problem” before it becomes obvious to everyone that it’s now just another entity making things worse.

These kinds of reforms would have had to begin decades ago to make much of a difference.

throwaway6734• 4 years ago

It bears questioning how, in ”the richest country on Earth”, something as important as a hospital ends up held together with spit and twine.

Voters are incredibly scared of change because it's so vital. The current situation isn't caused by a lack of resources but a lack of focused will

kibwen• 4 years ago

"the richest country on Earth"

This statistic is misleading. The US is only the richest country on Earth if you consider the mean wealth. By median wealth, the US is ranked 26th. The wealth gap is enormous, and if you're in the upper echelons of the pyramid your health outcomes are vastly better than the clownshoes shitshow that the rest of the country is subjected to.

pirate7872• 4 years ago

The system's complexity is a feature, not a bug. Regulatory capture is real. And much of the regulatory system in health care exists to limit competition. The AMA is a cartel of doctors that limits degrees even for qualified candidates. and the hospitals also operate as geographical cartels.

dnndev• 4 years ago

If the incentive is not more money in most cases then it won’t work.

And those who generously give may not oversee how money is spent and likely squandered to a certain degree.

Takes an incredibly self sacrificing individual to risk it all, which is what this requires.

rmbyrro• 4 years ago

Richest Country - RiCo for shorter - is not a sentient being that sees and controls all...

What you refer to is actually a collection of hundreds of millions of individuals, with all sorts of interests, sentiments, ambitions, sometimes conflicting ones.

nopenopenopeno3• 4 years ago

In other words, it is a matter of priorities. If the fines were significant, the initiatives would be prioritized. It is that simple.

someoneFromWeb2• 4 years ago

Have you ever heard about OpenEHR? https://www.openehr.org/

russnewcomer2• 4 years ago

FWIW, pretty sure duffpkg was involved in the creation of OpenEHR, and therefore probably has heard of it.

rgrieselhuber• 4 years ago

As a side note, Hanlon’s Razor is applied so liberally and in ways to shut down criticisms of what very well could be a number of root causes, some of which could include malice and greed.

At the end of the day, Hanlon’s Razor is just something some dude came up with to explain what is the most likely but not even necessarily correct assessment of a given situation. It is often unjustifiably treated as some immutable law when it is really just a flourish of rhetoric.

wefarrell2• 4 years ago

"There are some bad actors, absolutely true. However 'Hanlons Razor' -- never attribute to malice that which is adequately explained by stupidity -- definitely applies."

In healthcare especially incompetence opens the door for bad actors to exploit weaknesses in the system which amount to huge amounts of money being wasted. Medical fraud, for example, is one of the most sophisticated organized criminal activities in the United States. Mafias setup hijack doctors offices and pharmacies (or setup fake ones) and they know exactly how long it will take until they get caught. In the meantime they can extract tens of millions of dollars from insurance companies in fake claims.

And the fraud pales in comparison to the blatant waste. Doctors office's who order unnecessary CT scans when they or their affiliates happen to own a CT scanner. Pharmaceutical companies who market brand name pills that are no more effective than generics. Insulin manufacturers who manage to charge $1,000 a month for a product that's over a hundred years old.

In the case of pharma specifically, there are a lot of pricing inefficiencies that are deliberately not corrected due to political corruption so that they can be exploited.

coredog64• 4 years ago

$1000/month insulin is not 100 years old. Your comment is like complaining that because penicillin was isolated in 1928, nobody should have a patent on any antibiotic.

Humalog insulin was patented in the 90s, and IIRC, is what Walmart sells for $25/vial. Novo Nordisk (among others) continually improves the product. Those improved products are where you see the $1k/month prices.

tomrod• 4 years ago

I don't think vendor lock-in is a sufficient explanation here, respectfully.

I feel this is why efforts like FHIR are very important, though certainly scratching the surface.

ThaDood• 4 years ago

As someone who works for an HIE and in the interoperability space, I feel like we have been talking about FHIR for the last decade. Hopefully it hits critical mass soon but I doubt it.

dumb1224• 4 years ago

I remember getting educated about MUMPS when we were researching about health informatics and interoperability in my PhD programme. My superviser said it was the earliest record system and also most reliable one. I was then opened to a rabbit hole of sophisticated electronic standards for health information exchange and standardisation for multi-domain medical knowledge/terminologies in hospitals. To this date I think it's still pretty much the same status quo if someone is to do research in this area and go for an introduction.

IG_Semmelweiss5• 4 years ago

While what you are saying is all true, in general terms, but the key story seems missing: The "top of the funnel" system is very much fighting to preserve itself.

- Insurance companies are in bed with hospitals to collaborate swindling money from the govt: read about kickbacks sent by the US Govt to hospitals as Disproportionate Share Hospital payments.

- Hospitals have a PR arm moving profits to defend their monopolies, including using SALT rules to create barriers to entry by geography.

- Hospitals also use govt rules against it. They were able to obtain an absolute advantage over all other players (ASCs, Independents) by getting the vaulted nonprofit status, which independents cannot get.

- Hospitals use their nonprofit status and barriers to entry to buy out competition: nimbler independent providers that are actually able to lower prices.

So, hospitals create their own rules, drive out competition, and create monopolies that leads them to hoard cash, which then they use to buy out competition and mire them in 1970s technology so we all pay more.

Then there's also PBMs, and Insurers. That's a story for another day, but plenty of blame to go around.

I post that hospital systems are so large, that at the bottom, Hanlon's razor may apply, but at the top, there's incentives one cannot ignore - and a lot of prejudice to keep the game as-is.

robertlagrant3• 4 years ago

They don't create their own rules. Most of the things in your list are failures of government.

tunap• 4 years ago

All valid, but you forgot another big story, for another day: "medical billing". This, in my minimally-informed opinion, is the syndicate keeping the fence running. I've had dealings with 4 owners of separate small-to-moderately sized billers and their top-brass all owned > 1 multi-million dollar homes around the world. Also, their toy boxes contained millions in cars, boats & flying machines. It must be nice, but incompetence doesn't smell right.

theossuary• 4 years ago

Why are DSH payments bad?

fukepik• 4 years ago

If ever there was a need for an antitrust litigation and investigation such as United States vs. Microsoft (see below), then "Epic Systems" (see below) would seem like a corporation that needs to be investigated, penalized and broken into tiny pieces to prevent its predatory practises.

https://en.wikipedia.org/wiki/United_States_v._Microsoft_Cor.... https://en.wikipedia.org/wiki/Epic_Systems

BeFlatXIII3• 4 years ago

What kind of pieces should it be broken into?

buscoquadnary• 4 years ago

For those unaware of the travesty that is MUMPS please consult the following article.

https://thedailywtf.com/articles/A_Case_of_the_MUMPS

Brystephor• 4 years ago

I work in the payments and billing area for my company. So, this idea of medical billing being so out of date is interesting.

Can you share your insight as to why it is not something that smaller companies or starts up have tried to fix? You can also email me (email is my HN username at Gmail dot com). I'm interested in learning more about this on a technical/"behind the scenes" level.

datavirtue• 4 years ago

So just post the amounts actually billed/collected instead of a "price."

BeFlatXIII3• 4 years ago

Would rewriting healthcare systems in enterprise Java or modern JS or Clojure actually improve them any compared to MUMPS? From my brief experience, the #1 MUMPS problem is that the syntax makes Perl and regex look legible. The two points that I miss in modern languages are:

1. There is absolutely nothing special you need to do when handling values out of the database compared to in-memory values 2. The nested data structure—it's like a nested Python dict, except each level can contain a value and children.

Siira2• 4 years ago

Hanlon’s Razor is the most stupid meme I have seen. It doesn’t matter that X did not implement a way to cancel their subscription easily because they were “incompetent.” The key point to ask is, if the incentives were reversed, would X suddenly become much more competent? If yes, they are very much a malicious agent and must be dealt with accordingly.

caramelcustard3• 4 years ago

Correct me if i'm wrong, but aren't some hospital bills/prices considered to be negotiable estimates? If so, wouldn't that skew the data?

And yes, prices should be set in stone and be easily accessible, unless it's something that is hard to evaluate due to one reason or another.

lotsofpulp8• 4 years ago

Starting Jan 1, 2022, a healthcare provider has to provide an estimate and you are only liable for that estimate plus $400 in case of overage.

https://www.cms.gov/nosurprises/consumers/understanding-cost...

caramelcustard3• 4 years ago

Thanks for clarifying!

celdon252• 4 years ago

Here's a solution: Let doctors be doctors and not glorified algorithmic-assembly-line workers. Incentivize transparency through something better than Yelp reviews. Incentivize diagnostic outpatient facilities, make them more accessible and discoverable. Especially through telemedicine if possible, but make sure they can be seen in person by someone competent if needed.

I'm sure I'll get downvoted here for this part, but government shouldn't be micromanaging care standards, even through a proxy like medicaid and medicare claim criteria. Let the citizens regulate the system instead, and government's job should be to make it easier for them to do so.

Yes, transparency can come through price lists, but prices can never go down until quality goes up first. It's just like code quality: If it's bad, you'll have to spend more time dealing with technical debt than it would have been to invest in the quality up front. Bad medical care breeds more complicated patient situations, and the rate of seriously ill patients increases as a result. Supply cannot keep up with demand.

Analyzing price lists, shaming providers into lowering prices, etc., will not solve this, nor is that idea even novel. But it may be useful as a single part of a more comprehensive strategy to solve the root of the problem.

It's great for business, especially since Michael Moore's documentary made it politically incorrect to deny medical claims for terminally or seriously-ill patients. Still bad for life expectancy, but we'll probably need another "groundbreaking" documentary before the country really wakes up to the scheme.

And for Christ's sake, stop training doctors to ask "what are your symptoms" (when they are already reasonably aware of what the type of issue is), and use more yes/no questioning about specific symptoms. If doctors can't be trained fast enough to be able to do even that, I'd think about fixing that, too.

cycomanic4• 4 years ago

And for Christ's sake, stop training doctors to ask "what are your symptoms" (when they are already reasonably aware of what the type of issue is), and use more yes/no questioning about specific symptoms. If doctors can't be trained fast enough to be able to do even that, I'd think about fixing that, too.

I think you really don't understand enough about why these things get asked. Yes Gp work often seems like glorified flowcharts at first glance (especially if you only look at some of their study material), but once you dig into it (I helped my partner study for an exams and get to hear her stories every day), you realise the huge amount of background information that can flow into a diagnosis. Asking the patient about their symptoms is an important part of gathering the history and can not be done just with yes or no questions.

celdon252• 4 years ago

Asking the patient about their symptoms is an important part of gathering the history and can not be done just with yes or no questions.

I agree, but that wasn’t what I was arguing against. Absence of any yes/no question is what I was referring to.

And I’m not sure your argument is a good one. Things you do in the classroom or other training are intended to overprepare you, and are not supposed to mirror real life. While I did rebuild and scale (as a technical owner) an exam platform later used by millions, I am only mentioning that ironically. Appeals to authority tend to be pretentious, and serve to prop up an even more dangerous myth that professionals always know what they are talking about.

stevage• 4 years ago

Require a standard format. Pick JSON or CSV in some standard encoding. We don't need hospitals publishing XML files and Excel spreadsheets.

Definitely CSV. Always CSV. It's easy to produce, easy to parse, and kind of human readable. And easy to do some basic analysis with tools that everyone has access to - Excel, Google Sheets etc.

sp332• 4 years ago

I didn't like CSV because too much actual data has commas in it, so commas aren't a good delimiter.

slivanes• 4 years ago

Quoting every column is a safe way to handle this, at the cost of slightly larger files. You can then escape a quote with another quote.

patwolf• 4 years ago

From the perspective of reading/writing CSVs programmatically, I actually prefer that it's a common character. You'll discover very quickly whether the parser handles escapes correctly. With a more exotic delimiter it might be a long time to discover the problem, and by then it will be harder to fix.

From the perspective of writing CSVs by hand in a text editor, commas suck.

EvanAnderson• 4 years ago

Tabs are a better delimiter than commas. Using the ASCII control characters meant for record and field delimiters are even better: https://en.wikipedia.org/wiki/C0_and_C1_control_codes

albertopv• 4 years ago

In 2007 (15 years ago) Veneto and Lombardia italian regions elder health care ptivate facilities had to provide monthly data with a specific, mandatory excel template provided by regional health authorities. The company I worked for was in charge to collect data and create those files. It was not a perfect format, it was closed source format (still .xls) but everyone knew it was that format. Standards matter.

zarzavat• 4 years ago

You cannot require CSV as a standard format because CSV itself has no standard. There are multiple variants of CSV and there's no way for a CSV file to declare which variant it's using in a standard way, which means you have to manually check that every single file parsed correctly, because if you accidentally parse a CSV file as the wrong variant there is no way for the parser to know and it will just silently corrupt your data.

Sometimes CSV files themselves are ambiguous because they don't use any quoting so you end up with some lines that have more columns than others, and require manual repair line-by-line by a human.

Don't use CSV, it's a dreadful format.

hwillis2• 4 years ago

Sometimes CSV files themselves are ambiguous because they don't use any quoting so you end up with some lines that have more columns than others, and require manual repair line-by-line by a human.

It's wild that we haven't just started using unicode and line/group separator characters for tabular data instead of csv/tsv. Whoever decided to use a common semantic character as syntax is an evil, devious bastard.

That said, there is one thing I like about CSV and similar formats: they are inherently tabular. You don't have to worry about someone adding sub-objects to your JSON (or replacing a primitive field with an object/array). Extra columns are brainless to add or process, but converting sub-data to a line is not.

exabrial• 4 years ago

Where to start...

1. Somehow in the mid-2010s congress decided that anyway that walks onto private property, demands care from a private organization, will receive it, even if they declare they will not pay a dime to the staff working.

2. Congress could have totally create/build a system of hospitals that provides "one time care" for those people, but doesn't.

3. Instead they pass the buck and say "figure it out" to the private industry.

4. Hospitals are squeaking by largely flopping duties on nurses, making their jobs far less enjoyable (wrangling entitled individuals instead of healing people and providing care), and charing double-triple to responsible individuals who will pay for themselves.

5. E.R.s are now becoming "primary care" for large majority of the US population, as they show up, then disappear knowing they won't be stuck with a bill.

6. Members of Congress literally don't give a crap about "common folk" and go on golfing and enjoying their free healthcare for life. Meanwhile commonfolk and the poorest of the poor don't get the same deal. One set of rules for peasants, one set of rules for the 1%.

throwawayarnty• 4 years ago

I wonder how member of Congress justify that they need a special health care that is different from the public.

It seems to make sense and align incentives to have members use the same public systems (eg transport, education, health, housing) as everyone else, otherwise they will never understand how their policies affect real people.

dragonwriter3• 4 years ago

I wonder how member of Congress justify that they need a special health care that is different from the public.

There don't. Them not doing so is part of the ACA. Grandparent was just lying.

maxerickson5• 4 years ago

EMTALA dates to the Reagan era¹ and applies to hospitals that have contractual agreements with the Federal government (ones that accept Medicare).

What else in your analysis is terribly wrong?

1. https://en.wikipedia.org/wiki/Emergency_Medical_Treatment_an...

dragonwriter3• 4 years ago

Somehow in the mid-2010s congress decided that anyway that walks onto private property, demands care from a private organization, will receive it, even if they declare they will not pay a dime to the staff working.

False. I mean, not only is this an exceptionally emotionally loaded description of EMTALA, it was adopted in 1986 which is not, even approximately, the mid-2010s.

Congress could have totally create/build a system of hospitals that provides "one time care" for those people, but doesn't.

Yet another set of independent physical infrastructure would be even less efficient. The multitude of separate payment and delivery systems is a major source of the US inefficiency

Instead they pass the buck and say "figure it out" to the private industry.

No, instead they find hospitals that have a large share of uncovered patients through the Medicaid's Disproportionate Share Hospitals payments program.

E.R.s are now becoming "primary care" for large majority of the US population

Some support for this “majority” claim would be welcome.

Members of Congress literally don't give a crap about "common folk" and go on golfing and enjoying their free healthcare for life.

Under the ACA, members and staff of Congress don't have special government healthcare plans, they have access to plans they are required to have coverage through plans available to others created under the ACA including exchange plans.

bpodgursky• 4 years ago

Yet another set of independent physical infrastructure would be even less efficient.

I think this misses just how basic much of the care performed in an ER (which is oriented towards critical care for major problems) is. Duplicate infrastructure is OK when the use-cases are totally different. We need better urgent care clinics.

elhudy• 4 years ago

1)The hospitals that comply often publish the least information they can get away with 2)The CMS law appears to be written by non-technical people and leaves room for hospitals to do (1)

I know the people who wrote this law. #2 is actually a false assumption. The law was written like that to incur the least resistance as a first step toward change.

flenserboy• 4 years ago

Not only do we need public price lists, the middlemen need to be cut out — specifically, the doctors. You should be able to wander into a specialist's office and get an appointment without having to go through a GP first; you should be able to get most any test done in exactly the same way. Due to the insurance companies and the hospitals they work for, doctors aren't going to suggest anything other than the basic stuff you can find through Google about a low/high count in any test. Yes, GPs are useful and have a role — but as long as their hands are tied, they're glorified flowchart jockeys. Free the data, free the patients.

refurb8• 4 years ago

The reason insurers require a referral is to keep costs down. That even happens in places with universal healthcare.

It doesn’t make sense to pay for a dermatologist at $150 for a visit to look at a rash when a GP would do at $75.

throw1231231235• 4 years ago

You can do this with PPO insurance or paying cash.

pishpash4• 4 years ago

No you can't. Some specialists are referral only. They do this to satisfy medical necessity requirements to make sure they get paid by insurance.

refurb8• 4 years ago

I believe that this price transparency will have a pretty radical impact.

I used to negotiate with hospitals on reimbursement and if I were still doing the job, the first thing is do is pull up this data and say “This other plan of similar size is paying $X. I’m willing to pay the same.”

Sure it will take time to shake out. Hospitals will reject super low prices (that they were possibly losing money) for all payers. In exchange insurers will likely reduce the ultra high payments where they were paying a 500% mark up.

It will likely take a few years for it to shake out, but assuming the transparency remains I could see this actually driving prices closer to cost. Sure, big payers will drive it lower and small payers will pay more, but we could start to see a much smaller range.

Fingers crossed.

pishpash4• 4 years ago

What's cost though? You've seen inflation when the supply chain is constrained. This is the case with medicine so the cost is possibly infinity here.

sl-dolt5• 4 years ago

I'm as surprised as anyone to see this #1 on HN. Glad y'all like it. AMA.

Feedback, criticism, comments, directions to go, whatever.

JohnJamesRambo• 4 years ago

I wanted to see how different the price for the knee replacement would be at different hospitals.

sl-dolt5• 4 years ago

Good point. With the data as sparse and dirty as it is, it's hard to get a reliable analysis for specific procedures. Or at least one I consider publishable. That, plus, I don't have a good understanding of how medical billing works on the inside.

Some of that will hopefully change in the coming months as new data comes in (will write more about that in another blog.)

If you want to look at how prices for different procedures can vary between hospitals, you can get a rough idea from a previous blog post I wrote:

https://www.dolthub.com/blog/2022-05-06-the-most-expensive-h...

lotsofpulp8• 4 years ago

You can simply ask the hospital to give you good faith estimates:

https://www.cms.gov/nosurprises/consumers/understanding-cost...

joshgel• 4 years ago

You have to hope your hospital uses CPT codes and not, say, DRG coding, or something else entirely, otherwise you'll need to look up those codes too.

This is a bit of a misunderstanding. CPT codes are part of professional services billing, while DRGs are exclusively for inpatient acute care billing. If you are admitted to a hospital, you’ll probably have to deal with both.

sl-dolt5• 4 years ago

That's a great piece of information that I'd have never known about without an insider telling me. So thanks!

microSnowball• 4 years ago

re the CPT codes-- 27486 and 27487 are for total knee revisions, not for a first-time replacement. 27486 is used if you only revise 1 component (ie the femoral side or the tibial side). 27487 is billed when both components are revised.

sl-dolt5• 4 years ago

Thank you! I appreciate the correction, and this exactly shows how challenging it is for the average consumer to actually use these chargemasters in the first place to do their own research.

pc866• 4 years ago

Might be a dumb question, but if I joint hospitals and prices, and filter to the couple nearby hospitals that I care about, and I get 0 rows, that means they're violating the transparency law, correct?

sl-dolt5• 4 years ago

It's not quite that simple. Remember that this database was built collaboratively, and it's possible that our bounty hunters just didn't get to that hospital. We have fairly good coverage, but it's impossible to say if 1) they didn't find the chargemaster, but it exists or 2) they didn't look for it.

We'll probably run another price bounty in the future to capture the rest of the chargemasters.

peterfield• 4 years ago

Great stuff thanks a lot

brundolf• 4 years ago

Despite all the problems with the law and with compliance, I'm optimistic about this. I think various orgs are going to ravenously pick apart this data, normalize it, make it easy to use for regular people, etc. Gaps are gaps, but messy formats and inconsistent codes and such are the smallest of speedbumps, in my mind.

Journalists, nonprofits, and startups are going to extract every bit of juicy truth there is to find in this stuff. They're going to get to the bottom of every cryptic string by hand if they have to, because there's so much value in this for nearly our entire society. And hopefully, the fines will mean the true gaps get smaller and smaller.

pishpash4• 4 years ago

I'm not optimistic. The data that has been out there for years has not yielded end-user usable information. There is too much missing context and billing trickery that it's not possible to tell how much something costs unless you're a medical coder.

vivegi• 4 years ago

A few routine billing concepts that skews line item amounts in raw claim dumps or price lists derived from claim dumps:

- CPT modifiers (The service or procedure has both professional and technical components OR More than one provider performed the service or procedure. More than one location was involved OR A service or procedure was increased or reduced in comparison to what the code typically requires etc.,)

- Bundling (1 line item as opposed to 2 or 3 when the second and third procedures are an outcome of the first. eg: bone-xray + procedure(s) to fix the broken bone detected through the x-ray)

- Rendering provider vs. Billing provider (Rendering provider is the physician or provider that provided the service and billing provider could be the hospital/clinic/lab/ambulatory/billing company etc.,)

But here's the kicker. Medicare is the largest payer in the US and it already has a Fee-for-service pricing schedule. You can be sure that it covers all states, locality-wise price adjustments, hospital density factors in the price schedule and every possible procedure billing scenario. So, one just needs to compare (within a ZIP code or County or other geographic area) the hospitals prices against this to find anomalous pricing issues.

ddingus2• 4 years ago

Frankly, this exercise motivates me toward universal care more than ever.

I do not mean to devalue the work. It's great honestly! Thank you.

That said, this is a major league mess most of the world would look at and wonder whether we are crazy or high.

gjulianm• 4 years ago

Yes, as someone outside the US, the fact that this is a thing is just... weird. When I go to the hospital I'm already worrying about health, I'm thankful I don't have to worry about money too.

ddingus2• 4 years ago

It can be rough. Cost me a home once!

Right now, it appears the US will have to learn this all the hard way. The financials are super attractive for people at the business level, and can be compelling for care providers, who may have expensive school to pay down.

For most everyone else, including many employers, it is increasingly painful.

The nature of the issue also makes change hard. Many people do not want to disturb what is working for them however painful. Can't blame them.

killjoywashere• 4 years ago

This healthcare thread is amazing, I want to meet you all.

bradwood• 4 years ago

I live in England so I don't have to either.

dmje• 4 years ago

I did it for the UK. It didn’t take long :-)

rob_c• 4 years ago

And for the NHS at point of use (when you can get to the to of the queue): 0$ 0$ 0$ 0$ 0.....

Genuine wishes of good luck to those in dealing with that system and may you avoid it for as long in life as possible.

godmode2019• 4 years ago

Was this not a Trump policy?

camillomiller2• 4 years ago

I analyzed Italian hospital costs so you don't have to: it's 0.

Mordisquitos• 4 years ago

Your sarcastic comment was ironically invalidated by failing to copy the headline exactly. I assure you that the costs of Italian hospital are much, much greater than 0. Now, their prices on the other hand, that's another matter...

camillomiller2• 4 years ago

I love this comment

jacquesm• 4 years ago

American hospital price lists.

If you want this to improve: get rid of privatized health care. There are plenty of countries that set the example on how you could deal with this in a far more humane and fair way.

lr1970• 4 years ago

This study uses polars [0][1] -- a new Data Science library written in Rust (core) with bindings to Python and Javascript. Perfect replacement for pandas. Polars' claims to fame are speed (faster than pretty much anything out there [2][3]), low memory pressure (very visible when comparing to pandas) and consistent API across Rust, Python, JS.

[0] https://www.pola.rs/

[1] https://github.com/pola-rs/polars

[2] https://h2oai.github.io/db-benchmark/

[3] https://www.pola.rs/benchmarks.html

this_is_not_you• 4 years ago

Thanks! I had not heard of it before. As a Python pandas user I have to say this look really promising. The speed claims are obviously great but what really stood out to me is the syntax. Reminds of the the dplyr syntax which I enjoyed a lot when I was still using R.

bawana• 4 years ago

The fundamental problem is that we have chosen to use a free market mechanism for a condition that is not voluntarily acquired. No one chooses to get sick. Why then should we provide choice for its solution?

Can you imagine the same solution for our police? Military? Emergency services?

fapi1974• 4 years ago

Does anyone know if the 2019 law opens hospitals to civil action or whether individuals can be awarded some portion of the fines for reporting as in whistleblower cases? If so, that could be a decent alignment of incentives to get the hospitals to comply.

AdamN• 4 years ago

Having recently moved to Germany from Seattle ... it really is nice to not have to worry about this stuff. This is especially true since I have leukemia and take medicine daily. At some point I'll have a big frustration with the German healthcare system I'm sure, but it hasn't happened yet.

formerkrogemp3• 4 years ago

From an accounting and compliance perspective, not complying might make sense depending on the cost of upgrading systems. Hospitals and healthcare networks are going to upgrade their systems piecemeal and hodgepodge as their funding allows and pay the fines in the meantime. It'll be a good time to work in healthcare IT consulting. I'd imagine revenue will increase as EMR and so on require updates due to changes in regulation, assuming that we continue this trend.

zugi• 4 years ago

If the law were serious about medical price transparency, it would just state that no medical bills are valid or enforceable in any court unless the exact price is clearly disclosed to the customer and agreed upon up front. Without relying on any government enforcement, we'd see an end to surprise billing overnight.

Business practices would have to change. In cases where the all the steps and treatments aren't knowable up front, providers would have to pick a price and stick to it - like any business or service provider they'd make money on some and lose money on others. Instead of issuing separate random bills from various providers, hospitals would have to pay their subcontractors out of their fixed prices, like a normal business. There may be exceptions for emergency care but those would be the rare exception, not the rule.

I analyzed hospital price lists so you didn't have to

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