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.
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.
Politicians are often not great especially Teddy Roosevelt - a war-mongering, braggard focused on making a name for the himself and furthering the ‘forward race’.
Change if it comes at all will come by...
1. a populist demagogue with unchecked power
2. Or when the market wills it more than likely via technological disruption of some kind
Things must get worse before they get better as with all major advancements in human history.
wow, great guy. For those not clicking: responsible for single-payer health care in Saskatchewan (60s); voted greatest Canadian 20 years after his death. And Kiefer Sutherland is his grandson, yeah ;)
Looks like you're saying that they won't be good (a moral quality), not that they won't be great (a performance measurement); Alexander was Great, as well as the Great Khan Genghis, shaping the world as we know it, yet neither were good.
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
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.
It will last because any government who threatens it will be removed. We have watched what is happening in the U.S. and almost every Australia who is aware of the U.S. model is absolutely appalled.
Actually, the U.S.’s standing in Australia has totally dropped in the last four years, and was already gradually dropping before then.
Paying for healthcare via taxes would look very, very similar to how it is now. Because that's how insurance works: you are paying into a pool now to get access to help later.
I can't tell if you're being sarcastically libertarian or deliberately antagonistic.
I’m surprised you couldn’t tell because my reading is their point was quite clearly genuine and not at all sarcastic.
They were just expressing the notion that while the acute personal cost is zero the actual cost is still borne. They didn’t make the point in a very nuanced way but any system that divorces the cost from the person receiving the treatment hides information by suppressing the natural price discovery mechanism.
Anyway, I agree that insurance has a similar problem, at least if policies like “no pre-existing conditions” are followed. However if such policies are not in place then premiums would go up and thus the information propagation of the price mechanism is (all else equal) restored.
I don’t have time to get into it but speaking from the US perspective I really wish we had a real free market system with no government revelation or licensure laws whatsoever. What we have now is criticized by the ignorant as a “failure of unbridled capitalism” but it is of course anything but. It is absolutely absurd that I can’t decide that I don’t want insurance and equally that I’m not told what a procedure or drug or item will cost beforehand. I’ve been to the ER several times and you’re always treated like a bag of meat to poke and prod and I have to be very diligent about constantly getting them to tell me what they’re actually doing. (And don’t even get me started on the chargemaster system where they initially charge you 10x more than what they expect to recoup purely for leverage to negotiate with insurance)
Under such a system, if your choice is not to have insurance, what should happen if you step in a hole and shatter your ankle in a way that requires complex surgery to repair? And if the response is to simply pay the cost out of pocket, what if that "choice" not to have insurance was made because you're working at a minimum wage job?
> Under such a system, if your choice is not to have insurance, what should happen if you step in a hole and shatter your ankle in a way that requires complex surgery to repair?
In this hypothetical, I clearly wouldn't be able to afford the complex surgery, so either I would do without it or make use of any non-profit foundations/charities set up to give people in my position money.
It's worth noting that the cost, while still significant, would be FAR lower in a world with no regulation/licensure whatsoever. It's hard to understate how much cost (nominally expressed in dollars but the cost is so much more than that, to be clear) is introduced by all the layers of red tape.
And actually, now's a great time to mention that this problem occurs in our current US system, except it's way worse because (well, at least pre-Trump) you will get fined for not having insurance in addition to all the fun that comes with not having insurance. The obvious counterpoint here is to argue that if we had a single-payer system, where there's not actually private insurance companies at all (or at best they exist for people who aren't satisfied with single-payer and so those individuals both pay taxes for the single payer system and also pay for their own private insurance in parallel), that this problem wouldn't exist because it's impossible to not have insurance since the government already has it. That part is true, although you run into the classic problem that when everyone has government insurance, the client of a doctor/physician/etc is the state and not the individual, and therefore incentives are aligned against you right off the bat. Then factor in that you don't get to make decisions about your medical care - or rather, you can reject treatments but you can't decide to take a treatment that the government has decided you can't take, etc etc.
> And if the response is to simply pay the cost out of pocket, what if that "choice" not to have insurance was made because you're working at a minimum wage job?
I already implicitly answered this with my answer to the first question because I didn't shy away from saying that if you can't afford the surgery then you can't get the surgery without a benefactor. If I had tried to pretend that magically you would always be able to get the surgery then this would be more of a "gotcha" than it is.
While we're here though, this is a good time to mention that minimum wage shouldn't exist either. (Doesn't change your point, to be clear, but I can't help but mention that the whole concept of minimum wage is regressive policy masquerading as progressive policy)
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So, to conclude: resource scarcity is a thing and always will be a thing, and the best way to address is that to utilize our resources as efficiently as possible and maximize innovation, both of which require regulations to not be a thing. Regulations are always sold as "this will make things more efficient/safe/etc because the market dynamics aren't properly addressing this", but the reality is that regardless of your philosophical views on regulations, the actual utilitarian result is to make things more expensive with no increase in safety. And it of course makes things more inefficient.
You’re paying into a pool for the neediest to use. The social contract being that you implicitly admit you will one day be needy, no matter how healthy you live your life. Thus, you willingly throw your money away when you’re young and healthy and you do it smiling.
> You’re paying into a pool for the neediest to use.
Yes, that's the definition of insurance. Insurance company takes money from everyone (say, for car insurance) but only pays out to a few (those who crash their car).
As any insurance broker will happily tell you, the smaller the pool of people you belong to, the higher the premiums because they can't spread the risk as wide. Thus, a 100K+ employee company can buy health insurance for their employees at a better rate than a 4 person startup.
The optimal group size for an insurance pool is: everyone in the whole country.
Maximum pool size, risk is spread as widely as possible, cost is minimized.
Nobody is under the impression that there aren't costs to care, so your response feels like you're addressing a strawman argument and isn't really insightful.
None of these links say what you're claiming they say.
Your courthouse link:
> “For me, the important lesson is that single payer can re-direct huge resources – about $700 billion per year in the U.S. – from insurance paperwork and excessive drug prices to clinical care. In other words, with a simplified payment system, we can afford to insure everyone and with high quality insurance – broad benefits, minimal cost-sharing, choice of provider,” Kahn said in an email.
Your UCSF link:
> The U.S. spends more on healthcare than any other country, yet is one of only a few developed nations that does not provide universal coverage. Under proposed single payer bills, such as “Medicare for All,” a unified public financing system would replace private insurance, similar to the healthcare system in Canada and many other wealthy nations.
Your pnhp link:
> Honoring a rather unpleasant tradition, the September issue of Health Affairs published yet another peer-reviewed study confirming that administrative costs in the U.S. healthcare system are the highest in the world. These administrative costs do not improve patient care. They pay for more administrators.
> Each American physician requires 10 administrators to stay in business. Why does American healthcare require twice as many administrators as any other healthcare system?
None of these are saying single payer healthcare is free. They're saying the US system is fantastically expensive, and single payer would be cheaper and better.
Yes, MystK, if these are the texts you say support your thesis, then I think I might not understand what you mean by the statement that ”there are definitely people who think universal healthcare will cost nothing”.
If what you mean is that there are people who think that the costs could be less under such a system, and thus that a change would end up ”costing nothing” as contrasted with ”costs going up compared to the current system” - then yeah I agree, there are people who believe that, and I’d say they are right in doing so. I’d also say that the way you’ve chosen to express that is misleading to say the least.
I assume you don’t believe that these people think that it’s literally free, that paying workers, buying supplies, and building and maintaining facilities and so on cost literally nothing.
But if it’s neither of these two concepts that you’re referring to, then I honestly have no clue what you’re trying to say.
Yes the former is exactly what I mean. I've reread my comment and definitely see how it could be misconstrued. I didn't mean to cause confusion, but it was just the shortest way to express that idea.
I'm struggling to find where this author concludes that universal healthcare is free like free energy from a perpetual motion machine. Can't find it.
Could it be that you're misinterpreting the repetition of the fact that countries with universal healthcare have better health outcomes, and yet pay less than half of what we do for healthcare, with it somehow being completely free? The same fact that's repeated in the title "22 studies agree: 'Medicare for All' saves money"?
Which of those 22 studies claims that cheaper healthcare with better outcomes is the result of free labor?
Looking at the rest of links, it seems to me that you believe that anyone claiming, with evidence, that universal healthcare saves money somehow thinks that universal healthcare doesn't cost anything.
I see now that I was too terse with my initial comment. Cedarfjard explained it well.
> there are people who think that the costs could be less under such a system, and thus that a change would end up ”costing nothing” as contrasted with ”costs going up compared to the current system”
What is the cost of an unhealthy population that defers or forgoes medical treatment? Where is that price exacted? In a 2019 Gallup poll, 25% of US adults said they or a family member had delayed treatment for a serious medical condition that year for financial reasons.
Australian here - was listening to a local doctor who has a radio program. He travelled to the US for something and remarked on the number of people he saw squinting - apparently this is treated here by the appropriate glasses when young (for free) but not so over there.
Obviously he and his mother has already paid for in taxes, zero cost here is in the sense that the cost is not going to eat into their current savings.
While in the US you paid taxes and can still potentially go bankrupt if you have major diseases.
Under the US system, everyone's savings is also lower -- because of extremely high insurance premiums, co-pays, coinsurance, deductibles, high out-of-pocket payment maximums, uncovered care, predatory billing complexity designed to minimize "medical loss", lesser job mobility due to linkage of employment with the ability to get medical care, far higher drug prices, and so forth. It's a system full of holes into which almost anyone without wealth can fall -- even people with good insurance.
If you simplify and subtract the need for intermediaries to extract profit from this kind of system, remove all risk of anyone in the country being personally financially destroyed by their health care needs, remove from US businesses the obligation to manage and pay for their share of their employee health benefits, and distribute the resulting costs across the entire population, would you argue that would somehow cost more? That the resulting "higher taxes" would exceed the lowering of all the systemic, business, and personal costs and risk above?
I pay for health insurance on the individual market, without employer or government subsidies. It's a shitty plan that I pay over $9k in premiums for and have a $3k deductible with an $8k out of pocket maximum each year with co-pays, and that's without utilizing the plan at all.
If I wanted to buy the same plan I had from an employer, a family plan, it would cost over $30k in premiums, with an $8k deductible and a $17k out of pocket maximum each year with co-pays.
All of those costs and it is still routine for the insured in the US to find out that the care they received actually isn't covered by their insurance, as well, so they're on the hook for paying for some care completely out of pocket.
I would love to hear your explanation for how my savings is actually higher now while I'm being extorted each year with higher and higher premiums for less and less care.
50% of bankruptcies in the US are medical cost related, so the whole “you can save more in the US with lower taxes” argument is moot. You’re doing the same as driving without car insurance; it works right up until the crash site.
He meant the total cost to the patient is zero. We pay for this via a regular yearly Medicare levy (if you don’t have private health care) and via our taxes. As Australians, we are fine with this.
Yes I should have said zero to her at the various points of delivery. There’s a different method of accounting at play. Till recently a volunteer firefighter in an environment somewhat like California’s. You might call it socialism light. The tangible benefits to the wider community, and there are many she and her ancestors have brought, are also accounted for. The working population agree to pay a fixed proportion of their taxes for this very purpose. A community based insurance. This is an approach proven to not be very appealing in the USA. I think mores the pity.
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.
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."
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”
> 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.
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.
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.
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).
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.
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.
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.
They get world-class insurance. They do pay for it, but I never said it was free.
Incentives matter. If Senators & Congress people were given only medicare and not their ACA Gold plan + perks, medicare would probably be a lot better off.
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.
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.
> 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.
> 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.
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."
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.
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.
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.
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.
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.
Yet plenty of countries have well functioning private healthcare. Singapore is a good example. Hell, even in Canada most primary care doctors run private clinics.
Small private clinics run by a small bunch or even a single practitioner have almost nothing in common with huge healthcare companies. This is precisely what I mean when I say that docs have control over their own turf but no further. Such small private structures are perfectly acceptable since they're much less toxic to the system at large. Independent practitioners will never have the lobbying weight that whole companies have, and therefore are IMO the only form of private healthcare provider that can work. Hospitals should be public.
I've seen first hand the opposite in my country, where free market private health care is working almost near perfection. All it takes is minimal regulation and then watching the healthy patient incentives aligning with the profit motive without government meddling.
And I've been watching in real time as the government is actively blocking and preventing this same functioning private healthcare system from acquiring covid vaccines. Right now, this "evil" private healthcare provider has all the money and willingness to vaccinate us all for free, but the government is denying it because they want a slice of the potential Profit to pay for the vaccines for the rest of the country.
Ok, so we must have very different views of public health if you consider the south african system to work near perfection. I mean, can you really say that given south african HIV prevalence? And that's just an example among many others.
I think it's very fair (and as you know as an epidemiologist, correct) to differentiate between a country's public health system and medical system. And between a country's primary, secondary, and tertiary medical care systems.
It's true that SA has quite good tertiary and secondary care, while they struggle with public health and primary care.
I do think the pricing mechanism of almost any other country outside the US is more reasonable than ours. Insurance, big hospital chains, and yes, to a lesser extent the AMA, have ripped pricing from its market mooring.
There are many other countries that have well-functioning market-based medical systems (even as they sometimes struggle with public health system due to poverty): Mexico and India spring to mind. Even catastrophic medical care (eg, cancer treatment, or major trauma) is affordable to the middle class in both of those countries, unlike in the US, where those events can ruin a middle class family even with insurance (I've lived it myself, to some extent).
Regulation can play a positive role here, but not by creating more bureaucracies. Rather, we need more transparent pricing. We need enforcement of anti-trust legislation against big hospital chains. With some hesitation, I'd say we also need to resume of significant prior support of basic medical research to push big pharma beyond their current biosimilars business model. And we need to "encourage" the AMA to put out more physicians (the student loan issue can be mostly solved by getting the government out of the student loan game).
If by public health you are referring to the government's provision of health-care, then yes, you are right. It's absolutely abysmal and very unfortunate for those unable to afford a private medical aid here.
So in the grand-scheme of things, public-health in SA is a failure, with the majority of the public being very poor and unable to afford medical aid. However, the model of the private sector on it's own is something that we've seen works and can probably be scaled up if government stayed out of meddling and "tweaking" it to their social value system. So if all they did was give people money to spend on their preferred medical aid (similar to the proposed "school credits" in the USA), then I think it'd work and the poor would have great access to healthcare despite not being able to afford it on their own.
Unfortunately, the 11% of tax-expenditure being spent on healthcare is not enough to cover such a thing, and they'd have to scale that up. Other things to keep in mind is that they have a ridiculously tiny tax-base here due to the inequality (I.e. something like only 10% of people pay income tax). The other thing to keep in mind is that a lot of the money that tax-payers here pay for, they don't actually use at all. E.g. Police, ambulance, fire services. They might as well be non-existant and defunded because the private sector has picked up the slack. As an example, just the other day I found out their largest city has less than 10 working fire trucks.
So you're telling me that your private sector wants to vaccinate everyone for free? Sure, yeah! So, call me Red but I feel something between "free for everyone" and "private sector" doesn't align...
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.
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.
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.
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.
why wouldn't it be? if you leave early, you're no worse off than you were when you graduated med school. I guess you could be worse off if you wouldn't have gone to med school in the first place if the offer wasn't on the table...
I'd guess if you leave early you have to pay off your own debt, possibly prorated by years on the job.
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
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.
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.
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).
Most countries that have socialized healthcare still have private providers - the government is paying for healthcare, but they're taking on the role of the insurance provider rather than the healthcare provider.
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.
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.
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.
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.
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.
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.
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.
Up here in Canada I have not gotten a bill yet (including when my daughter had to get brain scans), but one thing is it’s very hard to get the actual scans. I had to no joke steal my own chest xrays to get a copy.
> one thing is it’s very hard to get the actual scans. I had to no joke steal my own chest xrays to get a copy.
unacceptable. In Asia, you have the personal email and cellphone of your dedicated administrative assistant (you won't ever have to talk to another one) who takes care of things like that. You just tell her to obtain your CT and fedex it to your doctor, and they call you back when it's done.
Some providers are getting better at this. The hospital I visit has an online system that gives you tons of details on your results (to be fair, I don't think you see actual scans, but you do see all the notes and observations made on them which are clearly intended to be communicated between doctors and other care providers primarily).
You're not wrong but this is a sign of a very broken system and the people least able to deal with it on even footing are people who may be in extreme pain or delirious from their injury.
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...
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.
Ah... the problem here is not that the pharma companies aren't getting paid.. The problem is there's a bunch of banks and government subsidies and a lot of middle-people creating cost on top of enabling the funds flow. I am not sure what's the solution, but there really are a lot of administrative middle-people involved..
Try a web search for the most profitable drugs in pharma. They're not one-off cures. They're drugs the same patient takes repeatedly for decades: insulin, statins, pain-killers, etc.
That's not the only factor, though. If someone else is avoiding selling a cure to do something more profitable, you can compete with them by selling the cure and still make enough.
There simply isn't a "cure for pain" to replace painkillers, but statins and co could be avoided if we taught people actual good diet advice.
I mean that any system that has money or power as it’s underlying motivation probably cannot reach the kind of level that is possible since there will be people who are gaming and manipulating it to take extra for themselves.
My actual point is that we (human beings) have the technology, the knowledge, and the capacity for compassion required to live beautifully vibrant lives free of most of the health problems that we see in our societies. And we can have all that when we get out of our own way.
Im not sure your last statement is true or makes sense. Healthcare provision is not solar power bogged down by a specific technological or policy barrier. It's a complex service industry that requires a lot of human touch as well the capacity for innovation has no bounds on cost.
Nobody wants to spend 100% of their income on healthcare, which means saying no has to become a habit.
I'm not talking about Healthcare provision, or the complexity of the current service industry (the whole industrial complex around healthcare is
I'm saying: pretend we could sweep everything 'off the table' and start over. Not just the industries and the political systems, not just fiscal structures, not just the concept of money itself, but the mindsets of every human being.
And let me be clear: I do not think that this is realistically possible in any sort of reasonable time frame (I'm not even going to argue that it's possible at all).
But, now that we've hypothetically swept everything off the table, my point is that we have the building blocks to build a society where the majority of people are effortlessly healthy.
With a clean starting point, there's no reason to build in a way that companies gain by keeping people sick.
We as a planet know how to be healthy.
We as a planet know how to keep the environment healthy.
We as a planet know how to be emotionally, physically, and spiritually vibrant.
We as a planet know how to treat many diseases cheaply and effectively. (Not all. There's definitely still a need for medical R&D so don't @ me on that)
Yes, we could argue all day about how these ideas are not profitable or realistic or 'how things are done' in our current societies, but none of those arguments matter against the fact that we have more varied understanding and capabilities now than we ever have in the past.
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.
Agree in part — but there has been some engineering due to the moneyed interests. Few other industries have the perverse incentive structure where you cannot “shop around” to keep costs low. Also, the tax code was most assuredly engineered: tax code, as insurance that pays for medical procedures is tax-free to workers. But if they want to pay for the same procedure out of pocket, they have to pay tax on it. This leads to more insurance coverage and less consumer control.
It does seem like it’s engineered towards making profits in extremely unethical ways?
I get they need to make money, but many times it seems like hospitals/doctors sent out bills just hoping people will pay.
Me, and my father used to have great union insurance (Cadillac plans). For years their were no problems. That started to change in the late 90’s.
1. I once got a $900 lab test from a hospital. They knew I had insurance. I called multiple times, and told don’t worry about it, but I still got the bills. Lather I saw what the the hospital charged my insurance company, and it was $90 for the test. I paid $9 for my premium. Isn’t in the hospitals interest to send out bills just hoping I might pay $900?
2. My mom is sent so many bills even though she has the same plan.
My point is there are no laws against sending out bills. Hospitals/doctors might not have it written down anywhere, but just send out a bill, and let the patient clean up the mess with their insurance company seems like a good strategy—for the heathens?
My mom had a bad tooth a few years ago. Went to her dentist, and he demanded cash upfront—conveniently on a Friday, and he knew she had great insurance. She paid because of the pain. She called up a few weeks later, and asked for a refund. She gave $2500, and insurance (Delta Dental) paid 90% of the bill. She kept calling the dr’s office, but always was told we need to contact the insurance company. I finally got on to a Delta Dental worker, and started to explain the situation. The work seemed to know exactly what I was trying to say. In thirty minutes, after Delta called the doctor, a highly apologetic money manger said we are sending off your check today. (I won’t publicly saw what the representative implied here of the doctor here.)
3. My father once went to Marin General for a routine hernia surgery. My father was beyond a hardened man. I saw him close to crying once, and it over taxes. Well he woke up after the surgery, and their was a Teddy Bear, and bouquet of flowers waiting for him. It wasn’t me, I told him. Anyways it was a mystery until he got his bill. Beyond the typical $12 Tylenol’s, there was a $330 psychological enrichment fee. Yes—that was the hospital charging my father, and insurance for the unasked for gift.
So it is it seems like it’s in their best financial interest to overcharge, do unethical things, and hope people just pay?
No one argues that the California or Texas power grids were geared to be unreliable and fail, but they were deliberately engineered over the years in specific ways for specific reasons.
Our medical system is no different. Insurers developed byzantine claims departments and custom plans as a way to make medical coding complicated and error prone for the purpose of denying claims due to error. They setup private panels and doctors to reviews claims and treatment plans with the explicit purpose of denying claims as not medically necessary.
The system is designed to intimidate, overwhelm, and confuse and it's stacked against both the customer and the medical provider.
There are three heads to this beast: hospitals, insurance companies, and drug companies. Each swears it is innocent and points to the other two and calls them the problem, but they are all guilty.
You've covered the evil tactics of insurers, but providers absolutely engage in intentional opaqueness, overbilling, and as much screwball behavior as the market will bear. No, the insurance company did not force them to charge $500 for an aspirin and "accidentally" bill in full for a procedure that was discussed as a hypothetical but never actually happened. "Look over there!" isn't going to cut it as an excuse forever.
Over billing is a result of the complexity of the system. Care providers have to hire full-time staff trained to deal with insurance and file claims. Insurers negotiate rates with care providers that put them in a position of having no customers or ones they're paid poorly for. They have responded by playing games with billing and insurance to make ends meet.
Is it fair or honest? No but if they suddenly became fair and honest it would solve nothing because they're a symptom of the problem, not a source.
Same goes for insurance companies: just letting providers overbill would not solve the problem.
I'm sure the overbilling and weaponized opaqueness are plausibly deniable, but I'm just as sure that providers don't mind one bit when they work, just as an insurance company doesn't mind when they discover an excuse to deny coverage. Providers are not "making ends meet," they are testing the limits of how far they can exploit the blank checks they have been written. They are not solely responsible for this mess, but they have a full share of moral and systemic culpability.
Sure, nobody sat down 50 years ago and said this is how we want things to happen, but each individual part was created and the direct interactions are intentional.
For example insurance pays for procedures not the process of doctors filling out insurance forms. That’s by design and ends up having horrifying implications for the healthcare system as doctors often spend more time dealing with insurance than the patient actually needing treatment.
The intent is to maintain status-quo despite evidence that it's a broken system for medical users. Profits are being made based on the system we have. It's boards & c-suite executives keeping their fiduciary responsibility to their investors by lobbying against structural change. The intent is clearly there.
The intent is socially entrenched though - it's not just c-level executives calling for keeping the government out of healthcare. America has a real problem with anything that even smells like socialism or egalitarianism.
> 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.
...but then also this:
> ...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...
So maybe there are "evil" people and deliberation at work, and it's not just emergent complexity?
There can be "evil" people who will work to prevent the dismantling of a system, even if those people did not deliberately design and build that system. All that is required is that they recognize that the status quo benefits them, and that's a very common situation for those among the elite.
The Social Transformation of American Medicine is an illuminating read. Much of how we got here came in the form of, essentially, patches on top of patches, some of which were for good reasons, some of which were not.
Non for profit is a nice smokescreen. Nonprofit status is a nice little windfall fir the permanent bureaucrat class at payors and hospitals.
Starting from cancer children's hospitals that do all kinds of tricks to energize fundraisers and draw donations.. which amount to a paltry 30% of their CEO's salary....
Is it any surprise that admins then balk at putting prices online, with an argument that can be summed up as "OMG, you make us put online the price from 2000 contracts!! Its too hard! "
Here is a little nugget. Nonprofit designation for hospital is a recent development. It didn't exist before 1900. The designation was effectively "compensation" by the government to hospitals, so the latter would agree to admit patients regardless of ability to pay. Quid pro quo.
Dont feel bad for hospitals and their "curse" of nonpaying patients. They got their pound of flesh.
Nonprofit status its not just federal exemption.. its ALL Taxes (state, local, real estate, commercial, etc).
Imagine your life if you didn't have to pay sale tax? Property tax? State tax ? FICA, FUTA SDI?
I've come to the conclusion the past couple years is we need to get rid of non-profit status. There is too much room for grift and I'm afraid narrowing requirements would just make more loop holes and continue the process. I don't think that would be a popular opinion but I really don't see another solution to the problems caused by non profits.
The executives, board members, and middle management at all of these companies. I've worked with some of the companies you named, they have lavish offices and gravy train jobs for everyone and their crony friends. Yes, they're "not for profit", but that doesn't mean no one gets (insane) bonuses. Checkout their 990s sometime to get an idea at the excess of cash being pocketed.
Employers and owners of practices, hospitals, clinics etc. Shareholders of pharmaceutical and medical device companies. Executives and administrative roles are paid well, too.
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.
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.
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.
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.
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.
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.
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.
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.
It's true you can negotiate, but it's also true their bar for "reasonably afford to pay it" absolutely can include emptying your savings and other assets.
Hospitals' bar for reasonably afford is low, in my experience. They want proof that you make poverty line wages or below to write it off, below 300% of poverty line (around 38k) for reductions.
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.
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.
> 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.
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).
> 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.
Well another provision of the ACA was the 80/20 rule, Insurance Companies have to spend 80% of premiums on care or refund the customers. So their overhead, salaries, etc was limit to the remaining 20%. Sounds great until you think it through a bit and realize that for them to increase their profits they need to increase premiums, they also then have to increase the payouts and the Hospitals, Doctors, Anesthesiologists, etc.. are all fine with getting paid more. So there you go higher premiums to cover their increased $ value of their 20%. Everyone in the system except the patient benefits from increasing prices.
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.
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.
Sutter Health can't find my insurance in their system.
I called the insurance, and waited while the agent told me they were calling Sutter sort it out. After they told me it was all sorted, I called Sutter Health, and they still couldn't find me in their system and refused to serve me.
So I called again, with the agent on the line, and Sutter took my information. But, neither the insurance agent nor the Sutter Health representative had any idea how to fix the actual problem, so I'll have to have have this fight every time I work with Sutter Health.
I spent close to two hours on hold today, with the Anthem insurance's help line dropping me from the queue every few minutes.
The only parts of the system that aren't an outright scam are intentionally neglected and broken: still part of the scam.
In many countries, the concept of the hospital is also different from what it is in the US.
Where in the US there are clinics, ERs, urgent cares, and specialty practices, elsewhere there's just hospitals and you can go for any kind of treatment big or small.
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.
I've been ignoring surprise medical bills for 10 years, at least $10k worth altogether. None have reported to credit bureaus yet so I will continue to ignore letters.
I had a funny interaction with accounting, not for medical services but import.
I got billed extra taxes like 100$ (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.
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)
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?
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.
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.
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.
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.
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)...
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.
I don't know why it is legal but that is entirely how it works. They can't quote you an exact price on any procedure. They always hem and haw about something could change, negotiated rates vary, all sorts of BS even when you have specified the doctor, the procedure codes, the hospital, the jurisdiction and basically removed nearly every variable from the equation.
> 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.
The Affordable Care Act had some good intentions but they had no courage to make the hard decisions.Trump was terrible for health care in many ways but forcing hospitals to open up their pricing was a very good thing.
I am just a little afraid that they will find other ways to obscure things quickly.
I don't think that applied as broadly as people think. I had to remove screws and a plate from my leg in NYC at a fairly large hospital so I went through what I thought was a pretty straightforward process.
1/ Got the procedure codes from the doctor
2/ Got the doctor's estimated billing for those codes
3/ Reviewed my insurance information and in/out network status and then called up the insurance company to confirm the amount they would reimburse for those codes
They REFUSED to give me a clean $ number on how much they would pay of the bill that the doctor would give me. The bill from the doctor was high so naturally I wanted to know the true cost that I might be stuck with and the insurance company just wouldn't give a straight answer.
Naturally if there are complications and you have to have new procedures then it makes sense to me the price could go up, but for a straight procedure code to price transparency there doesn't seem to be any change in my personal experience
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.
There are many industries that have this issue and deal with it in different ways.
I used to do consulting and fixed price estimates were common. Even when requirements were unclear. The way I mitigated this was with multiple clients.
Hospitals have lots of customers. They don’t have to perfectly estimate everything, they just have to be good on average.
Here’s a podcast from Econtalk with Dr Kieth Smith from Surgery Center of Oklahoma [0] where he explains how his hospital does it. Basically he estimate the cost for an average procedure and charge that, they are good at estimating and adjust each year. Sometimes extra stuff happens, sometimes less stuff happens. If the shit hits the fan during the procedure they have that rare event factored in.
It’s such an odd argument because they certainly could if they had to. But they don’t, so they don’t.
> They bill based on the procedures done and might not have that information until after the fact.
Quote a menu then. Something like:
If everything goes well, we'll do X, Y, and Z; which will cost $5million, plus an extra $200,000 for the Oxford comma.
Some potential complications are this and that and they cost even more, etc. All surgeries are risky, and you could require life saving interventions which will cost a stagering amount, and we won't be able to ask for consent.
The patient could say; well wait, I don't actually want an Oxford comma, please leave that out; and they could put that on the chart, and if it's added, it doesn't get billed.
> So how do they quote that when the complications can be unpredictable?
Then they should be ones buying “price insurance” to compensate them potentially exceeding the quoted costs. That also has the pleasant effect of aligning incentives so they can keep their costs accurate.
Because people will be mad if their bill is significantly north of what they were quoted.
And also because providers have genuinely zero idea what insurance will pay for and insurance has zero idea what a provider is going to bill for. You can get basically exact costs for specific codes but good luck assuming they’ll bill it that way.
Yeah but I didn't ask for a FULL quote. I simply gave them X Y Z procedural codes and then asked what the responsibility to me would be. I also know what the doctor was going to bill and I want to know how much I would be stuck with.
Even a car mechanic gives you a detailed quote of what he EXPECTS and then you sign off knowing there is a caveat that more work could be needed.
Our local hospital tried to quote us for a routine fertility related procedure because we thought insurance wouldn't cover it. It took several hours on the phone before they figured it out. Day of the procedure they told us they forgot to factor something in and they gave us the wrong price.
They said it was fine though because insurance would actually cover it.
But they were wrong on that account too.
In comparison, the actual fertility clinic we went to was upfront and told us the price of everything ahead of time.
Everytime I've had to deal with a hospital the billing experience has been a nightmare. Fuck hospitals.
Giving out quotes and sticking to them is obviously not an unsolvable problem since the private health industry in so many other countries manages to do that.
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.
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?
The reasoning is to make pricing transparent and grokkable as in every other industry, end the severity of this in-network out-network divide, and eliminate this ridiculous dance based around providers sending fraudulent bills to patients.
In the car analogy, there are natural differentiators between levels of service, namely completely different shops that Rolls Royce owners go to. Even so, the same shop could have a price list specifically for Rolls Royces, using Rolls Royce certified mechanics.
And the residual where a shop is willing to pay for damage caused by barely competent mechanics on less expensive cars, but only becomes concerned when that liability grows? It seems like that should fall on the business.
> 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.
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.
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.
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.
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.
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.
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)
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].
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
I know this may look a little dystopian, but solutions of this sort would be illegal in the US and then folks would have no choice but to just go without any help at all. (Save for if charity/gov't step in).
Same story with housing. Part of the reason we have homeless ness (or more realistically people living in cars) is because the homes they could afford are illegal. (Hence why somehow they can afford "home" with a motor).
Now we have monopolies with no regulatory requirements to provide service to customers. Read: Verizon refusing to rebuild landline areas affected by severe storms.
Removal of regulations for ISPs.
Data caps. Throttling. Zero metering. Deep packet inspection. Data injection. Opt out (if you even can) tracking.
Removal of oversight for agriculture and removal of animal welfare regulations.
More contaminated products. More waste being dumped improperly.
Like the argument about minimum wage. Wages aren't going to go up if they remove minimum wage as companies are already paying the least they can get away with.
The "free market" simply cannot be trusted to regulate itself. The argument that this wouldn't happen in a "true free market" doesn't hold water. Nor that less regulations would make it easier for newer companies to compete: We've only seen the actual reality of such a policy. Less regulations make it easier for existing companies to fuck the consumer over.
Regulations are written in blood. There is a reason they existed in the first place.
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'
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.
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.
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.
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.
I mentioned that Trump accidentally did something good and got downvoted to zero. Same comment without Trump mention gets up-voted. Interesting and disturbing.
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.