I had an odd but successful experience with medical billing recently. My daughter went to urgent care for an urgent problem; after things were mostly cleared up, they transferred her by ambulance to an ER (even though there was no emergency). Both the urgent care and ER were handled by our insurance but the ambulance company sent us a large bill ($4K for a short drive) which felt too large to us (they had already tried to get my insurance to pay, but insurance said it wasn't covered). My wife was going to call the ambulance company to try to negotiate it down, but I recalled that I had recently received a random piece of mail saying that my employer subscribed to a service that could negotiate medical bills.
We contacted the service and provided our info (the context of the situation, the billing information, the actions we'd taken so far, etc) and a couple weeks later, the service reported that they had converted the ambulance ride from an uncovered insurance to covered by insurance (since the transport was between a covered urgent care to a covered EHR) and had our insurance cover the majority- we ended up paying $500 to the ambulance company.
While I am not surprised that such a service exists, what did surprise me is that it's just a division of my insurance company: they literally have a division that negotiates with another part of the insurance cmpany to get better coverage for patients. I was pretty lucky to notice the mail about this- there's nothing on my employer's site saying we have this coverage(!) and the vast majority of people in the US likely don't have this service.
If there is anything that will bankrupt the US, it's excessive medical charges and a lack of knowledge of how to address them. Maybe AI will help, but I really doubt it long term.
I hear you that you didn't have to pay something crazy but the fact that you ultimately paid $500 for a short ride and you think it was "successful experience" is how they fool us. You think you got a deal when they are still laughing all the way to the bank for charging you $500 for a short ride.
I don't know, I don't run an ambulance company- what should the cost be (either to me, my insurance company, or to the government)? Can't be cheap to fully staff an ambulance with EMTs.
Yes, but I'm talking about the costs of actually running a 24/7 emergency vehicle operation- even completely idle, the emergency vehicle has significant costs that they need to cover.
as long as we have a significant portion of healthcare users who are basically fully price insensitive but not subject to any rationing, absurd US medical costs will continue.
Hard to believe you say we aren't subject to rationing when pre-authorization is as big as it is.
You should see some of the proposed rules. Pre-authorization will start to use a medical language called CQL and there will be literally thousands of queries EHRs will need to implement to ensure their customers can get the care they need.
> Hard to believe you say we aren't subject to rationing when pre-authorization is as big as it is.
If you want to see true rationing, look to the UK (especially) or Canada (less so) where I know plenty of people who have to wait over a year to see a specialist even after doctor referral.
Meanwhile, my parents in the US at a hospital get a CT scan, MRI 'just in case' immediately (or close-to for the MRI) and pay nothing for it.
> Meanwhile, my parents in the US at a hospital get a CT scan, MRI 'just in case' immediately (or close-to for the MRI) and pay nothing for it.
I live in U.S. and know people on ACA Marketplace plans, employer HDHP, Medicaid, Medicare, Medicare Advantage, people who are uninsured, people who are overinsured, and people who have crazy expensive fly-me-out-of-the-jungle emergency plans (one who actually used it in the U.S.).
I have never heard any of them get an MRI or CT scan same day "just in case." And for the one who got an MRI close to same day for stroke symptoms, it wasn't free. (And even in that case, the earliest appointment with the specialist to assess the MRI was nearly a month later.)
Someone getting their first colonoscopy had an appointment two months out.
Someone getting shoulder surgery four months out.
A person on Medicaid with Stage 4 cancer waiting a week and a half for a fentanyl patch because the pharmacy couldn't get approval from the Medicaid subcontractor for whatever reason.
People from the U.S. who post on HN: please tell HN which is more common:
* my stories
* your parents getting free MRIs and CT scans "just in case"
First, I didn't say same day and specifically caveated for the MRI. That said, the CT was either same-day or next-day, I forget which. It was for hyponatremia and was in the Washington, DC region.
My primary point was comparative - wait times are considerably longer for the NHS than in the US.
> My primary point was comparative - wait times are considerably longer for the NHS than in the US.
It depends what it's for. If you want something non-urgent, you may be waiting a bit longer.
If you go to A&E you'll be seen very quickly in the UK, but unless you're lucky with which hospital you pay to get into you could be waiting quite a while in the US.
In the UK, you can pay more (say 30%-40% the cost of a US health insurance plan), get treated like royalty in private care, skip all the lines for specialists, still be covered by the NHS to pay 0 for anything catastrophic, and still never get a bill in the mail from anyone.
It's not an either/or situation. The US has the least efficient healthcare system of any country in the world. It provides less treatment per dollar than anywhere else. You can provide universal basic coverage and still provide luxury insurance plans.
True of the UK, not true of Canada (where providing services covered by the public sector is illegal AFAIU). I think this is exactly the sort of model to move to, price sensitivity for routine care - government insurance and forced saving for the catastrophic. Healthcare should be entirely untied from jobs.
US healthcare is a mess and I'm not defending the cost - but it does have the highest number of top specialists in the world & strong R&D.
In the US care like that is rationed by wealth rather than by need. Your parents are getting MRI scans that they may not really need, while uninsured Americans aren't getting MRI scans that they may actually need.
I bet we could cut down NHS waiting lists a fair bit if we arbitrarily decided that ~10% of the population were no longer entitled to a wide range of non-emergency treatments.
This is true to an extent, but with the massive age-based confounder that is medicare, which renders the elderly close to price insensitive as well as by far the largest utilizers.
I think there are lessons to learn and improvements from both systems - for instance, catastrophic healthcare is a disaster in the US (in terms of cost), but we are better at timely care and providing incentives for pharma R&D.
Medicare has pretty good negotiating power, rather like the NHS. Medicare patients may not care how much Medicare is paying for their treatment, but the US government cares how much it spends on Medicare, and the IRA has given it some additional powers to negotiate drug prices in recent years.
Imagine if the U.S. government gave out free smartphones to some segment of the population. Over the years, they’d get used to replacing their phones for the smallest reason — a scratch, a tiny crack, dropped it a little hard — because it costs them nothing. Some might even start swapping phones every month or every week.
“Ah,” someone says, “but the government negotiates huge discounts with the phone makers since it buys in bulk!” I think this misses the forest for the trees when it comes to cost control.
We don’t have to imagine how Medicare works because it exists, so I don’t see the use of such analogies.
I suspect that it’s mainly doctors who need to be more responsive to cost incentives as they’re often the ones recommending unnecessary tests or treatments.
My analogy is not with socialized healthcare but with the medicare scheme. Socialized healthcare works in lots of other countries due to a combination of rationing and (in the case of drug prices) prioritizing accessibility over R&D.
> I suspect that it’s mainly doctors who need to be more responsive to cost incentives as they’re often the ones recommending unnecessary tests or treatments.
Doctors would recommend fewer tests if their patients were more price sensitive, I think. I'm not sure a more direct route to making doctors price sensitive when they are on the provider-side, why would they want you to utilize less? There probably also needs to be malpractice/tort reform in the US.
I edited my post to say Medicare shortly after your reply (sorry). But if there’s evidence that Medicare is especially profligate with unnecessary tests and treatments then you should give that evidence, rather than arguing by strained analogies.
I think that analogies are helpful for elucidating the point but in terms of concrete evidence, there are two gold standard studies that really reveal this issue. These studies are very hard to come by because it is typically difficult (for good reason) politically to experiment with people's healthcare, but we are lucky to have two: the RAND healthcare study and the Oregon medicaid lottery.
My understanding of both of those studies is that (particularly for pre-registered analyses), we saw that adding some sort of cost-sharing substantially reduced utilization of healthcare services (~30%) without any impact on health indicators even multiple decades down the line, with the possible exception of mental health indicators. Nowadays people try to p-hack their way out of these conclusions, but it is pretty strong high-N experimental evidence.
>Imagine if the U.S. government gave out free smartphones to some segment of the population.
Obama phones were literally a thing and
>Over the years, they’d get used to replacing their phones for the smallest reason — a scratch, a tiny crack, dropped it a little hard — because it costs them nothing.
Did not happen because this is absurd and not how any entitlement program anywhere has ever worked, and more importantly, in healthcare you WANT THIS TO HAPPEN
It's cheaper for someone to go see their doctor when they "think I might have something wrong" then once they actually know something is wrong, and so substantially cheaper that even US insurance companies try to entice it by making yearly physicals free or other preventative care, but it doesn't work as well for the US because even with insurance incentivizing it, you still end up with all the billing BS that can leave you harmed by going to the doctor
> I think this misses the forest for the trees when it comes to cost control.
Sorry, the actual empirical evidence is that the government setting prices has done better all over the world than whatever the US does. This magic belief that allowing the government to control access magically produces bad systems is just wrong. Government is capable when you vote for people who want to make good government
I waited over three years to get a routine colonoscopy in New Mexico and finally just got one after moving out of state. More standard waits for a specialist there are 9-18 months, if you can even find someone competent in the specialty. Many people have to go out of state for care.
Provider availability is non-uniform across the US.
In the middle of Albuquerque. Rural areas offer hardship pay to attract medical professionals, but it’s really touch and go. IHS has its own host of issues.
I live in the US in one of the largest metro areas. I've had to wait nearly a year to see a specialist in the past, and that was with "good" PPO insurance (see my comment history for trying to find a dermatologist for what I thought was potentially skin cancer). Its really not that uncommon to have long waits. I've had insurance deny prior authorizations over and over delaying care many months despite actually meeting their own documented criteria for approving the surgery. My kids have had to wait months to get an important, medically necessary surgery multiple times, because the decent in-network providers are massively booked out.
Comparing getting imaging work done to actually seeing a specialist is comparing apples to oranges. They're both healthcare related things but are massively different.
There's tons of imaging clinics staffed by people who only needed an associates degree from a community college, radiologists work remotely all over the place spending little time on each patient and writing a report. Overall its really cheap and easy to build and staff an imaging location.
Seeing a specialist requires actually going to the doctor in person, that doctor had to spend many many many more years and limited spots for an education, and probably only sees patients in clinic a few days of the week. You'll have a whole staff of nurses & PAs (who quite probably had more education than the rad tech) and office staff to support the small handful of specialists.
As a personal example, I had an issue with my knee, locking up from time to time bending with weight on it. I looked up kinesologists in my area covered under my insurance. Dozens within a short drive, awesome. Calling up, "sorry, we're not taking new patients", "we can see you in four months", etc. A few months go by, I finally get in to see the doctor. He has me do some motions, asks me a lot of questions, takes a quick x-ray in the clinic, recommends I go get an MRI and come back. I am able to find an MRI clinic that's covered and can get the imaging done that same day. However, its several more weeks until I can see the doctor again to actually review the radiologists notes. I finally go back, the doctor recommends surgery, a prior authorization gets filed. We wait. We wait. Denial, no MRI, imaging required to determine medical necessity. Huh, they paid the bill, didn't they wonder what the MRI said? Resubmit. We wait. Denial, MRI was inconclusive (it wasn't). Resubmit. We wait. Denial, physical therapy is recommended instead (except the thing they call out as a reason to have surgery is verbatim what the radiologist notes say). Resubmit. We wait. Denial, same response. Its now been almost a year of intense joint pain every time I crouch down, walking is starting to be difficult. I'm in a brace and crutches and the pain is getting worse. I finally just wait at the clinic all day, we spend hours and hours on the phone with the insurance company to try and get an approval over the phone directly. I finally get approval, and manage to get in for surgery several weeks later. I have the surgery in the morning, and I'm back to walking without any pain and without crutches or the brace by lunch.
And in the end, after the surgery, the insurance company complains they shouldn't have covered the procedure because supposedly I didn't have an MRI of that knee. Idiots.
This is just one of several shitty stories I have of dealing with health insurance companies. Multiple over the years.
And that's on the insurance side, not even the care side of things! One time, while waiting multiple hours in an ER complaining about becoming massively lightheaded and weak and barely able to sit, I finally passed out and fell on the floor out of my seat. The shock of hitting the floor woke me up a bit, and the first thing I heard was "sir, you're not allowed to lay on the floor, stand up." Uh, I would if I could!
All in all it took over a year of joint pain before I managed to get surgery to fix my knee, all because the insurance company was rationing care. A year I won't have playing with my toddler at the time (I couldn't easily crouch down to play and expect to stand back up easily). Arguments of "bUt RaTioNinG!" ring extremely hollow to my ears. We already have rationing in America, you just haven't experienced it yet.
The idea of an injured patient having to pay at all for an emergency ambulance ride to a hospital should stun any normal human being living in a civilized society.
Then who pays? If your argument is that we should socialize the cost of that ambulance ride across all Americans, they won’t go for that. Americans don’t want more taxes, but more importantly, Americans deeply mistrust their fellow citizens, and don’t want to feel like they’re paying for someone else’s life decisions.
America doesn’t have the same kind of social cohesion as most countries. We’re a nation of individualists. The general feeling here (rightly or wrongly) is that healthcare costs are largely driven by your choices in life, and Americans don’t want to feel like they’re on the hook for other people’s bad choices.
>While I am not surprised that such a service exists, what did surprise me is that it's just a division of my insurance company: they literally have a division that negotiates with another part of the insurance cmpany to get better coverage for patients. I was pretty lucky to notice the mail about this- there's nothing on my employer's site saying we have this coverage(!) and the vast majority of people in the US likely don't have this service.
100 years ago I used to work for the fruit company in phone support.
My KPI's were 100% customer satisfaction. However, I needed to get approval from another team to advance any kind of free/gratis repairs replacements or gifts.
That team's KPIs were opaque to me, but my understanding is that they were find as long as they offered some resistance.
Between those two pillars we got a lot of good done for customers. I dont think theres anything necessarily wrong with having internal friction like that if its designed correctly. Its probably better than having both responsibilities in a single person.
In terms of health insurance however it seems ghoulish.
We contacted the service and provided our info (the context of the situation, the billing information, the actions we'd taken so far, etc) and a couple weeks later, the service reported that they had converted the ambulance ride from an uncovered insurance to covered by insurance (since the transport was between a covered urgent care to a covered EHR) and had our insurance cover the majority- we ended up paying $500 to the ambulance company.
While I am not surprised that such a service exists, what did surprise me is that it's just a division of my insurance company: they literally have a division that negotiates with another part of the insurance cmpany to get better coverage for patients. I was pretty lucky to notice the mail about this- there's nothing on my employer's site saying we have this coverage(!) and the vast majority of people in the US likely don't have this service.
If there is anything that will bankrupt the US, it's excessive medical charges and a lack of knowledge of how to address them. Maybe AI will help, but I really doubt it long term.