> UPDATE: Monday, shortly after publication and broadcast of this story by Kaiser Health News and NPR, St. David’s said it was now willing to accept $782.29 to resolve the $108,951 balance because Drew Calver qualifies for its “financial assistance discount.”
Sounds all fine and dandy until you realize that these charges will just be made up for by people that aren't able to get NPR to publish a story about them.
When you realize that the hospital was charging $19,000 for a stent that cost $1,500, you realize that painting Calver as someone who is going to cost us all money is misdirected anger.
And, to be clear, they charged $19,000 for the stent, not "stent plus theater time to place it plus surgeon, anesthesiology, OR nurses", of course not. Those are all absolutely billed separately.
I believe there should be legal consequences for getting things this wrong. Wondering how they came up with the $19,000 number.
Also, in speaking with a vascular surgeon I know, their hourly rate is between 200-350/hr. The middlemen and hospitals have figured out how to milk this cow and they're feasting.
Absolutely, and it is this sort of practice that all Americans could get behind legislation that made it illegal. Unfortunately we can't seem to have a civil discussion on health care to find the issues we have in common.
>You could literally bill for breathing hospital air and people would have to pay.
Don't be ridiculous. You'd be billed for air and hospital odor separately!
Though I should note that a delivery is usually more complex than simply waiting there for the little one to fall out, there is some after care and such that is being performed plus the doctor is usually not that cheap either. (They have a lot of student debt to pay off after all)
Their liability insurance has to cover the costs of lifetime care for any babies that are injured during delivery (juries have made this clear enough). It's not strange that they pass this cost on to mothers.
Medical billing is a nightmare. I have HMO insurance (which means the process should be really streamlined - everything is in-house) and I once tried to figure out why certain rather simple bill item was billed certain cost. It took about three weeks, multiple calls and emails, and speaking to several people, to get to the stage where they said "this is probably because if it was classified as code X, though we can not give you rules why it is code X and not code Y, and there's no way to know upfront which it would be, we'll just send you the bill later and you pay whatever we say" and even then they couldn't answer why sometimes they billed certain percentage upfront and sometimes another, so that you end up getting different pre-payments and different bills for the same thing. This whole thing is an ungodly mess.
Hospitals should be required to publicly post prices, just like fast food restaurants are now required (in some places) to publicly post the calories for each dish.
This isn't just restricted to US. It has become very common even in a country like India for doctors and hospital owners to invite their doctor buddies for 'second opinions' and looking at non-issues and then billing the patients 'consulting fees'.
There is also a huge industry built along the lines of phony testing.
The term used for that think is called 'basin test', basically samples are flushed down the basin and made up numbers are put in reports. You can put in what you like as the doctors know the patient is healthy.
Hospitals should be legally mandated to accept replacement of materials in lieu of payment.
If I can source the same stents for cheaper than the hospital bills me, they should be required to erase them from the bill and accept them as material replacement.
It's not as if medical supplies are unavailable to the end consumer.
When I had a broken finger and was uninsured, I was charged ~$40 for a finger splint that costs $7 at Walgreens (yeah, the very basic one made out of aluminum and blue foam).
Also, a word of advice - never ever pay what you were sent from the hospital right away. I personally throw most medical bills in the trash and wait until they call me, then negotiate it down to a fraction of what was billed, offering to pay in cash.
> Hospitals should be legally mandated to accept replacement of materials in lieu of payment.
> If I can source the same stents for cheaper than the hospital bills me, they should be required to erase them from the bill and accept them as material replacement.
Meh. The only reason they inflate supply costs is because that's where insurance negotiations let them. Mandating supplies must be available at-cost to consumers is just a stupid cost-shifting game. Consumers shouldn't care in particular about the cost of supplies — overall cost is what matters.
Price-fixing in general does not really work. The difference is made up somewhere. Things that would actually reduce pricing stupidity and surprise bills are obvious things like: increased pricing transparency, consumer stake in reducing costs (HDHPs are a stab in this direction), and single payer.
Emergency care is not a great market to be a buyer in, but that does not change that market economics apply. And it is beside the point. The vast majority of healthcare is boring, predictable, non-emergency expenses that can be shopped around.
I agree that regulation makes sense, just not with the extremely specific proposal that medical devices be sold at cost (or whatever slightly higher unit cost is available to consumers).
> Mandating supplies must be available at-cost to consumers is just a stupid cost-shifting game.
That's not what I suggested in my post at all.
Also, if it reduces costs for the end consumer, what's the harm? Why should consumers subsidize hospitals with cutthroat billing departments who make up numbers out of thin air?
NHS is a single-payer system, which is one of the solutions I proposed.
Yes, mandating supplies be sold at-cost is exactly what you proposed:
> Hospitals should be legally mandated to accept replacement of materials in lieu of payment.
> If I can source the same stents for cheaper than the hospital bills me, they should be required to erase them from the bill and accept them as material replacement.
And to address:
> Also, if it reduces costs for the end consumer, what's the harm?
The problem is in the condition. At the end of the day, ineffective regulation increases costs for the consumer.
Are you suggesting that a sick person, recovering from an operation, be responsible for researching prices on the parts that were used in surgery? Most do not have the time or expertise for that, nor would anyone want to do it.
Have your spouse/relative shop around for replacement while you recover. Or be destitute for 10 years after being bankrupted by medical bills. I know which one I'd prefer.
> Most do not have the time or expertise for that, nor would anyone want to do it.
Is that a joke? You can find most of those things with a 30 second Google search. I thought this was a forum with technically apt people?
Is anyone working on an app that can do this? There were those parking ticket negotiating apps for a bit. I wonder if there is a way to systemize the negotiation process here. I bet you could charge people up to 10% of the money you save them.
People are surprised when I tell them I simply refused the 3k dollar (after insurance) couple hour hospital bill for having the flu. They couldn't tell me why two tylenols, a saline drip, and a prescription cost that much. (I was vomiting blood which is why I was taken in).
They ended up dropping the bill altogether as insurance had already paid them.
> They couldn't tell me why two tylenols, a saline drip, and a prescription cost that much
I know the US system is different to what I grew up with (UK NHS), but I have had similar "treatment" when ill as a tourist in 3rd world countries: couple of pills / drip.
I understand that the difference of systems in regards to extensive care, but a couple of pills and a drip - why on earth is such basic care just not free to all?
Have you been following the quality of people running our government?
I mean, I know this seems like just a snarky political comment. But it's just the honest answer. Our federal government is simply completely dysfunctional right now, incapable of solving anything.
For what it's worth, "Medicare for All" has been polling increasingly higher recently, due to more Americans being basically ready to give up on the current private system entirely.
Just now? It’s seemed dysfunctional to me since I was capable of understanding government, circa 15 years ago. My parents felt the same way 30 years ago, and their parents felt the same way 50 years ago.
Nope. No way. Have we learned nothing from "fulfilled by Amazon" counterfeits?
The supply chain has to be verifiable as genuine goods from the factory to the hospital floor. Trying to verify the authenticity of patient-supplied replacements would be a nightmare.
Then force hospitals to price match or force them to show YOU, the customer, how much the item actually cost when it was delivered to them for storage.
I wasn't actually seriously suggesting that patients be required to source the item physically, then physically deliver it to the hospital in person.
Honest question - does this really work? I have tried it once or twice without success. Are there particular 'magic phrases' you need to use, or is it jut a question of persistence? Does it impact your credit?
> Are there particular 'magic phrases' you need to use, or is it jut a question of persistence?
My situations varied, but when I had no insurance and was living off of savings, I found a generic "hardship" form and explained my situation to them - they waived 80% of the fee without much resistance. This is compared to the laughable discount of 2% they offered me on the spot if I paid in cash (at the moment of the visit)
In other situations, I'd imagine it's more a question of persistence, but I'd venture to say you can knock off at least 50% on _any_ hospital bill.
I recently bought a house, and my credit was 800+, so I don't think it does in any appreciable way.
That wasn't the gist of my post though. I was advocating more to resist the bullshit and to legislate something that allows the customer to replace materials instead of paying a hugely marked up item.
Same concept would be applicable, for example, for a car mechanic shop. Just because they billed me $600 for brake pads doesn't mean that they've actually provided me with a 10x markup of value on having bought brake pads myself for $60 - at some point this needs to be treated as "usury" (I don't know if there's a word for exorbitant markup on a regular good).
Another thing I would add - don't put your social security number on medical forms. I've never seen it enforced and there's no medical reason for them to have it.
Paying 300-500/mo for decades, as a chronic heart patient here. I've had multiple open heart surgeries and nothing sweeter than paying 6k for the recovery room and 0 for the surgery (along with sweet receipts for 1mil in aggregate surgery costs). The separate billing is a pointless red herring, in context of the article.
In the UK and paying a monthly National Insurance tax:
About 5 years ago, I had 6 weeks in hospital, a total of 3 angiograms, one MRI scan...and then 5 stents (should have been 4, but they tore something and had to put in a covered one!).
The wait was mainly down to an unfortunate series of events: One stent was needed in a 'tricky' place and so I was timetabled to be operated on by a specialist surgeon elsewhere, but his father fell seriously ill so he went on leave. My first op was rebooked for another hospital...and they had a 'flu outbreak so ops were postponed. Eventually I was booked in elsewhere had a one hour ambulance transport ride for 'third time lucky'.
The stents were fitted in two separate operations about two weeks apart. The most notable expense I incurred was for data top-ups on my cellphone because hospital wifi was still being setup and hadn't quite made it to my ward.
The NHS gets a lot of flak, and it's by no means perfect, but it's generally there for you when you really need it.
PS: I'm on a slew of meds for my heart condition and T2 diabetes - all free at the point of collection.
I had my surgeries in the middle of Los Angeles (Kaiser - 4867 W Sunset Blvd, Los Angeles, CA 90027). My insurance covered 7 days, but I paid for additional recovery time at about 2k a day.
In regard to your friend ... his 7 x 2 = $14k. That's a LOT for basically a bed, blood draws daily, limited TV and cafeteria food, but in the center of Los Angeles, that's what you get.
There is a whole industry of "medical billing advocates" you can pay to find what is likely thousands if not tens of thousands of dollars of completely made up charges on any given US hospital bill and "negotiate" them away. You don't necessarily need press coverage though it obviously helps.
Hell one time I got a $15k bill for something insurance should have covered. Called the hospital, turns out insurance had covered it and I didn't actually owe any money at all. How many people get this kind of stuff and just pay it anyway?
> Hiring someone became imperative for me when coordinating my mother’s care got to be a way-more-than-full-time job. (In retrospect, I wish I had done that months earlier.)
> It could also be worthwhile in less critical cases, if no one in the family can take enough time off from work, or in which you’d simply rather pay someone else to clean up after a hospital’s paperwork pollution.
> This role has developed only recently, as systems have broken down. There’s not yet a standardized term; “health care advocate” is one among several.
> Mine specializes in gerontology and dementia. Others specialize in other disease areas; or in other aspects of the administrative nightmare, such as sorting out bogus hospital bills, which frequently include fraudulent additions.
> They are not inexpensive (mine charges $150/hour), so not an option for everyone.
> There are good and not-so-good advocates. I spoke with several before hiring one. Some were clearly clueless; the one I hired last month has seemed consistently competent.
> Since they recommend particular providers, there is an inherent principal-agent problem. Ask if they get any compensation from services they recommend. Take their recommendations with a grain of salt in any case.
I went through surgery at the Stanford Hospital, using Stanford's insurance. Prior to the surgery, they charged me $2000, the out of pocket maximum. Then, a couple of weeks post-surgery. I got another $250 bill. I had to spend the whole day on the phone first with the hospital, then the insurance, and then the hospital.
Turns out, that all I had to pay was $250, that the hospital had made a mistake in billing me $2000 at the door. I got my money back a month later.
I would normally attribute this to ineptitude. But the frequency and scale with which this happens, reeks of widespread scams.
Yea, but to hire a medical billing advocate, you need: 1) knowledge/information that they exist and that hospital bills are BS, and 2) money to pay the advocate AND the reduced bill. If the final bill is $800 and the advocate gets a cut of the savings, how many people in dire straights are likely to be able to afford that? Keep in mind, most Americans don't have 1k in savings, living pay check to pay check because they have no choice. Facing a 100k bill, people are more likely to wait for the collector to show up and then declare bankruptcy, facing damage to their already poor credit, garnishment of already subsistence wages, etc..
I'm much less worried about the folks who pay it anyway than I am about the folks whose lives are destroyed by an industry predating on people in the worst of circumstances.
If you make money off them but save them more money than you costs, it is still towards their benefit. The only problem occurs when you start working with the hospital to create even more arcane bills that you get into immoral territory.
That's exactly the circumstance I outlined previously. This plan has you taking the debts of somebody who cannot afford to pay, reducing them to something above the actual cost, then asking them to pay the higher amount. You are making money from the least able to pay and profiting from a system driving people into bankruptcy. I cannot imagine starting such a company without serious empathy issues.
I'd start with a mentally forced mashup for each to get a few that might work. e.g. "If i've got to make money by lead generation with a medical bill review service/app, how could i do it?"
Then i'd focus on how we'd drive value to the consumers.
Then think about driving value to others parties who may be willing to pay for something similar.
ie would pharmaceutical and medical device companies be willing to communicate directly with these consumers?
note i'm not saying its easy by any means, but i do think its a real problem that could take off if an elegant and worthwhile solution came about.
I had a hernia surgery shortly after a plan change. The hospital believed insurance wouldn't cover, so they discussed cash pricing with me of around 7k. The insurance ended up covering their portion with me paying about 2k out of pocket.
But then I almost had a hard attack when the statement arrived. The first number I saw was 24k, WTF!! Well, reading on there was a very large "discount" applied and the final bill to the insurance company was about right. I could only imagine though, that under some circumstance, the hospital would have tried to stick me with that totally bogus 24k bill had the insurance not covered it or the pricing not been negotiated in advance..
Not always. My mom had a quadruple bypass about 6 years ago during a gap year where she stopped working but didn't have Medicare yet. Unlucky. I think she was billed for around $180k.
She told them "I'm on Social Security for $1000/mo, I'll pay you $50/mo". It was basically that or sending it to collections and never getting a dime from a retiree. So they accepted and told her a "non-profit" paid for the doctor's portion of the bill, which was all but about $40k.
She'll probably be around another 10 years max, which means she'll end up paying about $10k of that balance.
Medical debt is the least concerning type of debt for most lenders. If you ever fall into this hole, don't sweat it. [Unsolicited advice.] Just let it go to collections. You'll get harassed for a little over a year. Debt older than a year is almost never pursued by collections agencies. After things quiet down start sending letters to the credits agencies saying the collections debt has been settled. The collections agency will usually slip up and not respond at some point and it'll be gone from your credit history.
I worked with somebody who at 23 was bitten by a cat and it got infected. She didn't want to seek medical treatment even though her hand swelled up like crazy--"I don't have insurance, I will get better". I basically forced her to go to the hospital and she ended up spending a couple of days in the ICU. They told her if she waited another day, she might not have made it.
Total cost, something around $23,000 I think. This is somebody who was making maybe $10/hr. They took a payment plan of around $15/month, so she will be paying it back for the next 128 years.
Another anecdote about my mom. A few months ago she was rushed to the hospital for symptoms of a pulmonary embolism. She spent 36 hours in the critical care unit. They couldn't determine what caused her episode; no clots, etc. They charged her $25k for that. That's how fucked up the situation is. A single night in a hospital that may save your life ends up costing almost what your kid/grandkid is paying for a year of college.
Recently she got a bill for $250 for the ambulance, which she paid, and another letter saying her bill for the hospital stay was settled. She told me she would have offered $15/mo had they held her to the $25k or told them to screw off if they didn't accept. They're not even bothering anymore.
> Medical debt is the least concerning type of debt for most lenders.
Just another data point, a large property management company I used to work for specifically exempted bankruptcies due to medical debt when calculating applicant credit scores.
I have a friend who sells debtor data for a living. He literally sells Excel spreadsheets of debtor data (name, address, SSN, amount owed, etc) to collections agencies for $5k-$25k a pop. He makes mid-six figures doing it. The quality of the data is what commands the price. He said the least desirable debt are debts older than a year and medical debt. He can't even give that crap away.
Also, if you're ever called by a collections agency, you should ask them to provide proof that they actually hold the debt you're obligated to pay. In some cases they've just bought the data, usually from another collections agency who couldn't collect, and they're trying to shake you down. Once you use the magic phrase "provide proof" they give up and stop hassling you, because they have no proof.
I'm not sure I believe that debt over a year old is not pursued. Anecdotal, but...
I've had 4 different cell phone numbers in my lifetime. All of them were still getting debt collection calls or still are up to 15 years later. I've had my current number for over 15 years. I'd love to meet Tanya who ran up the bills for my current number.
Also, I had my appendix rupture right after getting laid off and going on COBRA. I am still getting occasional calls about that even though the insurance eventually paid off. That was over 10 years ago.
COBRA is another scam. $1650 per month that my employer was paying ~$600 for.
Scumbaggery is rife in the insurance industry. The Rainmaker should be required watching...
> Just let it go to collections. You'll get harassed for a little over a year. Debt older than a year is almost never pursued by collections agencies.
I don't understand. Is there no penalty to not paying other than a hit on your credit score? Can't you end up with wage garnishments or liens or something like that?
It'll definitely show up on your credit report. The key is a lot of lenders supposedly will just look past it. Ultimately it's up to them if you get a loan or not, not just based on the number alone.
One caveat, you definitely want to contest the debt in writing regularly. If it goes away because the collector failed to respond you are fine. If it goes away because they "forgive" the debt, its seen as income by the IRS and you will pay taxes on it. So imagine the tax bill if 200K of "income" is added to your taxes one year.
Where I live (Arizona) there's a statute of limitations on consumer debt, think it's 2 years for random bills and 3 years for recurring payments...or something similar.
Ok but can't the hospital (or the collections agency) take you to court? Let's say you have 100k bill from the hospital that you just ignore. They sell it to a collections agency for 60k. You refuse to pay the collections agency. Now what happens?
Yes, the hospital or collections agency can sue you to try to garnish your wages. If they win, you're boned.
If they lose, or they never sue for garnishment, it's unclear what happens if you refuse to pay. From what I can tell, the debt disappears from your credit report after seven years, but the debt is still valid and they can still try to recover the money from you, but they won't be able to use the courts to do it.
However, there's always the option of declaring bankruptcy. Even if they garnish wages, declaring bankruptcy will wipe it away. Obviously, that's the nuclear option and will destroy your credit rating for seven years.
> Sounds all fine and dandy until you realize that these charges will just be made up for by people that aren't able to get NPR to publish a story about them.
No, St. David's has already fully recouped their costs and then some. They were simply trying to extract as much money as the stone could bleed.
I was going to respond saying that most hospitals are nonprofits and aren't actually making a great profit margin off this sort of overcharging. But then I looked it up and St. David's, despite having a religious nonprofit-sounding name, is actually owned by HCA Healthcare, which is a for-profit that has almost 4x'd its stock price over the past five years while acquiring more hospitals to grow. So, yeah, this one is about corporations squeezing money out of people because they can.
> despite having a religious nonprofit-sounding name
They came by the name honestly, but it is indeed a shame the way it has gone since the St. David's Foundation partnered with HCA.
The hospital(s) were originally founded and run by St. David's Episcopal and were one of the first and foremost hospitals in Austin, with very high quality care and good service to the community.
After operating them for nearly 75 years, and growing to an enormous enterprise, it became clear that a church congregation simply couldn't and shouldn't be operating them any further and they were spun out. Some of the profits are still sent back to the foundation for community health care grants.
This particular wealth extraction strategy would never have occurred under church leadership.
(disclaimer: I was a member of the church during this period and hold it in very high regard)
My ex worked for HCA and she insisted that she could tell you the exact cost of a procedure before undergoing it.
Well at some point she needed surgery (at HCA), and about five months later after dealing with 10 < x < 20 bills including one we'd never heard about until collections came knocking she just looked at me and said "Nobody knows what this is going to cost." It really bums me out that a human being working in healthcare here isn't able to even remotely predict the cost of a procedure at the hospital at which they work.
For hospitals which really are non-profit a) the non-profit status doesn't prevent price gouging b) even if acting as a traditional non-proft, they may do so to balance revenue against people with no insurance and no ability to pay. (a burden we load onto hospitals that we should actually be sharing much more explictly and universally across our nation).
> squeezing money out of insurance companies because they can
FTFY.
But seriously, how can it possibly be the hospital's fault for doing exactly what the law and market incentives give them every reason to do? There's almost no downward pressure on prices: little competition, no transparent pricing, huge barriers to market entry, and third party payers.
The US (and others, but the US especially) has a long-standing practice of divesting corporations from the responsibility for their actions.
Worse, it's frequently the same people who argue that corporations are "people" arguing that corporations as a whole shouldn't be held responsible for their actions.
A profit-making corporation exists to make a profit, which isn't illegal or immoral, so I fail to see what 'responsibility' they have other than continuing to do what their shareholders have literally given them money to do. Your problem is with the system, not with my grandma whose pension fund is invested in the hospital.
For what it's worth, I'm not interested in blaming the corporation for trying to raise profits. I just think that clearly the system is not ideal, and the right way to fix the system is probably different depending on whether the diagnosis is 1/ inefficiently-operating nonprofits or 2/ non-consumer-happiness-optimizing corporations.
If making money from using people's lives as leverage is evil, then let's go ahead and condemn doctors, nurses, ambulance drivers, insulin injector manufacturers, and lifeguards while we're at it.
I'm almost rendered speechless at the absurdity of your suggestion.
Of course they deserve to be paid. And paid quite nicely, too, considering the education levels needed to work such jobs (Lifeguards, obviously requiring significantly less than doctors)!
But they can be paid nicely while charging reasonable prices. The $164k the hospital charged that man for his heart attack is beyond unreasonable.
But who gets to decide what is 'reasonable?' The point of the parent post is that there are no forces keeping prices down besides this vague standard of 'reasonableness', which obviously isn't very useful. Shame doesn't bring down prices; competition and structural reforms do.
The point is that the bill won't just go away for other people, regardless of how much profit is made and whether costs are already covered by the hospital.
What's strange is that many hospitals seem to legitimately be in financial trouble. You often hear about smaller hospitals not being able to make it financially, and being gobbled up by larger health networks. How can I be paying them $600 for an asprin, and other fake charges, and they still can't make any money?
Well, you'll notice on this bill in the article they've taken to charging "near retail" pricing for aspirin, and generic pricing for common drugs many of us will know the price of (still relatively outrageous, but $1/pill for aspirin, $10/pill for metoprolol).
Why? Not out of the kindness of their hearts. They know that their name showing up with a bill for $500 for ASA is bad PR, so better to make those common things realistic, and pad their numbers elsewhere (like charging $19,500 for a $1,500 stent)...
The power of companies. They write words and numbers on a stamped letter and now it's god spell.
I once played dumb to an importer abusing fees, after monthes of bouncing mails to different people babbling the same thing over and over, then dealing with a 'lawyer firm' who behaved the same (basically nobody knew precisely what they were talking about). They suddenly accepted to give me a rebate of NN%. So I received a new bill with 100$ - '80$ promotional deal' = 20$ (normal fee). A very partial grin ensued.
>Sounds all fine and dandy until you realize that these charges will just be made up for by people that aren't able to get NPR to publish a story about them.
> In a statement, the hospital said this offer was contingent on Calver submitting his application for a discount based on his household finances. Calver disputed that he owes any additional money to St. David’s and said this situation should have been resolved long before now.
I might be misreading, but is this saying that Calver isn't going to accept even the $700 charge, just to make a statement? I obviously side with him but this seems like a crazy stand to take on principle alone.
He shouldn't have to submit for a "discount" based on his "household finances" anyway! What if he doesn't qualify after all? Does he owe $100k if he makes more than $70k/year? Actually what level of income should be the low threshold for having to pay $100k after insurance for your life-critical health event?
I'm not saying he's wrong on the principle. I'm saying I wouldn't have the guts to risk $108,300 just for a chance to maybe win a moral victory over $700.
Sounds like the usual billing practice of "send him a bill for everything he'll ever have and then graciously negotiate it down merely everything he's got now".
I think this is pretty common. If you get a hospital bill and the insurance already paid a lot, call up the hospital and complain, and it will often be lowered. This happened to me once, a $15k bill was reduced to $3k. The insurance had already paid $50k or so. Hospitals don't really seem to care about the extra portion the patient is supposed to pay. The try to get it, but don't make much fuss when you challenge it, since they already got what they really wanted, the insurance company's money.
> St. David’s HealthCare defended its handling of Calver’s bill and sought to blame the school district and Aetna for offering such a narrow network.
So while dying of a heart attack he should have been negotiating with the ambulance driver, the paramedics, the nurses, each intern and doctor to make sure they are "in-network".
> St. David’s said it was now willing to accept $782.29 to resolve the $108,951 balance because Drew Calver qualifies for its “financial assistance discount.” I
You can pay $100k or just $700, whatever is cool with us. I guess, go to the media and try to shame everyone involved is your best hope? I can see if they did this to people buying luxury suites or yachts. Doing this to people who are dying of a heart attack is particularly disgusting. And it's not like anyone involved is going to be punished for this practice or learn a lesson. They'll turn around and do the same thing to the next patient.
> So while dying of a heart attack he should have been negotiating with the ambulance driver, the paramedics, the nurses, each intern and doctor to make sure they are "in-network".
Absolutely! </s> I work in EMS. Thankfully, our Medic One system is funded entirely by property taxes and we simply do not bill (at all) for any treatment or transport.
However, a few years ago United got a lot of grief over denying airlift transport claims from things like MVAs, or traumas in remote locations, stating that the "transport had not been pre-approved through the insurer".
Apparently in their mind, us paramedics (or maybe the chopper pilot) should have been calling in between stabilizing our patient...
"This is John, I'm a paramedic working on one of your patients who was hit by a truck. We would like to fly him to the hospital due to his extensive multisystem trauma but we need your approval. His name? Hang on, let me find his wallet. No, that's Smythe, S-M-Y-T-H-E, sorry, it's a bit loud with the jaws of life in the background... Yes, I can hold for a nurse consult..."
I wouldn't pay them a single cent more. The 782.29 is just as bogus as the initial charges. There is pretty solid pricing data suggesting the insurance company already over paid.
I once got cut by a skate playing hockey. Showed up at the hospital pulsing blood from my leg. My first question to them, “Do you take X insurance?” Only after they assured me that my insurance would be accepted did I drag my bloody leg into the care room.
Turns out the doctor that the hospital assigned to me did _not_ take my insurance.
I got billed the full amount, yelled very loudly at lots of people, and when I “resubmitted” the claim ended up paying like $50 out of pocket. I’m pretty sure that every item in the hospital is purchased by a separate company and that the Venn diagram of approved insurance companies never intersects.
My dad is a nurse and I grew up hearing how insurance was destroying health care. As a free market libertarian, I have no idea what to do about it. But next time I need stitches I think I’ll just opt for the super glue in my workshop...
It's not a free market if you (literally) can't walk away from the transaction. Trying to apply free market principles to non-free markets is what got us into this mess in the first place.
You have a need that the customer (patient) needs to fill with a product (medical care).
The problem is, if the customer doesn't get the need fullfilled within the next 10 minutes they die of cardiac arrest. Or worse, the customer is already in cardiac arrest and requires resuscitation.
An unconsicous customer can't make market decisions.
So now we get to the next stage, a hospital revives/saves the patient but they are unconscious for a few days in the ICU.
The patient can hardly walk away while being non-responsive or later when drugged up on painkillers so they don't scream all the time.
By the time a patient can leave a hospital without dying the hospital has likely already spent 90% of the money that would be spent if the patient stayed for a few days more to recover.
But is it free market to bill the patient for actions taken while they were non-responsive or not even consented too (because they were non-responsive and/or dying)?
IMO the answer is simple; free markets don't exist. They are an ideal construct similar to how a bouncy ball should mathematically bounce forever but doesn't. And especially in healthcare there are too many interfering patterns for a free market to actually exist. In other markets, you could make a free market because people could pick and choose and compare and consent (ie, buying logs of wood for your fireplace). But dying people can't participate in the market to not die freely.
I also advice against superglue for wounds, the stuff can be toxic and/or nasty and will likely lead to an infection. There are some natural glues that your body produces to stitch wounds and you can obtain them in your supermarket, though they aren't clean enough that I would consider them fit for that use either.
> As a free market libertarian, I have no idea what to do about it.
As someone who used to be a free market libertarian: take is as a data point, and make appropriate conclusions. Such as: free market doesn't solve every problem. It doesn't mean that we should ditch it - it's still the least invasive way to allocate resources, so it's a reasonable default. But we shouldn't elevate it to dogma. When it works, great! When it doesn't, regulate it. And thus, we can have the best of both worlds.
A good start would have them providing a price list, up front, so you can intelligently request transport to a hospital that doesn’t have a 1000% markup on parts, and reasonable charges on labor.
My father had a heart attack 4 months ago, and he’s been in and out of the ICU for 3 of those months. Everyone likes to think “oh, I’m insured. I’ll be fine.” But let me tell you, you won’t be fine. 3 months of ICU at Robert Wood Johnson was billed for $4Mn. BCBS-NJ only paid out $750k. The headache begins there- from a personal financial standpoint, and Tri-party incentive standpoint. Ignoring the difference of $3.25Mn “owed” to the hospital (technically, this $4Mn is an exaggerated number by RWJ to recoup as much as they can), the insurance company is essentially denying basic/reasonable services. The doctors have been fighting with insurance to get him to an LTACH, but the most they’ll pay for is a nursing home.
Insurance is a business. They aren’t looking out for you, or your loved ones. I hate to sound cynical, but boy, these past 4 months have shown me the deepest, ugliest side of commerce that inevitably results from aligning incentives with profits.
Health insurance companies' profit margins are restricted by law, whereas Robert Wood Johnson and its executives and doctors profit margins are not restricted. If anyone is on the patient's side from a cost perspective, it's insurance, and the ones benefiting from higher pricing and unnecessary procedures are the providers.
I've suddenly started seeing this take all over the place and I have no idea where it comes from because it doesn't make sense. That the insurance companies profit margins are restricted means rather little because executive pay isn't capped: if they earn too much money, they can simply pay bonuses to raise their expenses. Or cut shareholders a check. Or. Or. Or. Tangentially, this is why "non-profit" doesn't mean what people think it means.
And despite what caps exist (can you point me to resources on this topic?), the industry is enjoying record profits right now. That's not to say hospitals aren't as well, but I'm puzzled that so many people seem to want to point the fingers at doctors. Doctors and nurses actually provide the care. If there's anyone I'm less worried about making a little more, it's the people actually doing the work. The administrators and the corporations that set and negotiate prices with the insurance companies though... I'm with you there.
Lastly, the incentives of insurance companies do not align with the patients unless you ignore most of how the industry works. Insurance companies make money when they're able to deny you coverage or require you to pay more out of pocket (in vs out of network). That doesn't align with patients at all.
There should not be a profit incentive in health insurance.
> I've suddenly started seeing this take all over the place and I have no idea where it comes from because it doesn't make sense. That the insurance companies profit margins are restricted means rather little because executive pay isn't capped: if they earn too much money, they can simply pay bonuses to raise their expenses. Or cut shareholders a check. Or. Or. Or. Tangentially, this is why "non-profit" doesn't mean what people think it means.
This is not correct, as I understand it. Under the ACA (Obamacare), health plan providers had to ensure that at least 80% of premiums were paid out for patient services. That leaves 20% for overheard, including profit and compensation.
The "trick" here is that service providers (doctors, hospitals, MRI facilities, labs, etc.) are not limited in this way (except by "usual and customary" terms where applicable), and there are LOTS of layers of providers. So in the end you can get many multiples of actual costs by simply washing the underlying treatment or service through 5 or so layers of providers.
> This is not correct, as I understand it. Under the ACA (Obamacare), health plan providers had to ensure that at least 80% of premiums were paid out for patient services. That leaves 20% for overheard, including profit and compensation.
Doesn't this imply that it's in the interest of health plan providers for patient services in general to be as expensive as possible? That means premiums will have to be correspondingly high, and the 20% available for profit and compensation will be larger.
Right, they have less incentive to negotiate for lower rates, because higher rates mean higher premiums, and higher premiums mean higher executive compensation.
If they pay bonuses to themselves, then their premiums will be higher than other insurance companies so they would lose customers, the same that stops any other business from doing the same.
And since taxpayer funded healthcare is off the table in the US, we have to work with what we can. The biggest problem with health insurance right now is everyone is not forced to use healthcare.gov so the risk pools don't have the correct distribution of healthy and unhealthy people.
> If they pay bonuses to themselves, then their premiums will be higher than other insurance companies so they would lose customers, the same that stops any other business from doing the same.
This might stand up in a highly competitive market, but even there you have network effects, and asymmetric power/information issues, that keep it from ever being completely true. In a market like health insurance where large fractions of people get their coverage from their employers who make choices for their employees, it's not really credible to say that high premiums will drive an insurance company out of the market. Moreover, the data bears out that premiums, profits, and executive compensation are all increasing while the overall cost of our healthcare as a nation spirals out of control.
> And since taxpayer funded healthcare is off the table in the US, we have to work with what we can.
If you expect elected officials to fix it by writing them letters and angry comments on the internet, well, yes. But campaigning and petitioning are not the only routes to accomplishing political goals. The teachers' union/wildcat strikes across states with unified Republican control of the government that successfully forced wage and funding increases, despite timid unions that wanted to push for less, should be an indication of what actually works. We don't have to accept the system as it is.
> The biggest problem with health insurance right now is everyone is not forced to use healthcare.gov so the risk pools don't have the correct distribution of healthy and unhealthy people.
That's a problem in that will cause premiums to spiral faster and eventually shutter those insurance pools. But that's a slow death. The largest problem in health insurance right now are the actual, living people being forced across the country to either suffer or die from solvable medical problems, people who are rationing medication because they cannot afford to buy more, people who are being forced into bankruptcy by a broken system. When lives are already being destroyed today, a patch that prevents the rate of lives from being destroyed from increasing quite so quickly is nice, but it quite clearly misses the forest for the trees.
That’s why three party systems, such as this, is a headache. Everyone involved has vastly different goals, and incentives.
Insurance companies are mandated to strict profit margins, yes. But they aren’t mandated to align with what the other parties say a patient needs. This creates a situation where insurance companies can discriminantly choose which services, and level of care to agree to pay for.
I see it happening right now:
Long story short, to put it into everyday terminology, our family and the mechanic is urging for a new engine. Insurance is saying “all you need is air in your tires. That’s all we’ll approve.”
US voters don't want taxpayer funded healthcare, like other developed countries. US voters also aren't able to negotiate with medical providers directly, due to lack of knowledge and ability to negotiate while dying. The health insurance setup with capped profit margins seems like a decent option, considering no others have worked. There are a few problems, like allowing employers to offer it and tax exempt premium payments. If everyone was dumped on healthcare.gov, a healthy market for health insurance might emerge.
I don't think this follows. Insurance profit margins are restricted, but they're a percentage of overall payments to hospitals. If the total charge goes up, their total profit also increases.
Insurance companies are required to pay out 80%/85% of the collected premiums on medical care. Which means the remaining 20%/15% has to cover all the insurance company costs and any profit they can manage. If premiums are raised then their portion also will increase as a percentage. But if the medical costs increase without a corresponding premium increase, the insurance company won't see any profits.
Ideally, this is solved by a different health insurance company offering lower premiums, same as vehicle insurance. Obviously, there are some nuances in the health insurance market that make this difficult, but other than taxpayer funded healthcare, no one has come up with a better option.
> Health insurance companies' profit margins are restricted by law, whereas Robert Wood Johnson and its executives and doctors profit margins are not restricted. If anyone is on the patient's side from a cost perspective, it's insurance, and the ones benefiting from higher pricing and unnecessary procedures are the providers.
Untrue, because health insurers profits are limited by law, sure, but to a specified fraction of the costs they pay; if their payouts are too small, they have to refund the excess profits to the people paying premiums.
How does that make it untrue? Health insurance companies are supposed to compete with each other based on their premium prices, and the insurance companies with lower premiums (and hence lower costs) will win more customers.
> Health insurance companies are supposed to compete with each other based on their premium prices
It's not a market with particularly robust competition, due to small number of players, and barriers to entry, both natural (two-sided network effects, practical capital requirements) and regulatory.
That's because the government allowed tax exempt employer funded health insurance to stick around. If everyone was forced onto healthcare.gov then it could be possible. Employers would have one less thing to deal with that has nothing to do with their product and taxpayers wouldn't have to worry about being tied to their employers, and can more accurately compare differences in pay and whatnot.
I strongly agree with everything you said except forcing everyone to healthcare.gov. A free market for insurance can and should exist without the need for a government run website/market
A free market also requires knowledgeable purchasers to make informed decisions. In the case of health insurance, it's so complicated that it makes sense to simplify it to protect consumers and offer easy to compare options (bronze/silver/gold). I guess it doesn't have to be government run, but it's already built and does a pretty good job.
> Except the insurance market doesn't work like that. You get a job, that job determines your insurance.
That's not really the source of the lack of competition, as employers are motivated to minimize rates for what they ger, whether they are seeking to fulfill a government minimum-coverage mandate or provide a competitive benefit to attract/retain staff.
(It is a source of some other problems, just not the one at issue.)
Instead of insurance companies competing for millions of individual customers, they are vying for maybe thousands of business customers. Except that the insurance companies don't seem to care at all about giving small businesses a good deal, so subtract them from the pool of potential customers that insurance companies care about. Really big businesses don't buy insurance, they just self insure, so insurance companies aren't competing for those customers either.
Employer provided insurance absolutely reduces competitive forces (among other problems it causes, as you point out).
What's your point? Nothing says a nonprofit can't overcharge. If the hospital wants a few doctors and a new MRI, it's looking at many megadollars. Nothing says a nonprofit hospital would bill less aggressively than a for-profit one.
After a reporter made inquiries, St. David’s said collection efforts were put on hold, and a hospital representative called Calver, offering to help him apply for a discount based on his income.
I refuse to believe that the US medical system is run by humans, and not trolls we pulled from under a nearby bridge.
No, it's run by people like George Shultz, who himself pays for an on-call boutique physician, while the plebs can get their medical testing for cheap from Theranos. When the grandson, who was a Theranos intern, becomes concerned because Theranos' numbers are not better than throwing darts on a board the grandfather becomes enraged, arguing that his investment and his reputation are being threatened.
How is a regular person who has other things to do than to read and understated all the details and traps of his health insurance supposed to navigate this insane system?
From what I read going to a hospital is pretty much a gamble that has a certain probability to bankrupt you and there is pretty much nothing you can do about it.
There should be bipartisan agreement that these practices are just not acceptable and that there must be a way for a patient to get binding information upfront.
I'm actually not sure if you are being serious. If the information on costs for emergency services were clear and available up front people could shop around ahead of time and basically write up a living will saying, if I have a heart attack, take me here.
Insurance companies are the reason the costs are not clear and up front.
Are you serious? You think every American should be required to write a living will for them and their children listing every conceivable illness and injury by individually researching all the medical options in their area? And what, update it weekly as they follow the markets? Should they keep up with the latest medical research so they know what the newest drugs and treatments will cost? What about vacation, do you need to do a week of research to prepare for a weekend trip to NYC?
No. Just the ones that are true emergencies where you won't have time to do any shopping around ahead of time. Why is this such a hard concept? Think of all the times you've seen a doctor in your life. How many of those were super time critical? Big accidents and heart attacks are. Having a cold or flu isn't. Heck, even cancer isn't super time critical, you could take a few days to shop around treatment centers. Shopping around for most medical care shouldn't be that weird of a concept.
Another option would be to only have insurance for those critical time sensitive events, then you don't have to be super price sensitive for those, and the free market could drive down prices of all the other medical care we get.
So for each item on this list you'll need to find out every possible treatment and drug and what they cost at every hospital within ~50 miles. Make sure you look up allergies and any side effects when combined with medication you regularly take, you don't want to be in a situation where you listed Hospital X for meningitis, but their cheap drug can't be combined with your asthma medication, or whatever.
And again, how often do you update this will? And what about travel?
Is there anything else in your life that you shop around for in case of emergency?
Your google skills are strong. How many things on that list need treatment within minutes?
"Is there anything else in your life that you shop around for in case of emergency?"
Have you never heard of Preppers? But seriously, yes, I shopped around a little for a fire extinguisher in my home, I shopped around a bit for a good first aid class so I'd have some skills. I have spare batteries around the house in case the power goes out and shopped around for a flashlight. I have practiced changing a tire for my car just in case. I have a little food stored up in my house.
Why is preparing ahead of time completely off the table for people when it comes to medical care?
>How many things on that list need treatment within minutes?
Let's go down the list for things that don't need treatment in minutes:
- Malaria
- Rabies
- Salmonella
- Lyme disease
- Malnutrition and starvation (though you'd rather have this taken care of fast if possible, in severe cases minutes would count)
- Attempted suicide, non fatal (though only if you aren't up for anything else as a result of said attempted suicide, you'll be fine if you don't get immediate treatment)
- Psychotic episode (under supervision)
- Suicidal ideation (if you're under supervision)
- Smoke inhalation (in very very minor cases)
- HELPP syndrome (doesn't seem to be very dangerous in the minute range though you'll want treatment either way)
- Priapism (although it is very painful)
- Sexual assault (before you downvote consider that sexual assault is generally not fatal itself and you don't need urgent medical attention, though urgent psychological attention is, in general you'll survive if you need more than a few minutes to the hospital)
Most of these come with a few ifs, notably that no other medical emergency coincides and some depend on severity, the rest of the list is to my knowledge pretty deadly if you don't get it taken care of as quickly as possible and for half the list it is likely you'd be either in extremely severe pain, unconscious, non-responsive, dying or a combination of the previous in any order.
> How many things on that list need treatment within minutes?
I don't know, I think most? I am not a medical expert, and as such am not qualified to answer that question. I think that means I'm also unqualified to draw up a living will detailing what to do if I exhibit symptoms of any of these.
> I shopped around a little for a fire extinguisher
And then bought it immediately, right? You're not gonna wait for a fire to buy one. Same with the first aid class, the batteries, the flashlight, and the food. You cannot buy medical care ahead of time, or take a class to train you to treat yourself.
In case you missed it in my other comments, how often would you update your living will in this world? How would you prepare for travel within the US?
"Sorry, sir. Your spouse's living will restricted emergency care provider vendors such that she was unable to receive care in time. With our CareWatch(tm) package, we can give you geo-fence alerts with response times that would be outside your living will provider preference range. Press one to be connected with a sales associate."
Not sure if you are trying to be funny but you aren't.
"The next day, doctors implanted stents in his clogged “widow-maker” artery."
By that time they could have clarified the insurance situation. In any case I don't think it's acceptable that any kind of emergency can bankrupt you if you have the bad luck to end up at the wrong hospital or wrong doctor.
Looking at the bill, here is some ridiculous: NaCl (basically salted water) costing around $300/liter.
That's outrageous. These guys are protected by your politicians and make use of mercenary tactics. Villains in doctors clothing.
I'm for free markets but we are kinda going over the limit here. Maybe have fixed rates for emergency where you can't get the approval of the patient. Maybe give the patient the possibility to pay for these ridiculously priced items after.
I mean if I get you 1l of NaCl we'd be cool. And fix the rates for emergency.
What about this market seems free? The entry barriers for competition are so high, the only players are the well established, and much more importantly, well connected. And they can freely abuse the system with almost zero market or political repercussions. On a side note there is no industry more heavily regulated than the medical industry. Coincidence?
So... When you're in the ambulance dying of a heart attack, you're supposed to be negotiating over your saline drip or on the phone with another ambulance company looking for a better deal?
Maybe if you had picked an example of some medical supply that is used only in emergencies your sentiment would make sense. The price of saline, and nearly all medical supplies, absolutely could be subjected to market pressures in the majority of medical situations, which would drive the price down for everyone, even for heart attack victims.
Retail cost for Lactated Ringer's solution, injectable (basic saline fluid for IV) was over $40/liter in qty 12 liters about 3 years ago. I can imagine it has gone up since then.
The use of the health care system to extract every single excess dollar from the middle class extends to many, many layers of the supply and service chain. It may be that the saline was "merely" marked up by a factor of 2x.
Seems like the problem is broadly in the medical sector (including pharmacological). There is 0 reasons why it would cost over $1. Maybe $2. $40 is still way ridiculous. I mean in a competitive market.
The problem is there will never be a truly competitive market in most health care products and services. Necessary regulation creates too many barriers to entry and competition, and the ultimate consumer has very little demand flexibility or even choice of provider.
What is needed is a monopsony buyer who can negotiate in this arena on a more even footing. In other words, single-payer.
The US is proof that a free-market system for healthcare does not work. This is also illustrated by all the stories here.
For free-market to work, a consumer needs to be able clearly understand what he is buying and how much it will cost before he consumes whatever he buys. This allows him to shop around, and find the best seller and price.
The current system just drives prices up instead of down, as the seller, who is in it for the profit, can set his prices after the goods have been bought. Ofcourse prices will go up, there's no competition anymore, as the buyer has already consumed the goods.
Trying to make this transparent before an operation would not work. It would just turn healthcare into another IT project, where seller will offer you the lowest prices, and then come up with extra-work that also needs to be done. Image being operated on, and the surgeon informs you they've discovered some required extra work, asking you if you will agree with the additional cost...
It's clear to me that healthcare and free-market are an incompatible combination, it needs to be heavily regulated, and probably single-payer.
From my experience, no human at the hospital has any idea whether they will accept your insurance or not. The doctors certainly don't. They just report things into the bill-processing system which occasionally delivers patients a crazy $100,000 bill.
They have no idea if the insurance company will pay. I know this from personal experience where the hospital explicitly called insurance co to ask if a procedure would be covered, received confirmation that it would be, AND the hospital recorded the call. But coverage was subsequently denied.
Yep, this happened to my wife - she needed a fairly intensive and costly surgery and was told she was in-network and covered. It turned out the person on the phone was wrong and she ended up having to cash out her entire 401k to pay the 20k+ bill. We learned a lesson about the US healthcare system with that one...
"we accept it" is nowhere near the same thing as "the insurance company will pay for it". Of course they'll "accept" it, it just may not make a difference as to what you owe. they'll put it in their system.
the words used here have vastly different meanings to each party.
"accept an insurance" doesn't mean what you think it means.
It just means they will exchange paperwork with said insurance company. Whether or not your policy/company covers treatment is a completely different issue.
I feel like whenever I hear crazy stories like this about healthcare it usually involves these weird in or out of network issues. I'm certainly not an expert on healthcare, but is there no way to attack the problem from this angle?
If you have a hospital with a certain list price for a particular procedure, why is it legal for them to charge one insurance company 5% of that price and charge another insurance company or someone without insurance full price? It seems like exactly the kind of scenario that price discrimination laws are meant to prevent.
Similarly for the insurance plans themselves, why can you sell basically the same plan to employees of a large company for much cheaper than you sell it to employees of a small company? (This one might need to be a new law specific to insurance companies, because clearly there are many other products that give group discounts when selling to large companies, but I think health insurance should be treated differently).
I'm sure I'm missing what some of the downsides might be, but it seems like making these kinds of backroom network-based deals illegal in health insurance would go a long way in making prices more understandable/predictable, and that might allow for more fair competition on price to emerge.
> I feel like whenever I hear crazy stories like this about healthcare it usually involves these weird in or out of network issues. I'm certainly not an expert on healthcare, but is there no way to attack the problem from this angle?
Because hospitals, and physicians, have decided that, for the most part, it is better for each of them for physicians to be "independent contractors", so the situation of "your hospital is in network, but your physician was not".
Or for me, most recently, going to my doctor for a checkup on my hypertension at an Urgent Care/Family Practice hybrid. Facility? In network? Physician/Assistant? In network? Lab in the same building (to be clear, it wasn't a multi-tenant complex, this was a medical practice) that they sent me for CBC draws? Out of network. Boom, hundreds of dollars in lab bills.
Prices, more and more, are negotiated between very few providers and customers. It's like there are 3 fruit stands and 3 buyers of fruit, and those three buyers of fruit are willing to buy huge quantities of fruit (provide a hospital business with lots of patients) as long as the fruit stand meets their price demands. The fruit stand can take it our leave it. If they leave it, they lose out on 1/3 of their potential sales. They go through this kind of negotiation with each of the three fruit sellers every so often.
All this is a bit surreal (Canadian here), but it prompts the question: why won't people sue in a class action to refund money they gave to the insurance in the first place?
I realize it's a complex subject, but at the end of the day, the insurance companies advertise and sell: insurance.
But you can't always pick your providers. Example: You go to emergency room that is in-network. A month later you get the bill for the doctors that treated you - who aren't in-network.
"A new study that looked at more than 2 million emergency department visits found that more than 1 in 5 patients who went to ERs within their health-insurance networks ended up being treated by an "out-of-network" doctor — and thus exposed to additional charges not covered by their insurance plan."https://www.cnbc.com/2016/11/16/many-get-hit-with-surprise-o...
You think someone who is staring at bankruptcy is going to say to themselves "I know what I'll do, I'll spend thousands of dollars I don't have on a lawyer to solve this problem for other people in 5 years"?
You need a government that is responsible to its citizens. We don't have that - we have a government that is responsible to its biggest donors. The more some company or some industry can abuse the market to extract insane profits, the more they can lobby the legislatures to cover their ass and secure their business model.
And it's not just health insurance. Case in point: we have companies writing tax accounting software lobbying against simplification of tax code. And it works!
I know, at least at federal level the US isn't a democracy anymore, it's been taken over by corruption entirely. Until that is changed the problems for normal people like the one described in the post will only get worse.
This isn’t true at all. Insurance is heavily regulated. If you can’t resolve an issue with your insurance, most states have arbitration committee that will smack down insurance companies pretty quickly.
Crucially, that's only true if you have the money and time to fight. For the people hurt worst by the system, they lack some or all of: knowledge that they can fight it, money with which to fight it (or again, knowledge that a lawyer will take it pro bono), and the time with which to fight it and not work one or more jobs. I know people on this forum are relatively well off, but everyone reading this should try to put themselves in the shoes of someone working multiple jobs, trying to take care of a sick family member, and facing predatory companies trying to bilk them for all they're worth.
That the government will protect you, in theory, is not the same thing as in practice.
Here's the deal. Insurance is a simple concept. Take house fires. They are fairly rare, but they do happen. We could all just save up enough money to cover a house fire ourselves, or, since we know that house fires are rare, we can pool our money together as friends and neighbors and when one of us in that pool gets unlucky and has their house burn down, it can be covered by insurance. A lot of us pay a little money for peace of mind that if a rare catastrophic event does hit us, we'll be OK.
This same concept applies to some medical issues, but there are a lot of medical issues it does not apply to. Getting a routine infection and needing antibiotics? Everyone is going to need that. It makes no sense to pool our money and pay out for the rare person that needs money for that. How many other medical expenses are like that? Even things that are rare for a group of 20-year olds like heart attacks are actually a lot less rare (more common than house fires, probably) for an older age group. So while it might make sense for a group of 20-year olds to pool money together to pay for the rare heart attack amongst that group, it might not make any sense for an over-50 group of people to do that same. It definitely doesn't make sense for a 20-year old to join that group. Yet this is exactly what we do. We all pool our money together and use it to pay for every medical expense that comes up. Minor infection? Use insurance! Need a couple stitches? Use insurance. Routine screening? Wow, didn't see that coming, good thing I have insurance.
This is insane, and this is the root of all our problems.
I completely disagree. The reason insurance pays for the small things is to encourage people to seek treatment early because it’s cheaper in the long run. Almost nobody would pay hundreds for a cancer screening like mammogram or colonoscopy that they don’t believe they need, but catching these things early is orders of magnitude better both for health and financial outcomes.
Insurance covering a minor infection prevents needing to handle a major infection. Your system assumes humans are rational and a good judge of risk, something that has proven to be untrue countless times.
Not sure if you're joking, but that's a pretty lazy fallacy of composition there.
Ex: Human memory sucks, but you can generally trust the immutability of books, despite them being written and copied and bound and distributed and sold by humans.
It's all about using strengths in the right direction and order to sidestep weaknesses.
Fallacy of composition says I look at a few stupid humans and decide that all humans are stupid. That's what the person who I was replying to was doing in reply to my original post. I was trying to point out that if their supposition is true then we are all screwed no matter what.
Fortunately their supposition is false. Humans are not generally shortsighted and stupid, if you give them a chance.
> Fallacy of composition says I look at a few stupid humans and decide that all humans are stupid.
No, a fallacy of composition would be "the organization is stupid because its employees are stupid", or "metal boats are impossible because metal sinks in water." It involves something which is composed of the smaller pieces.
What you're describing is more like a hasty generalization, where individual-qualities within a sample lead to a conclusion about individual-qualities shared by the entire population.
> I was trying to point out that if their supposition is true then we are all screwed no matter what.
And -- even if their supposition is true -- I disagree!
Metal boats can float on water, even though individual metal pieces sink. Institutions can solve problems, even ones that individuals humans suck at.
One reason they do it that way is that if you don't pay for screenings and small problems, people tend to skip going to the doctor for them, and you end up paying for more big, expensive problems.
Yes, and is that line of reasoning working? Are we as a society saving money doing it that way?
It seems what people really need is just a savings account and some incentive to actually save money for future expenses (because knowing that someday you are going to get an illness that 100% of people get apparently isn't enough motivation).
HSA’s are available and most people don’t effectively use them, part of the problem is most people don’t/can’t save anyway. You’re not all wrong, but you’re talking about changing behavior which is much harder than just making the system work for how people actually behave.
HSA's are horrible. Way to much government nonsense with limits on contributions and providers and tying them to particular insurance plans. Completely ineffective. When you see that you could save some money for future medical expenses, but you don't qualify for any tax breaks because the amount you want to save is too much or your health insurance doesn't allow it, it's very demotivating for saving at all.
The thought I have is we should all definitely carry catastrophic health insurance, but then people should be on their own for the rest. I'm sure that payment plans and medical care clubs would spring up to fit the needs of those who absolutely need a way to force themselves to save ahead. Those things should not be called insurance, they should not be sold as insurance, nor should they encroach at all into the territory of true insurance that is meant for rare and catastrophic events.
Only having catastrophic coverage for most people over 35 does not work, maybe younger too. We’ve already seen this.
You are basically guaranteed to receive care in the United States, doesn’t mean it’s affordable. The people that can’t afford the ~$300 screening or basic healthcare end up waiting until it’s major then we’re back to catastrophic level. People who can’t or don’t pay their medical bills still cost everyone using the health system money, it’s just hidden in fees, higher costs, tax write-offs, etc.
I'd like to think HSA's are a good idea, but many HSA's have a "use it or lose it" policy that any money contributed that doesn't get used by the end of the year just disappears into the pockets of the HSA provider. It's almost a scam. It might be nice for someone that has some sort of ailment that needs frequent care, such as diabetes or cancer, but it's worthless for someone that wants to have money kept aside in case of an emergency.
You are absolutely right, but we should probably just stop calling it "insurance", since it is nothing like what you are talking about. It's more like a pre-paid health plan. You pay a certain amount per month, and the plan pays for your health care. It's more like a co-op.
The man had insurance, it didn't pay out. Or more accurately, the hospital intentionally overwhelmed the insurance company's willingness to pay.
I can't think of the right analogy for house fire insurance. Because you can take your payout after the fire, and either rebuild or use it to buy another house. There's never a situation where you have house fire insurance, and end up paying MORE when your house burns down.
From outside of the US, it baffles me ( and I'm sure others ) why the US doesn't embrace governement based healthcare. We pay the same kinds of tax rates etc and don't have to pay for health insurance on top of that(though you can get extra health insurance for pretty cheap if you want). It's kind of like governement education which the US does pay for up to a certain point. Not only is it worth educating your population, it's worth looking after their health as well.
The amount of misery and unpayable debt it seems to cause people who live in the US seems really unecessary. Not to mention nearly everyone in good heealth has a certain level of anxiety about whether their insurance is good enough and will cover them.
Mind you guns also seem unecessary yet the general response to that seems to be, It's ok, we will live with our fear and everyone should be carrying guns and make it so everyone needs to be prepared to kill other people in gun fights. If you get wounded of course, then prepare for living the rest of your life in medical debt.. :I
> From outside of the US, it baffles me ( and I'm sure others ) why the US doesn't embrace governement based healthcare.
The US has had majority public support for fully-public healthcare for at least ~30 years.
What it has lacked—even among politicians championing “healthcare reform” like Bill Clinton and Barack Obama—is politicians willing to challenge the insurance industry even with the backing of majority public support.
> Industry analysts and consumer advocates say St. David’s has a reputation for exorbitant billing and for trying to collect big payouts as an out-of-network provider.
Sounds just like St. David’s Medical Center in Austin, TX is run by crooks. I like the take-home message that "Faced with a surprise bill or a balance-billing situation, don’t rush to pay any medical bills you receive."
If you send me a bill for anything over $100,000, you might as well send me a bill for $10 trillion. It doesn't matter, I can't pay. I'm bankrupt now. Great, you get my house and my retirement savings.
The point of insurance is to prevent that from happening. I pay a small amount so that if I get unlucky, I'm not ruined. I don't care if "oh the bill was actually much higher before" because the number never mattered- me being ruined is what mattered. If I still am, then the insurance did not do what I wanted it to do.
It should be though: people do not understand healthcare, the insurance they are getting, what is included and what is not, and, very important, at times of illness you really do not have the time or bandwidth to think about it. To me it always sounds rather inhumane what happens over there. But then again, I only get my info from comments and articles like this.
The insurance company is basically saying, you should still choose the in-network provider even if you are unconscious or don't have a choice or we'll fuck you financially. I've had this happen to me, appealed, and after many months, actually won. In my case I was unconscious and the ambulance and hospital were out of network. I was lucky the hospital was willing to wait over a year and not send it to collections. It was hell. Why the fuck isn't there a law against this kind of shit? Do we expect people who are unconscious or having a heart attack to say, "oh no, take me to an in-network provider so I don't go bankrupt?" Fucking absurd the healthcare in this country and the lack of proper regulation. How long are we going to allow these insurance companies to get rich while people die and go bankrupt?
> The insurance company is basically saying, you should still choose the in-network provider even if you are unconscious or don't have a choice or we'll fuck you financially.
Actually, they are saying if you choose to cut premium costs by selecting a narrow provider network, well, there's a reason why the premium costs are low.
> Why the fuck isn't there a law against this kind of shit?
Because Republicans actively oppose any attempt at health security, and Democrats keep ignoring the majority support for single-payer that polls have shown for close to 30 years in favor of Rube Goldberg solutions that keep private insurers and this type of network-based limitation as central features, despite the fact that hey have less public support and are thus more subject to being politically sabotaged before passage (Clinton) and after (Obama).
Though there's signs of potential for that to change on the Democratic side in the near future...
Your first point is simply not true. There is no plan that covers every ER and every hospital. Even on the top plans, there are in-network and out of network providers. So once again, we're back to making decisions while incapacitated or unconscious. No matter how carefully you chose your plan and how much you pay, you're still fucked. Not to mention that almost everyone is stuck with the plans their employers choose. Even the platinum level ACA plans, however, are like this. That's what I'm talking about above, BTW, as well as equivalent plans provided by corporations. It's simply impossible to get a plan that covers everything and therefore prevents you from going bankrupt in all situations.
My first point is what the insurance company is saying. It's absolutely true that they are saying that. (It's also a true claim; your argument that all provider networks are limited such that the risk of similar problems exists at some level in all insurance plans is perhaps pedantically true, but not necessarily relevant—e.g., it may be that the only reason the care from the profile provider in this particular case was out of network was that the district's individually negotiated narrow network plan excluded providers that would have been included in standard plans this insurer offered in the area.)
> Not to mention that almost everyone is stuck with the plans their employers choose.
That's factually false; only 49% of Americans are covered by insurance provided by an employer (either their own or as a dependent) health insurance, and not all of them have no other practical option than that plan, so, no “almost everyone” is not stuck with their employer's plan choices.
But, in any case, the employer's plan choice is exactly what the insurance company is highlighting as the issue in this case.
> Why the fuck isn't there a law against this kind of shit?
There's a pretty clear answer to this question almost every single time it's asked... the people who benefit are wealthy and the people hurt are poor. The latter structurally lack the ability to fight it or lobby their congresspeople to change the law to help them. Until a mass movement steps forward to say "no, we will not tolerate this", nothing can possibly change. We have no recourse but each other and collective action.
Based on voting demographics, the poorest are the ones who are voting for politicians who hate the government and are opposed to any kind of subsidized healthcare.
How true is that? Poor people just don't vote, period. They're overworked, politicians don't listen to them, and in many states there are institutional barriers to casting a ballot even if one wanted to.
And it's not necessarily true among those who do vote either:
It's an old article and I don't doubt that 2016 has messed with the numbers, but the narrative of poor rednecks screwing themselves over every election is largely unfounded and smacks of classism.
Mostly because they believe and have been encouraged to believe that any protections/benefits would go to people who "don't deserve it" (also known as: whichever racial/ethnic demographic those voters have been raised to hate the most). They're very much in favor of discriminatory special-treatment programs that help them and only them, but very much against broad safety nets because they've been told such programs would only benefit the bad other people.
There's a lot to unpack here. First, neither party has the trust of the working class, whatever the rhetoric. Second, the candidate that talked about fixing the system, including healthcare, won -- that he was actually talking about breaking it further gets lost in the discourse around both candidates. There's a longer discussion to be had about how to build trust and what can be done about broken political systems, but it's not the parties that can act on that at this moment.
It will take something like the union/wildcat teachers' strikes, that forced Republican majorities with unified control of state governments to raise wages and increase funding, to do anything about healthcare or the many other structural challenges we face as a nation.
I should have written one health insurance company instead of one organization. Obviously it doesn't make sense to compare a health insurance company that has to abide by 50 different state insurance regulators to the US government.
Then they shouldn't be allowed to conduct business. Of course I expect them to cover all emergencies period. How they do that, I don't really care. If it were up to me, I'd ban these monstrous leeches from society altogether and only allow them to offer supplemental plans. They clearly can't do their own job so they should be replaced by a program like Medicare or Medicaid that can do the job. Would you accept a car insurance policy that only covers some accidents? That's beyond ridiculous.
whats amazing to me is how little money it takes to sway a politicians vote. yes there are big numbers in the list but most of them are 10s of thousands. its just amazing that they are willing to put their conscience aside and condemn people to bankruptcy or worse for that little. for the worshipers of free market they sure are selling themselves off cheap.
I'm amazed by just how high the donations can go. What the hell did senator Sherrod Brown do to get $1.4M from the healthcare industry? A quick Google search doesn't reveal anything out of the ordinary, except for maybe the most ironic tweet of all time:
The problem isn't that they're bought with $10k. They're approached and told "Take this money or we'll give your competitor $5 million to campaign and take your place". And they know they follow through with the threats, so they take the $10k.
That probably rules out every state and federal politician. Either way, this was on the hospital. Insurance paid $50k for an operation that costs $25k, and still the hospital charged him $109k.
>UPDATE: Monday, shortly after publication and broadcast of this story by Kaiser Health News and NPR, St. David’s said it was now willing to accept $782.29 to resolve the $108,951 balance because Drew Calver qualifies for its “financial assistance discount.”
> That probably rules out every state and federal politician.
That sounds absolutely dystopian. A politician running on a platform to reform healthcare can’t possibly be bribed by the companies that would die in the process.
Who said anything about bribes? A politician runs on a reform agenda. Some hospitals put together an advertisement where concerned doctors say that the plan is "Not right for America". People trust doctors more than politicians so the reformer loses the election. Politicians know this so they don't try any reform that will reduce profits too much.
The insurance industry is the enabler. Is there any other industry where you the individual do not know the cost until some third party that has agreed to pay the cost, negotiates said cost, and then even after negotiation may just give up and say, nevermind, pay it yourself?
This is why I plan on moving to Texas: creditor protection.
At any point in time I could require medical services and have medical service providers simply decide that I owe them a truly massive amount of money. The only route I have to mitigate that risk is through creditor protection laws.
In Texas, wage garnishment is limited to child support, unpaid taxes, and some other limited categories that medical billing doesn't have access to. Creditors can sue you, but they can only seize bank accounts, brokerage accounts, and the like - your primary residence is completely exempt, as are employer-sponsored retirement plans and IRAs.
So my emergency medical debt plan is to liquidate all taxable investments and close out bank accounts, send the cash from that to pay down a mortgage, and tell them to pound sand. The only real consequence is having to head to Walmart each month to cash paychecks and mail out money orders to pay bills.
Another easy solution, file for bankruptcy. No sane judge will kick a family out of their house over a medical bill. That would be counter productive to their recovery and cause undue hardship. If you don't see the utility in bankruptcy, just remember our President has used it several times over decades.
Edit: it's also known as unsecured-debt, which means the worst thing anyone can try to do to you is ruin your credit score. This isn't worth dying over and America is designed to bear the cost.
Bankruptcy really is the ultimate medical insurance. In fact, when so many people don't even have $2k in liquid assets, it almost makes more sense to skip paying actual medical insurance, and just declare bankruptcy in the event of massive medical bills.
What that doesn't help with, though, is something like being diagnosed with a chronic condition where pills cost $800 a pop.
Creditors can do more than ruin your credit score. It's state dependent, but they can also sue you to seize bank accounts, garnish your wages, etc.
Fortunately, it's Texas, so wage garnishment is out, as is seizing your primary residence. So is seizure of retirement accounts. Really the practical amount of debt is what the creditor can force you to pay, which is capped at your liquid assets.
Not in Texas it isn't. Wage garnishment in Texas generally isn't a thing that creditors can do. Skip out on child support? Don't pay your taxes? Yeah, you can get your wages garnished. But a random creditor who convinces the court that you have a valid debt that you're obligated to pay? They can mess up your credit and seize bank or investment accounts, and that's about it.
Exact same thing happened to me. I went last April and just now got it all "fixed". I ended up negotiating with the hospital, the contracting company for the hospital's ER department, and my insurance on the phone at the same time to reduce the cost to what the contracting company's ER doctor on staff would normally bill the insurance company and paid that out of pocket.
I guess you have to ask if the doctor who may or may not see you depending on what you're in for also takes your insurance? I don't even know.
Just cut the gordian knot and nationalize the system already. It's a political no-brainer. There are very few Americans, even conservative ones, who are in love with the intricacies of paying medical bills. The only people beholden to the status quo are those paid to defend it.
FTA St. David’s is out-of-network on his school district health plan
So apparently the "max out of pocket" on the cover sheet of your plan is b.s. and only applies in-network. I guess good luck having in-network coverage if you're on a vacation and have an emergency.
The article goes on to clarify the problem: the school district has a self-funded insurance plan.
Actionable advice: check if your employer-provided healthcare is a self-funded insurance plan or a fully insured plan. And then look up the relevant consumer protections in your state for that type of plan.
Also, in case you're wondering what the hell all those hospital administrators are dong, the answer is "shaking down your employer and screwing you over":
> In a statement, St. David’s HealthCare defended its handling of Calver’s bill and sought to blame the school district and Aetna for offering such a narrow network.
>“While we did everything right in this particular situation, the structure of the patient’s insurance plan as a narrow network product placed a large portion of the financial responsibility directly on the patient because our hospital was not in-network,” the hospital said.
> WellRithms reviewed Calver’s bill in detail at the request of Kaiser Health News and determined that a reasonable reimbursement would have been $26,985. That’s less than half what Aetna paid.
I wonder if the local county this school district is in, also provides only a "self-funded" plan to their employees. Are all the government employees getting screwed or just the teachers? It's a quaint ethical puzzle which is worse.
So the last line, "less than half what Aetna paid", does that ostensibly mean the hospital is definitely charging an unreasonable price, and by having been paid twice what is reasonable by Aetna that ostensibly this teacher shouldn't have to pay a dime? It's just a contractual reason he owes this money?
It's useful to understand what a "self-funded" plan means.
People in the US are used to their employers purchasing group health plans from insurance companies. In that model, a premium (often part paid by the employer, part by the employee) is paid to an insurance company in return for coverage. When there's a claim, the insurance company pays, out of its own money, and the insurance company's profit comes from taking in more money in premiums than it pays out in claims.
In a self-funded plan, the employer and employees still pay premiums, and all that money goes into a pool which is used to pay the claims. Typically a company is hired to administer the plan, but that company is not an insurer, and that company does not pay claims; the money to pay off claims comes directly out of that pool of premiums.
What this means is that the administrator just pays whatever it's told to pay by the company that hired them to run the plan. It's not the administrator's money being spent, and their profit is in the fees they charge to run the plan, not in denying or underpaying claims.
My very first real job out of school, years and years ago, was a place that did administration for self-funded plans. About once a month we'd get a call from one of our client companies saying "yeah, we know our plan's rules say not to pay that claim, but we want to pay that claim". And we'd say "OK, it's your plan and your money, you make the rules".
The downside is that if the company gets into financial trouble, its contributions to the pool of money that pays claims are often one of the first things to stop happening. I remember pretty clearly one client company that went bankrupt and just stopped paying into its plan, and once the money in the plan's pool ran out there were no more claims paid.
> does that ostensibly mean the hospital is definitely charging an unreasonable price
Not ostensibly, but actually.
The article goes on to identify some concrete charges that independent auditors felt were ridiculous, including charging $19k for stents that the hospital most likely purchased for about $2K.
> It's just a contractual reason he owes this money?
The hospital just straight up dropped all but $800 of the charges when they got PR heat.
Yeah, out-of-network coverage (if provided) is often limited by terms like "the usual, customary, and reasonable amount". When a provider charges unreasonable amount the insurance will not have any contracts that enforce the cost of services. And the patient left holding the bag. ;(
My guess is in a situation like this I'd get the reasonable amounts for services provided from my insurer and use them as a basis to refuse any unreasonable charges.
This is a rare case where the insurance company is entirely blameless. According to the article, they paid much more than what experts say is reasonable for the care provided.
The whole warped part of this is that the consumer has no way to anticipate cost in advance, and often the individual providers (doctors, nurses, etc.) don't either. Shouldn't the burden be on the insurance company to investigate and discourage excessive billing? Or are they too strict as it is, leading providers to play games with billing?
I think in this particular case insurance did investigate actual (or within a reason) costs and paid them. But there is no business relationship between the insurance company and an out-of-network provider. Should they go to the court on behalf of the patient? As a customer I'd like this. But it looks like combining health and legal insurances.
Another option is maybe to require that language on the "patient responsibility form" to include the blurb about fair prices. For instance:
In the event that my health plan determines a service to be “not payable”, I will be responsible for the complete charge and agree to pay the usual, customary, and reasonable costs of all services
provided.
Is there an analogy in the car insurance world? Let's say I know nothing about cars and I get in a collision somewhere far away from home. I need a repair th let's say I know nothing about cars and I get in a collision somewhere far away from home. I need some bodywork and a replacement for the flimflam crankslap in the engine. The shop knows that I don't know anything about cars, and they know that I am covered by insurance. What is stopping them from charging me an exorbitant rate for a new crankslap, and then me getting screwed when the insurance won't cover it?
I just don't see what value private health insurance companies bring to the table anymore. They are not helping get the best coverage for their patients and they squeeze the crap out of the care-givers until its hardly worth their time.
There must be a better way. I'm in the UK where the NHS is kind of flawed but at least they don't bill you like that. I'm kind of a believer in customer satisfaction as a guide to how to run things and it seems highest in hybrid systems like Singapore.
Has anyone in the US considered flying overseas to get treatment done? Many hospitals in third world countries are cheaper and more humane.
Sure, you lose out on the ability to sue them if things go awry but where is the tradeoff between six figure debt at an old age vs paying $10000 to get the whole thing done?
Not intentionally but this happened to me. I have bad adult asthma and spent 6hr in an my in network ER (on the advice of my pcp) a couple of years ago. Got some meds a chest X-ray (turns out I had pneumonia!) and got sent home stablized. my bill for the 6h (with BCBS insurance) was ~$3k. Last year I was in Japan for 2 weeks and again got sick. After avoiding it for a few days I again went to the ER and got the same treatments/test (this time it was only the flu). Bill (no insurance at all) $200. Round trip direct flight to Japan from my house is $1300 and takes less then a day. Makes me think what I might want to do next time...
> Has anyone in the US considered flying overseas to get treatment done?
I think a lot of people do but in a lot of situations you need to deal with things right now.
If you get a heart attack, you can't just hit the pause button on life, crack open Google and start searching for "best heart attack treatment center outside of the US", then research things, book the travel arrangements and take a long flight.
A lot of immigrants do that, but you have to know the local system of where you'll be treated (that's why it's mostly immigrants that do it).
For what I'm readying, for a lot of non-life-threatening care, it's way cheaper to fly here (Uruguay), have treatment, stay a month, and then fly back, than stay one DAY in the U.S. - a plus is that treatment will likely be better.
*Disclaimer: I'm not attempting to support HCA's billing practices here."
HCA has profit margins around 10%, which do not appear to me to be exorbitant. (https://investor.hcahealthcare.com/press-release/hca-reports...) While this patient's experience is clearly out of whack, and the $19k for a $1,500 stent thing is nuts, this points to a larger pricing / business model issue within US Healthcare. Typically, a few medical specialties (Surgery, Imaging, Rad Onc) have high profit margins, but are offset by losses in other departments (ER).
Thank you for pointing this out. How many medicaid patients paying below cost does it take to drag down profits from the occasional 1000% markup that the hospital gets away with?
Can't tell if you're being sarcastic or not, but yes, there are patients that pay (or are charged) a 1,000% markup, that in turn offsets patients not paying anything. I'm not saying the problem is the patients paying nothing; the problem is that the payment model is broken.
I have a relative sick with cancer right now and I’m seeing this first hand. Hearing stories like this you hope it’s a one off, but it’s absolutely the norm of how insurance companies operate.
My aunt is still employed, fully insured, and every day is a fight between her and her insurance company. They randomly deny claims for chemo treatments, and put her through invasive procedures to verify the disease after doctors formally diagnosed her.
The list of landmines they strategically place that could cause her to lose her insurance seems to only grow. This payment isn’t made on this date? Insurance gets cancelled. This form isnt filed on this day three months from now? Insurance gets cancelled. Forget the fact that she is too sick to work; her insurer is already busy trying to figure out how to not pay.
Unless you are wealthy enough to pay for everything yourself, everyone in the US should expect to be left behind by the health insurance they’ve paid their entire life for as soon as the insurer can figure out how to do it.
Well, it doesn't have to cost that much to take care of a heart attack. Remove the AMA from the equation and it'll clear up. The real problem is that we restrict the supply of doctors.
Without that, competing hospitals can arise that will compete on price.
Supply of doctors is definitely an important issue. But prices are high not because they can't find doctors. It is high because they have no real competition. When someone is suffering from a heart attack what options do they have than to go to the nearest hospital? Even in non-emergency situations people chose to go to the healthcare provider nearest to them. Also even if we assume people magically able to chose any healthcare provider in the country by teleporting themselves. On what basis they are going to make decision? Prices of healthcare services are opaque and almost secret until they surprise you with 6 figure bill.
That is why i laugh at republicans (Ben Shapiro et al) argument that healthcare competition is what making it the "best" in the world. Don't compare it with restaurant business.
If this were true, then nations with deregulated health care would also have high prices. Instead they have low prices and better outcomes.
Patients shop on reputation. In a country with less regulation, like India, you see competing hospitals across the spectrum of price and performance. Everyone knows which ones are good and which ones are expensive. People know which hospitals they're going to attend before they fall sick. The outcomes in their top cardiology departments are way better than those in top American cardiology departments.
Their doctors perform way more surgeries and are therefore far more practiced and experienced. They are far cheaper because there are so many more of them.
the Indian example you cite is correct, but only works well for the middle and upper classes who can afford to pay for the care (for now, see below).
For the majority of lower-middle and poor class, medical care is hard to obtain because they cannot afford the private care, and the government-run hospitals that offer low-cost care suffer from bad service, and inadequate facilities/medicine.
India is well on its way to emulating the American medical system:
(1) medical costs have been rising at a rate of 15-25% a year (where inflation has been 5-10%). This is okay for now, but in about 2 decades will price out even the affluent classes.
(2) Health insurance is being touted by the Indian government as a solution to this -- which is the first step to going down towards the American model of healthcare. India also has poor safeguards against crony capitalism so I expect large insurance companies to capture the regulatory framework to frame rules in their benefit.
When there's enough competition, all hospitals will be cheap. He won't price shop at illness time. He'll know which hospitals close by he can afford. There'll be three or four equivalently accessible ones and he'll already know which one he's going to go to.
Surgery outcomes in Indian top cardiology hospitals are better than in America. And they're cheaper. And more available. And perform more surgeries per week. Competition is good.
Why don't they compete now or why can't you even get a price upfront from them?
EDIT:
I am responding to a comment that the AMA is the problem. Maybe the AMA is a problem but it has nothing to do with hospitals not competing over prices.
Because price negotiations aren’t disclosed and are privy between hospitals and insurance provusers.
The real crux is that point, the patient is removed from pricing and so the whole market becomes distorted. It’s like going to a store without price tags and complaining that your bill is much higher than you expected.
"t’s like going to a store without price tags and complaining that your bill is much higher than you expected."
It's more like only having stores without price tags and then when you overpay people telling you that you should have shopped around for a good price.
You can get a price upfront in my experience. Especially for standard procedures. And definitely for outpatient stuff.
But it isn't reasonable to expect upfront pricing in things as complicated as heart surgery. Or where you are going in for unknown problems. There is no way to know what complications may arise or additional procedures, x-rays or scans may be required.
I was having trouble sleeping for a while; at one point my doctor recommending I go on oxygen for a while until she could figure it out. I called the company that provided the oxygen, and asked how much it would cost. Nobody knew. I called back 3 times, and still nobody could tell me. I called my insurance company; they couldn't tell me either. I ended up electing not to use it (which turned out to be perfectly fine), but it does seem like this was a fairly standard procedure, for outpatient stuff, and nobody involved knew what the prices were.
As someone who used to work in the medical field it can be a pain to even know how much insurances will reimburse for procedures. Especially when it comes to smaller / union insurance providers, health care providers have to call and wait for a fax or snail mail for a reimbursement table. This leads to balance billing or the provider just eating the cost.
On the consumer side I just found out about healthcare blue book and they have prices for just about any procedure.
The way out of this for the US is to have lots more doctors.
So tax hospital revenues (yes, revenues) to fund residencies and have an objective standard for accrediting medical schools, where meeting the objective standard automatically qualifies the seats.
Of course patients will then be paying for the residencies, but that's fine, it even makes sense.
Having more nurse practitioners and physicians assistants would also help, but doctors lobby against them starting independent practices.
When you are out of network then you are responsible to submit the claim to insurance. I paid < 1% in the end for a 5-figure bill in similar circumstances.
The scary part is you must carry this risk to your insurance who can then deny the out-of-network claim.
Am I misunderstanding something here, or is everyone else not understanding?
How it can be that inefficient? It looks like a monopoly or corruption. In Europe medical costs are way lower (not what the user pays, but the actual cost).
There are different horror stories from different systems. Bottom line is that access to health care professionals and equipment is a scarce resource, and any resource management process whether through governmental regulation, or individual funding, insurance program, etc will be faced with managing access to that resource one way or another.
And in some systems, horror stories are way more common than others.
The simple fact is that I don't know anybody from my European family or friends who would willingly switch their system to the US one. And as a very well insured employee in the US, if, hypothetically, I had the option to use my European health care in the US, I'd switch immediately a well.
I doubt it. Someone needs to pay for it, so this switch would have to imply a 20% tax increase. Unless you’re paid peanuts, it’s not worth the tradeoff.
There are many studies that show how the US system has incredibly high overhead that simply isn't needed.
Just an example: in the US, a primary care physician usually has a nurse and somebody who handles paperwork, insurance BS, and what not. Most European countries simply don't have this, mostly because there is no insurance BS to deal with.
There is insurance related overhead every step of the way.
And that's not including the free-for-all pricing of $500 saline bags.
Your 20% tax increase is ridiculous. It doesn't have to be nearly that high (and it isn't.) And even though I'm in the highest tax bracket, I'd gladly pay 5% more if it meant quality medical care for everyone without any risk of bankruptcy.
Once again, US share of taxes in GDP is 26%. Denmark: 50.8, Sweden 49.8, Germany 44.5, France 47.9, UK 34.4. So weighted by GDP it does cost quite a bit.
Why are you quoting figures for the entire tax take in a discussion about healthcare? To give you some perspective, the healthcare-only figures for those countries are US: 16.8%, Denmark: 10.3%, Sweden: 11%, Germany: 11.2%, France: 11.1% and UK: 9.9%. Data here:
Because OP wanted to "switch" to European socialized insurance, without also "switching" to their levels of incomes and taxes as well. Of course their cost of labor is lower: they socialize a bunch of costs that would otherwise need to be recouped through the earnings of doctors, nurses, administrative personnel, etc. On top of that they get US drugs for a fraction of the cost, and don’t do any serious pharma research (because there’s quite literally no money in it, given the cost of drugs). It’s not a valid comparison. My point wasn't that US healthcare is not expensive, anyone with any brain at all can tell that it is. It was that you can't pick and choose, and on balance, even with the more expensive healthcare, the US is a "better deal" for the vast majority of people who comment on this site.
Doesn't have to be higher taxes, that's my point. It can be solved by lowering the cost through technology and regulation, which Obama chose not to do, because that would eliminate a ton of jobs. Switzerland has essentially Obamacare, and does cutting edge pharma research (unlike the rest of the world, except for the US), and doctors get decent, albeit not exorbitant, wages (again, unlike in the rest of the world except the US), and if you look at the cost, their insurance is not that expensive, and their taxes are, on the whole, lower than in the rest of Europe. Pumping trillions of dollars through the government only adds overhead, because we all know how terribly inefficient government spending is.
Yet the administrative costs of Medicare or the French healthcare system are much lower than private insurances. I'm not sure the government is that inefficient...
That’s why I deliberately did not say income tax rates. They ream you in other ways. Canada’s taxes as percentage of GDP are 31.7%. US is 26%. And on top of that I was referring to Western Europe, where they are close to or above 50% GDP.
That's still 6%, not 20%. (It also pays for college tuition, childcare, and parental leave.) It's also a bit weird to do it as gdp percentage instead of individual percentage, which obscures the individual/business split.
But you would save more by not having to buy your own medical insurance.
I know an expat who moved to work for citi in the states from the UK and he was paying around 20% just for him -his wife kids are covered by her federal Job.
UK NI is about 13% and that includes state pension, unemployment and the NHS
I a non-immigrant here in SA's medical/emergency system is fully corrupted and broken. Citizen's of USA are not standing up/protesting this issue which can virtually affect everyone. Why are citizens sleeping? Same surgery with more experienced docs and equipment are done in 10-20 times less in my and the rest of the countries in the world. It's time to wake up USA
Propublica [1][2] has done some investigation into the amount of waste, beginning with a 2012 report by the Institute of Medicine of the National Academies. The unnecessary costs amount to roughly 5% of US GDP. For comparison: the defense budget is about 4.5% of GDP, and Social Security Disability Insurance outlays are about 5% of GDP. NASA's budget is about 0.1% of GDP.
A number of other commenters have castigated politicians on suspicion of being in the pocket of insurance companies or health care companies. Sure such things may happen occasionally. More certainly, politicians and bureaucrates are regularly attentive to the budget and financing of the government.
If medical care was cost efficient, it would 1) reduce GDP and the appearance of economic growth, and 2) wreck the back office math concerning whether the federal government can afford the deficit and the interest on the national debt. Elimination of mass incarceration and criminalization would cause a similar dilema. US economic growth has been 2-3 percent in recent years. If that were negated by substantial reduction of waste-masquerading-as-productivity, then the federal budget could not be financed without massive cuts or dramatic manipulation of interest and inflation rates.
There are others who potentially benefit from denial of treatment or claims beside the insurance company. Beside the doctors, medical institutions, and insurance companies are another set of actors: the benefits management and payment processing companies, who often profit per transaction. Some of the calculus in this camp can be seen in [3]. This part of the system (and others) can benefit when a patient is denied or discouraged from or uninformed of curative treatment and manipulated into some ongoing palliatve therapy - despite the possibility of greater overall long-term cost. The cash-flow gets distributed differently than curative treatment, and there are more smaller on-going transactions enabling a higher percentage of skim.
Here is a reminder that in the US, we pay much more and receive far worse outcomes than any other first world nation, by any metric you care about: life expectancy; infant mortality; incidence of chronic disease; obesity; incidence of addiction; etc.
Then consider we are the only first-world nation in which medical bankruptcy is not just a thing, but a profound source of anxiety and genuine risk.
What do we get in exchange for worse care, worse lives, and risk of financial ruin...?
A "free market" like the one functioning in OP's case. Oh, and in the time since the ACA passed? Record private industry profits.
Within the NHS specifically, there was the recent case of Alfie Evans[0], where the medical practitioners said there was no hope for him and the family wanted to take him abroad for care. The NHS and the UK legal system decided that his best interests were to die in the UK. His family was not allowed to take him for additional care.
That isn't really an issue with the NHS. If it's an issue it's with the UK's family law which recognises that the parents of a child doesn't always act in the child's best interest and allows the state to intervene.
There are better systems... over here in Uruguay, you have basic tax-paid "free" healthcare but you are able to purchase better services on top (I have several layers of extra care on top of national basic service).
The richest usually purchase insurance to be operated in the U.S. by top doctors (ironically, probably cheaper than what U.S. nationals pay for the same service), but local doctors are very good (there ARE some services where U.S. expertise is preferable).
The issues you mention are not directly health care related. There have been analysis of the mortality rate in the US, and when you remove people who die from things like being murdered or in automobile accidents and dying without receiving care, the US has the best mortality rate among developed nations. The data is old, but there's no reason to think it has changed dramatically in the last decade.
Obesity rates and chronic diseases that are the result of lifestyle choices are not health care issues, they are public health issues or public health policy issues. No doctor can legitimately be assigned responsibility for citizens who live unhealthy lifestyles.
When comparing cancer survival rates the US is, again, among the top for many types of cancers. It's almost impossible to compare infant mortality rates because the US doesn't adhere to any international norm for what is considered a live birth and reviews of the data have shown that the US will frequently label an extremely low birthweight child as a live birth, while many other countries will label the birth as a still birth.
The reality is that actual care in the US is what you'd expect from a developed country. The reports that put the US down the list of first world health care systems universally factor in cost and accessibility. These are real issues, but it's not the same thing as "paying more for crappy outcomes."
Countries with different systems have their own issues, which is why I pointed out situations like Alfie Evans. There was also Oliver Evans whom the NHS said could not be saved and would not get treatment. The family paid $170,000 out of pocket and crowd funded another $100,000 to bring him to the US where surgeons in Boston successfully removed a non-cancerous tumor from his heart and saved his life.
You joke, and the OP is possibly joking as well, but this is a reality for a lot of people... Their poverty freezes them out of the credit system, they lack health insurance, etc.
Poverty in the US has gotten so bad in some places that it rivals the worst of Africa[0][1].
I curious to know the details of his health. He just did an IRONMAN 5 months before. Why was he unaware of the status of his clogged “widow-maker” artery? Why was his artery clogged?
high cholesterol? What does his diet consist of?
Use of ultrasound imaging to measure the thickness of the inner walls of the carotid arteries that supply blood to the brain. Increasing carotid artery intima-media thickness, or CIMT, indicates a build-up of fatty deposits, known as plaque, in crucial arteries to the heart and brain. Plaque build-up in the arteries, which is usually affects adults, can restrict the flow of blood, causing heart attacks or stroke.
"I curious to know the details of his health. He just did an IRONMAN 5 months before. Why was he unaware of the status of his clogged “widow-maker” artery? Why was his artery clogged? high cholesterol? What does his diet consist of?"
That just happens. There are people who are in great health and drop dead one day. Whatever you do lifestyle-wise just improves your chances of being healthy but there are no guarantees. You can smoke a pack of cigarettes daily and live up to 100 and others will get lung cancer without ever touching a cigarette.
When did you last have an ultrasound of scan of your LVA? Have you had imaging done of your bile duct to rule out pancreatic cancer? Why don't you know your health status?
The answer is, of course, because there was no good reason to do the invasive testing needed to determine that status. There is an entire medical field dedicated to measuring the benefit vs cost (including testing-induced problems) of such things. No one recommends that ironman competitors do heart scans or arteriograms.
There's not always a lot in the way of warning signs, and people tend not to get casual arteriograms just for kicks. The apparently-healthy suddenly dropping dead isn't exactly a rare phenomenon, and "being in shape" can be misleading. Jim Fixx[1] was kind of the poster child for this sort of thing; his death pretty much kicked off the over-40 checkup routine.
Unfortunately you can't really get a heart arteriogram done as a checkup and anything else is actually guesswork.
Both MRA and CTA are really expensive.
Bloodwork can point to problems but there is still a plenty of differential diagnosis involved... You need a bunch of history (main factors are currently age and family history) to reasonably evaluate risk using e.g. European joint guidelines.
You can perhaps guess better based on local doppler USG of some big extremity artery or of carotid. Doppler of heart is not precise enough to show anything useful.
There are a lot of factors that can go into heart disease. Some of these factors are:
1. Under/over working out, especially for white men over working out can lead to increased shear stress on the arteries
2. Genetic familia hypercholesterolemia aka high cholesterol. This is caught by a blood test and fixed with statins.
3. High Blood Pressure again exams and medication
4. Size of ldl particles, this one is new
5. Genetic markers especially 9p21.3, sadly about a third of people have this marker. How it works we don't entirely know, but the best guess I've come up with is it has to do with interlukin
6 signaling which signals inflammation. Solution to this might be taking curcumin, lower weight, Mediterranean diet.
7. Low HDL again mostly genetic, niacin may help some as may exercise
From my research into the matter it seems that the initial damage is done via HBP, shear stress, or cell repair failure. Then inflammatory markers attach to site causing white blood cells and ldl to infiltrate between the inner and outer walls. Eventually the plaque grows and the inner wall continues to thin until one of two scenarios occur 1) hard cap forms (calcification) and the plaque grows until it restricts enough blood that it causes heart attack or 2) The much more dangerous scenario of the inner wall thinning and breaking causing a clot and instant heart attack. The bad part about 2) is that its undetectable except for angiograph or nuclear stress (treadmill can if the heart rate goes high enough and the doctor skilled at interpretation). Some hope for 2) is that statins seem to encourage calcification of those thin walls thus preventing the heart attacks.
This is just what causes the heart attack and the actual fix (stenting and balloon angioplasty) has its own issues. Where the only surefire fix after a heart attack is a bypass, but if more than 2 plaques are found you need to harvest veins which don't last as long. What the entrepreneur world needs to focus on in my opinion is easier at home detection of coronary plaques (sound, radar, electrical, magnetic, etc.). If the government got involved nanorobotics and bio compatible hearts could be explored along with angiogensis via external stimulation, but each of those would be a moonshot program.
A few of the other facts/assumptions you make are outdated. Statins do very little to improve mortality. Inflammation can be reduced by cutting out carbs and sugar. Eating more saturated fats and omega 3 also reduces your risk of heart disease.
In fact the whole dietary advice given over the last 60 years is responsible for the epidemic we now have with obesity, diabetes and heart attacks. But they can't come out and say they are wrong, but they are slowly changing it a bit at a time.
I wouldn't put much faith into the non ldl hypothesis we have extensive studies that show that lower cholesterol (total and ldl) cause less myocardial infarctions.
[1] This study makes the assumption that lower ldl is less risk and then looks for mutations in genes that lower ldl. It's putting the cart before the horse.
> e. In each study,
we estimated the odds ratio for disease among
carriers of any NPC1L1 inactivating mutation, as
compared with noncarriers. We then calculated
the summary odds ratios and 95% confidence
intervals for coronary heart disease among carriers,
using a Mantel–Haenszel fixed-effects
meta-analysis without continuity correction
[2] This starts off by saying that if we gave statins to 10000 people who are at risk that it would help 1000 and 500 people only. In addition 100 people might have adverse effects. If you ask me, an expensive drug that barely helps and only increases mortality by 5 days on average isn't worth it, and it comes with chances of adverse affects. If we just eat foods high in saturated fats and raise our HDL that is far better.
[3] a meta analysis of randomized trials. Says 11 out of 1000 patients had a reduction of major vascular events. So that is saying out of 90 or so people who take statins, only 1 of them will see any benefits.
Basically statins are poison that give hardly any benefit and treat an assumption that lower ldl leads to less heart attacks.
Cholesterol is a very low if not irrelevant marker for heart disease now. It's been a myth for 40+ years that food high in cholesterol will clog your arteries. Dietary cholesterol has very little impact on total blood LDL cholesterol levels.
Sounds all fine and dandy until you realize that these charges will just be made up for by people that aren't able to get NPR to publish a story about them.