What I find interesting is how in OP's original tweet, more than half of the comments blame him for the cost. Shouldn't have gone to that hospital! (it was the closest one). Should've drunken more water! etc. pp.
"Shop around" is a great capitalist mantra, except that medical emergencies are pretty obviously a situation where you're absolutely not going to shop around.
This is the obvious case. What is even more shocking is the happy case. You have a week to make an appointment for an outpatient procedure. Call around. No one can even give you a price. Doctor doesn’t know; sends you to some billing department. They don’t know. You will spend a month to find the actual price at 5 places, and it’s not even locked in price. Bill come for another amount? Tough
I needed to visit a sports therapist. Called an office near me and asked the cost to see the doctor.
> We can’t say, we don’t know what procedures the doctor might order.
I understand, I say. Just tell me how much for the consultation. Walk in the door and see the doctor.
> [repeat]
Let’s take the most common case. Say the doctor orders cortisone shot, but I decline this care. Then how much?
> Don’t you have insurance?
Yes. As I stated earlier I do have insurance, but I don’t have a co-pay plan. I have a deductible plan—-i don’t know why I need to explain the difference—-that means I pay full price until I reach my high yearly deductible. Since I haven’t been sick, I’m at $0 right now.
> Where did you get our number?
From my health insurance’s web site.
> I don’t think this is the doctor’s office for you. Click.
Some of this has improved under the No Surprises Act. In certain situations the provider may be legally required to give you a "good faith estimate", or at least not send you excessive bills after treatment.
If a provider organization is out of regulatory compliance, then you should file an official complain with CMS. I understand that this is a hassle but it's the only way to improve the situation.
I ended up in the same E.R. several months apart for the same thing. Other than an MRI the first time, identical treatment, prescriptions and length of stay.
I have MS and receive an Ocrevus infusion every six months. It's a labyrinth of a process. UHC (insurer) sub-contracts(?) to CVS Caremark to provide specialty drugs. CVS insists on calling me to confirm they can ship it to my house. F no! I'm not running an IV for myself. Sort it out with the hospital.
Last go around, the hospital coded the drug as coming from their supply instead of CVS so I got a surprise bill for $130,000+
Luckily, I've been through the process so there's records of the normal billing path. I fought the Hospital billing department and 5 months later I'm billed $700 which was about the expected amount.
It was still stressful and time consuming to figure out if I screwed up to the tune of 6 figures.
> CVS insists on calling me to confirm they can ship it to my house. F no!
You joke, but this is what my wife does for her infusion. Drugs get shipped to our house, and nurse comes to the house to administer the infusion. She gets to spend the time on the couch watching TV instead of in a hospital. And as a another indictment to the broken health care system, this is actually cheaper to the insurer!
Greetings from Australia. My brother has MS and gets a monthly infusion of Tysabri. All he does is show his Medicare card and it doesn't cost him anything.
My brother lives over the ditch in Australia. He developed very serious metastasised melanoma.
He was prescribed a very new drug which has worked brilliantly and saved his life.
The first time he left the pharmacy with his monthly prescription, the pharmacist told him to take care, because the pills he'd given him cost more than $20k. For a months supply. The cost to him - absolutely nothing.
I looked at leaving the US years ago. Australia was on my short list after spending some time in Melbourne. Alas MS is one of those things that makes immigration harder nearly everywhere because it "puts an undue burden on the health system". Never found a way around that aside from maybe marrying a local; it's been a while.
Glad he's getting the treatment he needs!! Drugs have made incredible advances in the last decade.
And yes drugs have made incredible advances -- my aunt (and hence my brother's aunt) had MS and her life was ruined by it.
Pretty amazing to see something advance that quickly with such a stark difference in outcomes between 2 of my own family members.
When my brother told me it was relatively benign given they caught it early and he had access to treatment I was like "I read 10 books for the MS Readathon in Year 1... You're welcome!"
My sympathies and commiseration. I am on a different infused medication and survived a couple of years of CVS Caremark acting as a Pharmacy Benefits Manager for "specialty drugs" before my insurance and the hospital system I work with negotiated a different delivery and fee structure. Not before, of course, my own higher-than-expected bill.
I am on an HDHP and arrange my finances and budget with the expectation that I will reach my out-of-pocket maximum. I am thankful that I am in a position to do that. The backside being that I am under enormous constraint in terms of my employer. They literally own my health, as while I am skilled and valued, I doubt that I am skilled and valued enough for another employer to keep me after poaching me away. I would expect something in the off-the-record review comments of "...health care costs are how much!?!?" followed by quiet PIP-and-dismissal or dismissal outright under the laws of my state-of-residence in the United States. Yes, I live in a right-to-work state, meaning that my employment can be terminated at any time, by either party, for any reason, or no reason given at all.
We spend $14K per person, or $4.5T on healthcare in the US. The typical cost for healthcare in comparable countries is 1/2 of that per person.
There is $2.25T per year of savings to be had. We can eliminate our national debt in 15 years, and with that also eliminate the $1T going to $1.5T of interest payments we pay each year on the debt, so a total savings down the road of about $3.5T per year.
To put that in perspective, our entire national budget was a bit less than $4T pr year pre pandemic.
There is absolutely nothing else that comes close to the potential savings on healthcare. All of the schemes I have seen whether they are tax increases or cutbacks in other programs, even the extreme ones, *might* save $2T over 10 years.
The problem is that the solution is subtractive not additive. Its, at the very least, a lot harder to make a business where people stop doing stuff.
What do we need to stop doing? All of the billing shenanigans with insurance. We need to stop insuring regular healthcare, and go back to insuring catestrophic healthcare.
What we do now with healthcare is like buying car insurance that pays for oil changes.
If a patient is diagnosed with lung cancer there is no reliable way to determine whether the root cause was smoking, radon exposure, or some random mutation.
> [surprise bills]… often stem from patients unwittingly receiving care from out-of-network providers…
If you do not have the agency to select an in-network provider (because you are mortally wounded / incapacitated / etc.), then the out-of-network provider should be legally transmuted into an in-network one. The insurer should be compelled to pay, and the provider compelled to accept it.
I believe that's the way it works. And then you have to transfer to in network provider as soon as humanly possible (perhaps not as humanely possible...)
One of the problems here is that the patient can believe they're at an in-network provider — and be correct about that — and still get hit with "out of network" charges.
One of the linked articles[1] explains it slightly better:
> Surprise medical bills happen when a doctor or other provider who isn’t in a patient’s insurance network is unexpectedly involved in a patient’s care. Patients may go to a hospital that accepts their insurance, for example, but get treatment from emergency room physicians or anesthesiologists who don’t — and who then send patients big bills directly.
I've seen this in my own medical billing: often times, I will get bills (to the insurance) from "providers" I had no (direct) interaction with. And that's the thing: if a in-network provider contracts/vendors/(who knows, I don't know how their business is structured) to some other company, you get billed "randomly". Sometimes I can piece together exactly what action caused it (e.g., okay, that ultrasound is this random charge), but not all the time.
Insurers refuse to help: they claim it's not their problem, as they're not billing you. Providers will claim they know nothing; after all, it isn't them that billed you.
Last year I had minor surgery, and before the procedure started, I asked the anaesthesiologist if she was out of network. Her response: laughter. Very comforting when I was about to trust her with my life.
Turns out she was out of network, and the cost of the anesthesia on top of my in-network hospital bill was around $1050.
Why are randos allowed to bill you directly if you didn't sign a contract with them? Shouldn't anyone working at the hospital be under contract with that hospital? Why did the hospital share your personal information with those people without your explicit consent?
This +1000. The whole billing / insurance system is intended to wear you down in a cascading swarm of bullshit.
You want to know if a doctor is in network? Good luck, because the insurance company clearly states that they only provide that information on a best effort basis. The doctor can’t answer, as they refer you back to your insurance company.
You want an outpatient surgery? Great! Make sure your doctor and facility is in network, right? Oops, wrong again! You forgot about the anesthesiologist who you can’t pick ahead of time and is rarely in network. Good luck figuring that out later!
It’s intended to wear you down until you’re afraid of your “rating” aka credit score tanking enough that you just pay up.
All well and good until you sign away those rights in one of the many forms you fill out- see for example this excerpt from one of my local hospital websites (emphasis mine)
It’s trivial to be coerced into signing one of these agreements when you’re in a high stress high stakes environment.
> If you get other types of services at these in-network facilities, out-of-network providers can't balance bill you, _unless you give written consent and give up your protections._
Can you simply just not pay? What are the legal consequences in that case? Effectively some random 3rd party is requesting you pay them for something you didn't ask for or contract them to do.
I'm generally a fan of HDHPs, but I echo some of the same complaints made in the article. For example, just a few months ago, my toddler was complaining about horrible pain in his stomach. Now, being 5, it's awfully hard to determine exactly how much he's hurting, and of course, the strong recommendation from every nurse, doctor, and UC clinic we talked to was to bring him to the ER. A UC clinic or PCP won't take the liability if it turns out to actually be appendicitis and not just a virus with nausea.
I knew full well the ER visit was going to sting, but I had no idea how much. The amount after insurance was almost exactly what was quoted in this article (almost like they plan that). That pretty much maxed out his OOP max, but I'm not wealthy enough that 5k doesn't make me mad. It shouldn't matter, but it feels worse that it was just a stomach bug, so $2 worth of anti nausea meds (that the hospital charged $150 for) was all we got out of it.
Rationally, I don't really see a way out for (possible) emergencies. That care is expensive, and HDHPs are a bit of a gamble that usually pay off if you're healthy. The OOP max ensures you won't be financially ruined, and 'cadillac plans' or gov care just means you pay far more in premiums or taxes for the majority of the years.
My mom was an RN and almost never took me or my brother and sister to the doctor when we got sick. Vomiting? Sip some 7-Up and rest. 24-48 hrs later I'm back outside playing at 100%. Same with practically every other malady.
I've adopted a similar mindset with my kid, now 18yrs old. Unless he'd broken a bone, is clearly in need of stitches, needs a vaccine or is otherwise laid low for more than a few days we'd try to stay out of the healthcare system.
That may be fine as practical advice, but it’s horrible from a national policy perspective. The best way for people to avoid being bankrupted is to avoid the doctor? It stinks.
Yeah avoid the HDHP if you have children or know you comsume a large amount of healthcare services. Otherwise, HDHP, the associated HSA account, and typically an employer contribition create a triple tax free investment that can't be beat.
Sucks though we have to guess how much health care we might use in the coming year.
On a postivie note if you hit your family max for the year, try and stuff in as much medical care you can.
One relief was that it happened in March, not on Dec 31, so it's not like I wouldn't have paid some of that bill in care, which is now 'free'
The other thing I learned, since the hospital was unwilling to negotiate on total price is that they just want you to commit to paying and will give you a long, low monthly, zero interest payment plan to make that happen. I'm a 'no debt' kind of guy, but if they'll float me a loan for free, I plan to just keep adding future visits to this network to my payment plan indefinitely.
This is one of the big problems: if one went without insurance entirely, the hospital may negotiate 50-75% of the inflated charges away for cash on the spot, but with insurance involved, I have no control over the price I pay for that $150 Tylenol, which insurance knocked down to $75. On a HDHP, I'm out that $75, because the hospital 'isn't allowed' to negotiate further after insurance.
An obvious example of this is with prescription drugs. I have a monthly script that is something insane like $250 'U&C' charge, but after insurance, it's $90. However, at a particular pharmacy, with GoodRx, it's $21. Paying 'cash' with GoodRx ends up being the better deal, even though it doesn't count towards my OOP/deductible with the insurance, because I'm not likely to hit that with a HDHP.
Would my total cash outlay for a hospital visit be cheaper without insurance? Maybe, but the fact that I can't determine that upfront unlike what I can do with a script is what is infuriating.
The US needs to adopt the healthcare model of Singapore. Universal coverage for everyone along with a strong private insurance market as well.
The problem is the current system is basically a giant jobs program. Healthcare spending is approximately 17% of US GDP. Politicians are terrified of rocking the boat on this, so the system will always remain broken.
There were proposals for Medicare for all, but unfortunately one of America’s scars from the Cold War is that any government program meant to help people is branded “socialism” which at that point you might as well have a Karl Marx tramp stamp.
Aren't you assuming that the healthcare system operates for the good of the patients? From my point of view, that doesn't seem to be the case in the U.S.
In all these cases, there is one constant: the patients get treated, and treated well. That's not the issue. It operates for the good of the patients (whereas for example, the NHS often gets criticized ...)
The NHS is being systematically destroyed by the Tories who want this broken US system in the UK because it makes them money.
Aussie healthcare is the best I've seen (and I've seen a few). Basically free, with more speed or better care (or whatever) if you want to pay for it. Health insurance is like US$75 a month and not tied to employment.
Absolutely anyone who’s ever dealt with healthcare system will tell you otherwise. From being denied necessary medical procedures because insurance doesn’t agree with it to subpar quality of care because how stretched the doctors and healthcare professionals are, US medical system is far from treating everyone well.
$10000 looks like he got off easy given he visited an ER. Some unfortunate ones have to pay close to that amount just for the privilege of sitting in an ER, without getting any meaningful treatment.
My wife had to go to the ER 24 yrs after delivering our second kid because of a medical error during post partum care at the same hospital. She sat in the ER from 9pm until 6am 72 hrs after giving birth and was offered the womens bathroom to pump in. She never saw a doctor or got past triage despite the delivery unit telling her to go to the ER immediately. We got a 4.5k bill, insurance paid most of it, but we’ve refused to pay the deductible on principal.
After to many of these we just have a family policy that we are the final arbiters of a reasonable and fair medical bill given the error rates in billing. We have a high enough credit score that collections doesn’t scare us.
It's not just some ER, it looks like he went to the Mayo Clinic which is one of the top hospitals in the world. It's the kind of institution that world leaders from around the world travel to for complex treatments.
He also bypassed multiple urgent care centers and went to the Mayo Clinic ER adjacent to North Scottsdale, instead of going to closer Banner University in Downtown Phoenix. He doesn't say if Mayo is in network, but that would be a shocker. Funny there is always a 'rest of the story' in these policy based stories.
There will be a charge for the facility itself. There will be a charge for the nurse that initially took you in and triaged you by looking at you and deciding you weren't immediately dying.
Then after sitting there for 4 hours, you might have gotten 10 minutes with a doctor who'd have said something like "You are ok, take a tylenol". This is not any run of the mill doctor, this is an ER doctor, so obviously their charges are in the thousands too.
Whenever this gets brought up someone replies with, "Well, it needs medical training to confirm that you are indeed ok", and I completely agree. And I won't be complaining if the whole visit costed a few hundred dollars. But a few thousand?
Following the trend on the level of care provided by overbooked veterinarian offices, an estimated bill greater than 1k would halt any procedure and ask for a signature and immediate upfront payment or to consider euthanasia as a humane alternative to being unable to afford services at your income level before continuing to provide care. If your injury is serious enough and you cant pay, your residency and citizenship will be immediately revoked and you'll be taken in as a ward of the state to then be forcibly euthanized with no representation from your former family or loved ones.
Payment plans are ofcourse intentionally excluded due to 'abuse of the system' for others who can't afford to pay.
It is important to plan your emergency visits as early in the year as possible. That way if you hit your maximum deductibles and maximum out of pocket limits you get free-ish healthcare the rest of the year. Had a bad appendectomy happen in November. The limits reset Jan 1st. Out another $5000 for the second attempt at removal after a surgery to stare at my appendix before deciding a week of hospital stay with IV antibiotics, 4 CT scans to determine when they would feel comfortable removing my appendix (maxed my $12000) family out of pocket.
I didn't realize HDHPs were still available in the US post-ACA, due to requirements that all plans cover certain minimum services 100% from the first dollar, making them kind of silly (it basically means there's a doughnut of approximately $2k-$6k in cost where someone might be personally liable in a given year).
HDHP plus great price transparency (especially pre service, where one can potentially cross-shop providers, vs. being in a facility and given only one option) would be good for cost reduction; if you can't surface and measure the costs, you won't have any incentive to lower them.
I personally have a fairly mediocre $230/mo blue cross plan in Puerto Rico which largely only covers care within Puerto Rico (and which I've never actually used for anything), and rely on medical tourism where I pay 100% out of pocket, and until Amazon bought them, OneMedical for cheap clinic care which I also paid 100% out of pocket. I previously had a WA state HDHP for $100-200/mo pre-ACA which was great but ACA killed those/insurers left the state.
The incentives in US health care are so upside-down that Americans pay significantly more for the same results as many of the other western nations. While the public systems of the UK and former colonies aren't perfect, they are still significantly cheaper to run for approximately the same outcomes. Ditto for other European countries.
I don't understand why this hasn't become a boil-over issue for Americans yet.
Perhaps because it doesn’t impact you until it does, and we can’t seem to agree on what exactly is causing these outcomes. It’s a legitimately tangled problem, and I do believe how to unwind it is not well understood by anyone. (Ignoring single payer, which is more of a sidestep than a true fix)
Many people are also insulated by expensive insurance plans. HDHP are a long term play to generally make the public more familiar with the problem, as they will no longer be fully isolated from the prices.
I'll posit single-payer is much closer to a true fix than you give credit for.
A significant fraction of the additional cost in the US is due to all the administrative overhead that comes with negotiating prices with thousands of insurance providers, as well as dealing with not only primary insurance, but secondary, tertiary, and sometimes even quaternary insurance providers for any given patient. And, as mentioned elsewhere, it gets multiplexed over each doctor involved in your care, since each may work with a unique subset of insurance providers.
Interesting that IV hydration is available for $500 from clinics.
I was taken ill in India. Went straight into hospital A&E and out within 90 minutes. I was given drugs for sickness, IV hydration and lots of tests.
Total price = £33
It seems to me that the costs for treatment in the USA are actually more than covered by the deductible. The rest is holiday money for the criminals running the system.
Go to urgent care instead. I told my kid once, if you think you need to see a doctor, tell me before 8 so we can bypass the e-room. The last time we went to emergency, I got a $3000 bill for a strep check and a generic pill.
I don't really think the suggestions made in the last section of this article really address the core issue here.
> Enhance transparency in healthcare pricing
So after you're in an emergency room, and a posted sign shows that to see any medical professional there, you'll be charged X plus a facilities fee Y. After you wait k hours to be seen, you're told that the treatment they think you need will cost Z. If you think that's too high, during an emergency do you try to go to a different hospital to see if they have the same treatment for W < Z?
> Institute arbitration for billing disputes
I mean, better than no arbitration, but if you're dealing with a serious illness , trying to recover from an injury or whatever, while getting time from work, bouncing between specialists for follow-up visits, still foggy from pain meds, etc should you need to navigate an arbitration process? Are you equipped to?
> Advocate for consumer protections: Educate and empower patients to advocate for themselves through measures such as the right to appeal surprise bills and negotiate payment plans with providers.
... so again, placing the burden on patients to defend themselves during what already may be a very challenging time in their life.
I think the highest level bit is that the most predictable cost for health care would be under a free-at-point-of-care, single-payer system, that lets us cut all the medical billing and medical insurance overhead out. Everyone pays the same (nothing!) for their care, and every earner pays a predictable amount for the system overall. Even if the exact same "amount" of health care was provided, we'd collectively pay less for it. But if we also went all-in on value-based/outcome-based care rather than fee-for-service, we might also be able to get people to live healthier longer lives with less total care (and costs). And no one who's sick or recovering from a medical crisis needs to spend their energy "advocating" for themselves, or in dispute arbitration, or researching which provider has the best prices for their needed service.
Another "fun way to lose money" is for example to get bitten by a wild animal. I am originally from a country where rabies shots are free. But here in an ER they could easily charge you $15k for that, which I was truly shocked about.
Related article quote about a bear attack:
"Literally, as I was being eaten by a wild beast, I wasn't thinking about Jesus or my family or my son. I was thinking my insurance was not going to pay for this," she told The Independent. "I had to make this calculus as I was being eaten, 'Do I want to survive this?' Not, 'Can I survive this?' Not, 'What am I going to look like?'" [0]
In an AMA, she said that the worst part of the bear attack wasn't the bear attack, but dealing with her health insurance. [1]
I have zero medical expertise, but were the two blood tests and an xray really necessary for what seems like a simple case of dehydration?
Anecdotally, I recently got a simple blood test to keep an eye on something that’s been borderline in the past. Unbeknownst to me, my doctor ordered nearly 30 things to be checked in the blood panel, at $50-$100 a piece. Luckily my insurance negotiated a much lower price and covered most of it, but I can’t imagine paying $2,000+ just to check e.g. your cholesterol level.
I think the problem is alignment of incentives: for a doctor, over-testing has little to no negative consequences, but under-testing could lead to guilt due to a patient dying, loss of reputation because something was missed, lawsuits, etc.
As a society, is this how we should be using our limited medical resources? What if we made fewer xray machines and instead spent more on something like cancer screening? How many net lives could we save?
Meanwhile, it's entirely possible to be out of 3000 dollars after an animal bite with a regular insurance plan. Nothing more than an x-ray and a couple stitches, and the out-of-pocket cost was 3000 dollars. One wonders where the premium goes.
> The average cost of life flight within the U.S. ranges between $12,000 and $25,000, according to NAIC (National Association of Insurance Commissioners). This is based on a 52-mile trip, which is also the average distance. This figure represents an out-of-pocket cost when not covered by insurance or calculated before an insurance company steps in. International flights can easily cost 3 to 5 times that amount.
…
In December 2020, Sean Deines was diagnosed with acute lymphoblastic leukemia (a fast-growing blood cancer) and took an air ambulance from Colorado to North Carolina, which also included ground transportation between hospitals and airports. His total bill was $489,000.
I wouldn't say never covered. The stuff in that article doesn't give any data on how often they're covered. But I'm sure they play the same games as regular ground ambulances.
The one I have experience with involved transportation between hospitals and it was covered. I've had experiences where other ground ambulance services were not covered.
A physician of mine has said that he thinks HDHPs are predatory and (in his opinion) should be illegal. They sound attractive until the moment you actually need to get medical care.
HDHPs are awesome if the deductible and OOP max is low-ish (less than $2000/$4000) AND you either don't see doctors very often or you see them all of the time AND your employer contributes. That is the only combination with which I'd ever recommend a HDHP. Just about everyone is better off with a PPO.
I had a HDHP for a few years. $1500 deductible/$2500 OOP max; employer contributed $750/year. I loved the concept and contributed myself, but basically any doctors appointment I'd have would wipe out my contributions. I saw many doctors in 2021 due to random stomach issues that were ultimately GERD. I landed up paying out of pocket before hitting the deductible. I now have a PPO.
The issue is that they are often the cheapest plan to get (because of the HD part) and many HDHPs have crazy high deductibles and astronomical OOP maxes (with out of network deductibles and OOP maxes that are of this solar system), so that + people (understandably) not understanding medical insurance = a very bad time
I like my HDHP. It's honestly not that much different than the other plans my employer offers. They all have large deductibles in my opinion. It's great because my premiums are lower and I contribute to an HSA. The deductible is only about $2k higher than the other plans. And yes, I have used it. I've hit my maximum out of pocket cap multiple years with it. I would have hit that cap under the other plans as well.
Now, that might change as I get older and I need care for chronic conditions that wouldn't hit the out of pocket max but would be above the deductible. And they aren't right for everyone - you need to be making enough to max out your HSA. Companies pushing low wage earners into them are probably predatory.
Yeah, and he does. But as he is arguing, the cost is exhorbitant, and if he had known what the cost would be, he would have chosen to do it himself at home. Even if you have an HDHP (especially if you have an HDHP) this is how it should be.
Highly educated anesthesiologist, former state and federal public health professional, and current employee of Purdue University since 2021, selects HDHP for his insurance plan and then gets upset when he actually has to pay the high deductible for the plan that he himself selected. News at 11:00. And, don't get met started on his assertion that having to pay that deductible prevented him from contributing to his HSA that year. This person is a shining example of what's wrong with US healthcare, not a beacon of light for fixing it.
Like the proverbial crabs in a bucket, only pulling each other down. https://x.com/JeromeAdamsMD/status/1761375417351430595