Anger is insufficient. Without consumer choice, there is no mechanism for individuals to impose pressure on Healthcare providers and insurers. They can continue to 'milk the cow'.
Just give consumers access to a price list before service is provided. That will go a long way towards helping the problem.
(Not that you are going to price shop for every service--a trip to the emergency room for a broken bone wonte get shopped--but some portion of health Care is discretionary or is deliberate enough it can be shopped.)
I agree. This probably won’t be a full solution but at least it would bring a little transparency into the process. Usually going to a US doctor or hospital means to pretty much hand out a blank check telling them to take as much as they feel like and your only hope is that they won’t rip you off too much.
Price lists and comparisons are available for health insurance plans. That hasn't stopped premiums and deductibles from rising to the point of popular furor.
I'm not talking about price lists for procedures, I'm talking about price lists for deductibles and premiums on health insurance plans.
Visit healthcare.gov and navigate to your state marketplace. They typically provide a detailed price comparison based on several adjustable factors (expected income, expected visits, number of medications, etc).
If readily available and detailed price comparison tools haven't stopped health insurance deductibles from tripling in the past year[1], why should we expect price comparison tools at the point of healthcare service to reduce costs?
That’s not enough. What the people should do is demand that corporate health insurance be banned and demand uniform/transparent pricing. (Removing the corporate tax deduction and adding a personal one would have the same effect)
That’d lower the cost of the average policy as their would be an influx of (on average) healthier people to the market for insurance.
We need to eliminate tax deductions as well. They distort behavior yet only benefit the wealthy.
Families making under $50k aren't paying much in federal taxes as it is. The federal tax bill for a family of 4 making $50k/yr is $2,739. Cutting their tax bill in half gives them back a little over $100/mo.
The individual tax deduction is meant to be a temporary bait and switch. A full top line individual deduction of health insurance premium would allow corporations to shift their current contributions to their employees with no net tax consequence (income paid is deductible for the corporation and the premium would be for the individual).
Once that’s in place the next step would be making the general populace aware that the majority of the deductions, at higher tax brackets mind you, are going to the top. That would give the political capital to eliminating the “fat cat insurance deductions” and gradually get us to sanity.
As long as you ignore the 15.2% that everyone pays in social security and Medicare. There is no separate account where those taxes go. It’s just goes into the general tax budget.
I work in Big Healthcare. It's unbelievable what this company wastes money on. It is my daily ethical dilemma. I came to the job to help make healthcare better and quickly found out that this is just a big, publicly traded company whose executives play up the "helping people" aspect but at the end of the day it's all about the money. It's funny because I have avoided the General Dynamics and Lockheed Martins out of concern for the ethics of that kind of work. But every place I have been has been ethically challenged one way or another. You would not believe how many companies are taking government money, for example. America is not the place you imagine it to be, it is truly fascism.
My health insurance costs have well more than doubled since 2014 thanks to ACA. I deliver that failure directly at the doorstep of Obama and his Administration as well as the gutless Supreme Court that could have struck down this awful handout to corporate America.
I have a high deducible plan and think its a good idea that everyone gets one. It means you're much more aware of costs and much more careful. One of the reasons the total US healthcare bill is so high is that many/most people get lots of unnecessary tests, lots of marginally useful procedures and lots of expensive emergency work instead of trying to be healthy in the first place.
Finally having people feel the sting of the bills will hopefully pressure people to change the system that is both very inefficient and overpays doctors, drug companies and hospitals.
With employer based insurance and lack of price transparency there is almost nothing the patient can do to reduce costs. You can’t get any upfront pricing, it’s hard to evaluate whether a test is needed, you can’t change insurance.
You are giving the patient responsibility for something they have almost no chance to understand.
Worse: One hospital charges less. Will I get equally good care there? Or is their rate of complications higher? Will I suffer consequences down the road, maybe for the rest of my life? Do I really want the less expensive hospital in that case? How much money is a lower chance of complications worth?
This idea would only hypothetically work without Medicare or Medicaid. Right now all it does is squeeze the middle class even more as they’re required to further bare the costs of the ever-rising, all-consuming system.
So now the middle class, a large, still-working tax base, is the only group required to ration health-care. I always found that a bit odd.
As with many things, a high deductible plan makes sense in theory and does not work very well for the average person in reality.
To walk through some but by no means all of the problems:
- The average person is bad with money. Always has been, likely always will be. A high deductible plan only "works" if you hold onto the money you would have spent on higher upfront premiums so that you can directly pay for care if you turn out to need it. The problem is, the average person lives paycheck to paycheck, saw the extra money in their bank account, and spent it. Now they're reluctant to get any care, even when necessary, because they don't have the money and it looks like a new expense. Which leads to worse health outcomes, and more things being put off until they become expensive emergencies.
- Few people have the medical knowledge to determine what tests are unnecessary or what procedures are marginally useful. Most people are not in the habit of challenging people who are the experts in the field, who they explicitly went to see for their knowledge.
- Even fewer people have that medical knowledge and have the time and energy to spend on navigating near-incomprehensible bureaucracies to actually compare prices, quality of care, etc to try to make an optimal choice.
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The solution to expensive healthcare should not be that everyone needs to become financially disciplined, a domain expert in healthcare willing to challenge authority figures, and to waste large amounts of their own time attempting to provider-shop in a system unlikely to ever make that a simple process.
I have a HDHP. I save a bunch of money with it, and unlike the average person, I'm in a position where I can do all those things. I get a relatively optimal outcome, although it still wastes a bunch of my time to navigate.
While I personally benefit, I strongly feel that HDHP's are not proving to be a net-positive for the system or society.
I have $6,500 deductable. It's insane how much work I need to do to get healthcare.
The biggest issue is price transparency. To get a price, I need the tax-id of the medical office and the procedure code. Often times the procedure code is unknown because I might have any number of different procedures, depending on what the diagnosis is.
So, I take my list of codes to the health insurance company with the tax ID and wait while they look everything up. This whole thing can take 2 hours.
That's if everyone knows what they're doing. Medical offices are so used to patients not asking about price, their back-office has no idea what to do when someone actually asks how much a procedure will cost.
Then there's the insanity of cash price being cheaper than the insurance price. So, I need to decide if I want to pay $600 and have it go towards my deductible or $450 and pay cash.
I agreed to pay $450 cash and no one in the office understood how to handle it. I finally get to pay the $450 cash and I still got a bill from my insurance for $600 because they also billed my insurance.
You get that? I paid cash and my insurance company still got billed.
Then we have billing errors. I got billed for things I never asked for and/or never received. More wasted time addressing that. Of course, back office is not used to patients reviewing their bill, so there's more confusion to deal with.
I also have an HSA tax free bank account that lets me pay for this stupidity tax free, yay! Dozens of more hours were thrown away trying to understand how HSA accounts work, what I can charge to the HSA account and picking a bank to handle the HSA account.
I spent nearly 100 hours in the last few years dealing with health insurance bullshit.
Imagine how many more wasted hours other Americans deal with.
I can't agree more. I also went the self employed route just after ACA went into effect and the level of stress this entire process causes every year is mind boggling. To add insult to injury, my premiums are increasing at astonishing rates - orders of magnitude more than a typical standard of living salary increase.
I agree with everything here, except the implication that this is only related to the self employed or ACA. Health Insurance companies have been pushing these high deducible + HSA plans for 15 years. They also raised the cost of the older less complicated PPO types plans. This has pushed even the biggest companies to "encourage" employees to "take control of their health care". Oh and each year, the definition of "high" keeps getting bumped. 10 years ago deductibles were $1500.
I once tried to find out how much some blood tests were going to cost me. This entailed a 3-hour ping-pong session between Quest Labs and my insurance company, each claiming the other would be able to tell me. Finally after reaching what sounded like some people in a basement somewhere -- who were baffled at the idea I was calling them, by the way -- I was able to get the "list price" for each individual test and add them up (came to about $1200). When I tried to find out from my insurance company how much I would actually pay, they said "well, it's got to go through claims then we'll know." I asked to speak to someone in claims -- nope. Not possible. The only way to find out what I would be paying is do go through with the tests and get the real price afterwards. Pretty insane stuff.
The most insulting part was after all this when the insurance "customer service" guy said to me, "We know what it's like to be unsure of your finances." What? I'm sure about my finances. You aren't -- you can't even tell me the price!
I tried to do the same with an HMO - where everything is inhouse, lab, accounting, insurance, billing, they do everything. The result was the same - nobody knows how much anything costs (or at least nobody will tell me), you'd know when you get the bill. Completely insane system.
This pattern of exploding healthcare costs didn’t begin with the passage of the ACA (though the ACA is also obviously not the solution). The ACA did increase costs as insurance companies couldn’t suddenly refuse service because they are actually sick (preexisting conditions), but what is our healthcare system doing if it’s NOT treating sick people?
> ACA did increase costs as insurance companies couldn’t suddenly refuse service because they are actually sick
Insurance companies are in business to make a profit. What the ACA did was ensure insurance companies have captive customers. A plan with a $6500 deductible vs pay a fine, nonsense. I should be free to choose between the plan or no fine. If it's all sick people in the plan pool because healthy people opted-out, that's the insurance company's problem, not mine.
Now that the individual mandate is gone, we can watch the deductibles climb ever higher and push people out of insurance.
For many people $6500 might as well be $50k.
I would support a full repeal of ACA and replacement with government payer for all, so long as private insurance is not outlawed and can go back to pre ACA form (I'd like to see more changes, but that's a starting point).
I should be free to choose between the plan or no fine
That’s fine as long as you support getting rid of laws that force hospitals to treat you whether or not you have insurance and you medical bills are not dischargeable in bankruptcy if you don’t have insurance.
I keep seeing this but it does t real jibe with facts on the ground.
Insurance is still priced based on the group you belong to. If you have a preexisting condition and you belonged to an eligible group - you worked for a company that provides insurance - they’ve always had to provide insurance regardless of preexisting condition.
What, that it was a half-measure that'd allow the garbage OP mentioned to continue? I don't think it was half, though, since quite a few Democrats didn't seem to want to go full single-payer or nationalized healthcare, and even the public option didn't make it in.
Hsa's are pretty simple.... Tax free account to pay for health expenses. If we all _exclusively_ had them, I think our insurance rates would drop significantly. Not only would purple be concerned about the price of procedures, but would actively keep a eye on their usage.
Apologies, I wasn't referring to that. I was referring to it's easy to keep an eye on the "total cost you've spent" using an HSA, because it's your money in your account.
Everything you said is true and part of the problem. I do want to clarify some things though that people may not know.
There are several reasons the back-office literally can't tell you what the price will be. First, is that if you have insurance, they don't know. It is up to the payor (insurance company) what the final price will be. Even though there are negotiated rates, most procedures have up to 5 service levels. So depending on the service level, the price will be different. And the service level is based on what service was provided which by definition hasn't happened yet. The only way to actually do it would be to be more like a garage. It is $50 to do a level 2 office examination and then I'll quote you on what we find out then and you can choose to continue or not. Most people would be annoyed by this.
Additionally, there are different codes for things like new patient vs existing patient. Seems simple, right? Actually if you haven't been to your doctor in the last two year, you are a new patient regardless of how long they have been your doctor. The service levels mentioned above are why for years, you had do fill out a paper detailing your patient history every visit. This is called taking a family history and allows for higher service levels and higher reimbursement. This is finally changing now that the family history is stored in the EMRs.
So, we finally figure this all out. An office visit might be always fine but some procedures require a pre-authorization. The rules for this are unique to your employers specific health plan, not the generic Aetna (e.g.). They may require previous diagnosis codes in your chart to indicate you are a risk before agreeing to pay. For example, a 25 year old with blood in their stool may want a colon cancer screening but that is only approved for people 40+. There is back in forth between the office and the payor to figure this out.
Oh, we didn't mention that a lot of employers are now self funded. This means that up to a certain loss threshold X, the company pays the bills, not the payor. This is handled by a company called a TPA (third party administrator). Obviously there are deductibles and other things they control and keep track of as well. This new procedure may now put the employer over their stop loss for the year. The TPA now needs to submit this bill to the re-insurer. They may require even more or different documentation in order for them to process and pay this claim. This is why offices have such huge back office components because a lot of the bills just get bounced back. They have to figure out why and resubmit.
So why are the list prices we see on our bill so high when insurance pays so little but the doctor accepts it anyway? It is mostly a hedge against mistakes. Again, since each employer plan may pay out differently even for the same insurance (there can be carve outs), the doctors are incentivized to over price and let the TPA and payor figure it out. If they accidentally charged $150 for something that is reimbursed at $250, they lose money. It is better to charge $900 and just accept whatever they get. They now don't need to constantly update the price of thousands of CPT (current procedural terminology) codes and make sure they are always up to date.
And this is just part of it.... The only problem in healthcare is mis-aligned incentives. As long as they are allowed, nothing will change.
To your case, I would get a new doctor. Paying cash is not that rare anymore and they should know how to handle it. In addition, they seem to try to overcharge the payor and it got dropped to you in this case. Not sure that I would trust them moving forward.
This is the problem but what are the solutions? In my opinion, we need to change three things. Each one would be beneficial separately. 1) Move to national reference based pricing. Said more simply, no one can charge more than Medicare * 1.5 or 2. This gets rid of all the bull crap negotiations and the doctors can still do fine. 2) We need healthcare to move aw...
I’m typing this from a phone I know you wrote a lot and I read it all. But the system you describe seems to be needlessly complex. I think when you try and justify why it works people will see that this isn’t working.
People aren’t stupid, they travel and see how healthcare works in other countries. Eventually we will end up with a public option. At this point it’s inevitable. We are reaching a tipping point where Biden and Pelosi can’t keep dressing the current situation up.
I used to be a lawyer (thankfully have since moved to a more rewarding career). My girlfriend at the time was erroneously billed $2000 for a procedure that the insurance company had pre-approved but later denied the claim for. She had them recorded pre-approving, and they failed to decline her claim within the statutorily specified period anyway so it was a prime facie invalid denial. I had to write several letters, talk on the phone with their legal department for hours, and ultimately get the state insurance commission to initiate an investigation before getting them to back down. It took over 60 hours of work from a qualified attorney to handle a grossly invalid claim denial. Had I charged her at what was then my actual hourly rate, it would have cost $18000 to handle her $2k problem, for which she received no compensation. I honestly don't know how people get healthcare in this country without getting a law degree first.
Interesting to hear that even lawyers can’t manage this better. I can’t think of any other industry with such corrupt and flawed billing practices that doesn’t get forced by law to clean up its practices. My girlfriend has spent months fixing problems that were clearly caused by the insurance. On the way the insurance lied repeatedly but in the end she was still on the hook for 100s of thousand of dollars if she didn’t fix this.
Better to deal with a mafia loan shark than with hospitals or insurers. Mobsters probably have stronger ethics.
> I agreed to pay $450 cash and no one in the office understood how to handle it. I finally get to pay the $450 cash and I still got a bill from my insurance for $600 because they also billed my insurance.
That's not how that works. If a provider submits to insurance, the insurance won't pay it, and the provider will send the unpaid balance to you. The insurance company won't send you a bill.
> Then there's the insanity of cash price being cheaper than the insurance price.
Not insane. They have to bill higher and the insurance company will have negotiated a 'discount' typically. Also, it costs more money to have people on staff to file with insurance rather than just accept cash. You have to pay for people's time.
> I also have an HSA tax free bank account that lets me pay for this stupidity tax free, yay! Dozens of more hours were thrown away trying to understand how HSA accounts work, what I can charge to the HSA account and picking a bank to handle the HSA account.
Totally agree with you on this one. It's pretty confusing to say the least.
UnitedHealth Group’s second-quarter 2019 revenues grew $4.5 billion, or 8.0 percent year-over-year, to $60.6 billion, led by double-digit percentage revenue growth at UnitedHealthcare Medicare & Retirement, OptumRx and OptumHealth.
Second-quarter earnings from operations grew 12.8 percent, or $540 million year-over-year, to $4.7 billion. Adjusted net earnings of $3.60 per share advanced 14.6 percent.
All I know is that in 2013 I was able to get insurance in the private market to cover myself. It was ~$80 a month and the deductible was $2000.
Now, there is only one company left in my state that will even offer plans in the private market. The closest plan to what I used to have has gone up ~6x in price and the deductible has tripled.
The prices started going up immediately after the ACA came into being I think the cause and effect are pretty clear.
The prices started going up as soon as ACA was being voted on, "just in case".
Edit: It seems my comment is being interpeted as for or against ACA, when the point was really that insurance companies will raise prices over every potential regulation change.
Your $80 insurance was trash. You think you had coverage but the moment anything serious happened to you, you'd get thrown off.
Cancer? Bye.
Heart problems? See you later.
They were a fraud and you were getting ripped off.
ADA put an end to that fraud. Insurance companies could no longer arbitrarily throw you off. That's why premiums went up from $80. They had to actually provide coverage.
I liked it just fine, I'm aware of the change the ACA brought into effect with regard to the preexisting conditions. I'd rather have affordable options than a single un-affordable choice. Whether the insurance company doesn't cover a pre-existing condition or you can't afford the premiums the out come is the same. I'd argue that no insurance at all is worse but reasonable people could differ on that.
People are acting as if things were paradise before ACA. I agree that it wasn’t a good law but before it passed there were plenty of people who couldn’t get insurance due to pre existing conditions or they would get thrown off their plans once they got actually sick. Blaming all problems on ACA is rewriting history of the worst kind.
1. Give employees a statement showing how much the employer paid along with their full year comp and other benefits
2. Detach health insurance from employers
3. Create price transparency for services
"Give employees a statement showing how much the employer paid..."
Box 12, code DD on your W-2 reports "the cost of coverage under an employer-sponsored group health plan" as required by the ACA [1] (includes the premiums you paid, but you can subtract those out).
Health insurance should be decoupled from employment. Its tax advantaged treatment causes distortions in the costs and coverage offered. I’d rather see people get more of their compensation in cash rather than a health insurance benefit. It would especially help poorer workers who would have more flexibility and choice.
More employers ought to do this, for sure. If I'm a young, healthy, twenty-six-year-old man, I almost certainly don't need medical care. If I've got a good job, I can essentially self-insure. I might want to keep actual insurance, i.e. high-deductible protection for catastrophic events, but nothing more.
1. I act in the interests of society, rather than my own. It's the issue of the prisoners' dilemma; I'm not going to be the sucker.
2. I honestly don't know what you mean here. I will almost certainly not draw much in the way of health expenses; this is exactly the way insurance is supposed to work. What is wrong with not billing every thing to insurance and not paying for the privilege? If every one did this, consumers would be price-sensitive and costs would drop.
I am not sure what you are describing is "exactly the way insurance is supposed to work." If you have an open mind about it, you might want to read about the three-legged stool[1].
I have started going to Mexico for many things. I get better care from a Dr 3 hrs away than I do my primary care doctor and the after surgery care is so good I can call the Dr 3 years after and still get free advice about things.
I cant even get my prescription renewed in the US without a 300 dollar checkup
Screw the US insurance companies and the mess they made of our healthcare
I used to work at a med school, and often I would be in the classroom. Once the Dean gave a presentation over the true cost of healthcare in the US. What was his final conclusion to the class? No one knows the true cost of healthcare. It's nonsensical.
The situation with healthcare in the US has been beyond ridiculous for quite some time. Often the conversation centers around those without insurance, but being under-insured is just as much of an issue.
We need to decouple healthcare from employment. We need a single-payer system. This would save everyone money on healthcare in the long run.
My partner works at a hospital billing insurance companies and nobody there can even figure out what prices are. They can't optimize their work based on price because a $700k bill might end up bringing in $30k in revenue, while a $45k bill might bring in $35k.
Hospitals basically need an army of lawyers to renegotiate costs on a per-patient basis. Talk about efficiency!
Medicare/Medicaid literally keep most hospitals afloat. They are basically the only insurer who is fair and pays consistently.
Why could I not buy my own insurance? Or why can't I self-insure? If I want to pay for the best, I ought to be able to buy it (again, if I will pay).
There's a difference between actual single-payer (in which there is a single entity which pays, the government) and a government health-care plan. For which are you advocating?
These are not leading questions. "Single payer" definitionally means there is a single entity which pays, meaning no insurance or private pay. You're using it like it means a government plan; it doesn't. The reason I'm asking is because some politicians are crazy enough to want to prohibit any thing but a government plan, and I don't know where you fall.
They are leading questions. You're assumptions about single-payer, based on what you think "some politicians" said, are baked into your questions. Again, there exists hybrid systems. Take a look at Spain or Australia. Canada almost exclusively works off it's public system, yet private insurance still has a minor role.
Maybe I'm "crazy enough" to think that there should be zero profit-motive in health insurance, but even I can confidently say that a public policy scenario wherein all but a government plan is prohibited just isn't realistic, nor does it reflect what many other western countries have done for 30+ years.
I doubt the people in this article are middle class. Only one income is mentioned, but $40k for a family of three is below the definition of middle class for most of the USA. Lots of people who think they are middle class are really poor.
We need a Federal expansion of Medicaid to be available to everyone with pricing based on income. Once wealthier people start moving over to it, the private insurance racket will collapse. I'd move over in a heartbeat, even if the costs were higher because the plans I have available to me are garbage and my family can't all see the same doctors because my insurance won't cover my partner's and vice-versa.
Poor whites think government is the problem. Wealthy people have private insurance from their employers. We are stuck with the current system, there is no impetus for change. Just a lot of stupid coming out of the white house. Sad!
Off topic, but... when you end your posts with "Sad!" like that, you sound just like a Trump tweet. Given your content, you probably don't want that (unless you're trying to parody Trump, and I didn't notice).
So much of the existing system could be simplified if providers were required to charge every customer the same price. It would be dead simple to implement- add to the Medicare regulations that if you accept Medicare, you can't charge any customer more than you charge Medicare. The massive subsidy that the privately insured provided to Medicare and Medicaid would be diminished so those prices would rise somewhat, but there would be no inefficient haggling with each individual customer. We would all effectively get the Medicare/Medicaid price for all health care. In-network out-of-network would go away. The differentiation on insurers would be how much they reimburse for particular procedures, not what price they happen to have negotiated with the provider closest to your home. The providers could have different prices from each other, but one provider could not charge a different price to each customer.
Instead, under the current system, we let the providers lose money on Medicare and Medicaid patients, while they soak the privately insured and uninsured for massive profits. Everyone coming in the door should pay the same published price.
"Most workers blame drug companies and health insurers for high healthcare costs"
How did the hospitals and doctors pull this off? The number one driver of higher health care prices in the US is the provider cost, but everyone wants to blame insurance.
The problem here is that years of abusing "insurance" - billing regular prescriptions to something intended to be used for catastrophic events - have led to prices being raised without the consumer feeling the net effect, right away. It was a band-aid, nothing more.
There was an article a few months back about an indian gentleman who was essentially industrializing health-care. This is what we need. Maybe some one who does routine carpal-tunnel surgery does not need a full MD? Some how, medicine was one of the few industries which never industrialized. By doing this, we can go back to looking at insurance the right way: something for catastrophic events. Regular health care is expensive, and no system can realistically have the balance of its members taking out more than they put in long-term.
I don't understand the push for price lists. Forecasting is hard enough with software, I can't imagine what it's like for medical procedures where every person is different. Hospitals treat patients regardless of ability to pay, and attempt to recoup losses for patients who can't pay. Why shop around on price if it's unpredictable due to the nature of the system, shopping around on quality of care would seem more important to me.
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[ 2.5 ms ] story [ 181 ms ] thread(Not that you are going to price shop for every service--a trip to the emergency room for a broken bone wonte get shopped--but some portion of health Care is discretionary or is deliberate enough it can be shopped.)
Visit healthcare.gov and navigate to your state marketplace. They typically provide a detailed price comparison based on several adjustable factors (expected income, expected visits, number of medications, etc).
If readily available and detailed price comparison tools haven't stopped health insurance deductibles from tripling in the past year[1], why should we expect price comparison tools at the point of healthcare service to reduce costs?
[1]https://www.latimes.com/politics/la-na-pol-health-insurance-...
That’d lower the cost of the average policy as their would be an influx of (on average) healthier people to the market for insurance.
Families making under $50k aren't paying much in federal taxes as it is. The federal tax bill for a family of 4 making $50k/yr is $2,739. Cutting their tax bill in half gives them back a little over $100/mo.
Once that’s in place the next step would be making the general populace aware that the majority of the deductions, at higher tax brackets mind you, are going to the top. That would give the political capital to eliminating the “fat cat insurance deductions” and gradually get us to sanity.
My health insurance costs have well more than doubled since 2014 thanks to ACA. I deliver that failure directly at the doorstep of Obama and his Administration as well as the gutless Supreme Court that could have struck down this awful handout to corporate America.
It's disgusting, completely disgusting.
Finally having people feel the sting of the bills will hopefully pressure people to change the system that is both very inefficient and overpays doctors, drug companies and hospitals.
You are giving the patient responsibility for something they have almost no chance to understand.
Broke your leg, now what? Start calling local hospitals to see who offers the best price?
It's impossible to be an educated consumer with healthcare. Impossible.
Any responsible citizen would have received insurance approval and checked out hospitals before breaking his leg. Same applies to car accidents :)
So now the middle class, a large, still-working tax base, is the only group required to ration health-care. I always found that a bit odd.
It's impossible to be an educated consumer with healthcare.
Slip, fall and break your leg. Who do you call first, 911 or your local hospitals to price shop?
How do patients know what something should and shouldn't cost?
To walk through some but by no means all of the problems:
- The average person is bad with money. Always has been, likely always will be. A high deductible plan only "works" if you hold onto the money you would have spent on higher upfront premiums so that you can directly pay for care if you turn out to need it. The problem is, the average person lives paycheck to paycheck, saw the extra money in their bank account, and spent it. Now they're reluctant to get any care, even when necessary, because they don't have the money and it looks like a new expense. Which leads to worse health outcomes, and more things being put off until they become expensive emergencies.
- Few people have the medical knowledge to determine what tests are unnecessary or what procedures are marginally useful. Most people are not in the habit of challenging people who are the experts in the field, who they explicitly went to see for their knowledge.
- Even fewer people have that medical knowledge and have the time and energy to spend on navigating near-incomprehensible bureaucracies to actually compare prices, quality of care, etc to try to make an optimal choice.
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The solution to expensive healthcare should not be that everyone needs to become financially disciplined, a domain expert in healthcare willing to challenge authority figures, and to waste large amounts of their own time attempting to provider-shop in a system unlikely to ever make that a simple process.
I have a HDHP. I save a bunch of money with it, and unlike the average person, I'm in a position where I can do all those things. I get a relatively optimal outcome, although it still wastes a bunch of my time to navigate.
While I personally benefit, I strongly feel that HDHP's are not proving to be a net-positive for the system or society.
Here's a recent Bloomberg article basically going through a bunch of those unintended consequences: https://www.bloomberg.com/news/features/2018-06-26/sky-high-...
The biggest issue is price transparency. To get a price, I need the tax-id of the medical office and the procedure code. Often times the procedure code is unknown because I might have any number of different procedures, depending on what the diagnosis is.
So, I take my list of codes to the health insurance company with the tax ID and wait while they look everything up. This whole thing can take 2 hours.
That's if everyone knows what they're doing. Medical offices are so used to patients not asking about price, their back-office has no idea what to do when someone actually asks how much a procedure will cost.
Then there's the insanity of cash price being cheaper than the insurance price. So, I need to decide if I want to pay $600 and have it go towards my deductible or $450 and pay cash.
I agreed to pay $450 cash and no one in the office understood how to handle it. I finally get to pay the $450 cash and I still got a bill from my insurance for $600 because they also billed my insurance.
You get that? I paid cash and my insurance company still got billed.
Then we have billing errors. I got billed for things I never asked for and/or never received. More wasted time addressing that. Of course, back office is not used to patients reviewing their bill, so there's more confusion to deal with.
I also have an HSA tax free bank account that lets me pay for this stupidity tax free, yay! Dozens of more hours were thrown away trying to understand how HSA accounts work, what I can charge to the HSA account and picking a bank to handle the HSA account.
I spent nearly 100 hours in the last few years dealing with health insurance bullshit.
Imagine how many more wasted hours other Americans deal with.
Fuck this shit already.
The most insulting part was after all this when the insurance "customer service" guy said to me, "We know what it's like to be unsure of your finances." What? I'm sure about my finances. You aren't -- you can't even tell me the price!
Insurance companies are in business to make a profit. What the ACA did was ensure insurance companies have captive customers. A plan with a $6500 deductible vs pay a fine, nonsense. I should be free to choose between the plan or no fine. If it's all sick people in the plan pool because healthy people opted-out, that's the insurance company's problem, not mine.
Now that the individual mandate is gone, we can watch the deductibles climb ever higher and push people out of insurance.
For many people $6500 might as well be $50k.
I would support a full repeal of ACA and replacement with government payer for all, so long as private insurance is not outlawed and can go back to pre ACA form (I'd like to see more changes, but that's a starting point).
That’s fine as long as you support getting rid of laws that force hospitals to treat you whether or not you have insurance and you medical bills are not dischargeable in bankruptcy if you don’t have insurance.
Insurance is still priced based on the group you belong to. If you have a preexisting condition and you belonged to an eligible group - you worked for a company that provides insurance - they’ve always had to provide insurance regardless of preexisting condition.
The exchange group plans are priced separately.
Thanks Obama and Congress!
Call your dermatologist and ask how much it would cost to get a mole removed and checked for cancer.
Now, 2 hours later, if they even have you a price, tell me if that's reasonable or overpriced. What are you basing that judgement on?
There are several reasons the back-office literally can't tell you what the price will be. First, is that if you have insurance, they don't know. It is up to the payor (insurance company) what the final price will be. Even though there are negotiated rates, most procedures have up to 5 service levels. So depending on the service level, the price will be different. And the service level is based on what service was provided which by definition hasn't happened yet. The only way to actually do it would be to be more like a garage. It is $50 to do a level 2 office examination and then I'll quote you on what we find out then and you can choose to continue or not. Most people would be annoyed by this.
Additionally, there are different codes for things like new patient vs existing patient. Seems simple, right? Actually if you haven't been to your doctor in the last two year, you are a new patient regardless of how long they have been your doctor. The service levels mentioned above are why for years, you had do fill out a paper detailing your patient history every visit. This is called taking a family history and allows for higher service levels and higher reimbursement. This is finally changing now that the family history is stored in the EMRs.
So, we finally figure this all out. An office visit might be always fine but some procedures require a pre-authorization. The rules for this are unique to your employers specific health plan, not the generic Aetna (e.g.). They may require previous diagnosis codes in your chart to indicate you are a risk before agreeing to pay. For example, a 25 year old with blood in their stool may want a colon cancer screening but that is only approved for people 40+. There is back in forth between the office and the payor to figure this out.
Oh, we didn't mention that a lot of employers are now self funded. This means that up to a certain loss threshold X, the company pays the bills, not the payor. This is handled by a company called a TPA (third party administrator). Obviously there are deductibles and other things they control and keep track of as well. This new procedure may now put the employer over their stop loss for the year. The TPA now needs to submit this bill to the re-insurer. They may require even more or different documentation in order for them to process and pay this claim. This is why offices have such huge back office components because a lot of the bills just get bounced back. They have to figure out why and resubmit.
So why are the list prices we see on our bill so high when insurance pays so little but the doctor accepts it anyway? It is mostly a hedge against mistakes. Again, since each employer plan may pay out differently even for the same insurance (there can be carve outs), the doctors are incentivized to over price and let the TPA and payor figure it out. If they accidentally charged $150 for something that is reimbursed at $250, they lose money. It is better to charge $900 and just accept whatever they get. They now don't need to constantly update the price of thousands of CPT (current procedural terminology) codes and make sure they are always up to date.
And this is just part of it.... The only problem in healthcare is mis-aligned incentives. As long as they are allowed, nothing will change.
To your case, I would get a new doctor. Paying cash is not that rare anymore and they should know how to handle it. In addition, they seem to try to overcharge the payor and it got dropped to you in this case. Not sure that I would trust them moving forward.
This is the problem but what are the solutions? In my opinion, we need to change three things. Each one would be beneficial separately. 1) Move to national reference based pricing. Said more simply, no one can charge more than Medicare * 1.5 or 2. This gets rid of all the bull crap negotiations and the doctors can still do fine. 2) We need healthcare to move aw...
People aren’t stupid, they travel and see how healthcare works in other countries. Eventually we will end up with a public option. At this point it’s inevitable. We are reaching a tipping point where Biden and Pelosi can’t keep dressing the current situation up.
Better to deal with a mafia loan shark than with hospitals or insurers. Mobsters probably have stronger ethics.
That's not how that works. If a provider submits to insurance, the insurance won't pay it, and the provider will send the unpaid balance to you. The insurance company won't send you a bill.
> Then there's the insanity of cash price being cheaper than the insurance price.
Not insane. They have to bill higher and the insurance company will have negotiated a 'discount' typically. Also, it costs more money to have people on staff to file with insurance rather than just accept cash. You have to pay for people's time.
> I also have an HSA tax free bank account that lets me pay for this stupidity tax free, yay! Dozens of more hours were thrown away trying to understand how HSA accounts work, what I can charge to the HSA account and picking a bank to handle the HSA account.
Totally agree with you on this one. It's pretty confusing to say the least.
Second-quarter earnings from operations grew 12.8 percent, or $540 million year-over-year, to $4.7 billion. Adjusted net earnings of $3.60 per share advanced 14.6 percent.
Now, there is only one company left in my state that will even offer plans in the private market. The closest plan to what I used to have has gone up ~6x in price and the deductible has tripled.
The prices started going up immediately after the ACA came into being I think the cause and effect are pretty clear.
Edit: It seems my comment is being interpeted as for or against ACA, when the point was really that insurance companies will raise prices over every potential regulation change.
ACA forced them to cover everyone, which raised costs and, therefore, prices for everyone.
It's true you're now subsidizing sick people, but you'll be happy to have the ACA if you're ever sick (or have a dick family member).
They would take your money while you were healthy but if you got sick, they'd throw you off.
That's not insurance. That's fraud.
Cancer? Bye.
Heart problems? See you later.
They were a fraud and you were getting ripped off.
ADA put an end to that fraud. Insurance companies could no longer arbitrarily throw you off. That's why premiums went up from $80. They had to actually provide coverage.
Now you know two things.
Box 12, code DD on your W-2 reports "the cost of coverage under an employer-sponsored group health plan" as required by the ACA [1] (includes the premiums you paid, but you can subtract those out).
[1] https://www.irs.gov/affordable-care-act/form-w-2-reporting-o...
2. I honestly don't know what you mean here. I will almost certainly not draw much in the way of health expenses; this is exactly the way insurance is supposed to work. What is wrong with not billing every thing to insurance and not paying for the privilege? If every one did this, consumers would be price-sensitive and costs would drop.
[1] http://web.archive.org/web/20170716081909/https://www.nytime...
The only people I know who like their health insurance are union members, government employees, and people on Medicare or medicaid.
I cant even get my prescription renewed in the US without a 300 dollar checkup
Screw the US insurance companies and the mess they made of our healthcare
https://news.ycombinator.com/newsguidelines.html
The situation with healthcare in the US has been beyond ridiculous for quite some time. Often the conversation centers around those without insurance, but being under-insured is just as much of an issue.
We need to decouple healthcare from employment. We need a single-payer system. This would save everyone money on healthcare in the long run.
Hospitals basically need an army of lawyers to renegotiate costs on a per-patient basis. Talk about efficiency!
Medicare/Medicaid literally keep most hospitals afloat. They are basically the only insurer who is fair and pays consistently.
Why could I not buy my own insurance? Or why can't I self-insure? If I want to pay for the best, I ought to be able to buy it (again, if I will pay).
There's a difference between actual single-payer (in which there is a single entity which pays, the government) and a government health-care plan. For which are you advocating?
A single-payer system, as I said.
>Why could I not buy my own insurance? Or why can't I self-insure?
These are leading questions. There exists healthcare systems that are a hybrid of single-payer/private insurance.
Maybe I'm "crazy enough" to think that there should be zero profit-motive in health insurance, but even I can confidently say that a public policy scenario wherein all but a government plan is prohibited just isn't realistic, nor does it reflect what many other western countries have done for 30+ years.
We need a Federal expansion of Medicaid to be available to everyone with pricing based on income. Once wealthier people start moving over to it, the private insurance racket will collapse. I'd move over in a heartbeat, even if the costs were higher because the plans I have available to me are garbage and my family can't all see the same doctors because my insurance won't cover my partner's and vice-versa.
Instead, under the current system, we let the providers lose money on Medicare and Medicaid patients, while they soak the privately insured and uninsured for massive profits. Everyone coming in the door should pay the same published price.
"Most workers blame drug companies and health insurers for high healthcare costs" How did the hospitals and doctors pull this off? The number one driver of higher health care prices in the US is the provider cost, but everyone wants to blame insurance.
Now, I'm not in favor of Medicare paying less than cost. It's a dishonest hidden subsidy. But be careful of how you fix it...
There was an article a few months back about an indian gentleman who was essentially industrializing health-care. This is what we need. Maybe some one who does routine carpal-tunnel surgery does not need a full MD? Some how, medicine was one of the few industries which never industrialized. By doing this, we can go back to looking at insurance the right way: something for catastrophic events. Regular health care is expensive, and no system can realistically have the balance of its members taking out more than they put in long-term.
I don't understand the push for price lists. Forecasting is hard enough with software, I can't imagine what it's like for medical procedures where every person is different. Hospitals treat patients regardless of ability to pay, and attempt to recoup losses for patients who can't pay. Why shop around on price if it's unpredictable due to the nature of the system, shopping around on quality of care would seem more important to me.