I see everyone getting excited about single-payer but it addresses the core issue of access via pricing as a mere sideffect that a single-payer happens to have serious leverage over pricing being, well, single-payer.
The core issue though is price of medical services.
When an ER visit to sew together 5 inches of a cut skin at 10AM can generate a claim for $40000, something is really broken.
The single-payer can outright refuse to pay $40000 for such a thing while you and I would have that debt hound us for the rest of our lives.
One solution that addresses the root issue is to clamp down on what is reasonable to charge to sew together 5 inches of a cut skin at 10AM.
That is called an all-payer rate set system.
It does not matter who pays - what matters is what price something is available at.
Doctor's regular, scheduled visit? $150.
You pay in cash? ? $150.
You pay in chickens with white feathers ? $150.
Your employer provides you with coverage and they cover the first $500 worth of expenses? $150.
Your'e an uber driver and that doctor would appreciate a ride back and forth for the next month? $150.
When the same doctor's visit can range in price from $10 - $1000 depending on what crap your employer signed you up for, we have a terrible access issue.
The U.S. has one of the best health care in the world, but also one of the higest financial distress including outright bankruptcy for medical bills.
Something's going to give soon as the system starts to come under strain due to SARS-COV2 and it's not likely to be pretty.
> actually get quoted a price for that service. I might choose to go across town if it saved me $40K
I have been working as a software consultant for decades now and always have a menu price ready.
Even with this menu pricing, my customers still need my help in figuring out what they need from the menu.
If my customers already knew what they needed to solve their problems, I have 0 value to add as a consultant - at that point, they just need to either hire staff/developers to execute on their requirements.
If I broke my hip today, how exactly would a menu of hip related items help me compare costs?
How would I even begin to know which items from the menu apply to my situation without having some idea what is involved in fixing a broken hip?
Do I need a MRI? XRay? Both? Which sections of the hip? We even have not started on diagnosis.
Price transparency is only useful when one knows exactly what is needed.
You pretty much have to be a doctor to shop prices unless you're doing an elective surgery where time is on your side and you can do some research as you wait and shop.
I'm not sure anyone's doing price comparison when their wife's on the delivery table and has just had some complications.
Another thing for readers to take note, what percentage of the billed amount does insurance actually pay? Would this continue to be an issue if insurance companies didn't try to negotiate down costs?
I agree that price regulation would be a great step.
But if the patient's cost is constrained to $150, the government is not only regulating price, but taxes are probably subsidizing a portion of the cost. This basically brings us back to single payer.
> taxes are probably subsidizing a portion of the cost
If you forced a business to provide a certain service at $150 vs. not provide it at all, you will be surprised how innovative that business could become in providing the service at $150
A lot of doctors, right here in California see patients for $50 cash - no subsidies, no pro bono, no nothing, so $150 for an office visit does not sound unreasonable.
Maybe the lounge music, the sodas, the Himalayan salt lamps, heated seats will have to go.
The biggest problem is not the lack of single payer, it's the lack of price transparency. You have no idea how much any medical service will cost until you get the bill, so everyone is free to price gouge you.
An example of how bad the current system is:
When my wife was pregnant and needed an ultrasound, her regular doctor was busy one month and recommended we go to the doctor upstairs. Our regular doctor charged us $200 for the ultrasound, the one upstairs sent us a bill for $1000!
This 5x price difference was in the exact same building, just a different floor!
Hospitals benefit from keeping the prices obscure, to the detriment of the rest of the country
Price Transparency + State Insurance Provider that can negotiate rates like a regular insurance company but must insure everyone by default would solve a bulk of the problem, don't you think?
We're trapped in a system of perverse incentives and third parties. FDR mandated wage freezes and price controls under WWII - so guess how employers bypass a wage freeze? Start offering health insurance! The government saw this and thought "gee, let's encourage this by offering lower taxes for employer expenses on health insurance." And so began the growth of a parasitic, complex industry that accomplishes so little at such a great expense.
The problem is health care is nothing close to a free market.
In many parts of the country, it is illegal to open up a new hospital without a government license. Existing hospitals often lobby to prevent competing hospitals from opening up.
> Why not have a system closer to food stamps but for healthcare? i.e. the government will cover costs for the poor up to some amount.
We have exactly that. It's called Medicare + Medicaid. The govt fixes the price for what doctors/hospitals can charge on these plans and that's why doctors/hospitals absolutely hate Medicare + Medicaid.
For Native Indians, we also have the Indian Health Services.
For veterans, we have the VA.
That said, you nor I would really enjoy being on a Medicare + Medicaid system.
Having the govt. set rates, getting out of the way and leaving who and how that price gets paid provides the ultimate flexibility and value.
> You have no idea how much any medical service will cost
Let's assume that that problem was solved tomorrow.
Thanks to that, you now know the regular doctor charges $20000 for the ultrasound while the one upstairs would charge you $100000.
What would you do next?
The issue in the U.S. is the $20000, $100000 fees that is normal here - NO ONE ELSE in the WORLD Pays those rates!
It's the same process to get a ultrasound done in Mexico, India, London, Poland, California - yet the prices are out of what when you introduce the US. into the table of prices (I am only talking about imaging, which is a fairly mechanical and routine process - not reading/interpretation).
Transparency seems like it will help, until you really think about it
> it's the lack of price transparency
I have been working as a software consultant for decades now and always have a menu price ready. The reason why I get referrals is because my menu price quote is very similar to what the client ends up paying in the end unless there is intense customization.
Even with this menu pricing, my customers still need my help in figuring out what they need from the menu because they have a very vague idea of what the solution is going to look like.
They kinda understand their problem, even hurt from it, but they don't know how to fix it properly.
If my customers already knew what they needed to solve their problems, I have 0 value to add as a consultant - at that point, they just need to either hire staff/developers to execute on their requirements.
If I broke my hip today, how exactly would a menu of hip related items help me compare costs?
How would I even begin to know which items from the menu apply to my situation without having some idea what is involved in fixing a broken hip?
Do I need a MRI? XRay? Both? Which sections of the hip? We even have not started on diagnosis.
Price transparency is only useful when one knows exactly what is needed.
You pretty much have to be a doctor to shop prices unless you're doing an elective surgery where time is on your side and you can do some research as you wait and shop.
I'm not sure anyone's doing price comparison when their wife's on the delivery table and has just had some complications.
Good point, but this sounds like a solvable problem. You would a primary doctor (at a known rate) who would say "You need X, Y, and Z now" and then refer you to a reasonably priced location.
He could do that because now even he can see the prices and that doctor doesn't have too much of an incentive to send you to be fleeced by someone else
There are some details where this would need to be worked upon, but it sounds like the kind of thing the free market would figure out.
Every problem, including death can be solved if enough effort is put into it. The question is which problem is worth solving.
The problem of price transparency is just not worth solving - because the main issue people have with healthcare in the U.S. is the price.
No one complains that they got better after going to the E.R.
People complain that they got their wages garnished by a collection agency after going to the E.R.
Shopping for the cheapest price might feel like a solution, but if you really think about it, it's really not.
> You would a primary doctor (at a known rate) who would say "You need X, Y, and Z now" and then refer you to a reasonably priced location
A few questions:
1. What does the primary physician gain out of telling you that and that too for a known rate which will likely be less than what they can charge for an actual medical consultation? Who pays for it? It's not an office visit - it's a "pricing consultation" and no insurance currently pays for "pricing consultation". They pay for medical necessity visits. Even if you paid for that out of pocket because you have liquidity/cash on hand, which most of the U.S. does not, the primary physician has only so many hours in the day and their time is definitely better served seeing someone unwell/running a fever than helping you haggle pricing.
2. NO primary physician is going to tell you specific procedures of what a specialist is going to do. First, they don't know how. Second, it does not make sense for them to. Maybe they can give a rough idea what you might need. Try asking your primary physician what ointment to put on your rash. Unless they are your childhood buddy, you get a referral to a dermatologist. Even the, they will highly recommend you see a dermatologist (or right now, a lab test because COVD19 can express as benign rashes).
3. We still have not addressed the core issue of why something that costs "EUR x" in most of the EU costs "EUR 500x" in the U.S.
The problem of why something in the U.S. costs 400x of what it does in other countries evenafter accounting for subsidies, is a problem far worth solving.
I find the comments that 'Single Payer' isn't intended to address pricing problems sort of strange.
'Single Payer' means that providers have to negotiate the prices with _one_ payer, the state, instead of separately for each insurance company (or having a go at every uninsured patient, for every procedure).
Of course a seller of high value products will want to negotiate the price individually for every sale; the cost is smaller than consumer surplus would be in such cases, right? That's why we have car salesman.
Without respect to whether it's a good idea, isn't forbidding price discrimination the whole point of single payer, rather than a side effect?
And yet, even when the government is the payer, they have shown consistently that they are unwilling to enforce pricing control. For example, even though medicare billing rates for doctors where supposed to go down several times, in each case, threats of strikes by doctors with very public "look how evil the government is" posts by doctors have kept the rates inflated.
Cost control isn't linked to single payer. Nor is efficiency. If you don't believe that, look at Germany. Not single payer, but incredibly efficient, and great at COVID19.
On top of that, there are places where the government enables horrible behaviour and payments. For example, they negotiated a shitty deal on CPAP machines, and now everyone who does CPAP gets medicare rules, which is $300 a month lease for a machine that is sold commercially for $650. When I pushed back on my insurance company they said that this was medicare rules.
Good governance is good governance. We don't have it, and single payer won't fix it any more then Obamacare and health rationing fixed it.
I think the need for single payer is best stated in terms of risk. There are many things that can and should be paid for by the end user, because they are things that you buy when you have money and forego when you don’t.
Health care is not one of those things. People get sick and poor at the same time. Especially if it’s a serious illness. It just makes no sense to sell it that way.
Setting all economics and politcs aside, the most gut wrenching part of this read for me was the image of a hospital whose patients never get organ transplants, but give organ transplants. That goes beyond one person getting treatment while another is denied. That's the denied person, in death, still giving. I dont know if single payer is the best system, or if a hybrid system or regulated private monopoly or some other weird approach is better. But this system that we have today isn't working.
There are many problems with health care, and single payer is just sweeping them all under the rug.
Single payer won't magically make the number of doctors or hospitals or surgeries increase. It is not a panacea by any stretch, and we shouldn't pretend it is one.
Broke my arm and needed surgery. We know that's pricey.
Before the surgery, I saw an ortho for 5 minutes. In what world are we living in where a 5 minute appointment should cost $475 and that excludes the few hundred billed by the radiologist.
+$475 Office or outpatient visit for a new patient (up to 45 minutes)
- $125.53 Insurance discount
= $349.47 Covered amount
Plan pays: $329.47 FOR A FIVE MINUTE CONSULT
We need 100x more medical schools in this country. Every single state school should be a medical school.
31 comments
[ 3.8 ms ] story [ 74.9 ms ] threadThe core issue though is price of medical services.
When an ER visit to sew together 5 inches of a cut skin at 10AM can generate a claim for $40000, something is really broken.
The single-payer can outright refuse to pay $40000 for such a thing while you and I would have that debt hound us for the rest of our lives.
One solution that addresses the root issue is to clamp down on what is reasonable to charge to sew together 5 inches of a cut skin at 10AM.
That is called an all-payer rate set system.
It does not matter who pays - what matters is what price something is available at.
Doctor's regular, scheduled visit? $150.
You pay in cash? ? $150.
You pay in chickens with white feathers ? $150.
Your employer provides you with coverage and they cover the first $500 worth of expenses? $150.
Your'e an uber driver and that doctor would appreciate a ride back and forth for the next month? $150.
When the same doctor's visit can range in price from $10 - $1000 depending on what crap your employer signed you up for, we have a terrible access issue.
The U.S. has one of the best health care in the world, but also one of the higest financial distress including outright bankruptcy for medical bills.
Something's going to give soon as the system starts to come under strain due to SARS-COV2 and it's not likely to be pretty.
https://www.npr.org/sections/health-shots/2019/06/24/7354323...
I have been working as a software consultant for decades now and always have a menu price ready.
Even with this menu pricing, my customers still need my help in figuring out what they need from the menu.
If my customers already knew what they needed to solve their problems, I have 0 value to add as a consultant - at that point, they just need to either hire staff/developers to execute on their requirements.
If I broke my hip today, how exactly would a menu of hip related items help me compare costs?
How would I even begin to know which items from the menu apply to my situation without having some idea what is involved in fixing a broken hip?
Do I need a MRI? XRay? Both? Which sections of the hip? We even have not started on diagnosis.
Price transparency is only useful when one knows exactly what is needed.
You pretty much have to be a doctor to shop prices unless you're doing an elective surgery where time is on your side and you can do some research as you wait and shop.
I'm not sure anyone's doing price comparison when their wife's on the delivery table and has just had some complications.
The ACA forced insurance companies to pay out 80% of their revenues in care costs or refund premiums or pay penalties.
Said differently, under the current ACA rules, insurance companies have 0 incentive to negotiate costs down.
They won't get any return on that effort.
It's less effort denying claims and narrowing networks so as to ration access naturally.
But if the patient's cost is constrained to $150, the government is not only regulating price, but taxes are probably subsidizing a portion of the cost. This basically brings us back to single payer.
If you forced a business to provide a certain service at $150 vs. not provide it at all, you will be surprised how innovative that business could become in providing the service at $150
A lot of doctors, right here in California see patients for $50 cash - no subsidies, no pro bono, no nothing, so $150 for an office visit does not sound unreasonable.
Maybe the lounge music, the sodas, the Himalayan salt lamps, heated seats will have to go.
An example of how bad the current system is:
When my wife was pregnant and needed an ultrasound, her regular doctor was busy one month and recommended we go to the doctor upstairs. Our regular doctor charged us $200 for the ultrasound, the one upstairs sent us a bill for $1000!
This 5x price difference was in the exact same building, just a different floor!
Hospitals benefit from keeping the prices obscure, to the detriment of the rest of the country
Take a look at the stupidity around getting a authorization to test for COVID19, and realize that this is not a aberration.
In many parts of the country, it is illegal to open up a new hospital without a government license. Existing hospitals often lobby to prevent competing hospitals from opening up.
It's not a problem, it's a feature.
In free market health care, those who can't afford care, die.
We as a society have agreed that's not acceptable and hence the regulations, EMTALA being one
Why not have a system closer to food stamps but for healthcare? i.e. the government will cover costs for the poor up to some amount.
We have exactly that. It's called Medicare + Medicaid. The govt fixes the price for what doctors/hospitals can charge on these plans and that's why doctors/hospitals absolutely hate Medicare + Medicaid.
For Native Indians, we also have the Indian Health Services.
For veterans, we have the VA.
That said, you nor I would really enjoy being on a Medicare + Medicaid system.
Having the govt. set rates, getting out of the way and leaving who and how that price gets paid provides the ultimate flexibility and value.
It seems we are on the same page.
Let's assume that that problem was solved tomorrow.
Thanks to that, you now know the regular doctor charges $20000 for the ultrasound while the one upstairs would charge you $100000.
What would you do next?
The issue in the U.S. is the $20000, $100000 fees that is normal here - NO ONE ELSE in the WORLD Pays those rates!
It's the same process to get a ultrasound done in Mexico, India, London, Poland, California - yet the prices are out of what when you introduce the US. into the table of prices (I am only talking about imaging, which is a fairly mechanical and routine process - not reading/interpretation).
Transparency seems like it will help, until you really think about it
> it's the lack of price transparency
I have been working as a software consultant for decades now and always have a menu price ready. The reason why I get referrals is because my menu price quote is very similar to what the client ends up paying in the end unless there is intense customization.
Even with this menu pricing, my customers still need my help in figuring out what they need from the menu because they have a very vague idea of what the solution is going to look like.
They kinda understand their problem, even hurt from it, but they don't know how to fix it properly.
If my customers already knew what they needed to solve their problems, I have 0 value to add as a consultant - at that point, they just need to either hire staff/developers to execute on their requirements.
If I broke my hip today, how exactly would a menu of hip related items help me compare costs?
How would I even begin to know which items from the menu apply to my situation without having some idea what is involved in fixing a broken hip?
Do I need a MRI? XRay? Both? Which sections of the hip? We even have not started on diagnosis.
Price transparency is only useful when one knows exactly what is needed.
You pretty much have to be a doctor to shop prices unless you're doing an elective surgery where time is on your side and you can do some research as you wait and shop.
I'm not sure anyone's doing price comparison when their wife's on the delivery table and has just had some complications.
He could do that because now even he can see the prices and that doctor doesn't have too much of an incentive to send you to be fleeced by someone else
There are some details where this would need to be worked upon, but it sounds like the kind of thing the free market would figure out.
Every problem, including death can be solved if enough effort is put into it. The question is which problem is worth solving.
The problem of price transparency is just not worth solving - because the main issue people have with healthcare in the U.S. is the price.
No one complains that they got better after going to the E.R.
People complain that they got their wages garnished by a collection agency after going to the E.R.
Shopping for the cheapest price might feel like a solution, but if you really think about it, it's really not.
> You would a primary doctor (at a known rate) who would say "You need X, Y, and Z now" and then refer you to a reasonably priced location
A few questions:
1. What does the primary physician gain out of telling you that and that too for a known rate which will likely be less than what they can charge for an actual medical consultation? Who pays for it? It's not an office visit - it's a "pricing consultation" and no insurance currently pays for "pricing consultation". They pay for medical necessity visits. Even if you paid for that out of pocket because you have liquidity/cash on hand, which most of the U.S. does not, the primary physician has only so many hours in the day and their time is definitely better served seeing someone unwell/running a fever than helping you haggle pricing.
2. NO primary physician is going to tell you specific procedures of what a specialist is going to do. First, they don't know how. Second, it does not make sense for them to. Maybe they can give a rough idea what you might need. Try asking your primary physician what ointment to put on your rash. Unless they are your childhood buddy, you get a referral to a dermatologist. Even the, they will highly recommend you see a dermatologist (or right now, a lab test because COVD19 can express as benign rashes).
3. We still have not addressed the core issue of why something that costs "EUR x" in most of the EU costs "EUR 500x" in the U.S.
The problem of why something in the U.S. costs 400x of what it does in other countries even after accounting for subsidies, is a problem far worth solving.
Obviously it won't work for non-elective surgery.
'Single Payer' means that providers have to negotiate the prices with _one_ payer, the state, instead of separately for each insurance company (or having a go at every uninsured patient, for every procedure).
Of course a seller of high value products will want to negotiate the price individually for every sale; the cost is smaller than consumer surplus would be in such cases, right? That's why we have car salesman.
Without respect to whether it's a good idea, isn't forbidding price discrimination the whole point of single payer, rather than a side effect?
Cost control isn't linked to single payer. Nor is efficiency. If you don't believe that, look at Germany. Not single payer, but incredibly efficient, and great at COVID19.
On top of that, there are places where the government enables horrible behaviour and payments. For example, they negotiated a shitty deal on CPAP machines, and now everyone who does CPAP gets medicare rules, which is $300 a month lease for a machine that is sold commercially for $650. When I pushed back on my insurance company they said that this was medicare rules.
Good governance is good governance. We don't have it, and single payer won't fix it any more then Obamacare and health rationing fixed it.
> health rationing
What are you talking about?
Health care is not one of those things. People get sick and poor at the same time. Especially if it’s a serious illness. It just makes no sense to sell it that way.
The medical insurance companies have deep pockets and lots of lobbyists.
Never going to happen.
I LOL a lot when I hear that the US can't afford to have single-payer healthcare, when lots of tiny countries can, and do afford it.
Single payer won't magically make the number of doctors or hospitals or surgeries increase. It is not a panacea by any stretch, and we shouldn't pretend it is one.
Before the surgery, I saw an ortho for 5 minutes. In what world are we living in where a 5 minute appointment should cost $475 and that excludes the few hundred billed by the radiologist.
+$475 Office or outpatient visit for a new patient (up to 45 minutes) - $125.53 Insurance discount = $349.47 Covered amount Plan pays: $329.47 FOR A FIVE MINUTE CONSULT
We need 100x more medical schools in this country. Every single state school should be a medical school.