One of the last tweets was the most interesting - "Just looking at Stanford's 2011 vs 2020 data, you can see charges going up more than 300% in some cases"
That is absolutely insane to me. I really don't understand how that's possible at all - I know no one really pays sticker price on any medical bills but still.
Here, take this for-profit, inelastic demand service you need right now without seeing the prices. Trust us. You won't be bankrupt soon. Like, what are you going to do? Get up from the ER gurney and comparison shop at another hospital?
Lol right? Although I'm guessing even for non-emergency services there's still not a ton of comparison shopping going on. People probably trust their own doctor's referrals and don't know to comparison shop - with the new rules it seems a bit easier but I'm sure hospitals don't make it all that easy.
My wife had a baby a while back. The hospital she went to did 50% of their business in delivery. Given 9 months of notice (the gestation period of humans), THOUSANDS of babies delivered every year, and professionals talking onthe phone - NO ONE could tell me how much it would cost to give birth.
6 months out, we're still getting random bills from our baby's birth. Only difference from first three is I know to expect it, so I'm numb to the insanity.
That’s the kicker - almost no one pays these prices so when they get stupid nobody notices. Unless you’re uninsured then that’s the price they use.
As someone in the healthcare field - the best way I can describe it is that providers and insurers fight it out however they can. The problem is is that patients get the shit end of the stick.
I think calling out that both hospitals and insurers are fucking over patients is a positive change. Hospitals used to always get a pass, but they’re a huge part of the problem.
> Unless you’re uninsured then that’s the price they use.
I don't think many uninsured people are paying sticker. Sometimes they automatically get charged with a discount, sometimes they have to call and get it. Some folks don't know to call, but these folks' bills are, I expect, not usually getting paid in full in the end anyhow.
But do uninsured people actually really pay this? My impression was that you still can (and should) try to negotiate with hospitals/providers whenever possible and/or ask them to create a payment plan for you. But maybe that's not common knowledge?
Since you're in the space, what do you think of the startup they mentioned in the thread, turquoise.health (or rather the idea behind it, not literally the startup)?
No, uninsured people also don't pay it. They are offered a fraction of the cost if they pay "cash" once you're leaving.
I went to the same ER in San Francisco with the same problem 3 months apart (kidney stones). The first time around I was uninsured and the bill was $2000- they told me that they'll cut it down to $500 if I paid on the spot, which I did. 3 months later I had the same problem, had purchased insurance, my bill came out to $8000 and my deductible was $2000.
Okay, interesting. I had read some articles about medical debt that alluded to those levels of savings for paying cash in one lump sum quickly but still, it's pretty striking that you get a 75% "discount" for cash on the spot.
And not to mention when they say "on the spot," they mean it. In the room, right there, as you're checking out. If you don't have access to any payment methods or you need to wait two days until you get paid or something, you're looking at a 50-100% increase over the final quoted "cash price" even if you're still paying cash.
Can confirm. Had a procedure (hernia repair) and at the time of setting it up my insurance was in flux. I asked for the cash price to move things along and was quoted just ~7k all up. Insurance ended up covering it but received one of those invoices were it starts at over 20k before the magic "discount" gets applied.
I have been assuming the magic discount is some sham the insurance companies push for to scare people into believing they would not get it if it weren't for the insurance.
It's BS IMHO to not be advertising the ACTUAL cash amounts they would quote somebody..
As always, it depends. There is a certain point at which your visit is tied into your insurance so you can't just undo it. At that point the hospital is now fighting with the insurance company to pay and you're stuck in the middle.
So you paid more on insurance? And the bill while on insurance just happened to be inflated so much that the deductible came out to be the price of the procedure the first time around? That sounds like fraud.
If you delay payment you probably have to help pay for those that will not.
One reason that stitching up minor cuts is so expensive could be that those who need that treatment (e.g. because they were in a fight) are statistically less likely to ever pay their bills…
Or you pay nothing at all (they aren't going to repo your kidney), or end up working out a deal to pay whatever you can later. They offer the discount because on average they figure the discounted price is higher than what they'll get paid later.
That's not my experience. I was out of state and needed medical attention. I was on Medicaid. Urgent Care straight up wouldn't accept my out-of-state Medicaid plan and suggested I go to ER. They too didn't accept out-of-state Medicaid, listed me as having no insurance, and billed me full-price for the some of the services. There was no discount for paying on the spot. I paid for those initial services and got more bills from the doctor and other departments. They never accepted my out-of-state Medicaid but eventually "gave me a discount." I paid some of it myself but told them if they wanted the rest to bill Medicaid.s
The people who get screwed the hardest are the underinsured (in all cases) and those who have high-deductible plans with coinsurance and HSAs (and have some acute issue).
I work in radiology and entered a few common procedures I see a lot in our data on https://turquoise.health/ (also linked in the Twitter thread). Then I entered information for our own HDHP+HSA plan. Guess what, having insurance costs you 40-60% more if it's an acute issue. So if you're healthy, you have zero incentive to use your insurance if you suddenly need a CT of something. The rub of course is if you pay cash, it doesn't count toward your multi-thousand dollar yearly deductible, so if it turns out to be a chronic issue you just shot yourself in the foot. But if it doesn't, you just burned thousands by using your insurance when you didn't have to.
It's a complicated issue and anyone who says they have the solution, including "just make it free / just have the government pay for everything," is either being disingenuous or doesn't understand the problem. As was stated in the Twitter thread, running a hospital 24/7 is astronomically expensive. Everyone has their finger in the pot trying to get paid for their services in a world of increasingly small reimbursements. Attending physicians as resident-run hospitals will sleep overnight while getting paid literally half a million dollars a year. Insurance companies will just decide not to pay something and will spend years in court to defend their right to pay whatever they want, down to and including $0. Vendors will charge tens of millions of dollars to implement monolithic thick-client applications where everything is so configuration-heavy that you literally can't have a test environment because it won't match. Interoperability is managed by a text-based standard named HL7 that if you're not familiar with, will make you rip your hair out. The standard itself is ignored by every organization who ends up with their own flavor, so every app needs to be configured to support nearly any value in nearly any field. Hospital IT is staffed by people making $40k/yr who don't understand modern computing, and run by executives with no technical background.
Every single entity and company involved in healthcare is complicit in the end result, which is skyrocketing patient costs with at best no change in patient care or patient outcomes.
Thank you for sharing this, really helpful to hear from someone inside the industry and of course, the issue is super nuanced and complex. I just wonder if/when something will give in the U.S.
But you said something that stood out - "Everyone has their finger in the pot trying to get paid for their services in a world of increasingly small reimbursements." Given the rising prices, why isn't the pot getting bigger?
I have friends that work at Epic but I don't do a lot on the EHR side. I will say I went several years ca. 2010-2019 or so without utilizing healthcare at all, and went from having doctors laugh at me when I asked for my chart and telling me that I wasn't allowed to see it from being able to log in to my doctor's portal and see my actual Epic chart, complete with their shorthand, typos, etc. The first time I logged in, after the initial shock, I was able to correct two errors in my medical history from when I was in HS. So from a consumer standpoint I am 110% pro-EHR.
I think the pot is getting bigger but it's getting bigger for gigantic organizations like Kaiser (not calling them out specifically but it's a name everyone knows). Someone pointed out, either here or in the tweet thread, that the 2011-2020 price increases are just going to Stanford. The physicians don't see any of that because they have their own reimbursement, and the patient gets their own bill. When we ran billing in-house it was not uncommon for patients to call us with billing issues because they didn't understand (nor should they have had to) that our radiology service bill was separate from the hospital. Which was separate from the anesthesiologist. Which was separate from the lab. Etc.
I see the pot getting bigger mainly for insurance companies, and large hospital systems, in that order. Some docs in some specialties are doing as well or better than they were ten years ago but a lot of the primary care specialties just get whatever the Medicare reimbursement is and don't have any control over it. Insurance companies will pay them whatever they decide to pay them. So short of increasing the cash price on that minority patients, all of whom are going to be very price sensitive, the independent docs and small practices can't do much to move the lever. Healthcare software vendors seem to be making out like bandits because their clients are typically the large systems and insurers who are flush with cash.
How does almost every other country in the world manage to do exactly this then? Clearly it's a feasible solution elsewhere, so why not in the US? As much as I'd like to believe we're exceptional, I know that in the end we're really not.
I'm not saying that couldn't be part or most of the solution. But there is a decided air of "well all these other countries do it, you idiot, so it's clear we just need to snap our fingers and do it too and everything will be perfect with exactly zero unintended consequences" whenever someone says we "just" need to have universal healthcare and everything else will work itself out.
There are some extremely good elements of American healthcare. Our healthcare education system with all its flaws is among the best in the world. We're a global center of medical and pharmaceutical research. Changes to the provider side need to take that into account or the entire world could suffer as a result.
> I really don't understand how that's possible at all
The MBA-ization of healthcare - they realized they could, so they did. Mostly because the business processes around medical billing have become so convoluted, with so many layers of middlemen, that it's essentially impossible for a layman to understand and reason about.
To be fair, Stanford's admitted hospital food is really, really good and the care is the best around.
Through a botched 12 lead ECG, I ended-up in their cardiac unit over a holiday a few years back. It was better than most hotels. Insurance covered 100%. I don't think I ever saw the actual costs.
What I learned the hard way is that non-us citizens who need minor medical help should go to a drop-in clinic, not a hospital. In the few times I have done that, the fees were reasonable. The one time I went to a hospital to treat an infection in my thumb, I had to pay over $5,000. The same procedure in Canada would have cost me $50.
Do they really have a way to track you down as a non-citizen for nonpayment? I know it's not the most ethical to skip out on a bill but charging incredible fees to foreigners who don't understand the American system doesn't seem that ethical either.
Fair enough! But I do hope you fought that bill really hard and got them to cut it down significantly. I was living in Europe a few years and signed up for travel insurance and thought it was really 'funny' that if you are going to America for more than a few days the rates basically double because the payouts the insurance has to provide are so extreme compared to the rest of the world.
Huh maybe not - I thought being able to show you could cover expenses while there (so insurance) was part of the questions on entry or when submitting for the waiver.
That's just to check you're not planning to work on your tourist visa and generally means having enough to cover accomodation, transport, food, and entertainment.
I already linked it on anothe rthread, but Germans can get insurance for that for up to 5 years, including the US tripples the price so, even if it remains quite affordable. So there are solutions I guess.
That is true for citizens too. Going to the hospital in the US, especially the emergency room, is crazy expensive. Unless I'm actually going to die imminently, I'm not going to the hospital. And if I actually know I'm going to die then there is no point in bankrupting the family by going to the hospital.
My dad thought this way, too. He resisted going to the hospital when there was something wrong with his heart. If he had gone at the first sign of serious trouble, he’d probably still be alive. Instead, he went into cardiac arrest, my mother panicked and gave him CPR while someone called 911, and my dad went through multiple surgeries and weeks of life support before dying with a bill over a million dollars.
So if you really, really don’t want medical intervention, make certain your friends and family will respect your wishes.
I wish my dad had just gone to the hospital as soon as he knew there was a problem instead of trying to be a financial hero.
I'm willing to see a doctor, just not at the hospital. Lucky for me my wife is a Nurse Practitioner, I get lots of free advice (though I still go to the office when I need drugs/labs/etc).
So can anyone who is in the medical field shed some light on this? Because if I was under obligation to list prices but didn’t want to I would probably inflate them like this too since I can give arbitrary 99% discounts.
Without a requirement that hospitals list their prices by billing code and must actually charge that price to everyone across the board with no adjustments or discounts laws like this are basically useless.
To make it sound like they're doing something about an issue (healthcare) which continually ranks highest on American's priorities without actually disrupting the status quo?
But this is pissing off both the people who did want it, because it’s extra regulation, and also the people who didn’t want it, because it’s ineffective. Nobody is happy.
Even then it would be kinda useless, because of the difference between hypothetical billing codes 22934a "Stitches, easy location, no complications" and 22934z "Stitches, weird location, infection present, uncooperative patient, resistance or allergy to common anaesthetics". Which is often very much up to interpretation and discussion as well.
"because I can't possibly fathom my hard earned money paying for someone else's treatment" seems to be the most common reason.
And you know what? Fine, whatever, in some twisted version of the world I can accept this as an argument. But I wish people would at least realize that by only having private healthcare they are fucking themselves over as shown here. The prices, the copays, the restricted access, the in and out of network treatments......all of that is completely made up to feed the system.
I mean on the surface level it kind of makes sense but when you add up all the additional costs from rent seekers like collections agencies, the lack of negotiation from medicare (although I vaguely remember hearing they might do this now) on drug and procedure prices, and hospitals overcharging those who can pay or with insurance to offset the emergency treatment they give to those who can't or won't pay I feel like this argument doesn't hold a ton of water. I mean, you're not paying it directly in taxes, just in a bunch of other ways.
Technically different, but all I care about is how much money is left per months after I paid for everything from taxes to mandatory insurance and social security. If somethings has me with more money left after that, I don't care if it called a tax or something else.
Technically, our taxes are used for all kinds of stuff we don't directly benefit from and you can argue that the insurance premiums we pay are paying for someone else's treatment.
I think another argument is that it'll be less effective (ex: longer wait times, etc) and that people will abuse it, ex: in Canada, I used to see people show up to ER because they were sneezing and I've seen people wait forever to get a doctor, etc, you're much less likely to do that if it costs you something.
This is the Singapore approach to everything the govt offers. Unless citizens have “skin in the game” over utilization happens. So even if you’re destitute, the govt will ask “well, what can you pay?” and if it’s $20/month for rent, we’ll, your rent is $20. Same with healthcare. Destitute? Ok, the gov’t will cover 99% of the cost, but we need you to pay $20. Private insurance had plans that paid 100% of costs and the govt created a regulation banning it. The end user must pay something.
No saying it’s the right approach or not, but it’s an interesting one.
Germany tried to solve this with a 10 bucks fee for seeing a doctor per mnth, unless one doctor sent you to another one. It didn't have much of an impact, only increased beuracracy at the doctors practices expense and was abolished after some time.
something to maybe remind people who are making that statement:
The US spends more as a percentage of GDP on healthcare and has the lowest life expectancy of all developed countries[1]. They are already spending their hard earned money on other peoples treatments, they are just getting less bang for their buck.
Life expectancy is a terrible measure for health outcomes. Too many confounding factors. Americans drive more than other countries, more road deaths. That drags down life expectancy and has nothing to do with healthcare.
Infant mortality is counted differently. The US system will try and save a kid that other system don’t - that’s a death where other systems don’t count it as a life.
how much of an impact do you think road fatalities and slightly different infant mortality counts has on an entire countries life expectancy? I would wager it does not come close to accounting for the massive discrepancy between the US and every other developed country.
I've had this exact argument with someone! Saying that you do know that by paying for private insurance you are paying for other people's treatments, right?? And they said that yeah, but at least they are choosing to pay, instead of being "robbed" through taxes and being forced to pay for other people's treatment.
That's what I find most wild about this argument. Not only is insurance paying for other people's healthcare, you're also paying to enrich a bunch of shareholders.
With single payer healthcare, that money goes to the government, which is bad.
In the current US system, that money goes to private companies, which is good.
Don't bother questioning this because it's axiomatic. It has ceased to be merely political theory; it's now core to many people's identity. Any threat to that status quo is a personal, existential threat.
Profits in the healthcare industry account for a single digit percentage of costs. Health insurers made $35 billion in profits in 2019: https://www.fiercehealthcare.com/payer/big-name-payers-earne.... Americans spent $3.8 trillion on healthcare that year. Okay, get rid of insurer profits. Your costs have gone down less than 1%.
Well as someone who has experience universal systems in 2 countries and the US system, if I ever got cancer I’d want to be in the US with private insurance (or hell, Medicare or Medicaid even). Yes, the US system is dysfunctional and very expensive, but one reason why it’s expensive is because they’ll throw everything plus the kitchen sink at you. In the countries I was in, if you get cancer they’ll pay for breakthrough from 3-5 years ago, but that drug approved by the FDA last year? Nope.
"Then I found out that this other country — which I thought had a healthcare system that was so superior to the U.S. — doesn't test for the tumour marker that saved my life, and doesn't cover this drug that is responsible for pushing my cancer into remission after traditional chemotherapy failed to do that."
Well, that's straight up not true. My own dad was treated with the very latest drug by Novartis because he had an extremely rare cancer that didn't have any other treatment yet. 100% paid for by the national health service.
People who come up with that argument don't understand how insurance works. An insurance company pools the premiums paid by their customers; so of course you're also paying for someone else's treatment. If your insurance premium only covered your own expenses, it wouldn't work.
It should be added that a healthcare system that relies on insurance companies isn't necessarily a problem, as evidenced by the number of countries (the Netherlands, Germany, Switzerland, etc.) with highly regarded healthcare systems that rely on private healthcare. Germany has a hybrid public/private system, while the Netherland system relies on mandatory personal health insurance. But these systems work because they are highly regulated and are designed to benefit the individual, with limits on how much providers are allowed to charge, for example.
The German system is fun, because while we call one part "public" (rather gesetzlich in German, which describes it much better) and private. Thing is, even the public (gesetzlich) part is run by private companies, they just have to offer a stanrdadized, regulated product at a set and regulated cost, they can offer additional services on top, they can even charge a couple of bucks more. They cannot decline anyone so (exept fringe cases like freelance artists for example, or others with their own profesion-based models) or exclude prexisting condition. Private providers can do that, that's why it is potentially cheaper when being young, but can be quite costsly when people get older. Which is the reason why I always stayed in the public model, less hassle overall.
> "because I can't possibly fathom my hard earned money paying for someone else's treatment" seems to be the most common reason.
But it is anyway in fact, since that's how insurance works even privately.
There is a model somewhere in between, like the swiss system. Here we pay a deductible amount of our own healthcare per year, which can be one of several set amounts. After that insurance pays 90% up to some set ceiling, then everything.
Costs including monthly premiums are regulated for essential treatment, and people who really can't pay can ask the government for assistance. The differentiator for health insurance is in add on packages. You want a private hotel room if you ever need to stay? Extra. You want something not covered by the basic insurance (most things you might reasonably need are covered)? Extra.
This has the advantage of making the cost of unnecessary healthcare visible to people, which discourages unnecessary use a bit, while making sure that if something really does go wrong you will be treated and you don't need to worry about going bankrupt. It isn't tied to employers either.
It isn't a perfect system but my point is that there is in fact a reasonable middle ground compromise if 'everything is free' isn't acceptable. It is also quite possible to make money even with a system that charges for basic healthcare.
I agree that the US system is probably unchangeable - too many entrenched interests. It seems a shame though. We need some level of safety net as a society.
If you think the most regulated sector of the economy with all sorts of rent-seeking and barriers to entry is an indictment of libertarianism, you’re more than a bit off the mark.
Free market principles require an educated buyer in a market with competitive service providers. When you're admitted to an emergency room, there is no shopping around even if you are educated in healthcare enough to know what your options are...
> all sorts of rent-seeking and barriers to entry is an indictment of libertarianism...
OK, so if I understand your point, US healthcare is not free-market enough and even more deregulation is the cure. In that scenario even more hungry profit centers are allowed to flourish between the patient and their doctor. But, that is even more "waste" from a patient money -> healthcare provided point of view.
What has become apparent to me is that some aspects of civilization are not compatible with privatization. Oof. This was a very bitter pill for me to swallow as my background is having escaped Soviet controlled Europe when I was a child. It has taken a lot of time for me to realize that the ideal solutions for our species may not be at the opposite extreme of ideology. The big realization may have been that solutions in reality are often closer to a tensor than any one-dimensional concept or pure ideology.
* Note: by "ideal solutions for our species," I mean optimizing for the survival of the species, and growth of our technological civilization.
Does the European Central Bank calculate inflation in the US? - but healthcare is almost always part of CPI, so people doing CPI calculations would typically include this and this would be part of inflation calculated uuing CPI. And yes, healthcare costs have risen much faster than inflation as a whole.
I’m not sure what that has do with my comment. But it’s also false, at least for the “official” CPI numbers in the US. 31.8% of the CPI is shelter. This includes rent and home purchases (calculated as owner equivalent rent which is basically mortgage + cost of ownership), but excludes renovations and investment purchases.
I’m not saying the price is ok, but I’m guessing based on the description that includes a plastic surgeon given its a wound to the face. Generally speaking they’re going to charge a huge premium for one of those guys because that’s the going rate: people don’t like scars on their face.
I’d be curious what the price is for non-face stitches.
So, how much of a premium would that plastic surgeon get? Even if it’s $50k ($2k per millimeter of stitchwork), that still leaves over $40k to explain.
Also, can a wound sized 2.5cm or less that can be stitched up be complicated to stitch? I would think/guess many of them would be glued nowadays.
It doesn't include a plastic surgeon. That CPT code is very specific and translates to "Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes".
Those numbers make kind of no sense. We had a 5 days delivery+postpartum at Stanford and were billed ~200k (insurance paid 50k, we paid 600$) which I found insane already. So 100k billed for stitches makes even less sense.
In the above example, the remaining balance gets accounted for as a loss to maintain the fiction of the facility’s not-for-profit status. It also provides the basis for a kickback the federal government sends to this hospital called Disproportionate Share Hospital payments [0].
In medical parlance, this is called uncompensated care or uncompensated revenue. The Center for Medicare and Medicaid provides a ton of detail [1].
It's a negotiation. The $200k is simply the starting/maximum ask by the hospital to the insurance company. A bunch of automated and (sometimes) manual systems go back and forth until a price is agreed upon. Eventually everyone agrees on paying $50k.
Like any negotiation you want to start high rather than low.
i live in Mexico, when my son was born we went to a private hospital.
i know Americand are imagining a horrible 3rd world facility, but its not. its a beautiful hospital with very kind people who take great care of you. we got the fancy big suite, so we could accommodate a bunch of family and friends. we were there for four days and i ended up paying about 4k USD, out of pocket, without insurance.
and I think this is where the problem is. I personally have friends who are doctors here (private sector) they have great lives financially, (nice cars, big house, trips to europe, etc). I get a feeling healthcare professionals in the US arent satisfied with upper middle class, they want to be hyper rich.
Maybe if youre the only person that can save me from a strange cancer you should be hyper rich, but not if youre doing regular procedures.
I don't know, talking to anyone who went bankrupt because of medical bills would stamp a bigger impression but oh well, it's a circlejerk at this point in my opinion. Everyone keeps pointing at the fruits while ignoring the root of the problem.
Guessing this is the starting figure they use for negotiating with insurance companies, who laugh at them and counter with $395, at which point Stanford says ok yes thank you daddy. But they can't use a different price for you if you don't have insurance. So just send them a couple hundred bucks and tell them to fuck off
From experience cost shopping, Stanford tends to be by far the worst. A simple EKG would cost over $3k, compared to around $1k or so at other providers.
Though just a few years back, it was like pulling teeth to get the insurance negotiated prices (which I pay entirely having an HDHP). Hopefully, more transparency results in more cost shopping, but it's been a surprisingly slow social change.
Price transparency will only help by putting pressure on providers for PR purposes, but it will not cause free market dynamics because much of the health care sector is not a real market. Take stitches, who would actually shop around before having the stitches done? You would go to your usual hospital and pay whatever the price ends up being. All urgent care is not a market from the point of the patient, because there is no real opportunity to choose providers. Insurers have to follow the patient or be blamed for not supporting out of network care, so insurers have little market shaping power either.
I don’t believe most medical care is urgent, but I would say the bigger factor is insurance. If you’re going to blow through your deductible anyways the price doesn’t matter much to the consumer.
As a Canadian, I am constantly flabbergasted when American friends tell me "Yeah, but a single-payer system would be way too expensive! Taxes would go up!".
It does not occur to them that in a single-payer system, the incentive on everyone is to find ways to lower the cost of healthcare, while in a privatized healthcare system the incentives are reversed. And examples like this twitter post show the result of those incentives.
There has been a massive disinformation campaign pushed on the American people saying “socialism medicine” would be much more expensive and you’d have to let grandma die. That Canada hates their system and you have to wait for days to get seen.
Any evidence to the contrary is met with “but my freedom”, idk how to fight back against this
Even those who have insurance end up paying a lot out of pocket and if the insurance provider decides to not pay the bill it gets chucked onto you and that can easily run in the 100000's of dollars.
>"That Canada hates their system and you have to wait for days to get seen."
I would not call that I hate the whole Canadian system, but parts of it for sure. Especially the ones when they let you wait for months for some things. Some people died because of it. All because the guvvamint only allows for so many procedures per period allowed. The rest does not fit into budget.
However you will find enough of deaths in the US that can be attributed to a lack of money as well.
Depending on how one gets sick the may hate Canadian system or the one in the US.
What disinformation campaign? Elizabeth Warren’s proposed healthcare plan would cost $52 trillion over 10 years, with $20 trillion in new federal spending: https://www.cnbc.com/2019/11/01/elizabeth-warren-releases-pl.... Warren estimates that $52 trillion is about what Americans would spend on healthcare over that time frame anyway.
When the candidate “with a plan” estimates that single payer wouldn’t reduce costs, does it take a “massive disinformation campaign” to convince people that, by the time all is said and done, costs would go up significantly?
I do know people in Canada who have to wait days to be seen for certain things or who pay for supplemental healthcare plans to fill in the gaps. That doesn’t mean they’d rather be in our system, which seems to get more broken every day.
> the incentive on everyone is to find ways to lower the cost of healthcare
why is this? Here in Chicago all govt run institutions are out of money with out of control budget overruns. eg: public transport( CTA) , usps ect. Not to mention pensions/pension debts which have spiraled out of control.
From the outside the Canadian healthcare system looks good. But I have friends in Canada who complain that it’s very very hard to get an appointment for a basic check up. They have to wait anywhere from 2 to 6 months. Also, they just end up going to emergency for anything. Your experience might vary. The same with UK also I hear.
I am no big fan of the American healthcare system but I don’t think any country (don’t bring up Switzerland and Singapore as examples, they are too small and don’t have the diversity, size and complexity of the US) has demonstrated an ideal healthcare model.
My indian friends travel to india to get routine medical procedures. My understanding is that you get priority if you have a pressing concern but long wait times for procedures that can wait.
> Canadians might wait several weeks or a few months to get a knee replacement
Hard to tell from this what else falls under "knee replacement" category of urgency. I personally know ppl who traveled to india to get a root canal. Weird to dismiss it as " deliberate propaganda campaign " and link to npr article with no actual statistics.
I still do not get why posts like yours get downvoted. What you say about Canada is true. Not always and depends on particular location but still there are examples of everything you just mentioned.
As a simple example, here in the UK can can call my GP and have an appointment for a basic checkup within a week or two and faster if there was an issue of concern. Things are a bit overwhelmed at the moment due to the relaxation of covid restrictions and surgeries starting to ramp-up to deal with the backlog of non-covid issues, but any claim that waits are multi-month is simply not true.
While no country has an ideal model, _every_ country has a better one than the US. If you put together a list of all of the worst possible decisions and mis-features you could possibly add to a public health system you would end up with the US model.
"Long wait times have become a defining characteristic of the Canadian health care system. In 2016, the Commonwealth Fund ranked Canada last among 11 countries surveyed on wait times for specialist care.1 Roughly one-fifth of Canadians report being negatively affected by wait times, citing experiences of stress, anxiety, pain, lost income, delays in diagnosis and treatment, duplications of tests, and deterioration in their conditions."
This study talked about accessing a specialist (cardiologist, obstetrician etc) not a general practitioner for a basic health check up. This borders on disingenuous.
> not a general practitioner for a basic health check up
I don't know what op meat by "basic check up". When i injured my knee i was referred to an ortho by my GP who then did a "basic checkup of my knee" to diagnose an mcl tear.
Also op said "basic check up" which you disingenuously changed to "basic health check up" which sounds like a generic health check.
In Toronto, my doc is always able to see me within two weeks for something non-urgent. They also have 24/7 number I can call to speak with a doc. And my doc responds to emails within a few hours. If there's something non-urgent but I want an answer right away I can go to a walk in clinic and be seen within an hour. The vast majority of Canadians live in dense areas like I do and have access to the same level of care.
Am in Germany and can get a basic check up figuratively every day of the year completely for free. It might take a day for a specific appointment, but if i just went to the doctor they would see me guranteed and could assess any ailments. So there you have a country that is similar enough to the US that shows how a single payer system can work. I agree, that there is no such thing as an ideal healthcare model :)
Canadian here, that’s just not true, you only have to wait if you want to see a specific specialist and they are fully booked, then you have to decide if you would rather wait or see someone else.
The argument about the US being too large for X gets made for all kinds of X, all the time. It tends to not make a lot of sense. As the size of the country goes up, so do the available resources. Maybe there will be a couple of layers of additional organizational overhead, but there's going to also be access to a lot more economies of scale so it should be just a wash.
Why would health care be harder to scale up in terms of the size of a country than, e.g. the military or the fire brigades?
As for diversity... I don't buy it for your specific example. Switzerland has:
- Four official languages.
- A federal system with similar levels of decision-making devolved to the cantons as to the US states
- 11 political parties significant enough win seats in the parliament
- High levels of immigration: 30% of the population are immigrants.
The reason Switzerland shouldn't be brought up is that the health care system isn't particularly good, just different. In particular it's the second most expensive in the world.
US has the worst of both worlds. It's very expensive and the wait times for specialist visit are not particularly fast.
Forbes says it takes 24 days on average to set up an appointment with an specialist in the US - https://www.forbes.com/sites/brucejapsen/2017/03/19/doctor-w...
I am Canadian. This is not true. Doctors are quickly available for check ups and basic stuff. Some surgery have long waiting list. I imagine 6 months would be typical for knee replacement. The good thing is that the thickness of your wallet doesn't affect your priority, just the severity of your medical needs.
So why is size and complexity an issue? Why is it that in a country of 1.3 million people I pay a reasonable amount of taxes, get free healthcare and even if I do prefer a private provider pay EUR 50.- per visit. But a similarly sized US town can’t do that. So maybe the role of the feds is to make it so that the size and complexity would matter less?
People say taxes would go up because every plan for single payer would involve taxes going up. Pretty much no one things you can squeeze major cost efficiencies out of the system.
I pay over $25k in insurance premiums a year for a family of four.
If raising my taxes by $10k eliminates that, I’m extremely ok with it.
The cost of US healthcare is 2-3x the cost of healthcare in the rest of the developed world - counting both public and private spend - and with very similar outcomes.
"If raising my taxes by $10k eliminates that, I’m extremely ok with it."
As would I, if there's a $15k savings. Is there any data to support that?
You mention costs in other countries. How do salaries, taxes, and cost of living compare as well? It seems that many places have lower cost of living, which seems to influence prices for any number of services.
Canada had a slightly higher cost of living than US. But we are a very very big country with low population density, so logistics are expensive.
Health care costs about 50/month if you have income. Simple. Cost never enters into medical decisions.
.(Some pharmaceuticals are a problem - expensive, if you have special needs.)
The cost is a consequence of a complex system out of hand, not a target metric. I would argue that paying $30k a year would be beneficial, _if_ the resulting system incentivized cost reduction. So the if is not in the cost but in the belief in the consequence of the change
Except neither Sanders nor Warren have proposed a plan that would cost you only $10k in taxes to save you $25k in premiums. Even on paper, Warren’s plan costs the same as what Americans already pay in health care costs.
> Warren bases her plan off of a recent analysis from the Urban Institute, which estimated that under current law, Americans would spend $52 trillion over the next decade on health care — that includes many types of spending, from employers, individuals and all levels of government.
> Warren's plan estimates that total health costs could be held to $52 trillion and that $20.5 trillion in new federal spending would be necessary.
Like with schools (where America also pays more and gets less), most spending in the healthcare system is payroll. An American nurse makes twice what a UK NHS nurse makes. The idea that we can cut those costs meaningfully is laughable.
Of course, you also have to contend with things like "medicare is not allowed to negotiate drug prices"... except now there's even _more_ motivation for drug companies to bribe politicians to get things like that encoded into law.
While I'm a proponent of universal healthcare, it does have some negatives.
So, the problems brought on by the uniquely weird and shitty US health insurance system will persist when we transition to the tried-and-tested alternatives the rest of the developed world use without those problems?
Medicare isn’t allowed to negotiate drug prices because it mostly doesn’t cover or pay for drugs. Drugs are covered under Medicare Part D plans through private insurers. It’s their job to negotiate drug prices.
"It does not occur to them that in a single-payer system, the incentive on everyone is to find ways to lower the cost of healthcare, while in a privatized healthcare system the incentives are reversed."
I don't think this is completely true. That greatly depends on the population. Regardless of single payer or private insurance, it's the underlying mentality of the people, or restrictions placed by the plan (which people then complain about). Many people think they have coverage, so they might as well use it. This can happen extremely often and for minor things. Think people going into the doctor or urgent care because they have cold symptoms (for less than a week) and want antibiotics. Most people want the easiest, most beneficial thing, like why diet and exercise when you can just take a pill for your type 2 diabetes, cholesterol, or blood pressure?
People don't think about costs during the most costly parts of life - end of life care. People want doctors to do "everything" to extend a person's existence, even if the outcome isn't likely to result in extended life. When the system does make choices about who to treat or how to treat, there is generally some public backlash (like NY letting many elderly die because they thought they needed to save the ventilators/beds for younger covid patients).
It's the views and intelligence of society that dictate behavior-based costs. This includes what restrictions are placed on both supply and demand sides.
What does the parent comment have to so with the cost of stitches at Stanford? I was responding to their generalized comment about costs, which also has very little to do with the cost of stitches at Stanford.
For one, people are using Stanford for the name and presumed quality of care (see tweet about price being much higher than other hospitals). That's shows patients are willing to spend more for treatment there. If you want to dig deeper into the cost, then we would need to know why the price is listed that high, as it is likely a mistake (also speculated in the tweets). It's not really a good idea to compare anecdote that is suspected to be a mistake against an unspecified cost in another system (implied by parent).
> Many people think they have coverage, so they might as well use it. This can happen extremely often and for minor things. Think people going into the doctor or urgent care because they have cold symptoms (for less than a week) and want antibiotics. Most people want the easiest, most beneficial thing, like why diet and exercise when you can just take a pill for your type 2 diabetes, cholesterol, or blood pressure?
I think this is not realistic, and it's the opposite of my experience in relation to all the people I've known.
I know far more people that _should_ go to the doctor and don't, or do it after a long time (sometimes too long) rather than people who go to the doctor's too much.
I actually can't think of anybody that goes to the doctor "too much".
I've known only one case of person going to ER for simple cold symptoms (excluding the epidemic problems), as one is going to briefly checked, then made to wait for a very long time.
That example I gave about wanting antibiotics for a cold was something I've seen in real life, multiple times. There are hypochondriacs and other people who do go too often. They even have a code/name for people like that to let other doctors know by reading the file. I personally know of a guy who would call 911 just to get a ride in an ambulance. Eventually they stopped responding to him.
I do know people who probably should have gone to the doctors sooner too. I don't know that many of them, but it's possible they are more common in other areas.
"I've known only one case of person going to ER for simple cold symptoms"
I said urgent care. Urgent care is not the same as the ER. I know of people who go to the ER just for the free ride (Medicaid transportation provisions).
Sure, if this was happening in Iran, there would be people on the streets and head on sticks.
Americans are all too ready to blame their individual selves for problems caused by the state and capital. A lot of people from other countries would make their voices heard.
Although this isn't by coincidence either. The government has been feeding this individual responsibility line with various forms of propaganda mixed with racism to the people. It's also been silencing anyone who dared to question the underlying system entirely.
Reminder that the FBI sent letters to JFK aimed to getting him to kill himself.
There's a lot we don't know and likely never will. Just look into the thing that happened in the Venezuelan trip... if there's even info out there on it.
> Many people think they have coverage, so they might as well use it. This can happen extremely often and for minor things. Think people going into the doctor or urgent care because they have cold symptoms (for less than a week) and want antibiotics
Do you have anything backing up that assertion?
I've been to the hospital feeling rotten on more than one occasion, and the doctor has said "You have the flu. Antibiotics won't help. Go home and get some rest." The doctor has no incentive to prescribe me drugs I don't need. There's always a few shitty doctors at clinics/hospitals who will over-prescribe, but the health care system has an incentive to find and stop those doctors- they're wasting taxpayer money.
Meanwhile in the US, the doctor would be financially incentivized to request a chest x-ray and prescribe whatever drugs might be helpful "just in case", fearing a lawsuit for doing too little and fearing their employer being mad at them for not up-selling to bring in more money.
It's anecdotes, generalizations, and informations from friends in healthcare. Which I'm guessing is similar to what your comment is based on (no sources).
I don't see how changing the healthcare system would implicitly change the torts. Medicare and Medicaid haven't changed that.
I also don't see how the single payer system would prevent over prescription or unnecessary treatment. These also occur under Medicare and Medicaid, as does substantial fraud.
No, I mean I don't understand your point. People can stay home or work from home without needing to see a doctor when it's something like a common cold. It's stupid to go in for something basic and demand a treatment that won't even help.
In real world, single payer systems cost beat American system consistently. None of my American economists friends able to cite another country which perform cost-wise worst than USA on a bet spanning a decade. The only saving grace for championing American system is having lots of mri and ct scanners in many hospitals across the nation.
I weakly support single-payer because it would at least hopefully save me from spending hours dealing with the vagaries of medical provider billing and free people from worrying about health insurance when job-searching, but I don't see much reason to believe it would lower prices in America.
There's some kind of horrific cost disease going on in America. Sure, the insurance doesn't help, but it's not the main problem. The cash price - with a discount - for me to get the five-minute opinion of a nurse practitioner is $125-$150. Self-insured companies are paying 20k+ in premiums for an employee's family health insurance plan.
This is reflected in the fact that a lot of hospital systems in the US are already publicly owned! Taxpayers in much of the US are already paying directly to built facilities and pay doctors and nurses for anything their billing doesn't cover. (Not even counting the VA system.) 64 million Americans are on Medicaid, about 20% of the population; [1] 18% of Americans are on Medicare. [2] (There's some overlap, so those aren't strictly additive.) More Americans than Canadians are already the beneficiaries of public health care! And Medicare/Medicaid is already the one of the biggest US government expenditures. [3] Whatever natural incentives are in place are already there. It may be the case that specific government policies are partly responsible for hamstringing cost-cutting, but I see no reason to believe those policies and worse ones wouldn't perpetuate themselves.
There's a lot of factors driving the crazy costs in the US. Unfortunately, I don't see a reason to believe single payer would do anything but mildly slow the rise, unless combined with a lot of very unpopular policies.
Personally, I would like to see the government use the VA to demonstrate what level of care and overall experience the public can expect if switching to a single payer or other government involved system. Most of us that have any knowledge of their workings would not be too optimistic about US government expanding their role in the general system. It's such an embarrassment.
Long waits for care, like waiting months for appointments, and can be very difficult to reschedule. Substandard care is pretty common. They try to cut costs and don't pay very well. They even have looser restrictions on physician testing than states, so sometimes you end up with lower quality people that couldn't hack it under the state requirements. Oftentimes you're seeing a PA or nurse practitioner rather than a physician. For basic things that could be ok, but usually the people in need of care at the VA have complex needs. Long waits for approval of benefits which can take years, require multiple applications as they almost blanket deny some claims, and sometimes require legal assistance with third party medical evaluations. Limited facilities means long drives for some people, and even makes it a near impossibility for some.
I honestly haven't heard anything good about the VA other than it's free (but was really earned through service). The good care tends to be at what I would call the active duty facilities, like Walter Reed and Bethesda.
The interesting part of socialized healthcare isn’t that it’s run by the government but that the cost burden is borne by the highest wage earners, i.e. the California and New York knowledge workers who make up a large part of this community. If your friend is part of this cohort then his concern is probably founded. Less so if he’s a line cook or even an IT admin in Wisconsin.
When I say things like that to my Canadian friends, what I mean is: “I am not confident in the ability of the government to implement a reasonable single payer system. I am concerned that regulatory capture, small government politics, and special interest groups will result in system that is worse than what we currently have.”
You had mentioned hospitals being incentivized to reduce costs. They could do that by avoiding sick patients. Or not treating sick patients.
Some “providers” already have this business model.
Also, it’s all but guaranteed hospitals would seek to increase revenue by providing non medical services at high expense.
$2000/meal. $500/night parking. $500 for a hospital gown.
America needs to address its weak administrative state, underfunded and under-qualified civil service, and overall shitty public sector before taking on a massive project like this.
> I am not confident in the ability of the government to implement a reasonable single payer system. I am concerned that regulatory capture, small government politics, and special interest groups will result in system that is worse than what we currently have.
It takes a special kind of delusion to believe that when every single country in the world that has a public health system is in fact not worse than the US system.
I think a large part of the problem is that Americans are brainwashed from birth to believe that the "Free Market" will solve all problems, and that it is superior to public systems 100% of the time.
It’s the complexity penalty. For years, in trying to make the system “better” for the current definition of “better”, the system has been made more complex. Probably to the point where no stakeholder understands it. But complexity breeds complexity (you need to understand something to not botch any change up) and the price of the system grows fater than the complexity (x times complexity increase leads to about x^1.5 times price increase, there’s research on it). It’s not profit margin, it’s the cost of dealing with the complexity.
In a competitive market, companies with high complexity penalties can’t compete, get pushed out or are forced to reduce complexity by force. In this case, there is no external pressure to reduce complexity but an increasing number of parties seeking to benefit from it. Which leads to predictable consequence of complexity growing like crazy.
Looking with European lens and reacting to people that think the universal healthcare is the solution to this problem: no, it is not.
The universal healthcare solves the insurance problem, not the cost of the hospital. What US needs is not insurance for people that don't pay for it, but reasonable prices at hospitals. We have this in my country: we have both public and private insurance and public and private hospitals. The competition in the system means private hospitals will never have such prices, otherwise there will never be clients.
Instead of universal insurance coverage, you need strong competition to hospitals so there is a market price that is closer to the costs. Here the private hospitals cost more, but offer a much better quality; still, the prices are double and most middle class people can afford to pay it without insurance if needed, so these stiches would be maybe $100 while in public hospitals it would be $50-60 and covered by the public insurance. Even here in Europe there is no full, unlimited insurance, emergency care is free but everything else is covered by a mandatory insurance every employee has (paid only by employee, not the employer) and it covers the spouse and kids (under 18 years old or in college) of the insured person. That means there are people without insurance and they receive only emergency care for free, nothing else.
Every EU country I know of (whch doesn't cover all 27, so...) has covered more than just emergency care. Payment is quite different, in germany so the costs are shared 50/50 between employer and employee, soe for unemployment and social security. Would be nice to know where you live.
Romania. It is part of UE since 2007 and this is the way healthcare works here for the past 10+ years. A few years ago the accounting part was changed so all the taxes and any other forms of payments to the state from the payroll appear in the employee payroll, the total amount did not changed but salaries were adjusted (up) to cover former employer part, so now the employee is paying everything (which was always the case everywhere, just differently booked).
Some employers offer as a benefit a negotiated private insurance co-payed; for good contracts the private insurance cover all the costs in private hospitals, for my company it covers about 50% of the doctor cost for consultations and about 20% of the hospital costs. I pay about 50% of the cost of this insurance, the benefit is a discount price versus the regular price of the insurance (about 10-15%).
It seemed like an opportunity for more people to just learn some of the skills for these expensive procedures so out of curiosity, I looked up what army field medics learn. It's a 16 week course. Stitches, bone setting, and minor surgeries should be done by the equivalent of barbers.
The prices are a perfect storm of what is essentially a unionized tightly gatekept profession, obviously perverse inventives in insurance, and the consequent inflation.
Swap debt for insurance, and you have the dynanic of the education market as well. Both of them are artifacts of regulatory capture.
Arguably, instead of teaching kids to code we could teach them to handle 50%+ of emergency room visit causes and the resultant widespread competence and research impact would make medicine progress at the rate tech has. I suspect the main reason we don't have biohacker first aid kits for routine procedures is drug controls on anesthetic, but there is a already robust global black market for drugs that could meet this need. A list of procedures sorted by risk and pain could be solved pretty fast. Of course there will be wildly irresponsible malpractice, but compared to the consequences of the current system, it probably nets out, and for medical industry people who don't think it would, they aren't really in a position to object to a free market in health services.
If we can create a market, knowledge networks and a disitribution system for 3D printed guns, we should apply the same ethos and skills and come for medical care next. We need a Cody Wilson of medicine.
> It seemed like an opportunity for more people to just learn some of the skills for these expensive procedures so out of curiosity, I looked up what army field medics learn. It's a 16 week course. Stitches, bone setting, and minor surgeries should be done by the equivalent of barbers.
But "can I do it?" and "can I do it well?" are different questions. For instance (IIRC), badly done stitches can leave more of a scar than expertly done ones and a badly set bone may heal in the wrong position. There's also knowing the difference between typical situations and more unusual ones that look similar but require a different treatment.
It's not a bad thing to know how to do those things for an emergency, which is the context an army field medic would do them, but that's quite different from an everyday accident with accessible medical care.
If I were to pay $10k or more for stitches anywhere else in the world, they would come with a set of top shelf breast implants and a hollywood quality facelift. In Cuba, they would give you a bonus hip or a new knee. There is no quality case for the price of the majority of routine american health procedures.
An Uber for medical toursism would even be more cost effective.
I'd happily take a scar if it saved me $20,000 on stitches. I do agree that I'm not leaping at the opportunity for getting untrained medical care.... but on the other hand I've been treated by residents pretty often and they still charged outrageous amounts.
You are right. What we need is a completely new mechanism that does not really work all that well and is dependent on completely new technology.
What we shouldn’t do is look at what nearly every other developed country has done to manage this situation, to the point where the most expensive amongst them is still half as expensive as the US system.
/snark
It still completely astonishes me how often Americans will come up with pie in the sky non solutions to solve problems that other similar countries have solved decades ago.
The fact that there isn't price transparency into all procedures at all facilities is a true market failure. Facilities are incentivized to to maintain opaque pricing so they can gouge.
My advise is to respond to the bill and let them know you'll only willing to pay $200 and that's all you can afford. Negotiations with these predatory billers go a long way.
Do these things really have purposeful list prices?
I had to go to the hospital for an allergic reaction on a visit to the USA. They let me go with $600 in cash.
When I asked for an itemized receipt, it has thousands in charges but nobody there really seemed to care if I paid that. The insurance company was welcome to pay if it wanted to though.
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[ 3.4 ms ] story [ 420 ms ] threadThat is absolutely insane to me. I really don't understand how that's possible at all - I know no one really pays sticker price on any medical bills but still.
It blew my mind - how can you NOT know?
Also, does your insurance cover these random bills or is it copay/80%?
As someone in the healthcare field - the best way I can describe it is that providers and insurers fight it out however they can. The problem is is that patients get the shit end of the stick.
I think calling out that both hospitals and insurers are fucking over patients is a positive change. Hospitals used to always get a pass, but they’re a huge part of the problem.
I don't think many uninsured people are paying sticker. Sometimes they automatically get charged with a discount, sometimes they have to call and get it. Some folks don't know to call, but these folks' bills are, I expect, not usually getting paid in full in the end anyhow.
Which is stupid, since the price has no basis with reality.
The insurance companies know this - when they negotiate, they look at $90k for stitches and say “yeah, we’ll pay you $1,200”.
The uninsured get screwed because the hospital acts like their charge master prices have some basis in reality.
Since you're in the space, what do you think of the startup they mentioned in the thread, turquoise.health (or rather the idea behind it, not literally the startup)?
I went to the same ER in San Francisco with the same problem 3 months apart (kidney stones). The first time around I was uninsured and the bill was $2000- they told me that they'll cut it down to $500 if I paid on the spot, which I did. 3 months later I had the same problem, had purchased insurance, my bill came out to $8000 and my deductible was $2000.
I have been assuming the magic discount is some sham the insurance companies push for to scare people into believing they would not get it if it weren't for the insurance.
It's BS IMHO to not be advertising the ACTUAL cash amounts they would quote somebody..
One reason that stitching up minor cuts is so expensive could be that those who need that treatment (e.g. because they were in a fight) are statistically less likely to ever pay their bills…
But it still sounds scammy pricing tactic to me. That is not how stores or anything else works or should work.
I work in radiology and entered a few common procedures I see a lot in our data on https://turquoise.health/ (also linked in the Twitter thread). Then I entered information for our own HDHP+HSA plan. Guess what, having insurance costs you 40-60% more if it's an acute issue. So if you're healthy, you have zero incentive to use your insurance if you suddenly need a CT of something. The rub of course is if you pay cash, it doesn't count toward your multi-thousand dollar yearly deductible, so if it turns out to be a chronic issue you just shot yourself in the foot. But if it doesn't, you just burned thousands by using your insurance when you didn't have to.
It's a complicated issue and anyone who says they have the solution, including "just make it free / just have the government pay for everything," is either being disingenuous or doesn't understand the problem. As was stated in the Twitter thread, running a hospital 24/7 is astronomically expensive. Everyone has their finger in the pot trying to get paid for their services in a world of increasingly small reimbursements. Attending physicians as resident-run hospitals will sleep overnight while getting paid literally half a million dollars a year. Insurance companies will just decide not to pay something and will spend years in court to defend their right to pay whatever they want, down to and including $0. Vendors will charge tens of millions of dollars to implement monolithic thick-client applications where everything is so configuration-heavy that you literally can't have a test environment because it won't match. Interoperability is managed by a text-based standard named HL7 that if you're not familiar with, will make you rip your hair out. The standard itself is ignored by every organization who ends up with their own flavor, so every app needs to be configured to support nearly any value in nearly any field. Hospital IT is staffed by people making $40k/yr who don't understand modern computing, and run by executives with no technical background.
Every single entity and company involved in healthcare is complicit in the end result, which is skyrocketing patient costs with at best no change in patient care or patient outcomes.
But you said something that stood out - "Everyone has their finger in the pot trying to get paid for their services in a world of increasingly small reimbursements." Given the rising prices, why isn't the pot getting bigger?
What do you think of Epic systems and EHR stuff?
I think the pot is getting bigger but it's getting bigger for gigantic organizations like Kaiser (not calling them out specifically but it's a name everyone knows). Someone pointed out, either here or in the tweet thread, that the 2011-2020 price increases are just going to Stanford. The physicians don't see any of that because they have their own reimbursement, and the patient gets their own bill. When we ran billing in-house it was not uncommon for patients to call us with billing issues because they didn't understand (nor should they have had to) that our radiology service bill was separate from the hospital. Which was separate from the anesthesiologist. Which was separate from the lab. Etc.
I see the pot getting bigger mainly for insurance companies, and large hospital systems, in that order. Some docs in some specialties are doing as well or better than they were ten years ago but a lot of the primary care specialties just get whatever the Medicare reimbursement is and don't have any control over it. Insurance companies will pay them whatever they decide to pay them. So short of increasing the cash price on that minority patients, all of whom are going to be very price sensitive, the independent docs and small practices can't do much to move the lever. Healthcare software vendors seem to be making out like bandits because their clients are typically the large systems and insurers who are flush with cash.
How does almost every other country in the world manage to do exactly this then? Clearly it's a feasible solution elsewhere, so why not in the US? As much as I'd like to believe we're exceptional, I know that in the end we're really not.
There are some extremely good elements of American healthcare. Our healthcare education system with all its flaws is among the best in the world. We're a global center of medical and pharmaceutical research. Changes to the provider side need to take that into account or the entire world could suffer as a result.
The MBA-ization of healthcare - they realized they could, so they did. Mostly because the business processes around medical billing have become so convoluted, with so many layers of middlemen, that it's essentially impossible for a layman to understand and reason about.
How can anyone price shop without knowing any of the prices, and if no one is price shopping there isn't any pressure to lower prices.
Through a botched 12 lead ECG, I ended-up in their cardiac unit over a holiday a few years back. It was better than most hotels. Insurance covered 100%. I don't think I ever saw the actual costs.
So if you really, really don’t want medical intervention, make certain your friends and family will respect your wishes.
I wish my dad had just gone to the hospital as soon as he knew there was a problem instead of trying to be a financial hero.
Without a requirement that hospitals list their prices by billing code and must actually charge that price to everyone across the board with no adjustments or discounts laws like this are basically useless.
And you know what? Fine, whatever, in some twisted version of the world I can accept this as an argument. But I wish people would at least realize that by only having private healthcare they are fucking themselves over as shown here. The prices, the copays, the restricted access, the in and out of network treatments......all of that is completely made up to feed the system.
I think another argument is that it'll be less effective (ex: longer wait times, etc) and that people will abuse it, ex: in Canada, I used to see people show up to ER because they were sneezing and I've seen people wait forever to get a doctor, etc, you're much less likely to do that if it costs you something.
No saying it’s the right approach or not, but it’s an interesting one.
The US spends more as a percentage of GDP on healthcare and has the lowest life expectancy of all developed countries[1]. They are already spending their hard earned money on other peoples treatments, they are just getting less bang for their buck.
1. https://www.commonwealthfund.org/publications/issue-briefs/2...
Infant mortality is counted differently. The US system will try and save a kid that other system don’t - that’s a death where other systems don’t count it as a life.
But physical and mental healthcare plays a major part in the other 95% of deaths.
In the current US system, that money goes to private companies, which is good.
Don't bother questioning this because it's axiomatic. It has ceased to be merely political theory; it's now core to many people's identity. Any threat to that status quo is a personal, existential threat.
An example: https://www.cbc.ca/news/canada/british-columbia/a-tale-of-2-...
"Then I found out that this other country — which I thought had a healthcare system that was so superior to the U.S. — doesn't test for the tumour marker that saved my life, and doesn't cover this drug that is responsible for pushing my cancer into remission after traditional chemotherapy failed to do that."
It should be added that a healthcare system that relies on insurance companies isn't necessarily a problem, as evidenced by the number of countries (the Netherlands, Germany, Switzerland, etc.) with highly regarded healthcare systems that rely on private healthcare. Germany has a hybrid public/private system, while the Netherland system relies on mandatory personal health insurance. But these systems work because they are highly regulated and are designed to benefit the individual, with limits on how much providers are allowed to charge, for example.
But it is anyway in fact, since that's how insurance works even privately.
There is a model somewhere in between, like the swiss system. Here we pay a deductible amount of our own healthcare per year, which can be one of several set amounts. After that insurance pays 90% up to some set ceiling, then everything.
Costs including monthly premiums are regulated for essential treatment, and people who really can't pay can ask the government for assistance. The differentiator for health insurance is in add on packages. You want a private hotel room if you ever need to stay? Extra. You want something not covered by the basic insurance (most things you might reasonably need are covered)? Extra.
This has the advantage of making the cost of unnecessary healthcare visible to people, which discourages unnecessary use a bit, while making sure that if something really does go wrong you will be treated and you don't need to worry about going bankrupt. It isn't tied to employers either.
It isn't a perfect system but my point is that there is in fact a reasonable middle ground compromise if 'everything is free' isn't acceptable. It is also quite possible to make money even with a system that charges for basic healthcare.
I agree that the US system is probably unchangeable - too many entrenched interests. It seems a shame though. We need some level of safety net as a society.
In a public health system waste is considered bad, and we would work to lower it.
In the private system waste is called shareholder value, and we work to increase it.
edit: I phrased this poorly, but certainly stand by my point. If anyone would care to discuss this or educate me, I am always open to change my mind.
OK, so if I understand your point, US healthcare is not free-market enough and even more deregulation is the cure. In that scenario even more hungry profit centers are allowed to flourish between the patient and their doctor. But, that is even more "waste" from a patient money -> healthcare provided point of view.
What has become apparent to me is that some aspects of civilization are not compatible with privatization. Oof. This was a very bitter pill for me to swallow as my background is having escaped Soviet controlled Europe when I was a child. It has taken a lot of time for me to realize that the ideal solutions for our species may not be at the opposite extreme of ideology. The big realization may have been that solutions in reality are often closer to a tensor than any one-dimensional concept or pure ideology.
* Note: by "ideal solutions for our species," I mean optimizing for the survival of the species, and growth of our technological civilization.
https://arbor.com/blog/how-does-rent-factor-into-the-consume...
I’d be curious what the price is for non-face stitches.
Also, can a wound sized 2.5cm or less that can be stitched up be complicated to stitch? I would think/guess many of them would be glued nowadays.
There are different codes for more complex work:
Intermediate repair (CPT codes 12031 – 12057)
Complex repair (CPT codes 13100 – 13160)
In medical parlance, this is called uncompensated care or uncompensated revenue. The Center for Medicare and Medicaid provides a ton of detail [1].
[0]: https://en.wikipedia.org/wiki/Disproportionate_share_hospita...
[1]: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manual...
Like any negotiation you want to start high rather than low.
i know Americand are imagining a horrible 3rd world facility, but its not. its a beautiful hospital with very kind people who take great care of you. we got the fancy big suite, so we could accommodate a bunch of family and friends. we were there for four days and i ended up paying about 4k USD, out of pocket, without insurance.
and I think this is where the problem is. I personally have friends who are doctors here (private sector) they have great lives financially, (nice cars, big house, trips to europe, etc). I get a feeling healthcare professionals in the US arent satisfied with upper middle class, they want to be hyper rich.
Maybe if youre the only person that can save me from a strange cancer you should be hyper rich, but not if youre doing regular procedures.
CPT 12011 - "Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes"
See: https://www.cms.gov/medicare/physician-fee-schedule/search?Y...
Though just a few years back, it was like pulling teeth to get the insurance negotiated prices (which I pay entirely having an HDHP). Hopefully, more transparency results in more cost shopping, but it's been a surprisingly slow social change.
I got one at an ER in an "expensive " private hospital here in Mexico. I paid less than $50 USd for the EKG and a doctors' checkup.
I understand that I the US salaries are 3X what in Mexico but even that doesn't justify the $1000.
It does not occur to them that in a single-payer system, the incentive on everyone is to find ways to lower the cost of healthcare, while in a privatized healthcare system the incentives are reversed. And examples like this twitter post show the result of those incentives.
Any evidence to the contrary is met with “but my freedom”, idk how to fight back against this
I would not call that I hate the whole Canadian system, but parts of it for sure. Especially the ones when they let you wait for months for some things. Some people died because of it. All because the guvvamint only allows for so many procedures per period allowed. The rest does not fit into budget.
However you will find enough of deaths in the US that can be attributed to a lack of money as well.
Depending on how one gets sick the may hate Canadian system or the one in the US.
When the candidate “with a plan” estimates that single payer wouldn’t reduce costs, does it take a “massive disinformation campaign” to convince people that, by the time all is said and done, costs would go up significantly?
why is this? Here in Chicago all govt run institutions are out of money with out of control budget overruns. eg: public transport( CTA) , usps ect. Not to mention pensions/pension debts which have spiraled out of control.
I am no big fan of the American healthcare system but I don’t think any country (don’t bring up Switzerland and Singapore as examples, they are too small and don’t have the diversity, size and complexity of the US) has demonstrated an ideal healthcare model.
Hard to tell from this what else falls under "knee replacement" category of urgency. I personally know ppl who traveled to india to get a root canal. Weird to dismiss it as " deliberate propaganda campaign " and link to npr article with no actual statistics.
As a simple example, here in the UK can can call my GP and have an appointment for a basic checkup within a week or two and faster if there was an issue of concern. Things are a bit overwhelmed at the moment due to the relaxation of covid restrictions and surgeries starting to ramp-up to deal with the backlog of non-covid issues, but any claim that waits are multi-month is simply not true.
While no country has an ideal model, _every_ country has a better one than the US. If you put together a list of all of the worst possible decisions and mis-features you could possibly add to a public health system you would end up with the US model.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7292524/
"Long wait times have become a defining characteristic of the Canadian health care system. In 2016, the Commonwealth Fund ranked Canada last among 11 countries surveyed on wait times for specialist care.1 Roughly one-fifth of Canadians report being negatively affected by wait times, citing experiences of stress, anxiety, pain, lost income, delays in diagnosis and treatment, duplications of tests, and deterioration in their conditions."
I don't know what op meat by "basic check up". When i injured my knee i was referred to an ortho by my GP who then did a "basic checkup of my knee" to diagnose an mcl tear.
Also op said "basic check up" which you disingenuously changed to "basic health check up" which sounds like a generic health check.
Why would health care be harder to scale up in terms of the size of a country than, e.g. the military or the fire brigades?
As for diversity... I don't buy it for your specific example. Switzerland has:
- Four official languages.
- A federal system with similar levels of decision-making devolved to the cantons as to the US states
- 11 political parties significant enough win seats in the parliament
- High levels of immigration: 30% of the population are immigrants.
The reason Switzerland shouldn't be brought up is that the health care system isn't particularly good, just different. In particular it's the second most expensive in the world.
The worst?
HN is one of the few forums that repeatedly leaves me speechless.
Even during Covid lockdowns that Sydney is going through at the moment, I can get a GP appointment this week with a 5 minute travel time.
We have a health system delivered by the States of our commonwealth, enormous distance to cover and extremely high health outcomes.
If raising my taxes by $10k eliminates that, I’m extremely ok with it.
The cost of US healthcare is 2-3x the cost of healthcare in the rest of the developed world - counting both public and private spend - and with very similar outcomes.
As would I, if there's a $15k savings. Is there any data to support that?
You mention costs in other countries. How do salaries, taxes, and cost of living compare as well? It seems that many places have lower cost of living, which seems to influence prices for any number of services.
From a patient perspective or system perspective?
"Health care costs about 50/month if you have income."
That's what is billed. What do the systems actually cost on a per patient basis adjusted for population risks (like obesity)?
https://www.npr.org/2019/11/01/775339519/heres-how-warren-fi...
> Warren bases her plan off of a recent analysis from the Urban Institute, which estimated that under current law, Americans would spend $52 trillion over the next decade on health care — that includes many types of spending, from employers, individuals and all levels of government.
> Warren's plan estimates that total health costs could be held to $52 trillion and that $20.5 trillion in new federal spending would be necessary.
Like with schools (where America also pays more and gets less), most spending in the healthcare system is payroll. An American nurse makes twice what a UK NHS nurse makes. The idea that we can cut those costs meaningfully is laughable.
While I'm a proponent of universal healthcare, it does have some negatives.
I don't think this is completely true. That greatly depends on the population. Regardless of single payer or private insurance, it's the underlying mentality of the people, or restrictions placed by the plan (which people then complain about). Many people think they have coverage, so they might as well use it. This can happen extremely often and for minor things. Think people going into the doctor or urgent care because they have cold symptoms (for less than a week) and want antibiotics. Most people want the easiest, most beneficial thing, like why diet and exercise when you can just take a pill for your type 2 diabetes, cholesterol, or blood pressure?
People don't think about costs during the most costly parts of life - end of life care. People want doctors to do "everything" to extend a person's existence, even if the outcome isn't likely to result in extended life. When the system does make choices about who to treat or how to treat, there is generally some public backlash (like NY letting many elderly die because they thought they needed to save the ventilators/beds for younger covid patients).
It's the views and intelligence of society that dictate behavior-based costs. This includes what restrictions are placed on both supply and demand sides.
For one, people are using Stanford for the name and presumed quality of care (see tweet about price being much higher than other hospitals). That's shows patients are willing to spend more for treatment there. If you want to dig deeper into the cost, then we would need to know why the price is listed that high, as it is likely a mistake (also speculated in the tweets). It's not really a good idea to compare anecdote that is suspected to be a mistake against an unspecified cost in another system (implied by parent).
I think this is not realistic, and it's the opposite of my experience in relation to all the people I've known.
I know far more people that _should_ go to the doctor and don't, or do it after a long time (sometimes too long) rather than people who go to the doctor's too much.
I actually can't think of anybody that goes to the doctor "too much".
I've known only one case of person going to ER for simple cold symptoms (excluding the epidemic problems), as one is going to briefly checked, then made to wait for a very long time.
That example I gave about wanting antibiotics for a cold was something I've seen in real life, multiple times. There are hypochondriacs and other people who do go too often. They even have a code/name for people like that to let other doctors know by reading the file. I personally know of a guy who would call 911 just to get a ride in an ambulance. Eventually they stopped responding to him.
I do know people who probably should have gone to the doctors sooner too. I don't know that many of them, but it's possible they are more common in other areas.
"I've known only one case of person going to ER for simple cold symptoms"
I said urgent care. Urgent care is not the same as the ER. I know of people who go to the ER just for the free ride (Medicaid transportation provisions).
https://slatestarcodex.com/2020/04/20/the-amish-health-care-...
Edit: why continue to downvote without comments?
Americans are all too ready to blame their individual selves for problems caused by the state and capital. A lot of people from other countries would make their voices heard.
Although this isn't by coincidence either. The government has been feeding this individual responsibility line with various forms of propaganda mixed with racism to the people. It's also been silencing anyone who dared to question the underlying system entirely.
Reminder that the FBI sent letters to JFK aimed to getting him to kill himself.
MLK Jr? Or maybe there’s more to the JFK story than I know…
Do you have anything backing up that assertion?
I've been to the hospital feeling rotten on more than one occasion, and the doctor has said "You have the flu. Antibiotics won't help. Go home and get some rest." The doctor has no incentive to prescribe me drugs I don't need. There's always a few shitty doctors at clinics/hospitals who will over-prescribe, but the health care system has an incentive to find and stop those doctors- they're wasting taxpayer money.
Meanwhile in the US, the doctor would be financially incentivized to request a chest x-ray and prescribe whatever drugs might be helpful "just in case", fearing a lawsuit for doing too little and fearing their employer being mad at them for not up-selling to bring in more money.
I don't see how changing the healthcare system would implicitly change the torts. Medicare and Medicaid haven't changed that.
I also don't see how the single payer system would prevent over prescription or unnecessary treatment. These also occur under Medicare and Medicaid, as does substantial fraud.
Uh...what else do you suggest that sick people should do? Be irresponsible and go to work or something?
The point is that people decide when they need care, and some of those people are idiots.
And if I don't know that something is cold, I don't assume it's cold.
There's some kind of horrific cost disease going on in America. Sure, the insurance doesn't help, but it's not the main problem. The cash price - with a discount - for me to get the five-minute opinion of a nurse practitioner is $125-$150. Self-insured companies are paying 20k+ in premiums for an employee's family health insurance plan.
This is reflected in the fact that a lot of hospital systems in the US are already publicly owned! Taxpayers in much of the US are already paying directly to built facilities and pay doctors and nurses for anything their billing doesn't cover. (Not even counting the VA system.) 64 million Americans are on Medicaid, about 20% of the population; [1] 18% of Americans are on Medicare. [2] (There's some overlap, so those aren't strictly additive.) More Americans than Canadians are already the beneficiaries of public health care! And Medicare/Medicaid is already the one of the biggest US government expenditures. [3] Whatever natural incentives are in place are already there. It may be the case that specific government policies are partly responsible for hamstringing cost-cutting, but I see no reason to believe those policies and worse ones wouldn't perpetuate themselves.
There's a lot of factors driving the crazy costs in the US. Unfortunately, I don't see a reason to believe single payer would do anything but mildly slow the rise, unless combined with a lot of very unpopular policies.
[1] https://www.cms.gov/newsroom/fact-sheets/medicaid-facts-and-... [2] https://www.statista.com/statistics/200962/percentage-of-ame... [3] https://datalab.usaspending.gov/americas-finance-guide/spend...
Personally, I would like to see the government use the VA to demonstrate what level of care and overall experience the public can expect if switching to a single payer or other government involved system. Most of us that have any knowledge of their workings would not be too optimistic about US government expanding their role in the general system. It's such an embarrassment.
I honestly haven't heard anything good about the VA other than it's free (but was really earned through service). The good care tends to be at what I would call the active duty facilities, like Walter Reed and Bethesda.
You had mentioned hospitals being incentivized to reduce costs. They could do that by avoiding sick patients. Or not treating sick patients.
Some “providers” already have this business model.
Also, it’s all but guaranteed hospitals would seek to increase revenue by providing non medical services at high expense.
$2000/meal. $500/night parking. $500 for a hospital gown.
America needs to address its weak administrative state, underfunded and under-qualified civil service, and overall shitty public sector before taking on a massive project like this.
It takes a special kind of delusion to believe that when every single country in the world that has a public health system is in fact not worse than the US system.
I think a large part of the problem is that Americans are brainwashed from birth to believe that the "Free Market" will solve all problems, and that it is superior to public systems 100% of the time.
As an America this is a very sad thing for me to say. But the basic mechanisms of government are failing.
according to this some manage >15% and profits are best ever https://www.forbes.com/sites/robertlaszewski2/2020/02/05/pro...
In a competitive market, companies with high complexity penalties can’t compete, get pushed out or are forced to reduce complexity by force. In this case, there is no external pressure to reduce complexity but an increasing number of parties seeking to benefit from it. Which leads to predictable consequence of complexity growing like crazy.
The universal healthcare solves the insurance problem, not the cost of the hospital. What US needs is not insurance for people that don't pay for it, but reasonable prices at hospitals. We have this in my country: we have both public and private insurance and public and private hospitals. The competition in the system means private hospitals will never have such prices, otherwise there will never be clients.
Instead of universal insurance coverage, you need strong competition to hospitals so there is a market price that is closer to the costs. Here the private hospitals cost more, but offer a much better quality; still, the prices are double and most middle class people can afford to pay it without insurance if needed, so these stiches would be maybe $100 while in public hospitals it would be $50-60 and covered by the public insurance. Even here in Europe there is no full, unlimited insurance, emergency care is free but everything else is covered by a mandatory insurance every employee has (paid only by employee, not the employer) and it covers the spouse and kids (under 18 years old or in college) of the insured person. That means there are people without insurance and they receive only emergency care for free, nothing else.
Some employers offer as a benefit a negotiated private insurance co-payed; for good contracts the private insurance cover all the costs in private hospitals, for my company it covers about 50% of the doctor cost for consultations and about 20% of the hospital costs. I pay about 50% of the cost of this insurance, the benefit is a discount price versus the regular price of the insurance (about 10-15%).
The prices are a perfect storm of what is essentially a unionized tightly gatekept profession, obviously perverse inventives in insurance, and the consequent inflation. Swap debt for insurance, and you have the dynanic of the education market as well. Both of them are artifacts of regulatory capture.
Arguably, instead of teaching kids to code we could teach them to handle 50%+ of emergency room visit causes and the resultant widespread competence and research impact would make medicine progress at the rate tech has. I suspect the main reason we don't have biohacker first aid kits for routine procedures is drug controls on anesthetic, but there is a already robust global black market for drugs that could meet this need. A list of procedures sorted by risk and pain could be solved pretty fast. Of course there will be wildly irresponsible malpractice, but compared to the consequences of the current system, it probably nets out, and for medical industry people who don't think it would, they aren't really in a position to object to a free market in health services.
If we can create a market, knowledge networks and a disitribution system for 3D printed guns, we should apply the same ethos and skills and come for medical care next. We need a Cody Wilson of medicine.
But "can I do it?" and "can I do it well?" are different questions. For instance (IIRC), badly done stitches can leave more of a scar than expertly done ones and a badly set bone may heal in the wrong position. There's also knowing the difference between typical situations and more unusual ones that look similar but require a different treatment.
It's not a bad thing to know how to do those things for an emergency, which is the context an army field medic would do them, but that's quite different from an everyday accident with accessible medical care.
An Uber for medical toursism would even be more cost effective.
What we shouldn’t do is look at what nearly every other developed country has done to manage this situation, to the point where the most expensive amongst them is still half as expensive as the US system.
/snark
It still completely astonishes me how often Americans will come up with pie in the sky non solutions to solve problems that other similar countries have solved decades ago.
My advise is to respond to the bill and let them know you'll only willing to pay $200 and that's all you can afford. Negotiations with these predatory billers go a long way.
I had to go to the hospital for an allergic reaction on a visit to the USA. They let me go with $600 in cash.
When I asked for an itemized receipt, it has thousands in charges but nobody there really seemed to care if I paid that. The insurance company was welcome to pay if it wanted to though.