> Hospital officials defend these fees as necessary to keep an emergency room open 24 hours a day as a community asset.
What nonsense.
This argument is effectively charging a rent without the consent or agreement of the renter (the community).
If the service were reasonable, the community would agree to them. They are not, so the hostipital instead games the insurance system and preys on individuals without the resourses/ability to defend against their predation
Everyone has an opinion on the root of the problem but I’d like to see an actual analysis with the costs and revenues in our medical system to better understand what’s happening.
A lot of it goes to inefficiency. Think of it this way. If you have a factory that makes 1 thing it can optimize around that. It can become cost effective. If you have a factory that can manufacture 10 different things, it becomes less cost effective because you need to be able to switch between the different things. If a factory can produce 100 different things it's even less efficient.
Hospitals deal with thousands of things. Their overhead and complexity are high. This leads to inefficiency which costs more.
I've read that the math around the costs map fairly well to the cost models around factories [1].
Non profits aren’t exactly virtuous or efficient with money. In fact, there are so many players involved in operating and running a hospital who want to get paid the fact that the overall hospital itself is a non profit isn’t very meaningful.
Pure inefficiency. The medical industrial complex is second only to the government in its byzantine bureaucracy. This is why we will never be rid of it. All those hundreds of billions of dollars wasted are mainly going to pay millions of middle class administrative salaries. I know 2 people whose companies would not even exist in a socialized health system. Woe to whatever politician tries to pass a bill that will put millions of middle class Americans out of work.
I have come to not view a given hospital as an entity. Rather, a hospital is a place (not just in spacetime, but in regulation, and in "the market") where numerous agents are at work in an opaque manner. Some are frantically billing anything that moves. Other agents are losing money on patients who will not or cannot pay and are looking for ways to balance those books so that they can continue to survive (consider the hospitals closing along the border as the "undocumented" end up in the ER). You have ambulance services struggling as people "cleverly" use them as taxis. Pharma slithers in and out, hoping to recoup their costs on nineteen failing drugs with wild sales of the twentieth. All of this occurs in the hospital "zone," and what patients see is a series of bills emitted, like push notifications out of an API.
Making all of this predictable, transparent, and detangled is only step one. Hitting people -- actual humans -- with fraud charges is also a grand idea.
The financials around US hospitals are something most don't understand. I didn't for a long time.
For example, many procedures at a hospital lose the hospital money. They don't cover the cost. Other things cost more and make up the difference.
Another element is that most US hospitals are very inefficient in what they do. In the book The innovator's prescription you can read the technical details on how those inefficiencies happen.
Healthcare isn't supposed to make money, it's supposed to stave off death. Just like schools aren't supposed to make money, or the postal service, or the military. Framing things in the context of whether or not critical services to society make or lose money puts it in a fundamentally unfair context.
I don't want hospitals to make a profit, or generate revenue. Every procedure should be losing money.
Hospitals need to break even on finances. What they take in needs to cover their costs. Anything other than this needs to be subsidized by an outside organization.
Exactly. Hospitals can't work like businesses or charities, they're a critical service that require federal, state, and local taxes to offset the cost of keeping communities healthy.
It's called promoting the general welfare and it's one of the primary roles of governments. Clearly private institutions are failing.
1. Buy expensive health insurance to cover medical bills
2. Never use it because even though you have no idea what you're going to be charged, you know it is going to be outrageous, even though you have insurance to cover medical bills
1. Buy an inexpensive high deductible insurance plan to cover only emergency expenses.
1.1. Make sure that for your plan out-of-network expenses count toward your oopm.
(1.2. Cry because your employer's health plan doesn't work for this.)
1.3. Have enough cash liquid to cover your oopm.
2. Max out your HSA contributions.
3. Pay cash for everything.
Sans 1.2. this has been working reasonably well for me. You would be amazed at the discounts you get once you say you're paying cash. Medical expenses suddenly are downright reasonably priced.
tl;dr Surprise! Everything is cheaper when you have money. Oh America.
You would be amazed at the discounts you get once you say you're paying cash.
Anecdotally I found this to be true with prescriptions. I didn't even ask for one but as soon as I told the pharmacist I was paying cash he said, "Oh, let me apply the coupon for you." and gave me a 20% discount. It was already a cheap generic but I wasn't going to complain.
You can short circuit this by working remotely for a US company from another country with a functioning healthcare system. If done properly (LCOL, excess income is invested), you mitigate not only healthcare system expense issues, but also can get towards a position of financial independence to mitigate the usual delays in finding your next role.
For example, to have a child's broken arm evaluated and casted in a Mexico capital city is less than $100, total. Annual cost of living for a family of four is $25k-30k/US.
This what happens when a significant portion of society worships the “free market” and wants to avoid government running things. In the U.S. we have managed to fully monetize just about every aspect of life. Even something as mundane as pumping gas has been almost fully monetized by blaring ads.
EDIT: I know the U.S. healthcare system isn’t a totally free market. We’ve designed a system that isn’t government run but has mandates like ERs having to see patients. Half the country labels anything that isn’t government run as free market and anything that is government run as communism. These are proxy words.
If you want a healthcare system that isn’t government run but that has a semblance of “free market” in it but that also “treats” most people this is what you get. Well, it’s what our system has morphed into.
The US government is capitalist. It primarily operates to defend the profits of large corporations. Yes, under either Democrats or Republicans, although the industries each represent only partly overlap.
I don’t understand the downvotes. It’s obvious that the each party represents differing corporate interests and those interests take precedence over everything. How much did Wall Street suffer for its malfeasance when Obama was President?
Do you have any references to their analysis? I would love to read it.
Most people talk about ideas and politics without getting into the technical details of what's happening.
The Innovators Prescription[1] is written by 3 PhD's (2 in medical and running institutions and one in business) who provide an analysis as part of the book.
There are people who want “free market” solutions and the definition of “free market” tends to be any solution that involves a corporation running it. Generally people deep down know that it is obscene for a country as rich as ours to have large numbers of people not be able to get some level of healthcare. Thus the Frankenstein system the U.S. has. We mandate ER center see patients and stabilize them but without government paying for it. Since no one works for free we get the asinine billing system the U.S. has.
Maybe this is splitting hairs, but it's more a problem with worshipping corporate capitalism. I don't think you can really describe healthcare in the US as a free market.
It’s the same thing…while the people here might be willing to split hairs on the exact meaning of those terms the people you are taking about are not going to.
Strategic ambiguity around “freedom” “free market” etc is a useful tool to prevent change. It creates a self reinforcing mythology in peoples heads and enough confusion about reality that blaming the victims for being “unprepared” can exist in the broad/abstract while also still feeling empathy and dying “that’s bad” in individual cases.
The health care market is about as far from a free market as you can get.
Tons of heavy regulation everywhere limiting supplies of doctors, nurses, ability for folks to see pricing info, for pricing info to matter etc. Consumer of the service often is not the one paying. So you can do crazy stuff like make an insurance co pay $10,000 per pill for something that overseas no one would ever pay that because they'd be paying themselves.
I've been in third world countries, cash pay places, no insurance, no govt stuff. You can call and ask how much something will cost, they tell you, you go, pay and done.
My bills in California have like 10 pages of notices and warnings on them for each charge. So it's a 5 page document per copay. Its crazy.
I never understand why do people think the government is going to do such a great job at running things. Have you never been to a DMV or had to interact with any federal/state/local authority? You get nothing but unthinking apathetic people who just want you to go away. I assure you government employees will care even less when something goes wrong.
Japan, Germany, Norway, Italy, Spain, etc. all run a national healthcare systems for far cheaper than the U.S. that covers everyone with more or less equal outcomes. The citizens of those countries don’t go bankrupt when getting care. It can be done.
DMV is quite good in my state. The Postal Service does an outstanding job of delivering packages. NIST and the Park Service provide great benefits to the nation. The U.S. military is government run and it does a great job at destroying organized state power. Should we privatize all of these organizations? How about privatizing the court system? Do you really want to live on Ferenginar?
Humor shouldn’t get in the way of understanding the point being made. Clearly this reference to Ferenginar was illustrative of a broader point. Equally clear is that it doesn’t underpin my understanding of economics. No reasonable reading of what I wrote suggests this.
"I never understand why do people think the government is going to do such a great job at running things." Because if designed competently, with audits/transparency baked in, it can.
Plenty of agencies in numerous nations have proved this out, but folks continue to have onanistic John Galt fantasies instead.
I do wonder how many other people you've interacted with.
There are many people in government trying to do a good job and many who aren't, just like private industry. I recently spent <15 mins at the DMV to get a vehicle title transferred and it was a very efficient process (granted I spent more time in the car as there aren't offices in every town).
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Perhaps you should talk to your local representative about the DMV's funding. There was a recent post to HN about how the FDA only has 10 employees to do declassification of documents, of course they will be slow at doing that. I wonder how many employees/per capita works at your DMVs.
It seems like what you’re talking about is the “financialization” of things rather than the “free market”. Essentially, you dislike the “market”ness of healthcare, not the “freeness” of the market for healthcare.
I certainly disagree with you that it being a market is the problem, but I think one can consider downsides to that pretty straightforwardly: the lack of price elasticity when you’re dying makes markets price poorly, discouraging people from healthcare is a societal bad, etc.
The idea that there should be a market but that it should not be free is something I just find really problematic since it’s just a steal-from-everyone-to-enrich-medical-barons thing.
If you don’t want to have the freeness argument then perhaps choosing other phrases will help. If you do want to have that argument, obviously you’ll find yourself discussing whether or not the market is free.
It's not about dying. Try to find a full price of something totally not related to dying. Some procedure or drug that you could shop for. Pretty quickly you'd find out you actually can't - you can't know the final price of almost any procedure ("estimate" is the best the could give, which does not guarantee a thing) and for the most providers the response to the request about prices is "we'll send you a bill after and then you'd find out". There's virtually no support for price discovery and zero tools for price shopping for many medical services. Maybe for drugs there are some limited ways, but outside of it, price shopping is insanely difficult if possible at all. So to which extent we can talk about the "market" if the basic activities of the market do not exist?
It's not that it's "isn't totally free market". It's as much "not totally free market" as North Korea is "not totally a libertarian state". It's one of the most tightly regulated and controlled areas of the economy. Literally every aspect of anything needs an approval - sometimes multiple ones - from regulatory organs. You can not become provider in the market without passing a myriad of regulatory barriers, which would make an average tech startup founder faint. You can not remain a provider without constantly complying with a mountain of always changing and mutating reporting requirements and compliance checks. Pretty much every regulatory scheme ever been thought up by a man is somewhere in medicine. And yet, we have this insane system. Whatever it is, it's not lack of regulation that caused it.
NPR has a series of these "Bill of the Month"[1] articles about surprise medical billing, and I am not exaggerating when I say they are the single most depressing, scary, disheartening thing I read on the internet.
The patients in these stories seem well-intentioned and well-prepared. They double check that their doctors are in-network. They triple-check what charges they should expect. But there's always a gotcha. There's always some hidden, between-the-lines reason hospitals come up with to charge you, and insurance won't cover. In one story, the surgeon invited an out-of-network surgical assistant into the surgery, without notice. In another [2], the labor and delivery department was classified as an ER, for a completely routine delivery.
When these charges are dismissed, it's always because NPR reached out for comment, and the hospital backs down, presumably because of the bad PR.
The unpredictably and seemingly arbitrary nature of medical charges makes me feel... queasy. And scared to seek medical help, which I know is what insurance companies want. Even with great insurance, which I'm lucky to have, it feels like there's nothing I can do to prevent medium-to-insane charges. The only way I can think of to try and combat medical billing is to retain a lawyer.
> Martand received almost no medical service. A nurse practitioner looked over the toddler, listened to his heart and stomach, and looked in his nose, mouth and ears, according to provider notes prepared by the hospital and shared with KHN by Bhatt.
> The nurse didn't change the dressing on the wound or order any testing.
> Emergency visits are usually classified for billing on a scale from 1 to 5. Level 1 is minor and routine; Level 5 requires complex care for life-threatening conditions. [...] Despite the lack of severity of Martand's wound and the absence of medical care, his visit was classified as Level 3, a moderate severity problem.
> In an email, Zoller Mueller said the charges were "appropriate" based on the "acuity of condition, discharge instructions, vital sign monitoring, traumatic wound care [and] numerous assessments."
> She added: "A patient does not have to receive additional treatment — procedure, labs, x-rays, etc. — to validate an ED [emergency department] level charge."
In my experience they are just outright lying and believe that patients will pay anything they bill. When my first child was born I received a monumental bill from the anesthesiologist, with the slight problem that no anesthesia was used and the person in question was not in attendance. Later, after I'd filed the consumer protection complaint with the office of the state attorney general and a formal complaint to the medical board of California it came to light that this person was golfing at the time, in another country. So it was just fraud.
The problem with this system is they act like everything is fine after they drop their claim, but what needs to happen is people going to prison. This is large-scale white collar fraud and it should be getting much more media attention than some guys stealing shampoo at the Walgreens.
The people getting service often are not ones actually paying (insurance pays, medicaid, medi-Cal etc).
The whole billing thing can be pretty darn maddening for providers as well.
There is absolutely no public pricing.
One thing I couldn't stand. A bunch of policians want to talk about how much money various govt programs save. So they do things like lower of cost or contract (penalizes you if you deliver to much service for same price) or some % of your charge sheet (ie, 50%). If 90% of your patient load is going through these programs, you basically have to set your cash pay charge to 2x it's normal cost, so that all these players can then report "savings".
The reality is there should be a cash pay DISCOUNT, you pay 80% if you pay in cash. But all these programs will not pay more than cash pay even though the overhead of dealing with them is massive. Ie, probably should pay 110% of a reasonable rate.
They get away with it because people have internalized that right-wing meme about "most litigious" to make it seem like the problem is greedy individuals abusing the system, when it's the opposite: greedy organizations are abusing the system and using right-wing memes to foreclose the legal remedies of individuals (such as via malpractice award limits).
Just because a hospital is big and has expensive lawyers, that doesn't mean that you have no rights.
My wife got a 4k bill that had no information on it other than the amount due. I called the hospital and asked what the bill was for and they said they would send an itemized bill, they never did, but I did get a letter from collections and I called them and said that I dispute the charges. And I never heard anything about it again.
You have rights also; the right to file for bankruptcy.
I had a family member get seriously ill and we racked up a ton of medical debt. There was no way in hell we could have paid it off and continued to live on one salary.
Filed for bankruptcy, and two years later started off with a clean slate. Honestly credit was back into the 700's, bought a new car and a new home two years later.
I’ve come to the realization that I’d rather die than leave my family having to pay huge medical debt. America’s healthcare system is completely broken (and I’m saying that as a child of a doctor from whom I learned how truly messed up it is).
I recently read a book on the history of socialized healthcare in Canada[0], which was fascinating. I'm very passionate about the development of a comparable system down here in the US but realized I didn't know anything about how such a program was established in countries where it actually exists! All I knew about Canada's case was that a dude named Tommy Douglas was involved (years later he was voted the Greatest Canadian[1]) but it's a bit more complicated than that. I had four main takeaways from the book:
1. Social programs can start regionally. There's a refrain you hear continually that if, say, California were to institute a socialized health insurance system it would immediately collapse because all the "takers" would move there (absent border control) to drain its resources. Yet that's how socialized health insurance developed in Canada - it was driven by the province of Saskatchewan, which had hospitalization insurance a full decade before any involvement by the federal government. To say that regional social programs are doomed to fail is simply against historical fact. This is how federalism is supposed to work! Experimentation is done at smaller scale and success bubbles up.
2. Doctors are the enemy. This was surprising to me, because I'm friends with a good number of (residency) doctors and all are very passionate about health equality. Maybe their opinions will change once that private practice money starts rolling in, I don't know. But basically organized medicine has opposed socialized health programs in every country they have been tried - an interesting counterexample to the idea that labor organization will per se lead to better social outcomes.
3. Liberals won't get it done (and might make things worse). This makes sense if you view it as a negotiation: socialists need to be pushing hard for radical change in order for the final product to land somewhere in the middle. If you're talking about the need for moderation at the beginning of negotiations, you've already lost. A good litmus test to tell whether someone is serious about healthcare reform or just making impotent gestures in its direction.
4. Socialized healthcare means more than free access to care. In retrospect this one is obvious, but I somehow had missed it. Just having access to healthcare doesn't actually make you healthy. The social determinants of health are much more powerful than going to the doctor once years of poverty have already taken their toll. The scope very quickly expands and you start talking about housing access, food access, and just economic equality generally.
These are good points. Doctors in general are against it because they're from an economic class above most of the population. In the US, you need to spend a lot of money to become a doctor, this make people see the profession as a capitalist investment that needs to pay a good return.
The point about liberals is very true, not only about health care. Just like the current president, they're elected to find a compromise, which essentially guarantees that nothing important will be done. They're in effect a tool of the very wealthy to placate or dishearten the population, disconnecting them from the democratic process. In contrast, right wing politicians are very effective in achieving the goals designed by their elites.
There is more than a slight difference between moving to California and Saskatchewan - just the same, adding another 10% to the state income tax will send quite a few people in the other direction.
I’d agree that universal health care probably wouldn’t come about incrementally, but there is no fundamental reason we can’t improve the system incrementally.
The ER visit ultimately cost $38.92. The system worked out exactly as it should have.
I'm getting a bit tired of these anti-US healthcare posts day after day. Sure, there are some issues, but this is starting to feel like reformist propaganda. I, for one, am very happy with the current system and don't understand why anti-government activists want to hand the government the keys to run the healthcare system.
"66.5 percent of all bankruptcies were tied to medical issues —either because of high costs for care or time out of work. An estimated 530,000 families turn to bankruptcy each year." [1]
The data is very clear Americans pay the most for healthcare out of every other OECD nation and yet receive worse outcomes [2].
> and don't understand why anti-government activists want to hand the government the keys to run the healthcare system.
Because it mostly leads to more efficient healthcare systems. For example, the per-capita healthcare cost in the UK is less than half that of the US for broadly similar outcomes.
1. He tried to negotiate the bill: "Dhaval Bhatt made numerous attempts to get the hospital to reduce the charges. He also appealed to UnitedHealthcare to review the charges."
2. The hospital refused: "His efforts failed....the hospital would not adjust the bill."
3. The hospital sent his bill to collections: "While Bhatt was trying to reach the patient advocate by phone, his bill was sent to Medicredit, a collection agency, which began sending him notices and calling him."
4. The hospital forgave the bill due to bad PR: "After KHN [Kaiser Health News] contacted SSM Health, Bhatt received a call from someone who worked on "patient financial experience" issues at the hospital. The hospital agreed to forgive the $820 facility fee."
> The system worked out exactly as it should have.
I had my gallbladder removed and was receiving new bills literally 18 months later.
Just because it worked out "this once" doesn't mean it works out in general.
Simple fact of the matter is we pay nearly double per capita what most of Europe, Canada and Australia pays for healthcare, and we don't even have universal coverage. Add in the fact that a majority of bankruptcies are due to medical debt and it paints a pretty damning picture overall.
This system is fundamentally broken. Anyone defending it is either willfully ignorant or shielded from it's worst aspects.
$38.92 for trivial, non-professional services they did not ask for. $1000 reversed only after spending days disputing the charge. Child remains at risk because provider was unable/unwilling to services within a reasonable time frame.
$38.92 for a medical assistant spending 1 minute to take your temperature works out to $2335/hour.
The article is not arguing for government control. Rather that medical services should be subject to the same transparency as any other professional business and without collusion with each other and insurance providers.
I cut an m&m sized piece off the tip of my thumb with a box cutter. Went to the ER, and a nurse came out and said it wasn't too bad. Washed it in betadine and put a bandage on it and sent me home. Bill was $7000!
The hospital in the article has a price transparency page here https://www.ssmhealth.com/resources/patients-visitors/pay-my... (behind multiple TOS of course). It seems to use epic / mychart. I used it to search for 'facility' and 'emergency' and got nothing. the embedded pdf bill calls this 'emergency services'.
My guess is that ER facility fee isn't a 'shoppable service' under CMS definitions because it can't be scheduled in advance, but the fact that it doesn't say 'abandon $800 ye who enter here' on the front door IMO should be a crime.
In network hospitals usually can't charge a facility fee, but it will depend on your plan. Honestly, Congress needs to act on this. Most hospitals get Federal funding.
I'm looking at the pdf embedded in the article -- on p5 the 858.92 charge is in the 'in net medical/rx combined' section -- I assume that means it's an in-network charge?
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[ 1.7 ms ] story [ 165 ms ] threadWhat nonsense.
This argument is effectively charging a rent without the consent or agreement of the renter (the community).
If the service were reasonable, the community would agree to them. They are not, so the hostipital instead games the insurance system and preys on individuals without the resourses/ability to defend against their predation
Does anyone have a good one?
https://www.kff.org/health-costs/issue-brief/americans-chall...
https://insights.som.yale.edu/insights/why-is-healthcare-so-...
So where does the money go? Is it going to treat people who end up not paying? Is it going to buy expensive diagnostic equipment?
Where does it go? No one seems to know.
Hospitals deal with thousands of things. Their overhead and complexity are high. This leads to inefficiency which costs more.
I've read that the math around the costs map fairly well to the cost models around factories [1].
[1] https://www.amazon.com/Innovators-Prescription-Disruptive-So...
Making all of this predictable, transparent, and detangled is only step one. Hitting people -- actual humans -- with fraud charges is also a grand idea.
For example, many procedures at a hospital lose the hospital money. They don't cover the cost. Other things cost more and make up the difference.
Another element is that most US hospitals are very inefficient in what they do. In the book The innovator's prescription you can read the technical details on how those inefficiencies happen.
I don't want hospitals to make a profit, or generate revenue. Every procedure should be losing money.
Even communist systems had budgets and financial rules.
That was entirely my point.
It's called promoting the general welfare and it's one of the primary roles of governments. Clearly private institutions are failing.
2. Never use it because even though you have no idea what you're going to be charged, you know it is going to be outrageous, even though you have insurance to cover medical bills
What a racket...
1. Buy an inexpensive high deductible insurance plan to cover only emergency expenses.
1.1. Make sure that for your plan out-of-network expenses count toward your oopm.
(1.2. Cry because your employer's health plan doesn't work for this.)
1.3. Have enough cash liquid to cover your oopm.
2. Max out your HSA contributions.
3. Pay cash for everything.
Sans 1.2. this has been working reasonably well for me. You would be amazed at the discounts you get once you say you're paying cash. Medical expenses suddenly are downright reasonably priced.
tl;dr Surprise! Everything is cheaper when you have money. Oh America.
Anecdotally I found this to be true with prescriptions. I didn't even ask for one but as soon as I told the pharmacist I was paying cash he said, "Oh, let me apply the coupon for you." and gave me a 20% discount. It was already a cheap generic but I wasn't going to complain.
For example, to have a child's broken arm evaluated and casted in a Mexico capital city is less than $100, total. Annual cost of living for a family of four is $25k-30k/US.
EDIT: I know the U.S. healthcare system isn’t a totally free market. We’ve designed a system that isn’t government run but has mandates like ERs having to see patients. Half the country labels anything that isn’t government run as free market and anything that is government run as communism. These are proxy words.
If you want a healthcare system that isn’t government run but that has a semblance of “free market” in it but that also “treats” most people this is what you get. Well, it’s what our system has morphed into.
Most people talk about ideas and politics without getting into the technical details of what's happening.
The Innovators Prescription[1] is written by 3 PhD's (2 in medical and running institutions and one in business) who provide an analysis as part of the book.
[1] https://www.amazon.com/Innovators-Prescription-Disruptive-So...
Strategic ambiguity around “freedom” “free market” etc is a useful tool to prevent change. It creates a self reinforcing mythology in peoples heads and enough confusion about reality that blaming the victims for being “unprepared” can exist in the broad/abstract while also still feeling empathy and dying “that’s bad” in individual cases.
The problem with US healthcare is not that it's private, it's that it's more expensive than it has any right to be.
A private system with a good framework of regulation would be good.
Tons of heavy regulation everywhere limiting supplies of doctors, nurses, ability for folks to see pricing info, for pricing info to matter etc. Consumer of the service often is not the one paying. So you can do crazy stuff like make an insurance co pay $10,000 per pill for something that overseas no one would ever pay that because they'd be paying themselves.
I've been in third world countries, cash pay places, no insurance, no govt stuff. You can call and ask how much something will cost, they tell you, you go, pay and done.
My bills in California have like 10 pages of notices and warnings on them for each charge. So it's a 5 page document per copay. Its crazy.
Makes it hard to discuss because people use the same phrase to mean completely opposite things.
Yeah, the rent seeking in medicine is insane.
Just residency slots are so hard to get these days.
DMV is quite good in my state. The Postal Service does an outstanding job of delivering packages. NIST and the Park Service provide great benefits to the nation. The U.S. military is government run and it does a great job at destroying organized state power. Should we privatize all of these organizations? How about privatizing the court system? Do you really want to live on Ferenginar?
Hollywood caricatures should never underpin your understanding of economics.
Plenty of agencies in numerous nations have proved this out, but folks continue to have onanistic John Galt fantasies instead.
There are many people in government trying to do a good job and many who aren't, just like private industry. I recently spent <15 mins at the DMV to get a vehicle title transferred and it was a very efficient process (granted I spent more time in the car as there aren't offices in every town).
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Perhaps you should talk to your local representative about the DMV's funding. There was a recent post to HN about how the FDA only has 10 employees to do declassification of documents, of course they will be slow at doing that. I wonder how many employees/per capita works at your DMVs.
I certainly disagree with you that it being a market is the problem, but I think one can consider downsides to that pretty straightforwardly: the lack of price elasticity when you’re dying makes markets price poorly, discouraging people from healthcare is a societal bad, etc.
The idea that there should be a market but that it should not be free is something I just find really problematic since it’s just a steal-from-everyone-to-enrich-medical-barons thing.
If you don’t want to have the freeness argument then perhaps choosing other phrases will help. If you do want to have that argument, obviously you’ll find yourself discussing whether or not the market is free.
Don't they realize you've suffered enough watching Season 8 six times?
The patients in these stories seem well-intentioned and well-prepared. They double check that their doctors are in-network. They triple-check what charges they should expect. But there's always a gotcha. There's always some hidden, between-the-lines reason hospitals come up with to charge you, and insurance won't cover. In one story, the surgeon invited an out-of-network surgical assistant into the surgery, without notice. In another [2], the labor and delivery department was classified as an ER, for a completely routine delivery.
When these charges are dismissed, it's always because NPR reached out for comment, and the hospital backs down, presumably because of the bad PR.
The unpredictably and seemingly arbitrary nature of medical charges makes me feel... queasy. And scared to seek medical help, which I know is what insurance companies want. Even with great insurance, which I'm lucky to have, it feels like there's nothing I can do to prevent medium-to-insane charges. The only way I can think of to try and combat medical billing is to retain a lawyer.
[1] https://www.npr.org/series/651784144/bill-of-the-month
[2] https://www.npr.org/sections/health-shots/2020/07/22/8919096...
[3] https://www.npr.org/sections/health-shots/2021/10/27/1049138...
> Martand received almost no medical service. A nurse practitioner looked over the toddler, listened to his heart and stomach, and looked in his nose, mouth and ears, according to provider notes prepared by the hospital and shared with KHN by Bhatt.
> The nurse didn't change the dressing on the wound or order any testing.
> Emergency visits are usually classified for billing on a scale from 1 to 5. Level 1 is minor and routine; Level 5 requires complex care for life-threatening conditions. [...] Despite the lack of severity of Martand's wound and the absence of medical care, his visit was classified as Level 3, a moderate severity problem.
> In an email, Zoller Mueller said the charges were "appropriate" based on the "acuity of condition, discharge instructions, vital sign monitoring, traumatic wound care [and] numerous assessments."
> She added: "A patient does not have to receive additional treatment — procedure, labs, x-rays, etc. — to validate an ED [emergency department] level charge."
The problem with this system is they act like everything is fine after they drop their claim, but what needs to happen is people going to prison. This is large-scale white collar fraud and it should be getting much more media attention than some guys stealing shampoo at the Walgreens.
The people getting service often are not ones actually paying (insurance pays, medicaid, medi-Cal etc).
The whole billing thing can be pretty darn maddening for providers as well.
There is absolutely no public pricing.
One thing I couldn't stand. A bunch of policians want to talk about how much money various govt programs save. So they do things like lower of cost or contract (penalizes you if you deliver to much service for same price) or some % of your charge sheet (ie, 50%). If 90% of your patient load is going through these programs, you basically have to set your cash pay charge to 2x it's normal cost, so that all these players can then report "savings".
The reality is there should be a cash pay DISCOUNT, you pay 80% if you pay in cash. But all these programs will not pay more than cash pay even though the overhead of dealing with them is massive. Ie, probably should pay 110% of a reasonable rate.
Also, surely there's a hefty opportunity for someone to be providing a service to audit and reduce bills for x% of the reduction?
My wife got a 4k bill that had no information on it other than the amount due. I called the hospital and asked what the bill was for and they said they would send an itemized bill, they never did, but I did get a letter from collections and I called them and said that I dispute the charges. And I never heard anything about it again.
I had a family member get seriously ill and we racked up a ton of medical debt. There was no way in hell we could have paid it off and continued to live on one salary.
Filed for bankruptcy, and two years later started off with a clean slate. Honestly credit was back into the 700's, bought a new car and a new home two years later.
It's important, however, that your heirs understand this and don't say or do anything that can later be construed as having accepted the debt.
1. Social programs can start regionally. There's a refrain you hear continually that if, say, California were to institute a socialized health insurance system it would immediately collapse because all the "takers" would move there (absent border control) to drain its resources. Yet that's how socialized health insurance developed in Canada - it was driven by the province of Saskatchewan, which had hospitalization insurance a full decade before any involvement by the federal government. To say that regional social programs are doomed to fail is simply against historical fact. This is how federalism is supposed to work! Experimentation is done at smaller scale and success bubbles up.
2. Doctors are the enemy. This was surprising to me, because I'm friends with a good number of (residency) doctors and all are very passionate about health equality. Maybe their opinions will change once that private practice money starts rolling in, I don't know. But basically organized medicine has opposed socialized health programs in every country they have been tried - an interesting counterexample to the idea that labor organization will per se lead to better social outcomes.
3. Liberals won't get it done (and might make things worse). This makes sense if you view it as a negotiation: socialists need to be pushing hard for radical change in order for the final product to land somewhere in the middle. If you're talking about the need for moderation at the beginning of negotiations, you've already lost. A good litmus test to tell whether someone is serious about healthcare reform or just making impotent gestures in its direction.
4. Socialized healthcare means more than free access to care. In retrospect this one is obvious, but I somehow had missed it. Just having access to healthcare doesn't actually make you healthy. The social determinants of health are much more powerful than going to the doctor once years of poverty have already taken their toll. The scope very quickly expands and you start talking about housing access, food access, and just economic equality generally.
[0] https://arpbooks.org/product/radical-medicine/
[1] https://youtu.be/g4_v2701GMg
The point about liberals is very true, not only about health care. Just like the current president, they're elected to find a compromise, which essentially guarantees that nothing important will be done. They're in effect a tool of the very wealthy to placate or dishearten the population, disconnecting them from the democratic process. In contrast, right wing politicians are very effective in achieving the goals designed by their elites.
I’d agree that universal health care probably wouldn’t come about incrementally, but there is no fundamental reason we can’t improve the system incrementally.
I'm getting a bit tired of these anti-US healthcare posts day after day. Sure, there are some issues, but this is starting to feel like reformist propaganda. I, for one, am very happy with the current system and don't understand why anti-government activists want to hand the government the keys to run the healthcare system.
The data is very clear Americans pay the most for healthcare out of every other OECD nation and yet receive worse outcomes [2].
[1] https://ajph.aphapublications.org/doi/10.2105/AJPH.2018.3049...
[2] https://www.pgpf.org/blog/2020/07/how-does-the-us-healthcare...
Because it mostly leads to more efficient healthcare systems. For example, the per-capita healthcare cost in the UK is less than half that of the US for broadly similar outcomes.
The ER visit ultimately cost $38.92, after:
1. He tried to negotiate the bill: "Dhaval Bhatt made numerous attempts to get the hospital to reduce the charges. He also appealed to UnitedHealthcare to review the charges."
2. The hospital refused: "His efforts failed....the hospital would not adjust the bill."
3. The hospital sent his bill to collections: "While Bhatt was trying to reach the patient advocate by phone, his bill was sent to Medicredit, a collection agency, which began sending him notices and calling him."
4. The hospital forgave the bill due to bad PR: "After KHN [Kaiser Health News] contacted SSM Health, Bhatt received a call from someone who worked on "patient financial experience" issues at the hospital. The hospital agreed to forgive the $820 facility fee."
> The system worked out exactly as it should have.
Could you clarify?
Just because it worked out "this once" doesn't mean it works out in general.
Simple fact of the matter is we pay nearly double per capita what most of Europe, Canada and Australia pays for healthcare, and we don't even have universal coverage. Add in the fact that a majority of bankruptcies are due to medical debt and it paints a pretty damning picture overall.
This system is fundamentally broken. Anyone defending it is either willfully ignorant or shielded from it's worst aspects.
$38.92 for a medical assistant spending 1 minute to take your temperature works out to $2335/hour.
The article is not arguing for government control. Rather that medical services should be subject to the same transparency as any other professional business and without collusion with each other and insurance providers.
(per this https://www.cms.gov/nosurprises/Ending-Surprise-Medical-Bill...)
The hospital in the article has a price transparency page here https://www.ssmhealth.com/resources/patients-visitors/pay-my... (behind multiple TOS of course). It seems to use epic / mychart. I used it to search for 'facility' and 'emergency' and got nothing. the embedded pdf bill calls this 'emergency services'.
My guess is that ER facility fee isn't a 'shoppable service' under CMS definitions because it can't be scheduled in advance, but the fact that it doesn't say 'abandon $800 ye who enter here' on the front door IMO should be a crime.
this thing https://s3.documentcloud.org/documents/21177150/january-2022...