What I learned from reading a thousand emergency room bills • Hacker News Board

Re: What I learned from reading a thousand emergency room bills

#201

Post by krupan » Wed, Dec 19, 2018, 10:25 PM UTC

mulmen wrote: post #151

cabaalis wrote: post #57

Earlier quoted context omitted.

> You simply don't get to "shop around" for emergency services You do actually, by where you choose to live and also by the services as detailed in [1]. I think there's merit to investigating public health care. That line stops for me in eliminating private care. 1] https://www.theatlantic.com/technology/archive/2018/11/kim-k...

"Move to a better market" seems like an argument that some local marketplaces have failed. The whole value proposition of the free market is that it improves the available services and prices through competition. If I have to move somewhere else to find a market where this is true then the local market is clearly failing and the free market idea doesn't work. Said another way: Should I then also move when I want to f…

I mean, I know people that moved away from Hawaii precisely because they couldn't afford the milk there.

Believe it or not there are people who move into cities because of better fire departments, police departments, etc.

Re: What I learned from reading a thousand emergency room bills

#202

Post by CWuestefeld » Wed, Dec 19, 2018, 10:25 PM UTC

rootusrootus wrote: post #154

briandear wrote: post #143

Earlier quoted context omitted.

The problem with single payer is that it results in shortages. Look at waiting lists for the NHS, especially for mental health or routine surgery. That is a direct consequence of single payer. An unpopular view, but it is a fact.

I am skeptical of a causal relationship there. In the United States, approximately 2/3 of healthcare costs are already borne by the government. My parents are both enrolled in Medicare and they are very satisfied. Why would it not work if we just dropped the eligible age for Medicare to zero? Hasn't this been extensively studied recently?

In many cases, Medicare doesn't even cover the actual cost to provide the service. The providers make up the shortfall by charging other patients more - including charging uninsured patients a LOT more.

So if everybody was covered by Medicare, either the providers would be going bankrupt left and right, or the Medicare reimbursements would have to rise - i.e., the price to the government would increase, and the only thing to do about that is to pass it on to the taxpayers.

It's a common misconceptions that Medicare is more efficient than commercial insurance, because on paper it looks that way. But in fact they're hiding their administrative expenses by forcing the providers to do much of their bookkeeping. (Source: my wife used to manage the department in the hospital that did that Medicare financial stuff)

Re: What I learned from reading a thousand emergency room bills

#203

Post by vkou » Wed, Dec 19, 2018, 10:25 PM UTC

vec wrote: post #181

bluGill wrote: post #127

Earlier quoted context omitted.

We do not have a free market. Most people get their health insurance from their employer - you cannot reasonably get insurance elsewhere (the same plan I have now for $100/month would cost over $1000/month, but I can't take that $1000/month to anyone else if I don't like my insurance so I accept it). This keeps me from taking a long leave of absence to live off my savings - until I quality for retirement (medicare).…

> We do not have a free market. Most people get their health insurance from their employer - you cannot reasonably get insurance elsewhere What you are describing are in fact the freest parts of the health insurance market. Employers, quite rationally and of their own free will, choose to offer health insurance as a benefit because it attracts and retains talent better than other similarly priced incentives. The fact…

And the reason that healthcare costs $1,000/month, is because this system has caused prices to spiral completely out of control, beyond the level of lunacy. Due to multiple agents in the market behaving of their own free will.

Every other developed country manages to provide equivalent care for a fraction of the price. So much for the free market optimizing for better outcomes, eh?

Re: What I learned from reading a thousand emergency room bills

#204

Post by ptaipale » Wed, Dec 19, 2018, 10:26 PM UTC

heavyset_go wrote: post #66

UnpossibleJim wrote: post #26

Earlier quoted context omitted.

Exactly. It's the same reason we don't have free market police and fire services. You simply don't get to "shop around" for emergency services, which includes privatized ambulance services (which are outrageously expensive, on the order of $12,000 for the ride I took when I had to take one, and it was a relatively benign one... thank god I had insurance). EMS is covered, but that's the Fire Department. After that, it…

The history of private firefighting is a particularly dirty one. In the past, fire companies would show up and demand payment before putting out fires. If a payment couldn't be made, the company might negotiate the purchase of the burning property at a steep discount. Later, insurance companies hired brigades to only put out fires on insured properties. Fire companies might have fought or sabotaged one another in ord…

Not everywhere, though. In Denmark, private operators have been handling emergency services since 1926; currently one company (Falck) is handling 65 percent of municipal fire brigades and 85 percent of ambulance services. No particular nastiness has been reported afaik.

Re: What I learned from reading a thousand emergency room bills

#205

Post by rootusrootus » Wed, Dec 19, 2018, 10:28 PM UTC

dragonwriter wrote: post #161

rootusrootus wrote: post #154

Earlier quoted context omitted.

I am skeptical of a causal relationship there. In the United States, approximately 2/3 of healthcare costs are already borne by the government. My parents are both enrolled in Medicare and they are very satisfied. Why would it not work if we just dropped the eligible age for Medicare to zero? Hasn't this been extensively studied recently?

> In the United States, approximately 2/3 of healthcare costs are already borne by the government. Less than half; US healthcare spending was around 8.5% GDP public, 8.8% GDP private in 2016. https://www.healthsystemtracker.org/chart-collection/health-...

I've heard the 2/3 number (sometimes a little less, most recently slightly over, 68%) from a few reputable sources recently. At the same time, I generally consider Kaiser pretty reliable. I think the discrepancy comes from what is being included in the total -- all costs, direct payments only, tax subsidies, etc. At least from what research I've done.

Even if we take the value to be 50%, my point stands -- the gov't is already heavily involved in funding healthcare in this country. Implementing single payer at this point would simplify quite a lot of bureaucracy.

Re: What I learned from reading a thousand emergency room bills

#206

Post by ams6110 » Wed, Dec 19, 2018, 10:28 PM UTC

PhasmaFelis wrote: post #130

cabaalis wrote: post #57

Earlier quoted context omitted.

> You simply don't get to "shop around" for emergency services You do actually, by where you choose to live and also by the services as detailed in [1]. I think there's merit to investigating public health care. That line stops for me in eliminating private care. 1] https://www.theatlantic.com/technology/archive/2018/11/kim-k...

> I think there's merit to investigating public health care. That line stops for me in eliminating private care. Has anyone proposed that? If not, I'm not sure why you mentioned it. Anyway, I suppose I can see the benefit to private doctors, but if private emergency response services for individuals are popular, then something is fucked, as your link demonstrates. Not saying they should be banned, but they shouldn't…

Yes, many people who advocate for "single payer" intend that to mean eliminating any private-pay option.

Re: What I learned from reading a thousand emergency room bills

#207

Post by vec » Wed, Dec 19, 2018, 10:28 PM UTC

krupan wrote: post #190

Let's be careful to not look at one type of health care, emergency care, and generalize to all types of health care. Right now we all (Americans at least) don't really have insurance. We are part of pre-paid health clubs and we try to use the health club membership to pay for everything. For true time-sensitive emergencies we should all have traditional insurance, and yes, the services should probably be supplied, li…

This works reasonably well for things like vision care because they're entirely opt-in. Patients who aren't satisfied with the prices they're being quoted can realistically choose to keep wearing glasses instead.

No one in their right mind is going to decide that the going rate for chemotherapy is a little steep right now so they're going to sit with the cancer for a year or two and see if the prices come down.

Re: What I learned from reading a thousand emergency room bills

#208

Post by jclay » Wed, Dec 19, 2018, 10:28 PM UTC

wmil wrote: post #109

andrei_says_ wrote: post #101

Earlier quoted context omitted.

What blows my mind is how a nurse costs $5k for the duration of a surgery. Surely the nurse did not make $5k. Where does this money go?

Hospitals are required to treat the uninsured, but the government doesn't actually compensate them for that. So they jack up everyone else's bills in the hopes that enough people will pay that they'll make a profit. Insurance companies will usually push back, so (sometimes partially) uninsured people with decent credit hit with huge charges.

For this reason, I'm beginning to think that we do in fact have "universal" healthcare in that anyone can turn up to the hospital and be treated despite their income. For those who don't pay (or don't have insurance) the hospital spreads that cost out over their other patients and likely marks up the price to insure against non-payment. So we end up with an unregulated mess where any one hospital has to insure themselves (in the form of passing on costs) against the percentage of patients that will simply never pay.

Given that this is going on, why not just switch to a single payer system and spread this out over a much larger population rather than each hospital trying to insure against it?

Re: What I learned from reading a thousand emergency room bills

#209

Post by vkou » Wed, Dec 19, 2018, 10:28 PM UTC

bluGill wrote: post #171

drak0n1c wrote: post #63

Earlier quoted context omitted.

Legislation requiring up-front presented costs to be honored and any additional procedures/costs to be cleared with patient consent as they happen (or a consent waiver obtained from the patient with a promised limit or incentive such as overall discount) might be an improvement. Or it may increase costs for the worse. Who knows.

Careful there though. If a surgeon is operating on cancer and discovers that the tumor is much larger than expected the operation will take longer - be more expensive - or the surgeon does the operation as planned and then charges even more for the second surgery to remove the rest. Or maybe all operations are estimated as the worst case and so you end up with no more clue about what you will pay than today - in some…

> Which is to say don't propose something until you understand the unintended side effects. You can get your desired result but while making everything worse.

I think the American experiment in trying to provide market health care has demonstrated that you can, in fact, have a 'free' market for healthcare, while making almost everything about that healthcare worse.

Re: What I learned from reading a thousand emergency room bills

#210

Post by tivert » Wed, Dec 19, 2018, 10:29 PM UTC

manfredo wrote: post #150

aidenn0 wrote: post #97

Earlier quoted context omitted.

In that article he specifically laid out the scenario of a vaginal birth with no complications.

But the hospital doesn't know if the birth is going to be uncomplicated until it actually happens. If the hospital gives out only a projected price, then it could lure people into false sense of security. A non binding price is effectively ad worthless a no price.

> But the hospital doesn't know if the birth is going to be uncomplicated until it actually happens. If the hospital gives out only a projected price...

The hospital can totally give a realistic, projected price: It can know what the probability of a complicated birth will be, and it is also able to amortize that over all the uncomplicated births.

There's no sane public-policy reason it should be structured like a reverse slot machine: you pull the lever, get a fixed prize, then find out how much you'll pay for it.