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

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

#231

Post by mandevil » Wed, Dec 19, 2018, 10:39 PM UTC

tgsovlerkhgsel wrote: post #62

Want to do something about it? Regulate it. Like literally, have some government body write a table: 1 pill of 400 mg paracetamol ............ $0.50 1 pill of 800 mg paracetamol ............ $0.60 prescribing medicine (once per day) ..... $4.32 base fee for an ER visit .............. $200.00 5 minutes of work by an ER physician ... $27.43 etc. and impose that as the maximum price that can be charged. It's not going t…

This probably helps but is not the sole solution. The state of Maryland has done this for 40 years and they have some of the highest Medicare hospital prices in the country. The problem seems to be consolidation: Johns Hopkins has gobbled up most of the other hospitals in the state, and so has significant control over prices.

(Source: my wife worked at a rural hospital on the border in a neighboring state.)

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

#232

Post by manfredo » Wed, Dec 19, 2018, 10:39 PM UTC

SilasX wrote: post #177

manfredo wrote: post #167

Earlier quoted context omitted.

A terrorist attack is an extremely low frequency event to the point is being nearly non-existent. The same cannot be said of birth complications. Baggage handler rates don't change on a dime. Labor rates do affect ticket prices, but they're drastically more predictable.

Yes, but the same logic applies: you either negotiate prices out with a network in advance, or insure against the major complications. None of that is different for a health care operation.

No. The same logic does not apply, as the two situations are drastically different. The regularity of airline costs is drastically greater than the regularity of healthcare costs. Airlines can set ticket prices upfront because they predict their expenses on a given flight with a reasonable degree of accuracy. Hospitals, subject to extreme and frequent irregularities between what patients may need, cannot. At least not with individual patients. Insurance companies are very different types of customers as compared to individuals. Because the negotiated price applies to a large group of people, the question isn't "how much do we have to charge to break even on X procedure?" The question becomes, "How much do I have to charge for X procedure, *averaged over hundreds or thousands of patients?". Each patient is effectively a slot machine for the hospital. Insurance companies negotiate on behalf of a large number of patients so that the aggregate cost becomes something that is predictable enough to negotiate.

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

#233

Post by rootusrootus » Wed, Dec 19, 2018, 10:40 PM UTC

bluGill wrote: post #184

rootusrootus wrote: post #80

Earlier quoted context omitted.

I find myself in the same boat. I've spent more from my HSA this year than I put into it (and I put in $6900) while I'm nowhere near hitting my deductible ($6K) because for whatever reason the insurance only thinks I've spent $2.7K. During this time I've tried to shop around, find the least expensive option (none of my medical needs this year have been urgent) and it's been impossible. Nobody can tell me. "You'd have…

Not enough people actually tried to do what you did, so the high deductible plans didn't provide the desired result. I think they could, but more people would need to be in them and try to do what you did. It needs to be enough people to eliminate the problem where insurance companies like the system being too complex because then you use them instead of paying for it our of pocket.

High deductible health plans are close to half of all policies now (in 2017 it was 43.2% according to the CDC).

Insurance companies clearly have nothing to worry about. I might be able to put in extra effort to negotiate my costs down by paying out of pocket, but then it would not count towards my deductible or out of pocket maximum. Even with HDHP, I am still clearly incentivized to just pay whatever the insurance company thinks I should.

It's a great racket to be in, really. They can negotiate the pricing in advance so that they appear to be useful in making my costs lower, while not actually incurring any costs other than paperwork. They hold all the cards and they have captured the regulatory authorities.

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

#234

Post by krupan » Wed, Dec 19, 2018, 10:41 PM UTC

CWuestefeld wrote: post #202

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 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…

This should be a highlighted comment in this discussion. My dad just retired and shut down his medical practice. He hated Medicare as a doctor (OK, my words, not exactly his), but now that he's using it as a patient he can see why people like it so much. It really isn't going to work like it does now if it becomes the only option for everyone.

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

#235

Post by munk-a » Wed, Dec 19, 2018, 10:42 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…

"Move to a better market" also fails with regards to the fact that you may need the services when not at home. If you were working in sales would you refuse to do an onsite meeting with a client because their office is near a terrible hospital?

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

#236

Post by ASinclair » Wed, Dec 19, 2018, 10:43 PM UTC

Verdex_3 wrote: post #126

duxup wrote: post #39

Earlier quoted context omitted.

Anecdotal illustration time: Both my kids were born early. The medical bills for both totaled (with hospital stays for babies and mom) north of 100k each, the second WAY north. Both involved situations that were "emergency" type situations. We couldn't shop around, we couldn't even sign anything. We trusted the hospitals and doctors and went from there. Fortunately I had good insurance, if for some reason I had to pa…

I think pregnancy and labor is what's going to finally break the camel's back. Having children is a pretty basic part of being human. And the costs are such that even millionaires are going to feel it. When basically nobody can afford to participate in reproduction, something is going to go sideways. With my "good" insurance, I still ended up with a multi-thousand dollar deductible. Which I thought was problematic un…

> Which I thought was problematic until I started hearing about people who have high deductible plans that only make you pay 20% after hitting your deductible.

If I'm not mistaken, those plans also have an Out-of-Pocket Maximum. So you pay 100% up to your deductible, then some fraction of the cost above that until you hit the OOP max.

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

#237

Post by gumby » Wed, Dec 19, 2018, 10:44 PM UTC

TheOtherHobbes wrote: post #132

heavyset_go wrote: post #66

Earlier quoted context omitted.

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…

These scams were happening at least as far back as Roman times. Supposedly Crassus, the richest Roman of his day, made rather a lot of money like this.

Crassus's 6000 crucifixions in just one of his wars helped people take his threats seriously.

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

#238

Post by ttcbj » Wed, Dec 19, 2018, 10:45 PM UTC

rhexs wrote: post #152

rootusrootus wrote: post #80

Earlier quoted context omitted.

I find myself in the same boat. I've spent more from my HSA this year than I put into it (and I put in $6900) while I'm nowhere near hitting my deductible ($6K) because for whatever reason the insurance only thinks I've spent $2.7K. During this time I've tried to shop around, find the least expensive option (none of my medical needs this year have been urgent) and it's been impossible. Nobody can tell me. "You'd have…

Do any doctors actively campaign to change these billing practices? Bogleheads.org seems to have quite a few Docs that post there, and the attitude is mostly "I went into medicine to practice medicine / Gee, I don't bill at all, I leave that to the hospital" and other great flippant attitudes. Probably a poor community to judge the standards of medicine by as it's mostly a 1%er forum that happens to have some good ad…

My wife is a pediatrician at a large research university/med school. She is totally uninvolved in billing. She has no idea how much anything costs. She is aware of it as an issue, but its a giant organization, and the reality is she isn't going to try to fight the power.

Personally, I don't think doctors are the answer. I used to really like the idea of high-deductible. But eventually, I just came around to the idea that only the gov't can fix it (with lots of tradeoffs in that fix, obviously).

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

#239

Post by gumby » Wed, Dec 19, 2018, 10:45 PM UTC

bluGill wrote: post #142

ademup wrote: post #103

Earlier quoted context omitted.

Although most humans are perfectly ambulatory, there are innumerable reasons why they don't get to "choose where to live". Income levels, employment availability, schooling, racial pressure, and many more factors come in to play. Not everyone can physically fit into the best areas. The best areas for emergency services don't necessarily align with the best education (although very high income levels tends to align wi…

True to an extent, but in any city (100,000 or more people) there will be two hospitals and so the poor can choose which of the two to use. Note that by poor choosing only a small number need to have the practical ability (which is to say the almost middle class) to choose since a hospital will want to attract them and that ups service for everyone even thoose who couldn't reasonably get to the other hospital.

You rarely have this choice in practice. Plus, as the article points out, even if you chose an in-network hospital you may well be seen by an out-of-network doctor.

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

#240

Post by manfredo » Wed, Dec 19, 2018, 10:46 PM UTC

tivert wrote: post #210

manfredo wrote: post #150

Earlier quoted context omitted.

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 re…

If it's a projected price, then the original commenter is still screwed if the birth becomes complicated. It's still a slot machine. Furthermore, it would incentivize sketchy practices like setting a lower base price than competitors but aggressively discovering (or manufacturing) complications so that the average price is considerably higher than the base price.