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

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

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Post by newyankee » Thu, Dec 20, 2018, 12:32 AM UTC

wyldfire wrote: post #186

newyankee wrote: post #162

Earlier quoted context omitted.

Isn't there something like generally accepted accounting principles in healthcare ? Genuine question if anyone knows the answer.

IIUC, much of healthcare billing in the US is governed by discrete codes for services performed. I suspect this allows big customers like Federal Gov't & insurers to audit bills easier. In order to either be more specific about the bills or allow less wiggle room, they made these codes remarkably more specific recently (ICD-10 [1]). IMO the descriptions of the items in these codes are humorously specific. Imagine if…

Interesting. Well the thing is if people really are motivated enough they will always find a way to skirt certain types of regulations.

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

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Post by jspiral » Thu, Dec 20, 2018, 12:33 AM UTC

SilasX wrote: post #159

manfredo wrote: post #83

Earlier quoted context omitted.

Realistically, no hospital is going to give out a price. They don't know what unexpected complication may arise that requires additional services.

Realistically, no airline is going to give you a price for transit to a destination. They don't know if there will be a terrorist attack or if the baggage handlers on the other end will jack up their rates.

I like the spirit of this. However, what the airline is really willing to price is "best effort to provide transit to location either beginning the time stated or as soon as convenient for them after". Fortunately, their operations are predictable enough that most customers are fine with this.

That's not quite enough scope control for all services.

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

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Post by fencepost » Thu, Dec 20, 2018, 12:37 AM UTC

ThomPete wrote: post #320

ThomPete wrote: post #303

Earlier quoted context omitted.

Scandinavia is different than the rest of europe and they dont have 11 million illegal immigrants too. Belive me i know both places pretty intimately.

How on earth can can i get downvoted for saying what is true?

You can get downvoted by sounding like a knee jerk racist. Go spend a little time looking into where healthcare money is actually being spent and written off as bad debt in the US then come back with numbers and sources. If you can back up that illegal immigrants are the source of healthcare cost issues in pretty sure we'll all be impressed.

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

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Post by CWuestefeld » Thu, Dec 20, 2018, 12:43 AM UTC

rootusrootus wrote: post #264

CWuestefeld wrote: post #202

Earlier quoted context omitted.

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…

That is a pretty bold claim, can you cite someone more authoritative than your wife? Kaiser, who has a plausible claim to expertise in this field, puts the overhead cost of Medicare at 2%. The raw number is more like 1.4% but Medicare does get to piggyback a lot of the administrative workload on Social Security so perhaps that is why Kaiser's number is higher. Insurance industry advocates, who are incentivized to pro…

Kaiser, who has a plausible claim to expertise in this field, puts the overhead cost of Medicare at 2%.

This is exactly what I'm talking about. I'm sure that number is accurate, if you're looking at Medicare's books. I'm telling you that when you look at the way Medicare forces the industry to handle their charges, it makes the industry much less efficient, both in terms of administering the provision of care to Medicare's "customers" as well as more generally across how the industry handles its accounting in general.

Every hospital (and skilled nursing facility) has a small team of people whose job is to compile the statistics that Medicare demands, and report it annually in what's called "The Medicare Cost Report". Add up 1 or 2 or 5 FTEs across every hospital and SNF facility in the country, Medicare's claimed efficiency is quickly turned upside down. There is some work that providers have to do for other payers, but its scale doesn't approach the order of magnitude of what Medicare forces. This isn't a matter of opinion (like my wife's); this is absolutely factual and objective.

It gets even worse than that. Because the care paid for by Medicare together with that of Medicaid (which is a separate program, but rides on Medicare's coattails for a lot of its reporting mechanics) dwarfs any private payer, hospital information systems (at least the parts that deal with finance) are structured around the way statistics need to handled for Medicare. That squeezes out the ability to do any more traditional cost accounting. This is the reason that the fee for a given service varies so wildly from hospital to hospital: because they're not doing normal cost accounting (but instead tracking Medicare statistics) the don't actually have a good idea of what any given thing costs, so their fee schedules are all over the place. (I'm generalizing here, there are hospitals that do it better, but my anecdata from hospitals we've had close association with show that this problem is quite widespread.)

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

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Post by __jal » Thu, Dec 20, 2018, 12:49 AM UTC

justtopost wrote: post #227

neurotrace wrote: post #98

Earlier quoted context omitted.

A lot of people don't get much choice in where they live.

Are they on felony probation? I have moved a few times with little money for better opprotunities. It seems like most people are just psychologically conditioned to die near where they were born. Most people just think the hardship is worth it, which is very much a choice. It is literally cheaper to move to most of the USA than live another month in places like california or nyc.

This ignores a huge array of practical reasons why people stay where they are.

Family networks are probably the number one reason. Child/elder care, food/housing/etc. sharing and a lot more are all major factors that by definition do not show up in economic reports.

And that's before people's "psychological conditioning" (which some people refer to as "being part of a family") is considered.

I, too, have moved around a lot - across the US three times, overseas and back once, with smaller cross-state moves in between. And it has worked out for me. I am also not married, have no kids, am not very close to my family, have a high degree of risk tolerance and high attraction to novelty, and seem to need a smaller community of folks in my life than many others.

I'm also well aware that I am an abnormally-unattached person. Most people have significantly more difficulty uprooting and moving somewhere else. Writing that off as conditioning that interferes with economic concerns not only fails to recognize very real economic aspects that don't show up a bank account, but also fails to recognize that humans value things other than money.

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

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Post by wisty » Thu, Dec 20, 2018, 12:50 AM UTC

crasch4 wrote: post #308

vec wrote: post #14

Exhibit A for why "free market healthcare" is an oxymoron. I have yet to hear a coherent explanation for how anyone can reasonably expect for price discovery to even pretend to function in a market where the consumers can't even guess the prices until after they've already purchased and frequently couldn't reasonably be expected to refuse service even if they did believe it was overpriced.

Price discovery is indeed difficult in the current market. However, the current healthcare market is no where close to a free market. For example, suppose you wanted to start a hospital that offered price transparency, like the Surgery Center of Oklahoma does. (1) In thirty-five states and the District of Columbia, you'd first have to acquire a certificate-of-need (CON) from the state healthcare regulators. In order…

Theory of the second best - https://en.wikipedia.org/wiki/Theory_of_the_second_best

Basically economics talk for how the second best solution might not be close to the best solution (i.e. there are local maxima).

A perfectly free market might be theoretically best, but socialised healthcare might be better than a badly regulated private system.

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

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Post by Gibbon1 » Thu, Dec 20, 2018, 12:51 AM UTC

ptaipale wrote: post #204

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…

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.

The US has lots services that are provided by regulated monopolies. My garbage company, power company are all regulated monopolies. A key thing is you're required to have garbage and power service but the rates are negotiated by a public utilities commission or the city or county.

However Healthcare in the US isn't a regulated monopoly like that.

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

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Post by jopsen » Thu, Dec 20, 2018, 12:52 AM UTC

crasch4 wrote: post #308

vec wrote: post #14

Exhibit A for why "free market healthcare" is an oxymoron. I have yet to hear a coherent explanation for how anyone can reasonably expect for price discovery to even pretend to function in a market where the consumers can't even guess the prices until after they've already purchased and frequently couldn't reasonably be expected to refuse service even if they did believe it was overpriced.

Price discovery is indeed difficult in the current market. However, the current healthcare market is no where close to a free market. For example, suppose you wanted to start a hospital that offered price transparency, like the Surgery Center of Oklahoma does. (1) In thirty-five states and the District of Columbia, you'd first have to acquire a certificate-of-need (CON) from the state healthcare regulators. In order…

Arguing that the current market isn't free, isn't an argument for why a free market healthcare system would work.

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

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Post by Fomite » Thu, Dec 20, 2018, 12:57 AM 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.

In addition to what other people have said about the impracticality of assuming choice, said hospitals will often not offer the same set of services, or will specialize in certain aspects of them.

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

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Post by sjg007 » Thu, Dec 20, 2018, 12:57 AM UTC

y-c-o-m-b wrote: post #245

sjg007 wrote: post #41

Earlier quoted context omitted.

You can try to appeal it.

Appealed twice and both times they denied it stating I didn't require the surgery despite the fact they pre-approved it and paid for all the in-network costs. I ended up paying it because I had the money and I couldn't handle the stress of a legal battle (which given what I've read is an uphill battle).

Sorry to hear that.. you can usually appeal up the food chain sometimes.. e.g. to your states insurance department if the plan is regulated by your state. And at the Federal level you can also submit a ERISA appeal. None of it is fun and then there are deadlines... Also if you are on an employer provided insurance plan, you can talk to your HR who will have an insurance rep who can sometimes make these things go away e.g. get them paid. If you are at a large employer that self insures and uses a third party admin (like Cigna) then they can tell the admin to negotiate with the doctor/hospital and pay it.