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

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

#61

Post by dv_dt » Wed, Dec 19, 2018, 9:20 PM UTC

SlowRobotAhead wrote: post #40

smileysteve wrote: post #35

Earlier quoted context omitted.

Because, then the single payer, can say "your policies/prices don't work with our system", fix it, or we won't cover any patients, effectively shutting you down.

What is stopping insurance companies from doing that now? If you're paying for insurance, it's in your insurance company's best interest to pay low prices.

Because insurance companies are fighting at both ends. If their payments are too low, their network providers will stop taking that insurance plan or company and then they lose customers for lack of network reach. Also, well-intentioned overhead limit regulations to spend at least 80% of funds on care, creates a countervailing accounting pressure to increase costs so that administrative spending can be higher - flowing more money to the insurance company.

I actually agree w/ overhead limits, but you also need other efficiency metrics to keep the anti-optimization in check. Or, personally I think we should go to some form of universal healthcare and wipe out private health insurance as it's currently constituted.

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

#62

Post by tgsovlerkhgsel » Wed, Dec 19, 2018, 9:20 PM UTC

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 to happen because "omg socialism", but this is literally how other countries handle it. Possibly with a multiplier that the hospital/doctor can apply within certain limits. If you really need to, maybe even allow deviating from it as long as the patient is conscious, in a position to make that choice (i.e. not emergency care), is explicitly informed that this is above the "official" rate, is informed about the rate, and signs off on it beforehand.

And I'd like to point out that this sort of regulation isn't unprecedented in the US either. Taxi prices are regulated this way in many areas. Apparently, transportation is more important and less suitable to be left to a free market than healthcare...

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

#63

Post by drak0n1c » Wed, Dec 19, 2018, 9:20 PM UTC

stdplaceholder wrote: post #38

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.

Even if you ask for the price and even if you get it in writing up front you will still get a different bill later.

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.

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

#64

Post by noja » Wed, Dec 19, 2018, 9:21 PM UTC

jclay wrote: post #54

y-c-o-m-b wrote: post #28

I was a victim of the surprise out of network bill in the Portland, OR area. I did all my research before hand: hospital in network, surgeon in network, etc. but ONE person in that operating room was not in network and SURPRISE i'm out thousands of dollars. The worst part about this is my state passed a bill to stop this prior to my surgery, but the bill's effective date was roughly 3 months later. Talk about bad tim…

Exact same thing happened to my friend. He did all his research, and while he was under anesthesia a nurse assisted that was out of network. $5k out of pocket. He ended up getting it removed after some run around between insurance and the hospital.

Today is "don't believe the comments day" it seems. How is an unconscious person meant to be stop an "out of network" nurse assisting? Is there a tattoo that you can get?

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

#65

Post by kawfey » Wed, Dec 19, 2018, 9:22 PM UTC

I'm patiently waiting to have injuries and sudden symptoms until ER bills become more reasonable and transparent. Until then, if something happens, I guess I'll just die.

-youth of today

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

#66

Post by heavyset_go » Wed, Dec 19, 2018, 9:23 PM UTC

UnpossibleJim wrote: post #26

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.

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 order to win the right to put out a fire and get paid for it.

While it isn't perfect, and it's often underfunded, I definitely prefer the system we have now.

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

#67

Post by cgag » Wed, Dec 19, 2018, 9:23 PM UTC

tivert wrote: post #25

ams6110 wrote: post #5

I'm not an advocate of government paid health care, but hospitals and medical providers should see that this train is coming and if they don't become more transparent it's going to be forced upon them. I don't have a problem with ER care being more expensive -- that isn't necessarily unreasonable when you are getting care in an expensive facility open 24x7, fitted out with equipment to handle any possible medical eme…

> But it is unfair to have no idea what costs you are facing and whether any of those costs are out of network on your insurance. It's practically impossible to make an informed economic decision about truly emergency medical care without heavy regulation. It's not uncommon to be literally unconscious while all the care decisions for you are being made by others. See this article for an example: some uninsured woman…

I would imagine regulation is a lot of what stops competing on price like everything else.

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

#68

Post by manfredo » Wed, Dec 19, 2018, 9:24 PM UTC

wycy wrote: post #46

y-c-o-m-b wrote: post #28

I was a victim of the surprise out of network bill in the Portland, OR area. I did all my research before hand: hospital in network, surgeon in network, etc. but ONE person in that operating room was not in network and SURPRISE i'm out thousands of dollars. The worst part about this is my state passed a bill to stop this prior to my surgery, but the bill's effective date was roughly 3 months later. Talk about bad tim…

From what I understand (which is honestly not much), I think in cases like this you can contact the hospital and just insist on paying the same amount your insurance would have paid, and they'll often take it. That's just what I hear, though.

Regardless of insurance, when you offer to pay cash hospitals will often slash the price considerably. If the hospital has to use a debt collection agency, then they're looking at getting a small fraction of the list price back - sometimes an order of magnitude less. They're willing to negotiate accordingly.

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

#69

Post by dv_dt » Wed, Dec 19, 2018, 9:24 PM UTC

SlowRobotAhead wrote: post #50

Arubis wrote: post #45

Earlier quoted context omitted.

The party responsible for payment (the government, in this case) can tell a billing party "I won't pay you more than ___ for that service, and if you don't like it, you can sue me" without taking on the same risk that an individual would. Lawsuits are a pretty inefficient, high-overhead way to bill out, so billing parties are incentivized to not raise accountants and auditors eyebrows.

I must admit I'm skeptical of the claim that "only government can negotiate a better price"... I think anyone that's worked on government systems knows that is not typically the case. Why wouldn't insurers argue for better prices now?

It works in 36 out of 37 modern OECD nations, with the US paying the most, and more than double all the other nations which have the government negotiate a better price.

Even in our own VA system, their negotiated prices are lower for drugs than the Medicare part D program, barred from negotiating (and with large pieces managed by private companies).

I think your skepticism should primarily be directed to wondering if private systems can ever negotiate a fair price in healthcare products and services.

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

#70

Post by debatem1 » Wed, Dec 19, 2018, 9:24 PM UTC

SlowRobotAhead wrote: post #50

Arubis wrote: post #45

Earlier quoted context omitted.

The party responsible for payment (the government, in this case) can tell a billing party "I won't pay you more than ___ for that service, and if you don't like it, you can sue me" without taking on the same risk that an individual would. Lawsuits are a pretty inefficient, high-overhead way to bill out, so billing parties are incentivized to not raise accountants and auditors eyebrows.

I must admit I'm skeptical of the claim that "only government can negotiate a better price"... I think anyone that's worked on government systems knows that is not typically the case. Why wouldn't insurers argue for better prices now?

Insurers are both victims and beneficiaries of a system in which people are terrified to go without medical insurance, but where that medical insurance often doesn't meaningfully protect you.

The proposed alternative is to give tremendous power to an organization with less conflicted responsibilities.