I took my 4 year old to the ER because he had a 103 fever. The doctor put an ear thermometer to him and told me to give him some childrens ibuprofen. The visit lasted all of 5 minutes. The cost: $756.00.
I refused to pay it. It was the first time I did not pay a debt and the first time I was sent to collections. I refused based on principle, and not because I couldn’t afford it. Collections called me for about 3 months, and every time someone called and said, “is this John Wheeler”, I would never confirm and then go about asking why they are calling for John Wheeler. Eventually, the calls stopped and the collection agency wrote it off to their unpaid reserves (I’m assuming), I never received a ding on my credit report.
Everyone is always asking why US healthcare is so expensive. People blame it on the insurance companies and the hospitals, but my theory is it’s the providers.
I worked at Vanderbilt on their payroll system, and I would regularly see general practitioners making $350,000 a year, and this was 15 years ago! It wasn’t uncommon to see teaching doctors getting paid a million dollars.
As society, we seem to be ok with millennials fresh out of college making hundreds of thousands of $$$ a year for a bunch Javascript that allows people to share pictures of their butt with their friends BUT we are not ok with doctors who literally - save lives - getting paid according to their responsibilities?
Same goes with football/basketball/etc.. players whose sole purpose in life and responsibilities are to throw a ball somewhere and for that, they are covered in gold!
I think doctors should be paid a lot of money and on the other hand, many other professionals should be paid way less compared to what they make now!
That said, this proves, yet another time, how unfair and inefficient this whole health insurance system is.
Health care should be a universal right and should be provided as a public service at a minimum cost for single contributors. People have the right to getting sick and receive the best possible care without going bankrupt or having to sell their houses for it.
It is that simple.
On this, the EU model wins hands down compared to the US one. And it's time
for Americans to open their eyes and realize how unfairly they have been treated in this regard for their entire lives.
> As society, we seem to be ok with millennials fresh out of college making hundreds of thousands of $$$ a year for a bunch Javascript that allows people to share pictures of their butt with their friends BUT we are not ok with doctors who literally - save lives - getting paid according to their responsibilities?
Programmers only make that because the services they build are extremely scalable, profitable, and wanted by many driving up demand for programmers. Eventually, supply should drive down wages which is fair. I also don't mind doctors making good money but they should not be able to artificially constrain supply just so they can jack up their prices.
What gets me at the end of the day is that almost the entire institution that makes programming "valuable" is wholly fictitious and socially constructed. Without institutional international copyright and IP protection the vast majority of software produced would not generate nearly as much revenue per developer hour as it does today. The entire industry is basically an accident caused by greedy corporations extending copyright indefinitely for a century before the commoditization of computation happened and suddenly having the correct number could make you impossibly rich while you were given government protections of your exclusive ownership of said number.
When you look at the stock market and you see ludicrous P/E ratios on companies like Google and Amazon it must be acknowledged the only reason money sees them as being so valuable is because governments the world over have awarded them, through employee ingenuity or acquisition, exclusive permanent monopolies to millions of ideas enshrined in copyrights any of which could explode into an infinite money machine on any given Tuesday. Paired with their treasure troves of harvested data on people they are the largest entities in existence not for the actual real world value they produce but for the untenable position they now occupy with the force of the state and international trade standing behind them to preserve their position as the total arbiters of information.
Its really gross, and I have to live every day knowing that I largely do this (the programming, computers, tech, etc) on the back of a power structure enshrined and grown cancerous over centuries with the intent to exploit perpetual monopolies on ideas.
If everyone could copy your IP which is essentially free to do these days with computers, how would anyone make money creating IP which is the main driver of GDP growth? Would you prefer to live in a stagnating economy while every other countries citizens gets richer than you everyday?
What copyrights do Google and Amazon rely on to stay a monopoly?
Actually, it feels like with everything hosted server side these days there really isn't a lot of benefit to IP protection to tech companies. Media companies yes, tech companies not really.
Even if all of googles source code was stolen today, and it was legal for people to use it, would that really change anything for google?
> As society, we seem to be ok with millennials fresh out of college making hundreds of thousands of $$$ a year for a bunch Javascript that allows people to share pictures of their butt with their friends BUT we are not ok with doctors who literally - save lives - getting paid according to their responsibilities?
FAANG companies make from 500k to over 1 million dollars in revenue per employee.
Paying someone 1/10th to 1/4rd of what they bring in is hardly outrageous.
> As society, we seem to be ok with millennials fresh out of college making hundreds of thousands of $$$ a year for a bunch Javascript that allows people to share pictures of their butt with their friends BUT we are not ok with doctors who literally - save lives - getting paid according to their responsibilities?
That is once again a US-centric view. The rest of the world doesn't overpay their programmers to nearly the same degree. It's a comfortable wage. Upper middle class. But the equivalent of "entry-level six figures", not "six figures, then a couple times over beyond that for good measure".
On holiday in Rarotonga, our 2 year old got a chest infection.
We made it way up the hill to the hospital. A stray dog watched from the side of the road as we drive into the parking area. No one in sight. Eventually we saw someone who pointed us to a building wherein sat the duty doctor.
Super efficient, trained in new Zealand, she examined the sprog, diagnosed him and gave us the appropriate meds. No waiting, all sorted in less than 20 minutes.
Finally she said apologetically that we would have to pay - $2.50.
She took the money and out it into an old fashioned money box and cheerily sent us on our way.
To be fair that isn't the whole story and doesn't really make for a convincing argument to the contrary.
Doctors should be paid well, and in the case of the Cook Islands I assume they have public institutions providing doctors and medicine. In which case, tax payers are paying for it. Which is almost always the most ethical way to do it, and the only really right way we have working practicably in the world today, but it isn't some impossible efficiency that $2.50 supports the costs of operating the hospital, the cost of the drugs, training the doctor, and paying them a wage to justify their skill and expertise required.
Its largely where many politicians in the US arguing for fundamental change to the system come from - its really hard to imagine anything much worse than what they US has now. It would actually take considerable effort to design a more inefficient, more obfuscated and incomprehensible, more exploitative and harmful way to organize medicine professionally.
People just don't want to acknowledge that the United States federal government is not acting on the behalf of its citizens in its decisions whatsoever. It hasn't for decades, but coming to terms with the dissolution of democracy and the reality that US citizens don't have a meaningful, statistical say in government anymore is a hard pill to swallow, because the answers to the question "what do we do about it, then?" are all ugly.
It wasn't meant to be a convincing argument to the contrary - merely a contrasting story.
And certainly if I had a rare cancer I would rather be in the Mayo Clinic, as long as my insurance was all lined up.
Certainly these are difficult problems to grapple with, and bewildering to people outside the US - the current situation and also the extreme proposals currently being touted.
Those numbers do seem to be a bit higher than the national salary averages for physicians [1]. However, physician pay only amounts to something like 8% of total health care costs [2]. I'm not saying that doctor pay at Vanderbilt isn't driving up their healthcare costs but this doesn't seem to be the whole story when it comes to national healthcare costs.
The structure is a messed up mix of the red tape and regulation of a government bureaucracy, monopolistic behaviour (try getting 3 quotes for a procedure like you would for a bathroom renovation), subsidies, freeloaders, and weird incentives.
The government has decided it's too stupid to run hospitals. But it's also decided that it needs to ensure both the supply of hospitals, and to maintain standards. So instead of just telling doctors what to do (and paying them enough to ensure a steady stream of high quality medical students) it tries to get all the red tape and subsidies right, while the private sector (hospitals and insurers) try to figure out how to outsmart the government and make the system more expensive.
The US government spends a similar amount (per captia or as a percent of GDP) as Canada on its public funding (Medicare, Medicaid, VA, and so on). But the US system is so fantastically inefficient (due to weird incentives and massive amounts of bureaucracy and profit seeking) that unlike Canada it can't even offer basic universal healthcare (despite spending an insane amount of tax dollars).
> The US government spends a similar amount (per captia or as a percent of GDP) as Canada on its public funding (Medicare, Medicaid, VA, and so on).
As of 2016, Canada's public spending was 7.4% of GDP, the US's was 8.5%; and the US per-capita GDP is higher, too, so I don;t think its really "a similar amount" per capita, and only loosely so per GDP. But, yeah, the big difference is that the US spends even more than the publicly spending in private healthcare spending, while Canada (like most other first-world countries) spends far less privately than the public share.
Reducing US healthcare costs sounds similar to reducing carbon emissions. Cuts need to come from everywhere because the system as a whole is inefficient. There's no single silver bullet.
to wit, as with teachers, i don’t mind doctors and other medical professionals getting paid well, but the AMA restricting supply to increase salaries is anticompetitive and wrong-headed. i also don’t mind medical devices, labs, and even drug companies getting a decent (but not exorbitant) return.
i’m less sympathetic to high administrator pay among medical networks, the whole medical records/billing industry, as well as the medical insurance industry. that feels like a very high tax burdened onto healthcare.
First, a disclaimer of sorts: I'm really not trying to take away from your central argument, that ER bills are way too high.
Second, another disclaimer: if you were a 1st time parent, I kind of understand!
103F/39.4C is unquestionably a high temperature, but it's almost always part of a viral infection, and ibuprofen and/or paracetamol will almost always reduce it. It's really not particularly unusual for kids to get a high temperature while they're ill, and I literally can't fathom why you'd take a 4yo to the ER for a high temp.
Here in the Europe, we give ibuprofen and/or paracetamol, and wouldn't dream of taking our kids to the ER without a very good reason, such as the meds not bringing the temperature down, or there being a rash, or anything else that raised alarm bells; I'm assuming of course that were there any such circumstances, you would have mentioned them.
At worst in Europe, we'd take them to the GP the same or next day. And the GP would, without doubt, assume you were a 1st time parent and say "it's viral" and (somewhat) politely kick you out. I've literally been there with a child having a 40C temp, and they weren't arsed. I've been there myself with a temp of 41C, and they weren't arsed.
Finally, someone said this. It's very rare to see putting some blame on doctors for such exorbitant medical prices in the US. I have made several comments about that on HN describing similar observation that I found. A recent example was when I went to see a doctor for ear infection. She put a otoscope in my ear, looked at it for one minute, prescribed me some anti-bacterial, and wrote up $250 for the service. The first time I came to the US, the same thing happened (I have had ear infection occasionally). I went to a hospital in NJ because my host family at the time drove me there. I didn't have insurance and they sent me to the ER department. I was charged $500.
In the US, the journey to become a doctor is made unnecessarily complicated and once people become doctors, they do gatekeeping and make sure it's equally as hard for others to become one. But the reality is that the physicians who treat garden-variety diseases can be trained much less expensively. No wonder physicians make loads of money while complaining about their massive student loan. My gf is a medical resident; my host parents in the US are both doctors; I have so many doctors as acquaintances; and I know that what they do is NOT even remotely difficult in terms of intellectual demand (only physically tiring and emotionally draining sometimes when you have to deal with difficult patients). I, as a programmer, would switch my salary with them in a heartbeat (regret leaving medical school in after second year in my home country, though I hated it at that time because of the sheer amount of rote memorization one had to do) and I do believe what I do everyday requires at least equally tasking mental load than what doctors do.
> the physicians who treat garden-variety diseases can be trained much less expensively.
So, how do you make sure that only garden variety patients see the medical assistant, while seriously sick ones or those who have only telltale signs of a 1-10k illness see the real doctor? If those rare ones don't get to the doc they die.
Seeing a GP isn't necessarily a guarantee that you will get diagnosed properly. Most PAs know their limits and will consult with a doctor if they're not comfortable. Doctors complain about malpractice insurance, but the rates are high for a reason. I was misdiagnosed when I had cancer, my wife was mis-prescribed when doing fertility treatments. Hell, being rich doesn't help; look at Bill Paxton and Neil Armstrong.
> Seeing a GP isn't necessarily a guarantee that you will get diagnosed properly.
so, because even the best make mistakes, that's a good reason to let under-trained (relative to an MD) people with even less skill make mistakes? Not following your logic here.
Seeing a PA for relatively normal issues frees up doctors for more serious cases. A triage system if you will. Doctors don't like this because it will hurt them financially. They want people to think of PAs as second rate, and that doctors are infallible.
In my case, my doctor felt that because colorectal cancer (at the time) was relatively unusual for my age demo, that he didn't really need to consider it. Instead of doing an actual DRE, or a fecal occult blood test, he simply dismissed it out of hand (pun intended) as internal hemorrhoids. A year later, I was having a full resection, chemo, radiation treatment, and a permanent colostomy. Thanks!
It is already happening. NYU Langone has been pushing hard on people to 'see' the doctors online for small stuff like allergies and fever. I wouldn't be surprised if this practice eventually extends to replacing doctors with a semi-automated (human-computer based) system .
For what is worth, a physician assistant can diagnose quickly (and they can be assisted with a ML/rule-based diagnosis system that is trained on something like "Pocket Medicine: The Massachusetts General Hospital", which is what most doctors in training use as a handbook) and escalate the difficult ones to the specialist doctors.
There's a lot wrong with the medical field, but this is a ridiculous argument. Programming is hard, medicine is hard. But it's in different ways - it's definitely not transposable (obviously- you switched the other way). I say that as someone who worked in FAANG software and is now in medicine.
Equating salary to mental load is also factitious. Manual laborers work harder than all of us, maybe we should switch salaries with them.
I 100% agree with the difficulty of becoming a doctor. I disagree with the gatekeeping however. Ultimately it comes down to residency positions available, and funding is government limited. We're seeing tons of new medical schools opening, acceptance of the DO crowd, and still the system is getting more competitive.
I discussed the funding in my comment above, in that medicare funding is only part of the problem. Nothing would stop a hospital from paying for resident training so long as the ACGME gave their blessing.
> Everyone is always asking why US healthcare is so expensive. People blame it on the insurance companies and the hospitals, but my theory is it’s the providers. I worked at Vanderbilt on their payroll system, and I would regularly see general practitioners making $350,000 a year, and this was 15 years ago! It wasn’t uncommon to see teaching doctors getting paid a million dollars.
I agree it's the providers which are most at fault. Hospitals (as well as drug companies) are providers too though not just doctors. It's hospitals that are charging $4,000 a night for a hospital room and $50 for 2 tylenol which you can pick up at Walgreens for $4 for a 24-pack. Actual examples from my hospital bill when I had my appendix removed a few years ago. The total came to about $50k, of which I believe the portion that went to doctors and surgeons was about $10-15k.
I recently took my GF to the ER because she had been stung by a bee and was worried she was allergic. She was feeling dizzy but once we were in the ER she started feeling better. They basically took her vitals, waited 30 minutes or so, gave her a steroid, and then sent us home. They told us it probably wouldn't be very expensive as she was uninsured.
Later the bills arrived: $1300 from the ER ($1900 minus a $600 uninsured discount) and $600 from the PA who saw us. Insane!
Generally speaking, that’s an example of a fundamentally wasteful ER visit, and why the lack of universal coverage is so dumb. That’s why ERs cost a fortune.
If you’re not bleeding, have a broken limb or other trauma or an expectation of being admitted, you don’t belong in the ER. Take a benadryl.
So why doesn't the triage nurse hand out the Benadryl, tell the patient to wait in the lobby for an hour, and see if that resolves it? They could charge $75 for the single pill, and still avoid using a bed or the services of additional staff.
In short, liability. So much behavior within the US medical profession is driven by a fear of getting sued for malpractice. Even though the patient would be sitting in the ER with treatment close at hand, if the situation did worsen and the patient suffered complications there will be the inevitable questions asked as to why the triage nurse didn't admit them in the first instance. For hospitals it's just not worth the risk of potentially expensive and lengthy lawsuits/settlements.
That’s not how the process works for an ER. A doc in a box urgent care would essentially do that.
An ER handles everything from bee stings to shootings or strokes. They’re optimized to deal with those emergencies, not optimize cost for minor dings, especially when most of the minor issues are uninsured people who won’t pay anyway.
Emergency medicine is not a profit center, and is often mandated to exist. You’re paying for all of the lost receivables and capability.
>A doc in a box urgent care would essentially do that.
Yeah, and urgent care facilities usually have working hours like 8AM-8PM. Because, you know, those are the only hours people every get minor sicknesses.
Emergency medicine most definitely can be a profit center. That's why you see all of these new freestanding emergency rooms that look like an urgent care center but are open 24 hours and bill 2x as much.
The ER is more like insurance. In this case she was fine and got better more or less on her own but what if she deteriorated quickly? The ER would have the appropriate skill and equipment in-house to save her, whether if she was at home it might’ve been too late to make it to the ER when things actually became critical.
"Clark had to decide: Should she take Lily to the emergency room?
She called a poison control hotline and the answer was yes ...
But Clark knew that the emergency room can be expensive.
...
“I’m weighing my options,” Clark says. “She could have a seizure at any moment. It felt terrible, as a parent, to be in the position of having to do that.”
Clark and her husband decided to give Lily some activated charcoal at home and drive to the emergency room. But they wouldn’t go inside.
Instead, they pulled their car into the second row of the parking lot, about 100 feet from the entrance. They start playing The Little Mermaid on the car’s TV screen for Lily to watch. And they waited.
“We were just sitting there, facing the door and watching Lily,” Clark says. “We chose the second row because we wanted to be close to the entrance, but also trying to look inconspicuous.”
The Clarks waited in the parking lot for a few hours, and Lily didn’t show any symptoms. They drove home without setting foot in the emergency room."
One really nice thing about single-payer back in Ontario was public salary disclosure, aka, the sunshine list. Since most physicians essentially work for the government, if they make over 100k/yr, the salary is public knowledge. Hint: Canadian doctors aren't eating dirt, by any means.
Everything you say is true. Modern healthcare is so expensive and inefficient because its built around the demands and capabilities of the past. Usually I hate it when people say something is fundamentally broken, but healthcare really is.
The time has come for a complete overhaul of the system. No more primary care doctors. They can be replaced by software and patient service representatives.
Diagnostic services should be the front line of healthcare. You should be able to get whatever diagnostic test you want, whenever you want.
All prices must be 100% transparent to the patient before any services are rendered. Opaque pricing allows for arbitrarily high pricing.
Huge increases in medical school enrollments. Removal of arbitrary licensing caps.
So much more needs to be done but this is a start.
> You should be able to get whatever diagnostic test you want, whenever you want.
Tests may be less expensive than what we are getting billed, but they aren't free. There are hypochondriacs who I'm sure would order hundreds of tests a year if allowed. There are many people who have hard to diagnose problems, and out of desperation, would order tests which have no possible bearing on their condition, just in case it finds something.
Let's say that you routinely screen everyone for everything, because why not, it's free. What is the burden of not only performing all those tests, but following up on the flood of false positives? It would probably swamp the healthcare system, allocating resources to the wrong places.
Unlimited licensing could lead to everyone getting paid too low or unemployment. I've honestly wondered if compsci is goingto need caps. Everywhere is unreasonably picky about who will be considered even for an internship, because they can, because there are so many compsci grads. Getting my first job involved months of searching and horrible offers like 30k until I got lucky. This being with extensive volunteer experience since high school, 3.8 college gpa, honors in a tech school my high school sent me to, and an internship. I've seen lots of horror stories of CS grads applying everywhere for years fruitlessly because nobody wants them. Is this what we want to happen to doctors?
Non-medical and medical collections tend to get different treatment nowadays[1][2]. It may have ended up on your credit but after a super long delay, or it'd disappear entirely if they were able to get something out of your insurance instead. And even if it shows up on your credit report, depending on the specific scoring model being used, it still may not have had much if any impact. [2] details how some of the scoring models treat medical collections.
Technically, anyone that's gone through the process to become a data furnisher can report anything they like to a credit bureau[1]. Although if they can't produce an agreement that denotes your confirmation of the debt or liability to pay for the service, then you can likely get it removed via a dispute.
Which, incidentally, is the same principle behind most "fix your credit" services. They dispute the accuracy and validity of the entries on your report, and if the reporting entity can't produce the appropriate documentation (such as a loan agreement or equivalent), it'll get dropped from your history. And even if it doesn't, while it's actively in dispute it'll be weighted differently by most scoring models[2].
I once went to an emergency room near Philadelphia -- Bryn Mawr -- and I was there for tops 2 hours. They didn't do anything fancy, beside an EKG (if you can even call that fancy).
They sent me a bill for $15k.
Luckily insurance covered 80% of it... But still! It basically maxed out my out-of-pocket for the year. And for what? An EKG -- at the time -- cost, on average, less than $100...
I remember calling the billing office to try to figure it out. They sent me the bill for $15k directly, so I thought that's what I owed AFTER insurance. Needless to say, I was panicked. I remember telling them, I'd sooner leave the country and move to Europe than pay them $15k, if that's what it came down to. I remember the billing office basically threatening my life. And then when they found out I had insurance (not sure why they didn't know that I did already), they suddenly got much more friendly.
So basically it would be cheaper to fly to Canada (/Europe/Russia/where er) for $500 roundtrip and get an EKG for $100 there. You know something's weird when this is what a better solution looks like.
I have read elsewhere, but cannot find a reference right now, that insurers typically pay only a percentage of any bill and expect the provider to accept it in final settlement. The percentage gets negotiated around.
If this is true, then it makes sense that the providers inflate their original bills so that when they get the proportional settlement, the amount they receive is reasonable.
The claim was that individuals settling directly are merely caught in the crossfire.
If this is true, then it's not the providers being unreasonable.
There a few different drivers of the ridiculous list prices at hospitals.
1. The gov't forces them to disclose a price and they can't charge higher than it. Thus, they have every incentive to make it really high, then give preferred customers (insurers) a discount.
2. The system is firmly locked into a cycle of "percent of charges". Basically the insurer says "I know your chargermaster prices are inflated, so let's agree on 20% of that". The following year the hospital jacks up the chargemaster prices during negotiation so they start from a higher initial point.
Same here. My child got a bean stuck in his nose. The doctor walked in, used a tool to pull it out and walked out. We spent less than 2 minutes with the doctor. The "procedure" maybe lasted 10 seconds. We got a bill for nearly $1000. It was listed as surgery!
> The doctor put an ear thermometer to him and told me to give him some childrens ibuprofen.
To be fair, the doctor also cleared your child of having a life threatening emergency. That is one of the critical jobs of an emergency medicine physician and it’s part of what you pay for.
ER bills are always shockingly expensive. If you don't think your condition is life-threatening, it's normally both faster and much cheaper to go to an urgent care clinic if one is open.
However, for potentially very serious problems (possible heart attack, stroke, serious injuries, etc.) you have no choice - you need to go to the ER and deal with the bill afterwards.
Yeah didn’t mean to criticize anyone’s behavior, just offering a tip for people in that situation in the future. A child with a high fever is probably going to get seen faster at urgent care, since the ER staff would triage them behind serious injuries, heart issues, etc.
IME an uncorrected 103°F fever is really no big deal. If you are already on Tylenol and Ibuprofen and still at 103 that’s a bit more interesting. Parent pro-tip, Ibuprofen has always been way more effective and also longer lasting than Tylenol at reducing fever in my kids.
I have a similar story from when my first child was diagnosed with T1D. The entire treatment consisted of administering 1 unit of subq insulin and a standard blood test. The bill was coded as intensive care and came to $15k. My OOP contribution was billed as $7k, but I fought it successfully and never paid a dime. Insurance unfortunately paid their full share.
This was Stanford Hospital, which is notorious for over billing, and actually I believe one of the most profitable hospitals in the country.
Stanford Hospital used to turn you over to collections if you didn't pay. And I use the word collections loosely here. The guys who showed up at my house were basically bikers with a license to carry. Scary dudes. I had to call the cops because they wouldn't leave my property. The cops had to pull their guns to get the "collectors" to leave. Oh, and after all the billing was sorted out, I didn't owe any money. They were just try to scare me into paying tens of thousands of dollars. One day, a big hospital is going to get indicted under RICO, and it will be well deserved.
We took our daughter to a children's hospital (CHOC, a pretty famous one), went through triage, and got put into a room. A nurse came in, asked questions, said the child needs to pee in a cup, and left. Two hours later, still nobody had checked on us, and no doctor. I had asked more than once for an update during this time to no avail. Also, we never even got the pee cup.
So we left. They billed us (something around $600?), we sent a letter explaining they didn't do anything, but they still demanded money. We never paid and it eventually went to collections. We explained what happened to collections, and surprisingly they went away.
Never go to an er unless it is serious or you’ll have a long wait. I took my daughter to CHOC with a 106 fever and still waited two hours to see a doctor. I’d rather go to an urgent care because you can usually see a doctor in under 30 minutes and at fraction of the cost.
Not that simple. This is a multivariate problem including massive student loans, crippling liability/malpractice insurance, regulatory burden and more.
You didn’t get that bill because you just saw a doctor for 5 minutes. You made use of an organization that has a basic cost-per-hour to exist.
This is a simple way to distill what it costs for that entire hospital to be there ready to see your child at whatever random time and day you need them most. That is very different from just seeing a doctor for 5 minutes. What you didn’t see are the hundreds or thousands of people who have to exist for you to be able to get in your car, drive there and see a doctor for 5 minutes.
That’s not to say our costs are not high. They are. Just saying we need to engage in root cause analysis before passing judgment.
Simple example: Our internal machine shop operates at a nominal rate of $200 per hour. That’s what we deem is the cost to utilize that resource. Larger operations can easily have a cost of $2,000 or $20,000 per hour, whether you use the equipment or not.
If you want to lower our healthcare costs, you have to go after real root causes. No amount of insurance scheme manipulation (public option or medicare for all) is going to fix the system until the fundamental structural issues are addressed.
Once it's at a collections stage don't pay it. The status change of paying it causes the time until it expires off your report to reset.
You instead send them a letter that asks for proof you owe the debt, and ask them to only contact you in writing. Often they won't have their paperwork in order and it will be removed.
> I refused to pay it. It was the first time I did not pay a debt and the first time I was sent to collections. I refused based on principle, and not because I couldn’t afford it.
Why not at least pay a portion of it that you would have felt was sensible?
Wait really? How so? It's not like they would otherwise lack sufficient evidence to show you showed up and received care, right? I would've thought acknowledging would just restart the clock, which would've made no difference here.
It's the same logic as refusing delivery of a shipped good when it comes to contract law (IANAL). It's expected that when a good arrives, the buyer pays. If the buyer refuses to pay then the good is not 'delivered.' In the transition to services the 'delivery' is the invoice you get and that is the moment you are compelled as the buyer to pay that invoice. If you start paying it then you have accepted the invoice as valid because you paid for part of that invoice. Given this the context of being sued would be that the seller observed that the invoice was valid by the buyer paying something towards that invoice, and therefore they should be compelled to pay the rest of the invoice.
On the other hand if an invoice is never realized because it's in dispute, then you have a stronger leg to stand on. A different way to look at is in sit-down dining. You receive service, you are delivered a bill, you are then expected at the moment the bill is delivered to review it and pay it, and if you pay it the bill is settled. If you have a dispute because nobody ordered a diet coke, then the bill is rejected and hopefully sorted out before a final bill is presented and people pay for it. The same sort of logic ends up applying here. If you paid for half the meal and left that has different outcomes compared to not paying the bill and causing a stink.
This was highly unethical. There is a minimum operational overhead to offering minimum care, including the availability of emergency equipment and staff. I have a local ER I've visited twice this year and there's almost never any patients there in the middle of the night. But dozens of medical personnel and the building and all the medical equipment i could imagine are always there and ready for me when I need it, on demand, no questions asked. This is what the American medical system optimizes for. And it costs a lot of money.
Does the "ER" refer to what is called "A&E" in the UK, which has a triage system before you get into any "Room".
This would ensure that you (a) wait at least 10 hours to be seen for this and (b) don't interrupt life saving surgery for it. If this is the case you should be charged less, but if you get an actual emergency doctor looking at it then maybe $756 is justified †, as they are a limit resource and there is a high cost of running an ER I would imagine.
† To the extent that non-free emergency healthcare is justifiable.
Wow. There's just too much irony in a medical school telling students to use religious vaccination exemptions because the insurance they provide doesn't cover their mandated vaccinations.
>I worked at Vanderbilt on their payroll system, and I would regularly see general practitioners making $350,000 a year, and this was 15 years ago! It wasn’t uncommon to see teaching doctors getting paid a million dollars.
It isn't uncommon for software developers to make $350,000 a year or even over a million if they get equity in the right company. Maybe the Googles of the world wouldn't have to spy on their users to the same extent if software developers weren't so greedy and taking such a huge slice of the value of their own labor.
Would anyone here agree with that statement? If not, how is it fair to apply that same logic to doctors?
It is also worth noting that doctors have other costs that don't apply to people in the tech industry such as the high cost of the extra schooling they must receive and malpractice insurance which can cost anywhere from a low 5 digits to $150,000+ a year deepening on their specialty.
You could make the same case for those on Wall Street. I think it’s a separate debate whether all that is fair. I think what’s different in medicine is
1. Medical care is not optional when you need it.
2. There aren’t readily available options to choose between.
3. You don’t know how much you’ll be paying when you need it.
4. Band-aids and tongue suppressors costing $30. stuff like that which is unquestionably egregious.
All of what you are saying is true. However none of that is dictated by doctors or a direct result of doctors' salaries being too high like OP suggested.
It depends. Are you paying for the visit or per hour / per treatment? Paying by visit aligns the doctor to perform the minimum required treatment instead of something expensive “just in case”.
> I took my 4 year old to the ER because he had a 103 fever.
Alone, a fever under 104°F that isn't for an extended duration isn't something you should take an otherwise healthy four-year-old to the ER for.
If you go to an ER for a non-emergency, you are definitely going to overpay for what you get, by an even wider margin than you usually overpay because of the need for those customers that pay to subsidize the costs of those who skip out on bills.
In this day and age when most insurance companies and many primary care practices have 24-hour advice lines, most people have access to the internet, etc., the rate of people who otherwise have access to general healthcare using the ER for non-emergencies should be lower than it is.
A 103°F fever (again, on its own) in your kid as a parent is scary, yes—I’ve been through it with two kids under four in the past week. It's not an emergency, though, and the ER isn't the right place to deal with it. Not only isn't it cost effective, but because the ER mandate is emergency stabilization which a kid in that condition doesn't need it's not plain effective (not even in most of the cases with that degree of fever where medical attention is called for: not only do you pay far more than you will for a primary care visit, you don't get the diagnostic attention you'd get from a proxy care visit.)
I’m not a doctor, so the usual disclaimers, but with three kids this has generally been our experience — young ones get some ridiculously high fevers by adult standards and generally, if they clearly have a virus, it’s not something too freak out about.
The big exceptions are if they’re really young — like still babies — or if they’re not themselves: can’t stand up, overly weak, not eating or drinking.
My main point of contention is around using the internet as a diagnostic tool — much better to call an advice nurse if you have access to one.
The reason why prices are so high is because of the complicated billing system that each insurance provider has. Medical providers have to create positions just for people to bill insurance.
It's gotten to the point where single-payer health care will be cheaper just because of the paperwork it'll save. (Not that I personally advocate for single-payer. We can also lower costs by correctly regulating private insurance.)
By the way, if you're into economics, look into Adam Smith's Wealth of Nations. Kings used to do the same things to keep peasants busy while they profited. This is no different.
You can’t compare the costs of labor-intensive services across countries with dramatically different labor costs. When we lived in Bangladesh, my dad made maybe $40,000/year (in today’s money). My mom stayed home and we had a full time live in cook, nanny, and housekeeper.
This is simply not true enough to be generalized. In most hospitals always pay at the exit unless you weren't there for some pre defined checkup package instead of proper consulting.
I am sure you have data to back up your claim that "standards of care, facility costs, and compensation for medical professionals is much lower." Care to post it?
I’ve only been in the hospital in India once (food poisoning), but everything was vastly different from the states. It was pretty cheap, and I had to pay up front.
Fairly sure Indian doctors make much less than American ones, because I don’t have the empirical evidence of that that you are looking for.
People saying, 'We should pay for the things I do in the economy, but not something someone else does, "out of principle"' is an opinion that exists in reality, it's just an unbecoming and non-constructive one.
with my insurance, it cost you about the same for healthcare whether you are insured or not... (not including the insurance costs or government fines for lack of insurance)... mainly because they give a discount to the uninsured....
A story. Emergency room visit for moi (super high BP plus PVC that appeared out of nowhere). They hook up an EKG machine, wait an hour, tell me to see my doctor. Since it was a heart thing, I got bumped to the head of the line but forget to fork over my insurance card.
Bill #1 $10k from hospital $2.5k from ER physician
Bill #2 $4k if I pay it right away in cash
Bill #3 $500 (deductible cost) once the insurance people are brought into the picture.
I think it's easy to blame the providers because 1) they are the "face" of the system and 2) they are relatively well-paid, but many times (especially in the emergency department) they don't even get a say in the price.
As another poster mentioned, physician salaries account for 8-10% of medical costs, but more importantly decreasing those salaries may not even decrease the cost that patients see.
Let's take the ED as an example... For the past several years, the average salary of an ED provider has been decreasing (due to the increase of physician assistants / nurse practitioners, who are paid less), but the cost-per-visit to an ED increased 235% between 2008-2017 even though ED utilization remained stable [1].
In the last decade, a lot of small physician-owned emergency medicine groups have been bought up by large corporations or health systems. As these large groups proliferate, they raise prices (to the tunes of 2x or more) [2, 3, 4], pay their employees the same or less, and take the rest as profit. So even if provider salaries go down (which these large groups often do anyways after a consolidation), little would change for the patient.
While some of these groups are led by a CEO with a MD, the physicians and other providers who actually see patients do not have a say in how things are run. In fact, some of these groups don't even show the providers how much they are billing for each patient, so it's really hard for them to do much about it [5].
But couldn't physicians/PAs/NPs protest, quit, or even start a competitor--shouldn't they? However, the larger markets (where the majority of patients are) are typically also the most concentrated, so sometimes it's the choice of one large group vs. another large group. I suppose one could move to a different town, but it's hard to uproot a family, and furthermore since these large areas are more desirable there's no shortage of folks who would take their place. And unfortunately for several specialties (EM included) it's very difficult to start a competitor, since one would also need to either secure a hospital contract (not happening if the competitors are health systems) or build their own facility ($$$$$).
None of this is meant to dismiss the issue, and I think physicians will continue to feel the brunt of the blame as long as prices remain high, but I hope it sheds a different perspective onto the issue.
I'm going to argue in good faith to try and derail this hate train. First, I'm a physician and I consider myself about a borderline expert in medical billing/insurance.
Let's disrupt some stuff here:
First, it is EXTREMELY rare for a physician to be paid a million dollars. You can easily look at most state's open records (California, Texas, Florida) and search the online databases and see that it's usually only several in an entire state and these are people of extreme qualification or unique talent. The Dean of a large/famous medical school (a CEO essentially), a very famous chair of a department (they helped invent some special technology or are well-known leaders in their field), or are simply prestigious to the institution because of notoriety (imagine an Atul Gawande or an Oliver Sacks).
Second, the costs of healthcare have been sliced and diced by countless experts and the numbers tell a different story than your theory--most analyses place physician payments at 10-20% of the total cost of healthcare depending on who is doing the study.
Third, there's no way you received ONE bill that wasn't itemized. Typically you receive two bills--one for the 'facility' and one for the 'professional.' It's usually obvious which is which because an ER might charge $1000 or more for that quick visit, while the physician probably would've charged in the $100-200 range. When you hear about those scary $50,000 bills for a night in the hospital and a $30 box of tissues... that's the hospital bill. It's extremely high because of many complicated reasons... most of which have to do with the fact that it NEEDS to be that high or insurance companies won't pay the negotiated rate of about 40% or less of that--it's an arms race that needs to stop.
I'll give you that there are complicated price gouging issues that come up on the physician side (out-of-network billing, surprise bills, etc) that may be unethical and some states are dealing with this... but it's usually a tenth or less of the total of what is coming from the facility in the same scenario.
So anyway, you could literally pay doctors nothing and you would save maybe 10-20% on all those bills. Does that sound like a viable setup?
You can Google some articles and read studies, but I'll save you the time and give you something to think about that should convince you that the physicians can't possibly be the primary problem:
Many (most?) physicians are now wage earners. They increasingly own less and less of the infrastructure (capital) of healthcare and are less independent than ever (consolidated, hospital owned groups, VC and publicly owned groups like Envision and MEDNAX).
In this kind of capitalist setting, where would your profits go? To your doctor workforce? No! It goes into C-level administration, shareholders/investors AND reinvestment/M&A.
Hospitals and Insurance companies, Drug companies, Device companies.... these are the real power players and their influence in seen all the time as they negotiate sweetheart deals (Medicare Part D for example), continue to consolidate ownership, and literally price gouge from consumers (EpiPen, insulin, etc, where a cheap drug is inflated in price for no reason).
I'm truly sorry for the state of the system in the US, but the fix has to come from Congress. If tomorrow every doctor was perfectly ethicall and paid 50% of what they earn today, all that savings would just end up as dividends for the capital owners and NOT as lower hospital bills.
Providers are the core problem. Various doctor associations (AMA et al) have strangled supply side of healthcare through State licensure and scope of practice laws.
Just read medical forums to get an idea of what an average doctor thinks about competition in the form of midlevels:
It's not politically talked about because it's much easier to blame corporations than your neighborhood doctors. There's enough leeches downstream too (insurance, pharma, PBMs, administrators, etc) but gatekeeping at the supply side is what's making it possible.
> Various doctor associations (AMA et al) have strangled supply side of healthcare
To add more details to this here's something I recently read about the supply constraint and its origins.
> Then as now, Medicare reimbursed hospitals for a significant share of residents’ salaries. The Balanced Budget Act established limits on those reimbursements, effectively fixing the number of funded residents at 1996 levels. (In 1999 Congress amended the limit for rural hospitals only, increasing the numbers of funded residents at those hospitals to 130 percent of 1996 levels.) Essentially, the law stipulated that if a hospital wanted to expand its pool of residents, Medicare would not pay for it.
How could such a provision make it through Congress? Lawmakers received cover from the American Medical Association (AMA), the Association of American Medical Colleges, and other major stakeholders in American medicine who endorsed caps on funding for residents and other graduate medical education programs. In March 1997, months before the Balanced Budget Act was enacted, the AMA even suggested reducing the number of U.S. residency positions by approximately 25 percent — from 25,000 to fewer than 19,000. “The United States is on the verge of a serious oversupply of physicians,” said the AMA and other physicians’ groups in a joint statement. Since most states require at least some residency training for medical licensure, reducing the number of residency positions would curtail the supply of doctors in the U.S.
Fast forward two decades, and what once seemed like a glut now looks like a shortage. The growth in the number of residency positions — and thus the number of doctors — slowed after the passage of the Balanced Budget Act. From 1997 to 2002, the number of residents in the U.S. increased by just 0.1 percent. Although the number of positions has increased since then, each year thousands of residency applicants fail to secure a position. Factor in an aging population and a projected increase in demand for health care services, and the U.S. is now forecasted to experience a shortage of 46,900 to 121,900 physicians by 2032. Absent a meaningful response from Congress, it will be doctors — particularly residents — and their patients who pay the price.
This a hundred times! The shortage is real and urgent. My gf, who is in her second year of a low-tier residency program, received many offers from various hospitals promising her $300K/year to work for them. This is well known among residents that once you survive residency (which is not a high bar to begin with), you will make at least $250K/year.
From the the people I know and know about, getting into medical school is a very high bar. Getting through is hard though doable if you could get in and devote your entire life to it. You probably won't get the specialty you want if it's one of the more generally desired ones, but you might.
Is $250K or 300K really that much compared to the amount of work / time these people need to spend going through formal education? With the additional stress that any decisions they make could adversely impact someone's life?
I mean software developers doing significantly less work can easily make this money while working half as much right?
SW Dev working 8hrs a day can make this, whereas a doctor working probable 60-80 hours a week makes the same?
I don´t know in which world you live where SW devs make that... some FAANG developers maybe - 5.000 to 10.000 people total? Compare to over a million doctors in the U.S. only.
Well said. I get a lot of flak from, well, pretty much everyone for pointing out that your neighborhood doctor is likely a scam artist. Clearly I’m generalizing but just suggesting it may be the case is usually met with undue skepticism.
Not to mention, having an inside look at med school gives you a different perspective on the motivations of most rising doctors. It’s rarely about anything but lifestyle and money. I mean, they are people too, but most med students I’ve met are looking out for number one first, and anything else is a distant second.
Not sure where you went to med school, but couldn't be different for me for med school and residency. Very little of being a doctor has to do with money. If I wanted money, I would have stayed in software and not gone another half a million in debt.
> your neighborhood doctor is likely a scam artist.
I don't blame a Dr for trying to charge 7x the actual value of their time if 6/7 people don't pay them at all (the case in ERs). They're employing the same practice as insurance companies. But when a Dr does it he's a scam artist?
That forum is amazing! Thanks for the primary source! That said, two quibbles/questions:
Those same threads have logins like "indebt4life" and "kids2feed", which matches what I've heard from doctor friends: the length and cost of medical training and insurance are so brutal that the folks gatekeeping are themselves in an unhealthy lifestyle and don't want it to get worse. In other words, and benefits of gatekeeping accrue to the school and hospital complex more than the individual practirioners.
Separately, what's the breakdown of specialist labor costs vs drugs and equipment? My experience has been that the crazy bills are for stuff , not people.
We see a lot of people trying to justify medical salaries due to the cost of education and malpractice insurance, but an integrated program could work around that.
We should treat it like the infantry. If you want to drive a tank and blow up people, you don't apply to a college and get a Doctorate in Blowing People Up. You don't buy insurance to cover if you blow up the wrong people. You join the army.
I'd like to see health care reform inspired by military structure. A high-schooler eager to get into medicine joins the Health Corps, and gets their education covered in exchange for n years of working in state-run facilities. There's strongly restricted legal recourse if the Health Corps hospital cuts off the wrong foot-- here's $500 and a really nice wooden peg.
As a self-contained system, I could also imagine it working around some of the structure that's restricting the industry. I'm picturing programmes to advance in both through direct study and training, and where appropriate "field promotions" (think of the 20-year term nurse who knows more than most of the doctors from experience, but will never be able to escape their position without expensive and onerous formal training/certification)
There would need to be other changes. Right now many doctors work insane hours. My dad is a doctor who we rarely saw growing up. Now in in his 70s he has retired to live near a native american reservation where he works at the clinic. He puts in 60+ hours a week and claims that that is retirement for a doctor. I imagine that young doctors not making the big bucks would not be willing to work themselves to death like the current ones do.
I have experience of single player (UK) and private insurance based but properly managed by the government (NL) and can tell you that single player is much cheaper to run. When I moved to NL about 15 years ago the UK was spending the same per capita on the NHS as The Netherlands spent from the central government to cover the shortfall to the insurers.
In 2019 there isn't as much difference: a significant amount of providers in the UK have been privatised which increased costs whilst at the same time the NHS budgets have been systemically strangled in real terms - something like annual 2% budget increases against annual 15% cost increases thanks to demographics and lifestyle choices.
So in short: single payer is great but the second the Republicans (or whatever the "don't tax the rich" party is at the time) get to touch it they'll ruin it.
> Those same threads have logins like "indebt4life" and "kids2feed", which matches what I've heard from doctor friends: the length and cost of medical training and insurance are so brutal that the folks gatekeeping are themselves in an unhealthy lifestyle and don't want it to get worse.
It's gatekeeping that causes that.
There are complex procedures that require a decade of medical training and simpler ones that don't. If you take the doctor with the extensive training and have them do only the complex procedures, it's easy to justify paying them mid six figure salaries that cover their costs.
But if you have regulations that require that same doctor to spend three quarters of their time doing simple procedures that could reasonably be done by a PA or a nurse, the average value of their services drops and they have a harder time commanding a salary that can pay for their schooling and insurance.
It's not just the cost of training. In the US there's implicit expectation that becoming a doctor is a way to become wealthy, similar in earning potential to becoming a lawyer. There's no such expectation in most other countries which are often used in arguments for how socialized medicine "costs less". Their doctors make a fraction of what US doctors do, so of course it "costs less".
Right now in the US you'd be "socializing" the expectation that a doctor should make $300K+ a year, with a very weak upper bound. Which I'm not going to say real good ones shouldn't, but good ones, in my personal experience, are few and far between.
This is something we'd need to deal with before forcing taxpayers to pay for these inflated expectations at gunpoint, _if_ we decide to go the "single payer" route. ACA, ironically, did nothing at all to address the _affordability_ side of things. If I'm forced to give up a good chunk of my income for "free" healthcare, I'd be categorically not interested in paying for yet another beach house some surgeon wants to buy.
Just like all problems involving human motivations, this is a tough one to solve. It's so tough, in fact, that I think the most realistic path forward is gradual automation of everything that can be automated, though technological means, such that we only use doctors where a robot or a computer can't do the job. Someone needs to start another Theranos, but do it for real this time.
There better be a $300k+ payday at the end of a doctor’s training, otherwise I don’t see how the gauntlet they get put through is worth sacrificing their best years (20s and early 30s).
Maybe the gauntlet would be less severe if there wasn't such a massive pot of gold at the end of this particular rainbow. Much of it is just hazing and weeding out of the "unworthy".
But that's sort of orthogonal to the problem I'm discussing. The cost structure that enables "low cost" socialized medicine in other countries is just not there, and it's not going to be there in this country in the foreseeable future. Given this, all this talk about "medicare for all" etc, is just electoral pandering and nothing else. It's not doable without turning the whole system into a money black hole that's even worse than what we have now.
If you are trying to make free market arguments for doctors salaries come on. The doctors guild restricts supply through the state. No free market here.
I’m saying with the current requirements of becoming a doctor, a very high pay is needed to incentivize smart people who have options to choose to become a doctor.
> Those same threads have logins like "indebt4life" and "kids2feed", which matches what I've heard from doctor friends: the length and cost of medical training and insurance are so brutal that the folks gatekeeping are themselves in an unhealthy lifestyle and don't want it to get worse. In other words, and benefits of gatekeeping accrue to the school and hospital complex more than the individual practirioners.
This really depends on the forums you read. If you hang out on the whitecoatinvestor forums you'll see that there are plenty of folks who are getting by just fine on their $600k annual salaries and may even be retiring early.
Reading those forums it's clear that there are challenges (not buying a doctor house, avoiding loan debt, budgeting like a resident even once you're in your real earning years) but there are plenty of opportunities, in some disciplines, to be happy with an eight-figure lifetime earnings and a balanced lifestyle.
Disclaimer: I'm still a medical student, take my biases into account when you read this.
It seems like mid level providers are being granted more and more autonomy each year. In fact, they have full practice authority in 20 states (no need to work under a physician). Knowing that, are the AMA et al truly strangling the supply side of healthcare? From the politico article you linked, it seems that the number of specialists we have is unnecessary, so that can't be it.
I'd like to think that most doctors aren't trying to out-compete mid-level providers, and that most doctors are trying to do right by their patients. Maybe that's naïve.
I also agree that the wages for physicians are too high, and that reform from the ground up (education costs, healthcare costs, and reimbursements) is desperately needed. However, to state that providers are the core problem is tremendously naive. The average salary of physicians, even at $250,000/yr, with 1 million physicians in the US is $250 billion/yr. In comparison, the revenue from the health insurance industry was around $1 trillion in 2017. The hospital industry made $970 billion in 2016. The pharmaceutical industry made $450 billion in 2016, I can only imagine that number went up. I can see how the insurance industry and hospital revenue would be tied in physician reimbursements somewhat, and obviously pharmaceutical payments, but the pharmaceutical industry shouldn't be impacted by physician salaries.
As a side note, very few doctors I've had the pleasure of knowing have any idea what their services cost patients. Proceduralists generally have a better idea.
For those of you interested, I'll try to explain what is needed in a residency program. Your program needs to provide you with the training necessary to be proficient at all aspects of that specialty by the end of your training. That means you need the patient volume, mentorship, and variety to meet that standard. It just so happens that it's very difficult to meet that standard unless you're at a larger institution. Community programs do exist, but today the vast majority of programs except for family medicine are at academic centers.
What that also means is that you can't train too many doctors in one place at one time. Especially in the case of surgical specialties - You need as many procedures as you can get in your residency, extra residents take those procedures away from you.
That isn't to say that more family medicine and primary-care track residencies aren't needed, they absolutely are. At the same time, without more Medicare funding for these residencies (per the politico article it takes around $150,000/yr to train a resident physician) hospitals aren't willing to take on the extra cost. A bill is hopefully making its way through the House to increase the funding for more residencies (15,000 new spots over 5 years).
Ultimately, I think the trend is going to be that more and more doctors will specialize, and mid level providers will be mostly nurse practitioner or physician assistants. Hopefully the data will continue to be positive in terms of outcomes, and prove that we just don't need the amount of training we thought we did for those providers.
P.S. While I'm not going into primary care, I loved my family medicine rotation in school. I felt like I had genuine impact on my patients, met some of the most down to earth doctors, and it was an active day with lots of variety.
Very few people would happily train someone to take their job. And, some of those people will be vocal about it. The midlevels do the same thing in reverse. It's a stretch to extrapolate this to all "providers" and call that the "core problem" of health expense. How much of your bill do you think goes to the "provider" anyway?.
if you are upset over their pay imagine how you must feel about those in public service, let alone their pensions. you can pull down those numbers being a city manager and get over 100k in pension to boot!
the medical profession is not easy and i don't begrudge them their fees.
If it was so easy to diagnose then why didn’t you do it yourself?
What you are paying for is piece of mind and expert advice.
What would you do if someone wanted your expert advice on something you told them your fee and then solved their problem in 5 minutes and they balked at paying you?
This is the old saw about $1 for the work and $999 to know where to hit the machine with a hammer.
OK, following your logic, when is too much, too much? Remember that prices are not disclosed before treatment. Would a million dollar bill be reasonable?
If they knew the costs before being charged, you could make a stronger argument. As it is, they are not being charged for expertise, but for being ignorant of the costs.
Thanks for your comment. Typically for HN it has inspired a lot of doctor bashing. The person reading Dr forums to find the ‘truth’ is particularly laughable, like making generalisations about young men from reading 4chan.
There are countries where healthcare is free, and doctors get paid well (eg Australia, Canada), and student debt is dramatically less. So you have the wrong idea why you paid so much, the real reason being that American Healthcare is a complex system in catastrophic failure mode.
I’ll give you a perfect example - at the American Society of Clinical Oncology Annual Scientific Meeting this year, the biggest and most important oncology meeting in the world where original research is presented, one of the plenary abstracts was a study showing that Medicaid expansion reduced racial disparities in oncology care. To someone in a single payer system this is blindingly obvious (if you have insurance you get better care), but in the US this counts for groundbreaking research. That is how backward US healthcare is, sadly. From the outside looking in, it is obvious that this is the case.
Beyond opaque and variable pricing for the same service, there is also the question of whether something simpler would do the trick.
Some years ago, I thought I might have broken my finger. I went to the doctor and it was actually the physician's assistant who saw me. I'd explained at the front desk that I had a high-deductible policy and I would be paying in full for the visit.
The PA said "Usually we would send someone for an X-ray, but since your insurance won't cover it, there is a quick test we could do and it would just be part of this office visit."
He opened a drawer and pulled out an instrument and asked me if I knew what it was. Being a musician, I said "Yeah, that's a big tuning fork. And with those weights on the end it must vibrate at a very low frequency."
He said, "You got it! The idea is we get the fork vibrating and then hold the end against your finger. If it's broken, it will hurt like the dickens, so just holler and we will stop and you go get that X-ray. If it doesn't hurt much, it's just a sprain, so take it easy and you should be fine."
We did it, and my finger was fine. Saved me a bunch of time and money!
Edit: Thank you everyone for the lively commentary! I would like to mention something that I forgot at first (it was ten years ago) and your comments reminded me of.
The PA didn't pull out the tuning fork until going through a complete set of manual range-of-motion and "does this hurt" tests. All indications were that my finger was not broken, it was just a mild sprain. I'd only gone to the doctor in the first place out of the proverbial "abundance of caution".
So it was my decision not to get the X-ray. Please, everyone, do not blame this on the American medical insurance system! I could have easily afforded the extra $150 for the X-ray, and of course I still had that option after the tuning fork test. But since both the PA and I were both so sure at this point that it was just a sprain, I figured I would same both time and money by skipping it.
It was my call how to proceed with this very minor injury, no one else's.
With a hand injury one might lose fine motor skills, they should be taken seriously by patients and physicians. In any other first-world country the physician would have taken an x-ray, treatment cost would be nominal, there is some form of universal healthcare in place, but in America you have a choice! Your money or your range of motion!
More worrying is that people support the racket! A tuning fork, like a barefoot doctor in 1950s China might have used is a good idea! You despair about the possibility of sanity in American healthcare.
Exactly the situation with me and my shoulder. Never got it looked at, because I was in college and it "only hurts a little but it doesn't interfere with normal life goings-on". Now it's still screwed up and I know a lot more about human skeletomuscular back and shoulder anatomy.
That ISN'T cool, that's quite dangerous, because if it was indeed broken, that may cause harm. Rule #1 of being a doctor is violated.
X-ray imaging on a finger is virtually harmless. Using a tuning fork to vibrate a potentially broken bone and causing a patient to feel pain is not harmless.
This mentality is the problem with current medicine. The doctor is not causing harm, they are mitigating it with a less than optimal method. If the tuning forks analysis has better outcome than no assessment, no harm has been done
If a doctor has a treatment with 80% efficacy that costs $1,000, and another with 90% efficacy that costs $100,000, there is nothing immoral about giving the patient the choice.
"Doing Harm" would be prescribing treatment that leaves the patient worse off than they started.
As I explained in an update to my original comment, the offer to use the tuning fork came only after an extensive manual exam with range of motion and "does it hurt" tests. I'm sorry I didn't make that clear at first, it was 10 years ago.
I don't see what harm the tuning fork would have caused me beyond a moment of pain which would show that it was worth my time to get an X-ray.
Feeling a bit of pain is not the worst thing in the world. One time I had a tiny cavity on a lower molar, and my dentist offered to drill and fill it without anesthetic. He said that of course I was welcome to get a shot or two of novocaine as we'd normally done. But the lower jaw takes so much time to recover, and he'd had a small cavity of his own filled without novocaine and it was nice to be immediately back to normal.
He also knew that I was fairly tolerant to pain and he probably wouldn't have made the suggestion otherwise. So I took him up on it, and sure enough, it really hurt for a few seconds. But I had a completely normal mouth when I left the office. None of the usual drooling and tongue biting for the rest of the day. I went right out for a nice lunch!
So that was another tradeoff I was glad for, and hopefully these decisions are mine to make.
Sure it's dangerous, but $400 out of pocket for an xray of your finger is also quite ridiculous. If my finger wasn't obviously broken, I'd probably take my chances with a tuning fork, too.
Here in Germany it's less than 20. I think it was between 10 and 15 € for a finger.
This includes an expert's opinion, albeit a succinct one.
I wish they'd do technical/industrial things in a similar fashion. Make appointment, bring piece, get xray, wait a few minutes, leave with xray image/dataset. For cheap. Require bagging for contamination reasons.
Here in Germany we pay highest healthcare insurance costs in the world. If you earn more than 55000 Euro/year, you have to pay 9600 Euro/year for health insurance alone!
And you cannot opt out!
Together with your spouse you have to pay insane 19200 Euro annually!
No wonder it is between 10 and 15 Euro for a finger. In USA if you pay $20000 you will be fully ensured and you will not need to pay anything for your finger check.
> If you earn more than 55000 Euro/year, you have to pay 9600 Euro/year for health insurance alone!
Half of which is paid by your employer. If you earn less, you pay less and still get access to the same health care.
> Together with your spouse you have to pay insane 19200 Euro annually!
Only if they also earn as much. If they don't work, your don't pay anything to insure them.
> And you cannot opt out!
Employees earning more than 60k and freelancers can opt out of the system.
> No wonder it is between 10 and 15 Euro for a finger.
With insurance you don't pay anything for getting your finger checked. That was the price without insurance (full bill including consultation would be probably 50€ or so).
Wrong. Your employer covers only 50% of base KV part and excludes PV and other extras. Take 14.6% from 55000 and divide it by 2 to see what your employer covers.
Oh, sorry, the price is the GOÄ (Gebührenordnung für Ärtzte) price the X-Ray place can bill you/your insurance. This includes the X-Ray consultation.
You are send there by your GP if the GP determines you need it checked like that. They write it down, give you a form, and the specialist uses it to bill the insurance (as they don't pay if you just show up at the X-Ray place directly).
Also a full hand, including the palm, is less than 10€ more I think. It's really not that expensive (a Finger was the cheapest I remember finding).
I don't see how it could be that dangerous assuming the doc first looked it over and couldn't find anything by hand. How would a tubing fork seriously hurt a small fracture if applied with skill?
Ah, too late to edit again, I was in a hurry on that update to beat the two hour limit. Just for clarity, that one sentence was supposed to read "I figured I would save both time and money by skipping it." (emphasis added)
Sure, but in the case that the "simple trick" didn't work and someone end up with something catastrophic (e.g. missed fracture that resulted in chronic disability), who do you think they sue? Yes, the guy who tried to do right by you by saving you money. In medicine, no good deed goes unpunished.
FYI, even if you had broken your finger the treatment is almost always splinting and time. Most doctors wouldn't do an x-ray or a vibrating test. Does it hurt? Splint it, come back in a week. Next.
Get it set properly, then splinting and time. If you're sure you (or someone around you) knows how to set it, you maybe want to go that route. But if it's not set right, and you splint it there, that may not work out so well...
That is true, I recall they mentioned $150 but we are in the same ballpark.
It wasn't the cost that steered me away from the X-ray, I just didn't want to take the time to wait in line after I felt sure that it was just a sprain and all I needed to do was take it easy on my hand. (I updated my original comment to note some of these details.)
Having a bone in my hand set without anesthetic, I suspect it's because when a broken bone becomes rapidly agitated it's causing a bunch of nerves to fire their pain signals. The tuning fork most likely resonates the bone rapidly -- if things are just sprained, the whole bone vibrates. If the bone is broken, it grinds against itself.
Glad you asked, I forgot to mention that. He did explain that if the bone is broken, the broken ends would vibrate against each other, and that would be as painful as it sounds.
I think because more energy is transferred to a smaller piece of bone which then vibrates more and is presumably more painful as it contacts pain receptors around it - whereas an larger intact bone will vibrate less as there’s more bone mass to move around.
Because instead of being a smooth unit the bone has broken edges, and with vibration its moving rapidly within the surrounding flesh; its kind of like having an electric knife embedded in your flesh.
and when you're having heart arrhythmia, since it is too expensive to send you to a specialist and hook you up to one of those EKG devices, why not just do a series of 20 pushups and 20 squats and see if you'll collapse?
alternatively, we could have a system where patients are entitled to some basic care, but hey..
I think it depends on the efficacy of the cheaper procedure. It's rare for the cheaper procedure to be as accurate as the more expensive one. If you knew the tuning fork was 80% accurate and an x-ray 100% accurate, would you still take it? I'd personally pay extra to make sure I was diagnosed correctly.
From the initial story the tuning fork would be followed up by an x-ray on a positive result; so you don't really care about overall accuracy but false negative rate (since a higher false positive rate than x-ray is immaterial, since the follow-up x-ray constraints the false positive rate.)
While the exact test done may not be common, its very common for any of a variety of broadly similar (in that they work by inducing motion which will almost certainly be quite painful if there is a fracture and but usually be tolerable otherwise) "does this hurt" tests to be used in a similar role with suspected fractures, and an x-ray only ordered if they indicate a likely fracture.
Indeed you have it right. In fact the PA did go through a whole set of range of motion and "does it hurt" tests which all indicated no fracture. The tuning fork was just a last check to verify that, and of course I had the option to go get an X-ray if I wanted it regardless.
I just didn't see any need at that point, since the treatment would just end up being "take it easy on your hand and don't engage in any sports for a while."
But if it heals wrong, the fix is to have it broken again by a specialist and constrained. it hurts as hell and costs 3x as much. Hence, going back to the point about large deductibles for simple procedures being total bullshit..
> If it looks straight, a hairline fracture will heal properly if unstressed for a few weeks.
If the fracture isn't diagnosed and the person is one who tends to engage in the kinds of activities that lead to a suspected potential fracture of the bone in question, it probably won't be unstressed for a few weeks.
The underlying point is that it'd be nice if you are able to get first world care instead of "lifehacks" for a range of very common conditions, given that you're insured, and not have to pay a giant deductible.
Insurance is not supposed to make routine things more affordable. It's supposed to spread the risk of catastrophic loss from unlikely events around to a large group of people so you don't have to worry about losing your house if you get struck by lightning. Everyone needs routine medical care at some point so an insurance model doesn't work there.
You don't have gas or grocery insurance, do you? If that were a thing would we all expect to pay less for gas and groceries, or would we just be tacking on overhead for routine expenses for no reason?
Using insurance for routine, affordable expenses is one of the problems. But it's a race to the bottom where insurance companies win, because everyone in the U.S. thinks "good" insurance pays for everything and makes a 17% profit out of nothing.
In addition to the transparency the article advocates for, we'd probably be way better off with a universal health care stipend and very high deductible insurance for rare catastrophic events. Insurance should not be involved in routine care.
There's no reason an insurance provider can't manage a guaranteed cost every year. It's basically just an offset on the risk curve.
You could look at health insurance like a buyer's club (we negotiate prices for a large group of customers) plus a true insurance (the unexpected happened, is expensive). The buyer's club portion can be useful in mitigating expenses for the unexpected.
That said, nowhere in here is there a strong incentive to reduce costs (I go into this in more detail in a different comment on this topic). If you really think about it, an insurer just wants predictability, the actual cost is somewhat irrelevant as long as people can pay it. Because insurance is usually "purchased" and subsidized through your employer, you're somewhat disconnected from that price.
Even if you weren't, you don't really have good alternatives. You can choose the private market (often less good plans without as strong a network) or you can choose no insurance at all. These aren't great choices, and frequently when you're making the "purchase" it's very very hard to know what you're buying.
I've shopped around for insurance, it's quite difficult for them to answer, "I think I might need this thing, how much will it cost me with your plan?"
The whole system needs to be rethought. Likely through a combination of forced transparency, mild price controls, breaking up monopoly-like consortia within the industry and forced standardization of some products to make them understandable.
Agreed, calling it health 'insurance' is a horrible misnomer. But, I don't think that your solution (stipend + insurance) is good, since there are conditions that increase the frequency of 'routine' care. So, for instance, a diabetic with no income/wealth, who has to rely solely on their stipend for healthcare, would still be screwed with one of these conditions.
You might say that insurance should cover this kind of condition and not consider it 'routine care', but we see how well this works in the current for-profit medical insurance system. Insurance providers seem to be okay paying out low-frequency high-cost events, since that's the risk profile they model, but they hate paying out recurring care costs. Once you become a recurring cost, it is in their profit interest to reduce your care, or get you off their rolls.
> Insurance is not supposed to make routine things more affordable. It's supposed to spread the risk of catastrophic loss from unlikely events around to a large group of people so you don't have to worry about losing your house if you get struck by lightning. Everyone needs routine medical care at some point so an insurance model doesn't work there.
And this is why all of our heated political debates go nowhere in the US. You have Democrats ranting and raving over how they want to provide health insurance for everyone, even if private companies help provide it. (With their supporters full of sob stories.) You have Republicans ranting and raving over how great it is to keep everything private and allow insurers to not cover everyone. (With their supporters pretending its just "insurance" you can live without.)
Meanwhile, its not really "insurance" at all. Its basically a cartel of companies that negotiate a situation where healthcare is effectively unaffordable without them acting as an intermediary.
> You don't have gas or grocery insurance, do you?
Some people do have analogous "insurance" for gas or groceries: Anyone with a Sam's Club, Costco, or Amazon Prime membership pays a subscription fee so that they can get a negotiated discount on routine, affordable expenses.
So, yeah, I guess most "health insurance" could be more accurately called "healthcare buyer's clubs (that also happen to include some insurance)". Unfortunately, we're in the late stages of an economy where the buyer's clubs have eaten the entire market and are free to extract fat margins with little consequence.
There's still a benefit in insurance for routine procedures to balance costs between the young and old. (As long as young people are required to have insurance)
...but the fact that the median income of young people (at the beginning of their career, whatever it is) is much lower than old people, pretty much nullifies this. If you want to balance out the costs over a person's life, there are much better ways than making the coffeeshop barrista subsidize the middle-manager's health costs.
The reason this logic fails is because income and healthcare costs are on different curves but of similar (or far greater in the case of healthcare) magnitude.
Say you start out your career making $30K as a barrista and end up making $150K as a middle manager in your 60s. A single surgery can be $150-$300K and you're more likely to have them when you're older. Cancer patients can cost millions in a given year, again you're more likely to have that as you get older. I don't have the number for a diabetes patient off the top of my head but I think it's 10s of thousands a year.
The income growth curve is far shallower than the healthcare cost curve, and the healthcare cost curve is essentially unbounded whereas for most people income doesn't go all that high. Remember median income in the US is something like $55-$60K. Most people won't ever see 6 figures and if they do, they'll see the very low end of that.
It seems like someone could start an insurance company, where all customers had to claim they had no insurance, but then sent the bill to be reimbursed.
The "insured price" contributes to your annual out-of-pocket maximum. Care providers want insured patients to hit their cap as soon as possible so that the patients' marginal cost of care drops to zero. Once this happens, they can get patients to keep getting expensive treatments "for free" while the care providers can continue to bill insurance companies whatever they can get away with.
(American here.) Funny, my last several doctors visits the cash price has always been higher than the negotiated price.
These are all for services in the $150-300 range, and I was told upfront what the cash price would be, but they couldn't tell me what my negotiated plan rate was. (I inquired because I have a high deductible plan so I'll pay in the end no matter what.)
The negotiated prices were all at least 1/3 lower, and the most expensive one turned out to be free because it was classified as preventitive.
So it's even worse because you never know. It's certainly not a rule at all that cash prices are lower.
> Funny, my last several doctors visits the cash price has always been higher than the negotiated price.
There is nothing funny about it. Once you tell the provider that you have insurance, the price they can quote you is in their contract with the insurance company. You need to go somewhere new and tell them you do not have insurance to get the real price.
They didn't have to check that, and certainly didn't. They knew the prices off the top of their head.
The doctor had no idea what health plan I had or even if I had one -- they leave that up to their staff to sort out, they couldn't care less personally.
Um, no. My original comment explained, their cash prices are higher than the prices through insurance. (Also there's no single "insurance price", they're different for each plan they accept.)
And honestly, that's supposed to be one of the points of insurance prices, that they negotiate prices down by providing volume.
So there are clearly different economic factors at play, in different doctor's offices and hospitals. I'm just making the point it's not always the case that the cash price is cheaper -- it can be more.
I don't need to "think about it", it's just the facts.
There is a "cash price" in many contracts between the insurance company and provider. If you tell them you have insurance the provider must quote you this inflated price.
You need to go to a place that does not know you have insurance, say you do not have any, and then get the cash price from them.
How do you know that? I'm looking online and can't find any mention whatsoever. What's the contract term for it? And what percentage of health plans in the US does that apply to? And how often do doctors actually follow that?
In my case, the doctors in this office are certainly unaware of anything like that. Like I said, the doctor quotes the cash price, which is standard for the office, not having the slightest idea of which insurance I have.
You keep insisting there's this separate higher cash price, but I'm explaining to you the fact that in this case, there obviously isn't, in practice.
Because you don’t want to deal with the type of person that doesn’t have insurance. They may be more likely to not pay, or otherwise unpleasant to deal with.
Another option is to just let it go to insurance, and if they fully reject it, then call the place and tell them the insurance wont cover anything - then you'll get heavy discounts (usually they just feel bad and remove codes and what not). Unless you had gone to a corporate place, of course, which they all tend to be now.
A lot of the price has to do with doctor's vouching for certain costs as well. Other than the airline industry I can't think of a worse case of being built on a giant house of cards.
>The near-total lack of transparency in healthcare pricing is a key reason we have the highest costs in the world — roughly twice what people in other developed countries pay.
ITT: people who assume doctors are accountants and go home in their sports car every night to tweak their prices and count the stacks of 100s they made that day
The reality is is doctors often have no control over cost. Yes, if you are the increasingly rare private group that is physician owned you do but certainly not if you are employed. These are 100% set by the bean counters who are paid twice my salary and have no idea about what we do on a day-to-day basis.
I have no idea what my services cost and for ethical reasons I don't want to. That inflicts bias and can lead to misdiagnosis.
I sacrificed 10 years of my life and took on over $275,000 of debt that continues to grow thanks to compound interest. I live in an average house and drive an average car because I have this debt to pay back.
Daily I am responsible for not harming dozens of patients while trying to make their lives better. With each decision I make I have the risk of being sued and losing everything I have worked for. All the while, my mid-level providers work relatively liability free because they work under my license and their mistakes are on my back. Adminstration pushes for higher numbers of patients andmore uncompensated work. When was the last time you spoke to a lawyer on the phone or had them complete a 5 page document for free?
Think twice before you criticize doctors and the sacrifices we have made. I didn't do this for the money, I assure you.
Why? Why are insurance companies not demanding cash price and reducing premiums? There should be lawsuits against hospitals, this seems like something which is generally considered highly illegal at this sort of scale... charging different customers different prices -- especially when the ones paying more are more than capable of taking hospitals to court.
I found this interesting article on the situation. They say 1/3 are profitable, 1/3 are break even and 1/3 are losing money. And a lot of those losing money are in rural areas. And "In general, hospitals lose money on Medicare and Medicaid patients, but make up for that by charging private-sector insurers more."
"non-profit" doesn't mean "doesn't make money" its just rules on how you have to spend that money.
There's nothing saying a non-profit can't raise prices of service and then expand the hospital to buy a new wing, or better equipment or hire more doctors. They need the money to provide their services.
I understand that, but there is a limited amount of that which can be done before it becomes spending for spending's sake, which is pointless.
Also "expand the hospital to buy a new wing, or better equipment or hire more doctors" sounds like exactly what they should be doing, because it means they can service more people at a higher standard of care (which is the reason they exist in the first place).
I'm a generally anti-legislation kind of person, but as long as breaking up big tech is a hot topic, why not pass a bill requiring cash prices for any not-for-profit insurance providers and co-pay networks? There's a lot of interesting competition happening in those spaces, and making not-for-profit insurance a better deal seems like a great way to get capitalism grinding at the issue of overpriced healthcare.
That doesn’t work for emergency care - where the patient really doesn’t have the time to go window-shopping while having a cardiac arrest.
And while greater transparency is good - not everyone in the public is able - or willing - to understand a medical price-sheet and might opt for a cheaper but medically-inappropriate procedure with similar-sounding-name to the procedure they actually need.
I would prefer a system where they charge everyone the same amount. It wouldn't surprise me if the insurance companies would be in favor of that, the whole price negotiation overhead goes out the window.
I can't speak to Medicare/Medicade but the general idea is this: Doctors and the things they use/services they provide have a cost associated with them. Insurance works by spreading risk. Guy who breaks his wrist essentially takes money from the pool that wasn't used by the guy who hasn't been to a hospital in 6 years. So far everything is fine.
When you have people who exist outside that system of resource reallocation, the doctors have to find ways to ensure they're still getting enough money to cover their costs. One way they can do this is by suing patients who don't pay, but that takes time and more money and doesn't always work. Another option, would be that they then raise their rate to the insurance companies because they know that the insurance companies can afford it since they have such large pools of money. The insurance companies then raise the rates for everyone buying into the resource reallocation pool, and eventually everything spirals out into our current non-system.
Is it more complicated than this: yes, but that's the elevator pitch on it.
> they know that the insurance companies can afford it since they have such large pools of money
This is exactly why Medicare for All is touted as a solution. It would create the largest pool.
It would also reduce the significant overhead presently involved with billing N different insurance companies. Why isn't the conversation about those costs imposed by the current system?
Americans in general are in love with the idea of the "just world". If someone gets sick, it's because they did something to deserve it. If we treat their illness for free, they won't learn.
Additionally, lots of employers also love holding their employees hostage via healthcare and they spend millions lobbying to this end.
Yep, your comment is underrated. Employees need to protest though.. these rising deductibles and coinsurance out of pocket costs are getting out of hand.
I'm having an ultrasound (at a private clinic) in about two weeks to check for a gall bladder stone.
I have no idea what it costs but I guess out of pocket it would be about $20 "co payment", same as when I had a MR scan for my neck earlier this year. If you're out more than $200ish a year you don't have to pay the "co payments" anymore either, but that's only happened once for me.
If you need to go to hospital it's free regardless.
Norway here, guess we have a tax funded "single payer" system. Wouldn't have it any other way.
As mentioned below, the price doesn't matter when nobody is available to see you.
Also, the opportunity cost of sitting around with a broken hip waiting to be seen can be higher than going to a privatized country/province and paying for the surgery, in which case you're a super-sucker who paid extra taxes for decades just to end up paying out of pocket for surgery anyways.
Anyways, the US system is probably worse overall but it can work quite well (better than socialized medicine) for upper-middle-class people and above which is why it's still around.
Funny, I have a sister in Canada and a sister in Switzerland, neither of them have had trouble getting ultrasounds. My wife's grandmother is also in Canada and was treated the same day for her broken hip.
I'm really sick of being told things are impossible in the US that are normal in other developed countries.
I live in Canada and have waited 4 months for a specialist at great personal cost (but not financial cost).
I have also seen my mother suffer for 6 months on a surgery wait list and then recover slowly and painfully in a room with 4 other people who were constantly screaming during the night. And she was a lucky one because the hospital was so overcrowded that other patients were living, sleeping, and recovering in the literal hallway. Google "hallway medicine Ontario" to see I'm not making this up.
It's not a perfect system by any stretch and it's much better than nothing but I bet upper-middle-class and above citizens in the USA enjoy better care.
I live in the United States and in June of last year I was told to make a appointment with a ear, nose, and throat doctor. So I called and was told the earliest they could see me was in October.
I started chemo before my original appointment with that doctor. (Yes, it was mouth and neck cancer)
> Also, the opportunity cost of sitting around with a broken hip waiting to be seen
This example is bad. New Zealander here: a broken hip will be fixed in reasonable time, and I think if you have private insurance it likely would be diagnosed, fixed, and recuperated in the same hospital.
Private insurance does help if you need a hip replacement. On public, you will wait for a long time, and you will be in pain for a long time. Private is much more proactive at replacing a hip early.
However hip replacement is that common that I strongly suspect you would be financially better off paying for it when you need it (whether poor or rich).
If you are from the US, you should take care before projecting any experience you have of hospitals upon other first world countries. I think your system is so severely broken you cannot reasonably model anything about a foreign system.
I live in Canada and my experiences are with the Canadian health care system in Ontario.
Edit: I have friends that live in the US and work in tech and enjoy better care. Like I said, the Canadian system is much better if you're poor but the US system is better for tech-worker income and above. This is why it sticks around: powerful people and voters in the US are likely to be old or rich-enough and enjoy good care.
If you are the sort of person that can afford good health insurance in the US, then you are also the sort of person that can afford to go private for certain things in a country that has a good public system.
The existence of a public system keeps the prices for the private system in line. They can't get too ridiculous because there is always the free option available.
In NZ, I have found that diagnostic on the public system to be plenty fast enough. Then when it comes to treatment option you can weigh a quote of getting it done privately immediately vs waiting for a specified amount of time.
And due to the public system I wouldn't even think twice about going to the doctor as soon as I have any kind of issue at all.
From most of the folks I talk to here and abroad, waiting times for the things you're thinking of are longer in the US. I just spent 3 months waiting to see an ankle surgeon here in NYC and it cost over $1,500 to have x-rays in the office and be told I'm a bad candidate for surgery. A friend had to spend the better part of a month waiting for a mammogram and ultrasound to diagnose breast cancer.
Someone in the dorm next to me in college died of an asthma attack because he couldn't afford the ambulance and took a cab.
The system is still the way it is in the US because of money.
> Previous studies have shown that the average wait times to see a neurologist are increasing. The average wait time for a new patient to see a neurologist in 2012 was 35 business days, up from 28 business days in 2010. The average wait for a follow-up visit in 2012 was 30 days, up from 26 days in 2010.
> The average wait for a new patient seeking an appointment with a dermatologist in a major metropolitan area is 32.3 days, according to a recent survey conducted by Merritt Hawkins.
You're presenting a false dichotomy. If people are being gouged then you can pass laws to limit that. You don't need single payer to solve these issues. Everyone knows the pricing system is BS. If that's the case then we should pass laws to change this.
I had injured ligaments and tendons in my dominant wrist after an airbag went off during a car accident. Splinting in the ER, sure. "Follow up with a Physical Therapist, get that started."
Give it up, dude. I lived in a top 20 city, with great insurance. Any specialist visit was at least 3 weeks out. GP 2 weeks, 1 if I settled for a nurse practitioner. Our health care sucks, and there is no defending it.
Most of you who attack doctors have no idea how this complex health care system works. Doctors are UNDERpaid. A majority of the billing goes to overhead for the hospital facilities, nurses, labs, meds, administrators, etc, with doctors getting much less than 10% of the revenue even though they are responsible for generating most of it. Your resident doctor friend (who has way more qualifications than your software engineer friend - including top tier college, and medical school) gets paid about 60-70k a year for working at least 80 hours a week. Yes, the man or woman who assists in your brain surgery after your aneurysm popped gets paid less than your uber driver for 7 years time, and he sacrificed his/her best years to be a sleep deprived medical student and then brain surgeon working under constant rush and stress, as their 300k med school debt accumulated under high compound interest. Meanwhile, your mediocre software engineer friend graduates debt free, gets paid 160k out of college to build the next best sexting app, at a company with free lunch and gym.
Also, don't forget about the malpractices. 10 years down the line, your radiologist friend gets successfully sued for 11 million dollars bc the parents of a child for whom they read a chest radiograph decided to sue because lawyer convinced the parent and jury that radiologist was at fault for not saying the heart is enlarged and somehow that is responsible for all the kids ailments later on in life (the truth is much more complex than that). The radiologist probably got paid 7.50$ for that read, btw. This is actually a true story, look it up in the Boston Globe. Now all providers are on edge and overdiagnosing and overordering everything - who would want to miss a diagnosis.
I'm dealing with an insurance mess right now. I got a physical at a in-network doctor a month ago and they sent my blood sample to an out-of-network lab. My insurer sent me a statement last week saying that $444 of the $954 bill is eligible for payment. However since I hadn't met my deductible for out-of-network spending yet, I would have to pay that entire $444 on top of the $510 that they wouldn't cover even if the sample had been sent to a in-network lab.
I believe/am hopeful that since I live in New York, which prohibits out-of-network providers from surprise billing patients without the patient's informed and explicit consent that the procedure would be considered out-of-network [0], that I ultimately won't be held liable for the bill.
Fortunately as a software engineer, I can trivially afford to pay the bill in the worst case. But I shudder to think of the consequences for someone in a much less privileged circumstance.
I write this very candidly, and many on HN would likely constantly argue if I always chimed in with my personal views. I am a very conservative person, and always have been. That said, I will vote for anyone who promises single payer healthcare. Our healthcare is completely broken, and I feel honestly that anyone defending it is either being paid or brainwashed.
The cash price being lower is lucky. Sometimes uninsured cash prices are jacked up due to collusion with the insurance racket.
We see a hint of that here: "Cigna gets a contractual discount of just over $1,000 because it’s, well, Cigna." In this particular case, the negotiated discounts didn't bring the price below the cash one, but in many cases it will.
I recently had a "$140" blood test that Cigna declined. I was billed $6.48 (which is what Cigna would have paid if they accepted). I'm pretty sure I would have been charged more than $6.48 without Cigna involved.
I'll start by saying I agree with the premise of the article - transparency of pricing is not just helpful, it is necessary.
However...I can also understand why paying by cash should much cheaper Adding another company or companies into the transaction, trying to standardize the various medical procedures, invoicing and managing co-pays, deductibles etc adds a significant amount of overhead.
One would hope that the insurance companies would leverage the volume of transactions and the pools of clients to get price improvements but this is not the case.
Yeah I think the big problem here is related to the scale, not the fact that it's cheaper when you pay in cash. But that insurance would pay $500 (after negotiating the price down) and then push a > $1k charge to the patient when the clinic would have been ok with a $500 payment up front is just wrong.
It's also worth noting that many clinics, if not most, won't actually try to collect the balance here. They'll often go through the motions and forgive the balance after some number of attempts to collect.
There are many times when a practice will quote you a much higher cash price just because you don't have an insurance company negotiating for you.
I have privileged foreign friends with private "worldwide insurance" from a European provider, but it is just a reimbursement scheme. So they appear uninsured to American providers and have to float potentially extremely large costs which might not actually get reimbursed.
And then things like birth control aren't insured by their "worldwide insurance" nor some dental work deemed cosmetic, and these people aren't surprised their great "worldwide insurance" doesn't cover those things because their state run insurance wouldn't cover those things either, but confused why the cost is so high in America.
I have to tell them that "privileged" people in America don't pay those costs, and explain to them how dangerous or ill-advised acting uninsured in America is.
Why would you use insurance for something you know you are going to need? I got new glasses and an eye exam and they were surprised I didn't pay via insurance? Why would I want to pay extra to insure for something I know I will need to get? This makes no sense at all.
privileged people have the option of using pre-tax + employer funded FSA/HSA accounts, where a wide array of hygienic purchases, medical purchases and even copays can be paid for and further subsidized.
These are part of your overall “insurance package”, in conversation this is typically called being insured with no regard to whether an insurance company is actually picking up the tab.
Wouldn't the "privileged" prefer to have actual money they could spend as they want instead of be forced to use it for a single purpose, including the extra cost of a middle man? It sounds like some sort of tax scam.
The opposite also happens, where the uninsured price is a lot more than the insured price.
I was in this sort of situation once. I needed a CT scan, but it was on a late friday afternoon, and the hospital couldn't get prior approval from the insurance company. They quoted one price that they would bill the insurance company if it was approved, and another much larger priced that I would have to pay if the insurance company rejected the claim. (I ended up getting the CT scan the next day at a hospital that charged a lot less. I think it was covered by insurance.)
The thing about this that's bad is that it's over-charging the people least likely to be able to repay, and (if they can come up with the cash) they're effectively subsidizing the insured customers. This is the other side of narrative that poor people are driving up health care costs for everyone else because they don't pay their bills.
If you have a similar story: stop reading, open a court case in small claims court and come back to post about it. You will get all the support you need here from extremely qualified people, including specific filings you should make and also answers to every question you will have.
If you have to go to minor emergency clinics that are popping up all over, say you dont have insurance and want the cash price, its 1/4th the cost. If you pay with insurance and have a co-pay or a yearly deductible its just not worth it. Then pay with your HSA card.
How long has it been broken like this? By my count, at least 346 years, reckoning from the premiere of The Imaginary Invalid by Molière.
The opening scene features the protagonist iterating over a series of rationalizations for reducing his medical bills to 1/3 of the list price.
That this scene was expected to be received by an audience which could relate to the necessity of performing these sorts of arithmetic gymnastics (though perhaps exaggerated for comedic effect) suggests that this was already a well-established norm in 1673:
SCENE I.--ARGAN (_sitting at a table, adding up his apothecary's bill with counters_).
ARG. Three and two make five, and five make ten, and ten make twenty.
"Item, on the 24th, a small, insinuative clyster, preparative and gentle, to soften, moisten, and refresh the bowels of Mr. Argan."
What I like about Mr. Fleurant, my apothecary, is that his bills are always civil. "The bowels of Mr. Argan." All the same, Mr. Fleurant, it is not enough to be civil, you must also be reasonable, and not plunder sick people. Thirty sous for a clyster! I have already told you, with all due respect to you, that elsewhere you have only charged me twenty sous; and twenty sous, in the language of apothecaries, means only ten sous. Here they are, these ten sous.
"Item, on the said day, a good detergent clyster, compounded of double catholicon rhubarb, honey of roses, and other ingredients, according to the prescription, to scour, work, and clear out the bowels of Mr. Argan, thirty sons." With your leave, ten sous.
"Item, on the said day, in the evening, a julep, hepatic, soporiferous, and somniferous, intended to promote the sleep of Mr. Argan, thirty-five sous." I do not complain of that, for it made me sleep very well. Ten, fifteen, sixteen, and seventeen sous six deniers. "Item, on the 25th, a good purgative and corroborative
mixture, composed of fresh cassia with Levantine senna and other ingredients, according to the prescription of Mr. Purgon, to expel Mr. Argan's bile, four francs." You are joking, Mr. Fleurant; you must learn to be reasonable with patients; Mr. Purgon never ordered you to put four francs. Tut! put three francs, if you please. Twenty; thirty sous. [Footnote: As usual, Argan only counts half; even after he has reduced the charge.]
"Item, on the said day, a dose, anodyne and astringent, to make Mr. Argan sleep, thirty sous." Ten sous, Mr. Fleurant.
(the above is just the first half of Argan's recitations - they go on for another paragraph or two!)
This ridiculous symptoms come from ridiculous regulations and their unintended consequences. Apart from emergency care, I think the health care industry actually needs very little regulation.
This adds to my recent thought stream that it ought to be charge 2 people a different price for the same thing (basket of things) ...
Why is it that someone who is a new customer for service X gets a sweetheart deal but those of us who have faithfully paid for months/years are charged a premium?
Why is it that 2 people in a hospital pay entirely different prices for the exact same thing?
on and on the insanity goes.
I am, of course, not talking about packages/bundles etc. Yes it makes sense that someone who buys 10 could get a better price than someone who buys 1.
Price discrimination yields the most profit for a seller. You want to be able to capture all that each person is willing to pay, because your cost of goods sold remains the same.
Also the new customer doesn’t permanently get a sweetheart deal, it’s always a temporary incentive to join, which doesn’t seem unfair to me at all. However, as a buyer, if you’re not always shopping around, expect to pay more than someone who does. That’s just how the game works.
I agree that you're talking about an optimal analysis of the current game.
However, one of the roles of government is to alter games which are suboptimal for society. For example cartels are illegal despite them being optimal for the sellers.
What’s a little tricky here is that the cash price is only $521 because the insured price is $2,758. If the patient were able to choose the cash price or the insured price, the cash price would be much higher.
One of my family members once told me he is against socialized medicine because it subsidizes the bad choices of the poor. True enough, but that’s no different from the current situation (since hospitals can’t refuse to treat) except that the one we have is opaque.
I always got a kick out of the DO's in training at a WA DO school telling us they were all on WA medicaid, as they didn't have another option in which to obtain healthcare.
Huh, that's odd.
A friend who asked how much the retina re-attachement would cost. Weighing her options.
I'm just sad that healthcare seems like such a luxury.
I do enjoy stories of friends not just being complacent. Going out of country for dental procedures. Getting good results for 1/10 the price.
No one in American healthcare knows how much it costs to deliver care. And as a result, the bills are more like: "They look rich. Let's see if they'll just pay it."
Having lived in the US for over a decade, I am disappointed with the system. I also notice that nobody in this thread, so far, has talked about liability and the overly litigious aspect of the American society. There are so many lawyers that are willing to file malpractice lawsuits against anybody in the medical industry which also raises costs overall.
Malpractice costs are a relatively small proportion of the total costs for healthcare[1]. Probably around 3%. Doctors love to complain about being sued and about the high cost of premiums, but being able to sue for malpractice is the only recourse a patient has when a doctor or medical practice screws up.
I’ve been purchasing drugs entirely by cash, optimizing markets as best I can, for about 7 years now. I began when I discovered my employer’s drug plan, Optum, was charging me significantly higher prices than the the spot prices on the open market.
Are "cash" prices always cheaper than what's billed to insurers? What if one starts an "alt-isurance" company that just gives people cash for their medical bills that operates completely outside the medical industry network?
We already have that .. sort of. They're called Health Savings Accounts and by law they're tied to high-deductible policies. Mine is $2500, so I'm on the hook up to that amount. With some caveats, such as payments for drugs, etc. The good news is that money is yours to keep and use (only!) for health related expenses. So unlike a FSA the balance will roll over to the next year and continue earning interest.
The other trend along these lines are concierge doctors. They don't accept insurance, and typically operate on a subscription basis (X dollars per month).
No. Not all hospitals are willing to offer discounts. Sometimes, the cash price is higher than the insurance rate (which is negotiated).
It's pretty hard to pull off an external company since many hospitals won't even tell you what their negotiated rates are (I have an HDHP where I'd think the point is to shop around, but can't because of the lack of price transparency).
For what it is worth, goodrx.com is doing a variant of this with drugs.
That's called "indemnity insurance", and it very much exists. You get $x every time you need to see a doctor (capped to $y/year, or such). E.g. $3000/day if you're confined into a hospital.
It's tough to figure out the plan that works well for non-routine things. But then again, bigger operations are tough for everyone who doesn't have the best employer-based HMO/PPO plans.
It's important to remember that an insurance company has very little to zero incentive to lower costs. The only incentive an insurer has is to ensure costs are predictable. It doesn't matter if costs go up 20% next year as long as they know costs will not go up 25%. The extra cost gets shunted into the premium.
There is no party in the current healthcare system whose incentive is to lower prices. Medicare/Medicaid can achieve low costs by fiat, but it's broadly accepted that the whole system as structured today couldn't operate on those prices [1]. This means private insurance picks up the delta.
Doctors, Hospitals, Pharmacies, Drug companies, Medical device companies all have zero incentive to lower prices. You might think technology that makes doctors visits (to pick one example) would just win out in the marketplace, but there's a flawed assumption there. Most people are insured, so most people are paying the insured cost. For something like a doctor's visit, you pay your copay (say, $25) and the insurer pays the rest (lets say up to $70). Assume you could get an app or a technology that gets that price down to $35. This would be a huge achievement and you'd go out of business because it's more expensive than what the consumer sees.
Ah yes, but maybe you can pitch to insurers, surely they would love a lower cost! Probably not. You're small so you can't reduce their costs across the board. Even if you succeed, they have caps on how many profits they can take (usually something like 15-20%) so if you drop their costs, that might actually force them to refund customers. Good, but not the primary driver for profitability.
Let's even grant that the above isn't true. You're still a small player, you basically need to fit inside their (extremely cumbersome) protocols to be able to bill them. Now you have to do all sorts of billing and management, maybe you need to hire extra staff to run billing. That $35 now financially doesn't make sense, maybe it's now $55. Still cheaper but now you're in the system and don't have much of a competitive advantage that's visible to the consumer. Now you differentiate by offering better services, maybe a good online portal, that costs more engineers, and now we're back up to $70. Insurer doesn't care much, you're just another provider, they'll pay, you'll make money, and we're back to square one.
We're not even considering the, "Is the cancer doc that costs 25% less the same value as the other guy?" problem, which is damn hard on its own.
Healthcare is really hard, and the incentives across the board are perverse. I'm increasingly skeptical a solution that doesn't dramatically reshape the market is likely to make a difference.
I don't see how mandating clear pricing is supposed to address medical inefficiency. If it threatens your life, you're going to pay no matter what, or in other words, demand is inelastic. Insulin is often used as an example of an inelastic good in Economics 101. I'm not sure how people are supposed to comparison shop for hospitals in an emergency situation and even for elective procedures, lots of hospitals in an area are often owned by the same overarching company and it's not difficult to collude. For "the market" to work, we would need to let people die, which is not very popular among society at large.
No. For the market to work, substitute goods would need to have transparent pricing so the customer can choose with price in mind. Most ultrasounds — indeed, most entire hospitals — are pretty close to identical goods. Everyone will die without food, but supermarkets don't take advantage of that fact to mark up food by 500%.
It's easy to evaluate the quality of an apple and there are dozens of substitute goods (other fruit). It's not easy to evaluate the quality of an ultrasound machine, the staff required to operate it, and their interpretation of the results. Depending on the medical issue, there may not be a substitute good (procedure).
I disagree, I would think that imaging centers produce comparable results. On the medical side, the substitute good isn't a different procedure, it's the same procedure done by a different provider.
Most people do not currently make any of those evaluations anyway, so as far as the consumer is concerned, they are de facto substitute goods since they have no rationale for making a choice.
I would recon life threatening emergency medical care accounts for a small fraction of overall healthcare. Even comparison shopping for birth is virtually impossible and one has 9 months to do it.
I refused to pay it. It was the first time I did not pay a debt and the first time I was sent to collections. I refused based on principle, and not because I couldn’t afford it. Collections called me for about 3 months, and every time someone called and said, “is this John Wheeler”, I would never confirm and then go about asking why they are calling for John Wheeler. Eventually, the calls stopped and the collection agency wrote it off to their unpaid reserves (I’m assuming), I never received a ding on my credit report.
Everyone is always asking why US healthcare is so expensive. People blame it on the insurance companies and the hospitals, but my theory is it’s the providers.
I worked at Vanderbilt on their payroll system, and I would regularly see general practitioners making $350,000 a year, and this was 15 years ago! It wasn’t uncommon to see teaching doctors getting paid a million dollars.