The True Cost of Healthcare in the US(truecostofhealthcare.org)
truecostofhealthcare.org
The True Cost of Healthcare in the US
http://truecostofhealthcare.org/
15 comments
For example 1: The reason why the hospital charges so much is the fact that it gets stiffed for a lot of emergecy patients without insurance. Many hospitals are on the brink of bankruptcy especially in poorer areas. This does not always reflect in the huge disparity in prices people pay, but is a big factor. Hospitals try to offset their losses by charging paying customers more.
The real problems here especially with emergency care are that hospitals are forced to eat the cost of treating non insured patients, and that patients have no idea what something costs when they are there or if the people treating them will be covered by their insurance. Insurance companies spend a lot of time negotiating rates and making them somewhat uniform for them, but this is totally opaque to the patient. We need to make it more clear to the people being treated what things cost, and who is "in network". There have been times that I went to an emergency room "in network" and I was "balance billed" by nearly every doctor there due to them not being in network. What is a patient to do? Sit there with a book of providers and procedures?
The real problems here especially with emergency care are that hospitals are forced to eat the cost of treating non insured patients, and that patients have no idea what something costs when they are there or if the people treating them will be covered by their insurance. Insurance companies spend a lot of time negotiating rates and making them somewhat uniform for them, but this is totally opaque to the patient. We need to make it more clear to the people being treated what things cost, and who is "in network". There have been times that I went to an emergency room "in network" and I was "balance billed" by nearly every doctor there due to them not being in network. What is a patient to do? Sit there with a book of providers and procedures?
The real problems here especially with emergency care are that hospitals are forced to eat the cost of treating non insured patients
That problem is not unique to hospitals and emergency centers. My father runs a private practice and he can't collect payment on a double digit percentage of patients. Yet, because he is a private practice, he gets compensated significantly less than a hospital for same procedures.
I am not convinced that the root cause of high hospital cost is to make up for patients that don't pay. It seems to be a circular argument given that a decent percentage of patients can't pay because the cost is so high.
That problem is not unique to hospitals and emergency centers. My father runs a private practice and he can't collect payment on a double digit percentage of patients. Yet, because he is a private practice, he gets compensated significantly less than a hospital for same procedures.
I am not convinced that the root cause of high hospital cost is to make up for patients that don't pay. It seems to be a circular argument given that a decent percentage of patients can't pay because the cost is so high.
That's also a symptom.
One root cause is that the Federal government (ie. Medicare) must get the best deal. If you give anyone else a better deal than Medicare, you are committing an act of fraud, and DoJ will go after you. This is known as a price floor.
Layer upon this the web of contractual arrangements surrounding different insurance providers, and you get to a place where you need to mark up the MSRP of a procedure to safely operate as a business.
The issue with poor areas having bankrupt hospitals is obviously complex. Hospitals are good for emergencies, really sick people and procedures. Not so good or profitable for primary care -- they are a lowest common denominator. You cannot afford to scale up quality outpatient medical practices if you are reliant on Medicaid to pay everything, and you can't operate small medical practices effectively and deal with all of the compliance activity that medicaid comes with.
One root cause is that the Federal government (ie. Medicare) must get the best deal. If you give anyone else a better deal than Medicare, you are committing an act of fraud, and DoJ will go after you. This is known as a price floor.
Layer upon this the web of contractual arrangements surrounding different insurance providers, and you get to a place where you need to mark up the MSRP of a procedure to safely operate as a business.
The issue with poor areas having bankrupt hospitals is obviously complex. Hospitals are good for emergencies, really sick people and procedures. Not so good or profitable for primary care -- they are a lowest common denominator. You cannot afford to scale up quality outpatient medical practices if you are reliant on Medicaid to pay everything, and you can't operate small medical practices effectively and deal with all of the compliance activity that medicaid comes with.
> One root cause is that the Federal government (ie. Medicare) must get the best deal. If you give anyone else a better deal than Medicare, you are committing an act of fraud, and DoJ will go after you. This is known as a price floor.
Interesting; I don't see any obvious reason why other insurance companies couldn't do exactly the same thing by contract.
Can you charge Medicare for things Medicare makes you do that other insurance companies or individuals don't, such as billing them for time spent processing their red tape?
> Layer upon this the web of contractual arrangements surrounding different insurance providers, and you get to a place where you need to mark up the MSRP of a procedure to safely operate as a business.
Sounds a lot like selling enterprise software: corporate purchasers expect to receive a discount, so you can either antagonize them by not giving them what they expect, or mark up the price enough that you can offer "discounts" back to the real price.
Interesting; I don't see any obvious reason why other insurance companies couldn't do exactly the same thing by contract.
Can you charge Medicare for things Medicare makes you do that other insurance companies or individuals don't, such as billing them for time spent processing their red tape?
> Layer upon this the web of contractual arrangements surrounding different insurance providers, and you get to a place where you need to mark up the MSRP of a procedure to safely operate as a business.
Sounds a lot like selling enterprise software: corporate purchasers expect to receive a discount, so you can either antagonize them by not giving them what they expect, or mark up the price enough that you can offer "discounts" back to the real price.
Do you have any links backing that statement up?
It sounds plausible but I'd love to verify it. I have no idea what % of people in the emergency room are uninsured and what % are not in an emergency setting.
It sounds plausible but I'd love to verify it. I have no idea what % of people in the emergency room are uninsured and what % are not in an emergency setting.
It varies by region. Your state health department probably publishes the data.
Remember that emergency rooms cannot turn people away, doctors can.
Poor people in general often don't have primary care providers -- even with Medicaid or private insurance. Reasons are varied and complex. Access is a big issue... for example, if you don't have a car, how do you get to the only doctor who is accepting new medicaid patients across town?
Remember that emergency rooms cannot turn people away, doctors can.
Poor people in general often don't have primary care providers -- even with Medicaid or private insurance. Reasons are varied and complex. Access is a big issue... for example, if you don't have a car, how do you get to the only doctor who is accepting new medicaid patients across town?
After visiting the ER with a 108F temp due to pneumonia, I can attest to the fact that ER visits are a rip off. 3 unique doctor visits to the room + 1 IV + phlegm sample + 1 $60 pill + 1 prescription = $4200 for 50 minutes of office and 120 minutes of wait. Afterwards, I explained I did not have insurance. $60 pill was wrote off instantly. $4200 turned into $1200. Govt reimbursed 3/4ths of the bill instantly to the hospital. $1200 got wrote off after 3 months because it was not worth collecting...
Edit: The interesting thing was each doctor had an individual bill of $600 sent to me. These are still in collections. The phlegm sample cost $120 and come from a separate clinical laboratories bill.
My wife's birth control has a package value of $130/mo. Health insurance ($600 for wife, and kid), had a copay of $40 for this medication. I called the same clinic, requested generic and expressed my need to pay in cash. Instantly brought the price down to $8/mo.
I did not sign up for health insurance this year. It is a complete waste. I usually pay more than just asking for generic and paying with cash. The 'poor' clinics here have a higher quality of care and staff, and are more affordable than my co-pays.
Edit: The interesting thing was each doctor had an individual bill of $600 sent to me. These are still in collections. The phlegm sample cost $120 and come from a separate clinical laboratories bill.
My wife's birth control has a package value of $130/mo. Health insurance ($600 for wife, and kid), had a copay of $40 for this medication. I called the same clinic, requested generic and expressed my need to pay in cash. Instantly brought the price down to $8/mo.
I did not sign up for health insurance this year. It is a complete waste. I usually pay more than just asking for generic and paying with cash. The 'poor' clinics here have a higher quality of care and staff, and are more affordable than my co-pays.
ERs are expensive for two reasons:
1. You are paying for a standing army. 1 hour of scheduled doctor time is much different than 1 hour of doctor time ready to deploy in an instant.
2. The ERs need to cover all the non-paying clients.
These two items probably feed on each other.
Emergency departments are about 1% of total health care costs. They can be a good indicator of other symptoms that are wrong (medical billing is a maze, on purpose[1]), but fixing it won't really address health care costs.
[1] http://www.thedailybeast.com/articles/2013/02/22/how-hospita...
1. You are paying for a standing army. 1 hour of scheduled doctor time is much different than 1 hour of doctor time ready to deploy in an instant.
2. The ERs need to cover all the non-paying clients.
These two items probably feed on each other.
Emergency departments are about 1% of total health care costs. They can be a good indicator of other symptoms that are wrong (medical billing is a maze, on purpose[1]), but fixing it won't really address health care costs.
[1] http://www.thedailybeast.com/articles/2013/02/22/how-hospita...
I'm in the same boat. My insurance premium changed this year to $950 a month. We have 3 younger kids and are all healthy. I would be paying almost $12,000k a year for the privilege of being able to pay "less" after the deductible is met. Paying around ~$120 for an office visit is so much less than premium + copay, and like you said a lot of services prices change once they know you don't have insurance.
I wish health insurance were more like car insurance (accidental coverage, not maintenance) and I think we wouldn't have the same convoluted pricing we have now.
I wish health insurance were more like car insurance (accidental coverage, not maintenance) and I think we wouldn't have the same convoluted pricing we have now.
Not having health care works if you don't have a catastrophic injury, and/or you are willing to let the hospital write off services and pass the bills on the the rest of us.
This isn't really a sustainable plan for the nation.
This isn't really a sustainable plan for the nation.
There's a hidden truth in 'writing off'.
Insurance companies wager paying the bill too. They say "We'll pay 60% of that $8000 ER visit."
Guess who covers 25% of that leftover 40%? In a majority of cases, the government.
(Source: My aunt has worked for a hospital performing these write-offs the majority of her 45 year life.)
Insurance companies wager paying the bill too. They say "We'll pay 60% of that $8000 ER visit."
Guess who covers 25% of that leftover 40%? In a majority of cases, the government.
(Source: My aunt has worked for a hospital performing these write-offs the majority of her 45 year life.)
> My wife's birth control has a package value of $130/mo.
Wow. My girlfriend's birth control is $9/month, without health insurance (Target's generic Ortho Tri-Cyclen).
Wow. My girlfriend's birth control is $9/month, without health insurance (Target's generic Ortho Tri-Cyclen).
I suppose you are prepared to starting paying the tax penalty for not having insurance under the PPACA?
If necessary, I will pay the penalty. I assume the credit for health care costs and taxes charged on health care should make up for any penalties incurred by the PPACA. If I read correctly, my penalty should only be $950-1300. Inevitably, with my insurance rates, I would spend that on 2 months of health coverage for my small family.
Just to break down costs: $600/mo health for wife/kid. $7200/yr. vs ~200/mo + 1000 penalty. $3400/yr.
We're not exactly getting Xrays and CT scans on a daily basis in my household! If my wife was to get pregnant, I know most hospitals offer a specialized bundle plan for dealing with the pregnancy for a set flat rate. All check ups, ultrasounds, single doctor, etc, for $6000.
Just to break down costs: $600/mo health for wife/kid. $7200/yr. vs ~200/mo + 1000 penalty. $3400/yr.
We're not exactly getting Xrays and CT scans on a daily basis in my household! If my wife was to get pregnant, I know most hospitals offer a specialized bundle plan for dealing with the pregnancy for a set flat rate. All check ups, ultrasounds, single doctor, etc, for $6000.
You don't need to have traditional "insurance" to be exempt from penalty under PPACA.
There are exemptions for members of certain groups (IIRC, Native American tribes and religious groups that are opposed to the concept of insurance, like the Amish). There are also exemptions for participants in "health cost sharing ministries" [0]. My family pays $135/month for what, practically, functions like a high-deductible plan [1] -- a little more expensive than just paying the penalty, but it's worth it to mitigate the cost risk associated with catastrophic illness.
[0] http://en.wikipedia.org/wiki/Health_care_sharing_ministry . There's a list of Christian health-sharing ministries at http://www.healthcaresharing.org/ ; I don't know what other religions or non-religions might have similar programs.
[1] the friend who referred me to this signed up for a no deductible option. He was diagnosed with cancer a month later, and they covered everything.
There are exemptions for members of certain groups (IIRC, Native American tribes and religious groups that are opposed to the concept of insurance, like the Amish). There are also exemptions for participants in "health cost sharing ministries" [0]. My family pays $135/month for what, practically, functions like a high-deductible plan [1] -- a little more expensive than just paying the penalty, but it's worth it to mitigate the cost risk associated with catastrophic illness.
[0] http://en.wikipedia.org/wiki/Health_care_sharing_ministry . There's a list of Christian health-sharing ministries at http://www.healthcaresharing.org/ ; I don't know what other religions or non-religions might have similar programs.
[1] the friend who referred me to this signed up for a no deductible option. He was diagnosed with cancer a month later, and they covered everything.
I'm not in the USA, but 'only $950-1300'? That's more or less what I pay for a whole year of health insurance in the NL. How much does insurance cost in the USA?
Unless you have low income, you pay more than that in the Netherlands.
Payment for health care is composed of two parts:
You pay about EUR 867 to 1,140 directly to an insurance company PER ADULT depending on how much you want to pay yourself in case of required care.
Then there's the socialized income dependent part of the insurance that's either payed via your employer or by yourself, which, in the latter case, is 5,65% over up to EUR ~51 K.
A family of two, each with an income > 51K then pays between EUR 7,480 to 8,026 (atm USD ~10K) each year for health insurance, subsidizing insurance for lower income groups.
Payment for health care is composed of two parts:
You pay about EUR 867 to 1,140 directly to an insurance company PER ADULT depending on how much you want to pay yourself in case of required care.
Then there's the socialized income dependent part of the insurance that's either payed via your employer or by yourself, which, in the latter case, is 5,65% over up to EUR ~51 K.
A family of two, each with an income > 51K then pays between EUR 7,480 to 8,026 (atm USD ~10K) each year for health insurance, subsidizing insurance for lower income groups.
Here is an example rate sheet for where I live (Northern NJ):
http://www.horizon-bcbsnj.com/SiteGen/Uploads/Public/horizon...
http://www.horizon-bcbsnj.com/SiteGen/Uploads/Public/horizon...
when I left my last job, I had the option to continue the health insurance the company was paying for, for up to a year (this rule is called "COBRA"). It costs me about $1100 per month, to cover two people.
$200/mo per kid.
$350/mo for wife.
$600 for wife and unlimited kids.
And for the record: that's what qualifies as "incredibly inexpensive" in the US.
Many people pay well over $1000/mo for family care, not counting what their employer contributes.
These costs are roughly what I'm faced with as well. I have insurance on myself but my kid is uninsured because I can't bring myself to pay so much per month when my child is only at the doctor 2-3 times a year and the cost is probably around $180 for a whole year, or less than the cost of a single month of insurance which I'd still be paying a copay on.
I haven't read the whole site yet but I jumped to the topic I know fairly well, medical malpractice. Just some additional notes to consider:
* 9 out of 10 physicians would discourage their children from becoming doctors.[3] There are many reasons for this. Malpractice insurance premiums are a factor. Not the only factor.
* California physicians have the lowest insurance premiums in the country. This is directly the result of tort reform, and caps on pain and suffering payouts. His survey of physicians he knows in the area is subject to this sampling bias. Malpractice is a big issue in other states.[0] California is the model for tort reform for this reason, by not acknowledging this fact, he's missing a big aspect of the national (not just Californian) issues regarding healthcare.
* California physicians also have some of the lowest reimbursement rates in the country.
* As he indicated, internal medicine docs pay far less in premiums (as he noted) than other specialties. Surgeons pay much higher premiums. [1]
* The California Department of Insurance does a good job of keeping most premium information public. It's not a secret what your average doctor pays in insurance.[2]
[0] : https://en.wikipedia.org/wiki/Medical_Injury_Compensation_Re...
[1] : http://cl.ly/image/0m390m1F2D2D
[2] : http://www.insurance.ca.gov/0250-insurers/0800-rate-filings/
[3] : http://www.thedoctors.com/ecm/groups/public/@tdc/@web/docume...
* 9 out of 10 physicians would discourage their children from becoming doctors.[3] There are many reasons for this. Malpractice insurance premiums are a factor. Not the only factor.
* California physicians have the lowest insurance premiums in the country. This is directly the result of tort reform, and caps on pain and suffering payouts. His survey of physicians he knows in the area is subject to this sampling bias. Malpractice is a big issue in other states.[0] California is the model for tort reform for this reason, by not acknowledging this fact, he's missing a big aspect of the national (not just Californian) issues regarding healthcare.
* California physicians also have some of the lowest reimbursement rates in the country.
* As he indicated, internal medicine docs pay far less in premiums (as he noted) than other specialties. Surgeons pay much higher premiums. [1]
* The California Department of Insurance does a good job of keeping most premium information public. It's not a secret what your average doctor pays in insurance.[2]
[0] : https://en.wikipedia.org/wiki/Medical_Injury_Compensation_Re...
[1] : http://cl.ly/image/0m390m1F2D2D
[2] : http://www.insurance.ca.gov/0250-insurers/0800-rate-filings/
[3] : http://www.thedoctors.com/ecm/groups/public/@tdc/@web/docume...
Do you happen to have more digestible numbers? Something like: "In California, malpractice insurance is ~X% of cost, in the rest of the country, it is around Y% of cost."
My understanding is that for all the attention it gets, malpractice insurance isn't that big a deal. But I haven't researched it very much.
My understanding is that for all the attention it gets, malpractice insurance isn't that big a deal. But I haven't researched it very much.
Not at my fingertips, because I dealt almost exclusively with physicians in California. I'm basing this on almost every out of state physician remarking on how much lower premiums are when the move to California. NY and FL seem to be some of the worst states to work in for doctors paying their own premiums.
Malpractice rates are a factor, not the only factor in physicians deciding where and if to practice. Just like reimbursement rates.
Malpractice rates are a factor, not the only factor in physicians deciding where and if to practice. Just like reimbursement rates.
Richard Thaler just had this op-ed in the NYT on ways to reduce costs, talking some about tort reform: http://www.nytimes.com/2013/02/24/business/overcoming-obstac...;
I'm skeptical about tort reform as a panacea. However, lawsuits are incredibly expensive, and so doctors take steps that we would otherwise call economically unreasonable to avoid them.
The amount of tort reform I think is really necessary is whatever would allow me to set up a private equivalent to the UK's NHS here. If someone thinks they are getting denied care that they deserve to have, the decision needs to be very cheap to adjudicate.
I'm skeptical about tort reform as a panacea. However, lawsuits are incredibly expensive, and so doctors take steps that we would otherwise call economically unreasonable to avoid them.
The amount of tort reform I think is really necessary is whatever would allow me to set up a private equivalent to the UK's NHS here. If someone thinks they are getting denied care that they deserve to have, the decision needs to be very cheap to adjudicate.
Yes. Malpractice insurance isn't super costly, but knowing many doctors (my father was a doctor as well), the adversarial relationship that malpractice suits sets up is a heavy burden. We know that overtreatment is a huge source of the cost overages we have in the US relative to other countries with the same health outcomes, and malpractice threats are a significant contributor to that, although it is obviously very hard to measure.
Personally, I think there could be some advantages in making a more patient-responsible system. The most expensive healthcare we have is ongoing (chronic) stuff, and most people with issues like that end up being experts on their own conditions. Why not allow them to get their own medicine and equipment directly rather than be forced to visit the doctor every N weeks to refill a prescription? Or be severely inconvenienced by being somewhere where it is difficult to obtain the right prescription for the medication they know, any sensible person knows, they need? That's silly and inefficient.
Personally, I think there could be some advantages in making a more patient-responsible system. The most expensive healthcare we have is ongoing (chronic) stuff, and most people with issues like that end up being experts on their own conditions. Why not allow them to get their own medicine and equipment directly rather than be forced to visit the doctor every N weeks to refill a prescription? Or be severely inconvenienced by being somewhere where it is difficult to obtain the right prescription for the medication they know, any sensible person knows, they need? That's silly and inefficient.
It's not a panacea. It's a part of the very complicated system that is providing and paying for healthcare. How important are insurance premiums relative to other factors? It depends. But there are costs to having uncapped settlements, and lack of tort reform.
Also, insurance premiums effect practices of different sizes differently. I personally think you can attribute the shift away from smaller private practice groups towards larger groups and hospitals are for other reasons. Insurance premiums are somewhat to blame, but I think the bigger driver is that many of the government mandates are too expensive (n.b. this doesn't mean it shouldn't be done) to take on for most smaller private practice groups.
I'm not sure how to respond to your comment about tort form if it get's us to an NHS like system, because I disagree that's the best way forward. But that's a topic for another day.
Also, insurance premiums effect practices of different sizes differently. I personally think you can attribute the shift away from smaller private practice groups towards larger groups and hospitals are for other reasons. Insurance premiums are somewhat to blame, but I think the bigger driver is that many of the government mandates are too expensive (n.b. this doesn't mean it shouldn't be done) to take on for most smaller private practice groups.
I'm not sure how to respond to your comment about tort form if it get's us to an NHS like system, because I disagree that's the best way forward. But that's a topic for another day.
Most opposition to tort reform comes from the left, and fans of European-style health care also come from the left, so saying that we couldn't set up a European style because of the legal climate is intended to cause cognitive dissonance.
(I'm not advocating putting everyone into a government system run NHS-style system. Surely, though, me and a few thousand of my friends ought to be able to get together and attempt to emulate it if we wish.)
(I'm not advocating putting everyone into a government system run NHS-style system. Surely, though, me and a few thousand of my friends ought to be able to get together and attempt to emulate it if we wish.)
This Time article seems particularly apropos:
http://healthland.time.com/2013/02/20/bitter-pill-why-medica...
http://healthland.time.com/2013/02/20/bitter-pill-why-medica...
According to the Center for Responsive Politics, the pharmaceutical and health-care-product industries, combined with organizations representing doctors, hospitals, nursing homes, health services and HMOs, have spent $5.36 billion since 1998 on lobbying in Washington. That dwarfs the $1.53 billion spent by the defense and aerospace industries and the $1.3 billion spent by oil and gas interests over the same period. That’s right: the health-care-industrial complex spends more than three times what the military-industrial complex spends in Washington.
So, the same root cause as many other problems in this country. As soon as we get the government into purchasing e.g. video games, closet organizers, computer security, vacuum cleaners, etc. we'll have the same problems with those industries we have now with healthcare, education, law enforcement, etc.
So, the same root cause as many other problems in this country. As soon as we get the government into purchasing e.g. video games, closet organizers, computer security, vacuum cleaners, etc. we'll have the same problems with those industries we have now with healthcare, education, law enforcement, etc.
Read it this weekend: I'd love to see a response from the health care industry that wasn't hand waiving. If he's right on 50% of his facts, it is disgusting how the system works.
"If he's right on 50% of his facts, it is disgusting how the system works."
There were only a handful of actual statistics in there. The one thing he is wrong about though is that healthcare isn't "roughly 20% of the GDP", rather it's about 17.9%. The furthest out cms.gov gives yearly projections is to 2021, and even then healthcare is only supposed to be 19.6% of the GDP. And I think that might even include things like herbal supplements 'other non-durable medical supplies', I'm not positive about that though.
Source: https://www.cms.gov/Research-Statistics-Data-and-Systems/Sta...
There were only a handful of actual statistics in there. The one thing he is wrong about though is that healthcare isn't "roughly 20% of the GDP", rather it's about 17.9%. The furthest out cms.gov gives yearly projections is to 2021, and even then healthcare is only supposed to be 19.6% of the GDP. And I think that might even include things like herbal supplements 'other non-durable medical supplies', I'm not positive about that though.
Source: https://www.cms.gov/Research-Statistics-Data-and-Systems/Sta...
Facts are more than just statistics. There were numerous statements about (what seems to be) gross, gross overcharging on everything from pens to surgical gowns to diagnostic equipment. There were the exorbitant salaries and let's not forget the chargemaster.
Exactly: that's the part I'd like to see a rebutted (if there is a rational rebuttal). The ad-hoc nature of their pricing model seems crazy.
Hi, My name is David Belk and I wrote the website. I noticed a lot of traffic from here this Morning. I'd just like to say thank you and, are there any questions I can answer? I'm having a busy Morning but I'll be free in about an hour.
One question : just how would you prioritize actions to turn heathcare into a real market, or as close to it as possible ?
I would go for:
1) full price transparency
2) making price discrimination illegal
3) attacking the information asymmetry by providing a free, subsidized first line triage
Whether treatment is taken or the patient decides to do without it, making sure tests and diagnosis are performed could help proper self regulation of consumption
It could also be made as a public service since it seems very close to a natural monopoly (due to the subadditivity of the cost function - see for ex http://www.clt.astate.edu/crbrown/eleven1.htm - having big labs to process blood test gives economy of scales but require high fixed costs)
It could therefore be politically defensible on grounds of efficient pricing (ie pricing at the marginal cost, which requires subsidizing for natural monopolies since average cost are above marginal costs), to avoid deadweight loss.
The first line triage could then provide full price transparency (diagnosis -> probabilistic DRG), from which the patient could either decide to "wait and see", or to browse a catalog of hospital offering services (DRG -> prices) knowing the price paid would be no different with or without insurance.
At that point, it might be possible to remove all price caps and floors, and let the market work.
So basically, we could get a working market on the treatment side.
Traditional monopoly and oligopoly management (watching the HHI before allowing fusions) could then keep it that way.
I'm a bit out of idea however to have integral pure and perfect competition, at least until we get user-operable "all-in-one diagnosis devices" (like Star Trek tricoders) to remove the information asymmetry.
My last rants on this topic were posted on http://news.ycombinator.com/item?id=5261137
I would go for:
1) full price transparency
2) making price discrimination illegal
3) attacking the information asymmetry by providing a free, subsidized first line triage
Whether treatment is taken or the patient decides to do without it, making sure tests and diagnosis are performed could help proper self regulation of consumption
It could also be made as a public service since it seems very close to a natural monopoly (due to the subadditivity of the cost function - see for ex http://www.clt.astate.edu/crbrown/eleven1.htm - having big labs to process blood test gives economy of scales but require high fixed costs)
It could therefore be politically defensible on grounds of efficient pricing (ie pricing at the marginal cost, which requires subsidizing for natural monopolies since average cost are above marginal costs), to avoid deadweight loss.
The first line triage could then provide full price transparency (diagnosis -> probabilistic DRG), from which the patient could either decide to "wait and see", or to browse a catalog of hospital offering services (DRG -> prices) knowing the price paid would be no different with or without insurance.
At that point, it might be possible to remove all price caps and floors, and let the market work.
So basically, we could get a working market on the treatment side.
Traditional monopoly and oligopoly management (watching the HHI before allowing fusions) could then keep it that way.
I'm a bit out of idea however to have integral pure and perfect competition, at least until we get user-operable "all-in-one diagnosis devices" (like Star Trek tricoders) to remove the information asymmetry.
My last rants on this topic were posted on http://news.ycombinator.com/item?id=5261137
Price transparency is good but, what's also missing in health care is value transparency. In other words, not only do most people (including most physicians) not know how much anything in health care really costs, they don't know how much anything should cost! The level of blindness in this business is truly unprecedented.
What's also needed are a number of consumer protection laws that we take for granted in pretty much every other industry. Those alone would go a long way toward correcting many of the problems we have in health care.
I have a question that I think about a lot and for most part, have not found an answer that makes logical sense.
Why do insurance companies play such hardball with compensating private practices or medical groups? It would seem like it is in the interest of insurance companies for private practices to flourish given that the same thing done at a hospital costs the insurance companies 3-6 times more money.
Most doctors that I ask this question suggest there is a conspiracy where insurance companies are in bed with hospital. Frankly, I don't buy it. I'm probably missing something and I'd love to hear someone's take who has thought about these issues deeply as you clearly have.
Why do insurance companies play such hardball with compensating private practices or medical groups? It would seem like it is in the interest of insurance companies for private practices to flourish given that the same thing done at a hospital costs the insurance companies 3-6 times more money.
Most doctors that I ask this question suggest there is a conspiracy where insurance companies are in bed with hospital. Frankly, I don't buy it. I'm probably missing something and I'd love to hear someone's take who has thought about these issues deeply as you clearly have.
The insurance companies pay long after we see the patient and most of them play about the same games. So, either we don't take any insurance (which would drastically reduce most of our incomes) or we just learn to play their games.
For the record, my wife has gotten pretty good with the billing so I usually get paid for what I do. At first it was very painful because dealing with insurance companies has a steep learning curve in the beginning, but it's not so bad now.
It's still highly inefficient billing each insurance company for each separate patient I see just to collect the amount most people pay to fill the gas tank of their car but, that's hardly the worst problem with health care in this Country.
For the record, my wife has gotten pretty good with the billing so I usually get paid for what I do. At first it was very painful because dealing with insurance companies has a steep learning curve in the beginning, but it's not so bad now.
It's still highly inefficient billing each insurance company for each separate patient I see just to collect the amount most people pay to fill the gas tank of their car but, that's hardly the worst problem with health care in this Country.
Why do you think insurance companies play this game if it is not in their interest? I would think they would want private practices to flourish so their patients reduce use of hospitals and in the end, save the insurance company money.
Again, no doctor turns away a patient who has insurance that he takes. Insurance contracts are signed by doctors years in advance. Insurance companies learned long ago that they can get away with being obnoxious as long as they're not so obnoxious that doctors would drop them. They walk that line rather well.
Got it, and I agree that insurance companies walk the line rather well in getting doctors to accept them.
But at a macro level, don't you think the insurance companies have failed themselves given rise in private practices closing shop or being bought out resulting in insurance companies needing to pay a lot more to hospitals?
But at a macro level, don't you think the insurance companies have failed themselves given rise in private practices closing shop or being bought out resulting in insurance companies needing to pay a lot more to hospitals?
Do other countries have employer-funded health insurance? Why doesn't my employer pay for, say, my car insurance? This system discourages people from leaving a job to start their own business because private health insurance can be very expensive.
In the UK, it's not unusual for employers to offer private health insurance (or at least, it's pretty common for profesional jobs - I can't comment for other types of jobs!). From their point of view, it's comparatively inexpensive and the cost is probably easy recouped from their employees being able to get health problems dealt with faster than they might on the NHS so they're off work for less time.
Edit - Given that we've got the NHS as well, losing your private coverage isn't such a big deal. It's nice to have, not a must have.
Edit - Given that we've got the NHS as well, losing your private coverage isn't such a big deal. It's nice to have, not a must have.
I had private health insurance from a previous employer, and in my experience it was almost completely pointless. I'm not inclined to rate its provision as a substantial benefit for compensation purposes.
That's my doctor's site! The real takeaway (to me) is that single-payer health insurance would be the way to go.
I think it's a bit more complicated than that. It's easy to look at other countries and say, hey, that works there, therefore it will work here. But not all governments are created equal. If the government in the U.S. had a better track record, maybe it would be more palatable. But as is, I don't see single payer being the solution to our problems.
It doesn't solve everything but it should help to simplify matters greatly.
What would help too is ubiquitous electronic records management, e.g., any records from a visit with one doctor should be usable by the patient at another doctor.
Add to that cheaper testing and more AI / self-help and that should take it even further.
Lastly, kill the corn lobby and get some real sense into people about how their diet and lifestyle directly impact their health. What percentage of US healthcare costs are going towards diabetes and any related illnesses? And what percentage of that is directly related to obesity and a sedentary lifestyle?
What would help too is ubiquitous electronic records management, e.g., any records from a visit with one doctor should be usable by the patient at another doctor.
Add to that cheaper testing and more AI / self-help and that should take it even further.
Lastly, kill the corn lobby and get some real sense into people about how their diet and lifestyle directly impact their health. What percentage of US healthcare costs are going towards diabetes and any related illnesses? And what percentage of that is directly related to obesity and a sedentary lifestyle?
Electronic Health Records are harder to implement than you'd expect. HIPAA sets really harsh penalties for violations that can occur much more easily if hospitals and doctors provide open access to other facilities. Organizations are also often reluctant to provide their data to other facilities because of a perception that it will lead to a loss of competitive advantage. Add to that the typical problems of cross-vendor interfacing between organizations.
That said, EHRs are definitely the way to go, and we'll see much more of them in the future. Once Stage 2 of Meaningful Use[1] kicks in, you'll see a bunch of hospitals scrambling to upgrade their IT infrastructure to make sure they continue to receive the bonus Medicare/Medicaid payouts they're receiving now.
1. http://www.healthit.gov/providers-professionals/meaningful-u...
That said, EHRs are definitely the way to go, and we'll see much more of them in the future. Once Stage 2 of Meaningful Use[1] kicks in, you'll see a bunch of hospitals scrambling to upgrade their IT infrastructure to make sure they continue to receive the bonus Medicare/Medicaid payouts they're receiving now.
1. http://www.healthit.gov/providers-professionals/meaningful-u...
Other countries are pretty diverse with how they implement single-payer. Britain has NHS, Canada has private hospitals with government handling the insurance.
One thing in common: They all suck, yet are all much better than our system.
One thing in common: They all suck, yet are all much better than our system.
"They all suck, yet are all much better than our system."
By what measure? If you're trying to see a specialist -- say, to get a surgeon -- soon, our system is far superior, which is why Canadians routinely cross the border to take advantage of our system.
A still simplistic and incorrect but fairer appraisal would be to say that the NHS and Canada's Medicare are optimized for everyday care and our healthcare system is optimized for specialty care.
By what measure? If you're trying to see a specialist -- say, to get a surgeon -- soon, our system is far superior, which is why Canadians routinely cross the border to take advantage of our system.
A still simplistic and incorrect but fairer appraisal would be to say that the NHS and Canada's Medicare are optimized for everyday care and our healthcare system is optimized for specialty care.
By "better/equivalent average outcomes for significantly lower average cost" as a measure.
IMHO the best solution would be a standard health care product paid for in a standard way (but reasonably affordable/means tested). It doesn't mean that the government has to collect all the money, or that the actual care has to be provided by the government. But what it would mean is that a baseline is available to everyone. It should also include discovering and disseminating best practises, improving overall health through any practical means (ie not just pills and doctor visits), and looking at things like hospice care for end of life instead of very expensive procedures and drugs.
And on top of that the free market can provide extras using whatever economic model works for them.
And on top of that the free market can provide extras using whatever economic model works for them.
It's probably better if the federal level of government sets standards and it's up to the states to implement them.
Vermont, for example, is already ahead of the curve here.
Vermont, for example, is already ahead of the curve here.
That is why I put "discovering and disseminating best practises" in there. We can all guess what the best way of specifying and implementing the standards is, but why not experiment and find out? This ranges from the setting of the standards (eg how detailed they are), through how they are implemented. And of course all the other things (eg reducing hospital infection rates, improving overall hearth health).
The author missed a very important reason why hospitals are charging such high fees. In 1986 Reagan passed the "Emergency Medical Treatment and Active Labor Act". Since that time, hospitals are required to treat anyone, regardless of whether or not they have insurance, as if they were a fully insured patient. My wife, who is a physician in a busy hospital, consistently sees about 40% of her patients have no health insurance and are receiving free healthcare from that hospital. This may vary based on location, but I cant imagine by much. Hospitals foot the bill in this situation, and that is why costs to the insured are much higher.
Everybody seems to think they are smarter than everyone else when it comes to healthcare reform, but in all of the "smoking gun" articles that are posted, none of them have ever touched on this fact.
Even the new healthcare plan that passed does not address this directly, it assumes that the people who do not have healthcare will use a state healthcare exchange to get their own. I am a little pessimistic about this, and am assuming that only a small percentage of those people will do this.
Everybody seems to think they are smarter than everyone else when it comes to healthcare reform, but in all of the "smoking gun" articles that are posted, none of them have ever touched on this fact.
Even the new healthcare plan that passed does not address this directly, it assumes that the people who do not have healthcare will use a state healthcare exchange to get their own. I am a little pessimistic about this, and am assuming that only a small percentage of those people will do this.
You should read my epilogue on why hospitals are going bankrupt: http://truecostofhealthcare.org/epilogue
Or watch the video: https://www.youtube.com/watch?v=LieVr0QvkME
No one is admitted to the hospital these days who doesn't qualify by a rather strict set of criteria. If you qualify and have nothing then, in most States, Medicaid picks up the tab. If you have anything, the hospital gets it.Hospitals give free care the way Heidi Fleiss gave free love.
Atul Gawande covered the issue in this article: http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_...
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I'm not sure if this is true, but I heard that in some parts of China you only pay for health care when you are healthy because when you are not health care failed.
Ofcourse this raises a lot of questions about responsibility. But in our society health care is making money when people are unhealthy. That is an unhealthy situation.
Ofcourse this raises a lot of questions about responsibility. But in our society health care is making money when people are unhealthy. That is an unhealthy situation.
Call me naive but why doesn't the US simply switch to a healthcare system similar to the UK's NHS? I live in Britain and I live happy knowing that if I get a scratch, I won't go bankrupt.
A significant portion of Americans don't trust their government to provide efficient services. In general, we'll trust other citizens and corporations to do a better job. On top of that, you have many people who are reasonably insured and don't have to worry about it, many people who don't want to pay for other people's healthcare, and many people who are scared of socialism. Once you combine those groups, you end up with a pretty significant chunk of the country that is opposed to single-payer for whatever reason.
That said, the US healthcare system's problems go much much deeper than just single-payer vs private-public.
That said, the US healthcare system's problems go much much deeper than just single-payer vs private-public.
At the end of the day, my guess is it all boils down to your FREEDOM. right guys?
I pinged Dr. Belk about the dialog here and invited him to join this conversation.
Back when he was alive, Milton Friedman did a study of the costs of health care in the US from 1900 to the 1970s. (I think the first study was in the 1970s, and it was updated in the 1990s)
What he found was that the funding mechanism of health care over that time had shifted from patients paying out of pocket to government paying hospitals and government incentivized (by making it a tax write off for employers) and regulated (by preventing efficient pools of insured with state-by-state regulations) insurance.
Consequently, not only did the availability of health care go down, but the costs went up 26fold.
Or put another way, despite massive improvements in technology, medicine and productivity over 70+ years, costs skyrocketed from what you could afford out of pocket to what would bankrupt you. To put it in 2013 dollars, if you hypothesize a $100,000 surgery, in 1970[1] it would cost you $100,000, and you'd need insurance or go bankrupt, but in 1900 it would have cost you $3,846 (an amount you could put on credit cards today.)
Command economies don't work, and the change in health care over the last century has been a centralization in control. I with Obamacare this has dramatically ramped up and now there are boards to decide who gets what care based on cost measures, rather than medical need.
Whenever someone talks about the need for socialized medicine because "otherwise people would go bankrupt", remember it is the socialization of medicine that caused costs to rise to the point where people would go bankrupt.
[1] The study was originally done in the 1970s, but I'm using 2013 dollars here so you can understand how cheap things would have been.
What he found was that the funding mechanism of health care over that time had shifted from patients paying out of pocket to government paying hospitals and government incentivized (by making it a tax write off for employers) and regulated (by preventing efficient pools of insured with state-by-state regulations) insurance.
Consequently, not only did the availability of health care go down, but the costs went up 26fold.
Or put another way, despite massive improvements in technology, medicine and productivity over 70+ years, costs skyrocketed from what you could afford out of pocket to what would bankrupt you. To put it in 2013 dollars, if you hypothesize a $100,000 surgery, in 1970[1] it would cost you $100,000, and you'd need insurance or go bankrupt, but in 1900 it would have cost you $3,846 (an amount you could put on credit cards today.)
Command economies don't work, and the change in health care over the last century has been a centralization in control. I with Obamacare this has dramatically ramped up and now there are boards to decide who gets what care based on cost measures, rather than medical need.
Whenever someone talks about the need for socialized medicine because "otherwise people would go bankrupt", remember it is the socialization of medicine that caused costs to rise to the point where people would go bankrupt.
[1] The study was originally done in the 1970s, but I'm using 2013 dollars here so you can understand how cheap things would have been.
There is an easy way to refute your argument: what you're saying about 'socialization' also happened in most developed countries. At least in France, so-called 'social security' (which is about mandatory health insurance, and not pension as in the US) came in place just after WW 2, and without the US insanity in price inflation.
Comparing with 1900 prices is a bit of nonsense given that there was little surgery at that time as well.
Also, there are quite a few things that are inherently expensive: diabete, dialysis, cancer (things that would have got you killed in the 1900). I don't know about the US, but dialysis costs around 100-200k euros / year, diabete around 100 k euros / year in France.
I would be curious to know how much cancer + dialysis + diabete contribute to health costs. I am ready to bet it is not in the low 2 digits.
Comparing with 1900 prices is a bit of nonsense given that there was little surgery at that time as well.
Also, there are quite a few things that are inherently expensive: diabete, dialysis, cancer (things that would have got you killed in the 1900). I don't know about the US, but dialysis costs around 100-200k euros / year, diabete around 100 k euros / year in France.
I would be curious to know how much cancer + dialysis + diabete contribute to health costs. I am ready to bet it is not in the low 2 digits.
He is comparing prices by putting it into 2013 dollars. It has nothing to do with availability. You can take a car, computer, or any other good that has a price and easily convert it back to 1865 or 1900 or whatever dollars and this helps understand the cost of things relative to today.
This makes your two middle paragraphs irrelevant.
If you want to just look at cancer here is a place to start: http://www.cancer.org/cancer/cancerbasics/economic-impact-of...
Much of the health care costs in America are generated by major medical issues. I've recently seen a number released by my insurance provider that said that 7% of those who use them for insurance generate 90% of the claims by dollar amount. The thing is, no one knows when they will be in the 7%.
This makes your two middle paragraphs irrelevant.
If you want to just look at cancer here is a place to start: http://www.cancer.org/cancer/cancerbasics/economic-impact-of...
Much of the health care costs in America are generated by major medical issues. I've recently seen a number released by my insurance provider that said that 7% of those who use them for insurance generate 90% of the claims by dollar amount. The thing is, no one knows when they will be in the 7%.
Comparing medicine in 1900 and 1970 is just silly, full stop.
Regarding everything about 'government' vs 'free market'.. do you feel like you're in a free market healthcare system in America? I sure don't. I feel like I have no idea what's going on with medicine and the only difference between my insurance bureaucracy and a government bureaucracy is that the insurance company is actively trying to fuck me rather than just passively doing it.
I'm not saying big government bureaucracies are great -- they're terrible. Yet every other industrialized country's disaster of a bureaucracy is miles better than our private-public system. They have the same cost issues and also have cost inflation, but it's less inflation on a lower cost.
Regarding everything about 'government' vs 'free market'.. do you feel like you're in a free market healthcare system in America? I sure don't. I feel like I have no idea what's going on with medicine and the only difference between my insurance bureaucracy and a government bureaucracy is that the insurance company is actively trying to fuck me rather than just passively doing it.
I'm not saying big government bureaucracies are great -- they're terrible. Yet every other industrialized country's disaster of a bureaucracy is miles better than our private-public system. They have the same cost issues and also have cost inflation, but it's less inflation on a lower cost.
The cost of cancer/dialysis/diabete is quite relevant since those things are inherently expensive today, and you won't be able to pay it from your pocket unless you are in the top few % income wise.
Regarding the 7 % costing 90 %, it does not surprise me much (the figure I heard in France was something like 10 % costing 60 %, but I don't pretend for their accuracy). You need to take into account that the 7 % are not uniformly distributed (age being an obvious factor). Also, in France at least, there is no such thing as Medicare/medicaid, so the mandatory health insurance costs can't easily be compared.
Regarding the prince thing: I don't understand the argument of putting things from year X in year Y in 2013 dollars for things that did not exist at that period X. If we discover in 50 years a definite cure against say cancer, getting the price in today's USD is meaningless (how much would someone like S. Jobs be willing to have paid for it ? Much more than anything related to inflation).
Regarding the 7 % costing 90 %, it does not surprise me much (the figure I heard in France was something like 10 % costing 60 %, but I don't pretend for their accuracy). You need to take into account that the 7 % are not uniformly distributed (age being an obvious factor). Also, in France at least, there is no such thing as Medicare/medicaid, so the mandatory health insurance costs can't easily be compared.
Regarding the prince thing: I don't understand the argument of putting things from year X in year Y in 2013 dollars for things that did not exist at that period X. If we discover in 50 years a definite cure against say cancer, getting the price in today's USD is meaningless (how much would someone like S. Jobs be willing to have paid for it ? Much more than anything related to inflation).
It's an attempt to measure relative affordability, part of this is that humans are unable to take a value such as an average inflation rate of 3.4% and work backwards over 20 years.
I'm not sure how useful that number is, however, I'm pointing out that it doesn't add to the invalidity of his argument.
I'm not sure how useful that number is, however, I'm pointing out that it doesn't add to the invalidity of his argument.
>>I with Obamacare this has dramatically ramped up and now there are boards to decide who gets what care based on cost measures, rather than medical need.
It would help if actually knew what you were talking about. There are no "boards." There is the IPAB which makes cuts to medicare if congress can't. I'm sure you are in favor of reducing this "socialized medicine" so your stated basis of opposition is nonsensical. Maybe you would prefer instead a "board" made up of people elected across the US that will make cuts to medicare instead. It's called Congress and maybe you should learn about it as I hear it has existed for a long time.
>>Command economies don't work, and the change in health care over the last century has been a centralization in control. >>Whenever someone talks about the need for socialized medicine because "otherwise people would go bankrupt", remember it is the socialization of medicine that caused costs to rise to the point where people would go bankrupt.
Milton Friedman also said that single payer system have many advantages over the system we have right now.[1] It isn't centralization of control its a broken system that has never had any reform whatsoever.
[1] http://www.hoover.org/publications/hoover-digest/article/729...
It would help if actually knew what you were talking about. There are no "boards." There is the IPAB which makes cuts to medicare if congress can't. I'm sure you are in favor of reducing this "socialized medicine" so your stated basis of opposition is nonsensical. Maybe you would prefer instead a "board" made up of people elected across the US that will make cuts to medicare instead. It's called Congress and maybe you should learn about it as I hear it has existed for a long time.
>>Command economies don't work, and the change in health care over the last century has been a centralization in control. >>Whenever someone talks about the need for socialized medicine because "otherwise people would go bankrupt", remember it is the socialization of medicine that caused costs to rise to the point where people would go bankrupt.
Milton Friedman also said that single payer system have many advantages over the system we have right now.[1] It isn't centralization of control its a broken system that has never had any reform whatsoever.
[1] http://www.hoover.org/publications/hoover-digest/article/729...
One of the ideas I've heard discussed is that the only way we will ever get the cost of health care down is if consumers are back in the drivers seat with how the dollars are spent. Right now it's disconnected. I go in to have something done, the doctor bills my insurance company, and I really don't know (or care) how much it costs, unless I happen to look at the insurance paperwork. The same goes for pharmaceuticals. Which pharmacy in your town has the lowest price on that antibiotic that was just prescribed for your son's ear infection? Who cares, right? It's a $15 co-pay no matter where you go, so you go wherever is most convenient.
One solution that's been proposed is the increased use of HSAs + high deductible policies. That way people are paying their expenses out of pocket (for the day-to-day things at least), and are therefore more likely to shop around.
I'm not hear to argue the merits of that, but it definitely seems like an approach that might work. I fail to see how anything that takes control out of the hand of the individual will fix this problem (short of regulating the prices, which I wouldn't be a fan of).
One solution that's been proposed is the increased use of HSAs + high deductible policies. That way people are paying their expenses out of pocket (for the day-to-day things at least), and are therefore more likely to shop around.
I'm not hear to argue the merits of that, but it definitely seems like an approach that might work. I fail to see how anything that takes control out of the hand of the individual will fix this problem (short of regulating the prices, which I wouldn't be a fan of).
Unfortunately healthcare is not a market you often willingly participate in. Some health needs can be anticipated, and doing more to encourage consumer empowerment would definitely lower prices. Think about cosmetic surgery or LASIK. Every participant in that market is voluntary, so all the providers are motivated to do it cheaper and better.
But when you have a major health crisis, your "empowerment" is just fundamentally limited. If you get into an accident with a loved one and they're unconscious, you're not doing to be in a position to decide whether you should go to the hospital 1 mile away, that may be X% more expensive than the one 5 miles away. Your ability to price discriminate is also fundamentally limited by your own knowledge of medicine. If you have a tumor and one doctor suggests taking medicine A which costs $50,000, and medicine B which costs $5,000, is A better than B? Is it 1000% better? If it's only 2% better, unlike any other consumer product, are you trying to optimize for "value" or "not actually dying"?
There's definitely things we can do in terms of government policy to encourage more customer empowerment to bring down costs. But ultimately you have a market with unvoluntary participation and opaque pricing, which means Adam Smith can't really do his thing.
But when you have a major health crisis, your "empowerment" is just fundamentally limited. If you get into an accident with a loved one and they're unconscious, you're not doing to be in a position to decide whether you should go to the hospital 1 mile away, that may be X% more expensive than the one 5 miles away. Your ability to price discriminate is also fundamentally limited by your own knowledge of medicine. If you have a tumor and one doctor suggests taking medicine A which costs $50,000, and medicine B which costs $5,000, is A better than B? Is it 1000% better? If it's only 2% better, unlike any other consumer product, are you trying to optimize for "value" or "not actually dying"?
There's definitely things we can do in terms of government policy to encourage more customer empowerment to bring down costs. But ultimately you have a market with unvoluntary participation and opaque pricing, which means Adam Smith can't really do his thing.
You make some very good points, and I think you're spot on for the most part. I think HSAs have more benefit for the lower end of the cost spectrum, such as routine care, or minor medical issues (sprains, fevers, and the like). But I don't know what percent of the total US healthcare spend is on those types of items, vs cancer treaments and MRIs. So maybe it won't help as much as I'd like to think.
My family is actually on a plan similar to the one you describe (high deductible and a spending account).
Before I used it, it seemed fine. I tend to do alot of research regarding upcoming tests/procedures and such, and so adding in an element of cost/shopping around wasn't too much more hassle.
In practice, it's been awful. I have no problem shopping around, but it's been essentially impossible to get the information I need to make an informed decision.
As an example, our primary care physician determined a procedure was needed and provided a list of specialists in the general area who were equipped to do it. So I filtered those for in-network providers using the insurance's website and then called those practices. Out of the 4: 2 refused to quote me the price at all; 1 gave me such a run-around that I eventually gave up; 1 (whose employee started our conversation with "We don't normally give this out, but Jane said I had to") gave me the price they would bill if I were uninsured. None of the 4 were actually able to tell me what they would bill me.
However, I did manage to get them to list the CPT codes relevant for the procedure, so I then called up the insurance company. Despite being able to list specific providers and the exact codes they would bill, the insurance refused to quote the member rate. The best they would do was give me that average cost for that CPT in my area which is useless if what you're trying to do is shop around within your area.
So, I don't disagree that people having a more direct link to the actual cost of their treatment wouldn't be a good idea, but until the system adjusts to provide up-front visibility into those costs, the only effect from that linkage is going to be post-procedure sticker-shock.
Before I used it, it seemed fine. I tend to do alot of research regarding upcoming tests/procedures and such, and so adding in an element of cost/shopping around wasn't too much more hassle.
In practice, it's been awful. I have no problem shopping around, but it's been essentially impossible to get the information I need to make an informed decision.
As an example, our primary care physician determined a procedure was needed and provided a list of specialists in the general area who were equipped to do it. So I filtered those for in-network providers using the insurance's website and then called those practices. Out of the 4: 2 refused to quote me the price at all; 1 gave me such a run-around that I eventually gave up; 1 (whose employee started our conversation with "We don't normally give this out, but Jane said I had to") gave me the price they would bill if I were uninsured. None of the 4 were actually able to tell me what they would bill me.
However, I did manage to get them to list the CPT codes relevant for the procedure, so I then called up the insurance company. Despite being able to list specific providers and the exact codes they would bill, the insurance refused to quote the member rate. The best they would do was give me that average cost for that CPT in my area which is useless if what you're trying to do is shop around within your area.
So, I don't disagree that people having a more direct link to the actual cost of their treatment wouldn't be a good idea, but until the system adjusts to provide up-front visibility into those costs, the only effect from that linkage is going to be post-procedure sticker-shock.
> now there are boards to decide who gets what care based on cost measures, rather than medical need.
How is this different from insurance companies, or are those what you are referring to? I'm really confused by your statement.
How is this different from insurance companies, or are those what you are referring to? I'm really confused by your statement.
You can thank Rush Limbaugh politik for the "government death panels" garbage.
Hardly anyone is really approving or denying care based on cost-effectiveness. Which is why costs are out of control.
>Whenever someone talks about the need for socialized medicine because "otherwise people would go bankrupt", remember it is the socialization of medicine that caused costs to rise to the point where people would go bankrupt.
Because there are thousands of Canadians every year that go bankrupt because of health care costs. Your argument doesn't even begin to make sense.
Because there are thousands of Canadians every year that go bankrupt because of health care costs. Your argument doesn't even begin to make sense.
Because there are thousands of Canadians every year that go bankrupt because of health care costs.
Actually, there are. They go the US to get care that's not offered in Canada. The care here is about as good as former soviet bloc countries. If there was a chance that an illness such as cancer could kill me, I'd get out of Canada in a heartbeat and embrace poverty if it meant keeping my life.
Actually, there are. They go the US to get care that's not offered in Canada. The care here is about as good as former soviet bloc countries. If there was a chance that an illness such as cancer could kill me, I'd get out of Canada in a heartbeat and embrace poverty if it meant keeping my life.
"as good as former soviet bloc countries"... really.. ?
How many Americans (like Sarah Palin) are going the other way across the border?
According to one study [1], only 0.61% of Canadians are going to the US for healthcare. And you have to consider that that the Canadian government pays for much of that care in the US. I'd imagine that if things were as bad as you claim, that number would be a bit higher
[1] http://www.aarp.org/politics-society/government-elections/in...
How many Americans (like Sarah Palin) are going the other way across the border?
According to one study [1], only 0.61% of Canadians are going to the US for healthcare. And you have to consider that that the Canadian government pays for much of that care in the US. I'd imagine that if things were as bad as you claim, that number would be a bit higher
[1] http://www.aarp.org/politics-society/government-elections/in...
> And you have to consider that that the Canadian government pays for much of that care in the US.
It does not pay a dime.
It does not pay a dime.
"Most patients who come from Canada to the U.S. for health care are those whose costs are covered by the Canadian governments. If a Canadian goes outside of the country to get services that are deemed medically necessary, not experimental, and are not available at home for whatever reason (e.g., shortage or absence of high tech medical equipment; a longer wait for service than is medically prudent; or lack of physician expertise), the provincial government where you live fully funds your care."
http://www.denverpost.com/recommended/ci_12523427
http://www.denverpost.com/recommended/ci_12523427
> If a Canadian goes outside of the country to get services that are deemed medically necessary, not experimental, and are not available at home for whatever reason (e.g., shortage or absence of high tech medical equipment; a longer wait for service than is medically prudent; or lack of physician expertise),
Oh, yes. You try getting that through. It doesn't happen. It's something people trot out to say "see, everything is paid for" but the reality is far from different. And try to get that through for long term care.
And you want something else: "not experimental" That's not determined by the medical establishment. Rather, it's done by the government. So, even if every medical professional says otherwise, real treatments can be deemed experimental.
So no, the Canadian government does not pay for much of that treatment.
Oh, yes. You try getting that through. It doesn't happen. It's something people trot out to say "see, everything is paid for" but the reality is far from different. And try to get that through for long term care.
And you want something else: "not experimental" That's not determined by the medical establishment. Rather, it's done by the government. So, even if every medical professional says otherwise, real treatments can be deemed experimental.
So no, the Canadian government does not pay for much of that treatment.
Excuse me, what was that about Sarah Palin?
"we used to hustle on over the border for health care that we would receive in Whitehorse"
http://www.telegraph.co.uk/news/worldnews/sarah-palin/740955...
http://www.telegraph.co.uk/news/worldnews/sarah-palin/740955...
It's just not true that large numbers of Canadians go to the US for healthcare. You need to supply evidence of this. The numbers are vanishingly small.
The numbers are vanishingly small
Well, compared to what?
The odds of having your private health insurance rescinded in the US is also very small -- but it's quite likely among people who suddenly rack up big health care costs.
Similarly, if you compare Canada-to-US medical tourists to the Canadian population, I'm sure it's amazingly tiny. But how does it compare to the people of means who have a medical procedure denied by the Canadian system?
(I don't fault Canada for denying care in some cases. Sometimes it's not worth it. But the Canadian system would be better if people were still allowed to top off the denied care with their own dollars and didn't need to leave the country to get it.)
Well, compared to what?
The odds of having your private health insurance rescinded in the US is also very small -- but it's quite likely among people who suddenly rack up big health care costs.
Similarly, if you compare Canada-to-US medical tourists to the Canadian population, I'm sure it's amazingly tiny. But how does it compare to the people of means who have a medical procedure denied by the Canadian system?
(I don't fault Canada for denying care in some cases. Sometimes it's not worth it. But the Canadian system would be better if people were still allowed to top off the denied care with their own dollars and didn't need to leave the country to get it.)
Well, I can't find any canadians who don't want their system. I can't find any (non-partisan) news sources complaining of a even a small number of people who would opt out of the Canadian system. Tommy Douglas, the founder of the system, is repeatedly voted the most popular Canadian in history... And...anecdotally every Canadian friend of mine loves to likes the system. I'd love to see some, any, hard evidence that the Canadian system is such a disaster that they're fleeing to the US to escape its tyranny.
I live in western Quebec, home to two of the worst hospitals in the country (those in Hull and Gatineau). Getting a family doctor here requires years of waiting, and many will go across the river and pay out of pocket to see a doctor in Ottawa. You'll no doubt find some Canadians who live in areas where things are working out pretty well. People in the US don't often realize that the Canadian system is not monolithic, and is based more on your province, and sometimes where you are within a given province.
As I said to your sibling comment, it's helpful to hear of your experience.
My wife, who is Canadian, used to love the health care system in Canada. After actually relying on it, she came to despise it. We left Canada and came to the US precisely for health care for my son (who is also Canadian). He received more care in the first 2 weeks here then he ever received in Canada. She now sings the US health cares praises.
I could go on and on about the abuse my son received at the hands of the Canadian health care system, but I'll just say that I hate the system. At every step of the way, despite doing everything we could, my son suffered because of the system.
A part of me understands it's because it was Quebec, but Quebec is an example of how the Canadian system fails, and fails hard.
A part of me feels as if it was my fault. I should have moved sooner, when we were first lied to. But we figured if we played by the rules, things would work out. We were wrong.
So no. I'd fight tooth and nail to prevent that abuse from coming to the US. And if it did come, I'd leave. I will not let my family suffer like that again.
I could go on and on about the abuse my son received at the hands of the Canadian health care system, but I'll just say that I hate the system. At every step of the way, despite doing everything we could, my son suffered because of the system.
A part of me understands it's because it was Quebec, but Quebec is an example of how the Canadian system fails, and fails hard.
A part of me feels as if it was my fault. I should have moved sooner, when we were first lied to. But we figured if we played by the rules, things would work out. We were wrong.
So no. I'd fight tooth and nail to prevent that abuse from coming to the US. And if it did come, I'd leave. I will not let my family suffer like that again.
sorry to hear about that. Your comment is very helpful as most, in fact, all Canadians I know are from big cities, and so I now have a richer set of anecdotes... ;)
When someone says you need to back up with numbers then it does seem a bit silly to ask for numbers as a counter argument. :)
I'll ignore for a second that you asked the parent for evidence, and then proceeded to make a statement without providing any evidence yourself.
>> The numbers are vanishingly small
Maybe as a % of the overall Canadian population, perhaps. What about the % of critically ill? People with cancer? My aunt is an oncology nurse at one of the best hospitals in the nation, and she sees a lot of Canadians who come to the US for treatment that they can't get at home.
So yes, people with the flu or a broken arm probably aren't flocking here for care. People with serious illnesses? You bet they're coming here.
>> The numbers are vanishingly small
Maybe as a % of the overall Canadian population, perhaps. What about the % of critically ill? People with cancer? My aunt is an oncology nurse at one of the best hospitals in the nation, and she sees a lot of Canadians who come to the US for treatment that they can't get at home.
So yes, people with the flu or a broken arm probably aren't flocking here for care. People with serious illnesses? You bet they're coming here.
But don't you think that if it were common for people with serious illnesses to come to the US, we'd see much more made of it than we do from those with a large vested interest in noting the influx?
I think you can do better than Rush Limbaugh's favorite right wing advocacy group to back up your opinions.
Here's a study that puts the numer of Canadians using the US healthcare system at about 0.61%: http://content.healthaffairs.org/content/21/3/19.full.html
Here's a study that puts the numer of Canadians using the US healthcare system at about 0.61%: http://content.healthaffairs.org/content/21/3/19.full.html
I wasn't claiming that wasn't biased. It was stated that nobody was talking about it, but I don't think that's the case. I've heard it since the health care debates started in the U.S.
As for that study, I'm a little concerned that they only looked at a handful of states, and this little line at the bottom:
"The authors acknowledge financial support from the Canadian Institutes of Health Research (formerly the Medical Research Council of Canada) for this research."
My guess: both your source and mine are biased and flawed, and the truth lies somewhere in the middle.
As for that study, I'm a little concerned that they only looked at a handful of states, and this little line at the bottom:
"The authors acknowledge financial support from the Canadian Institutes of Health Research (formerly the Medical Research Council of Canada) for this research."
My guess: both your source and mine are biased and flawed, and the truth lies somewhere in the middle.
That's a peer reviewed academic journal. Even if the authors have a bias, it's not comparable to the bias of a right wing advocacy group that gets financial support from the Koch Brothers.
That's EXACTLY what i was looking for, thanks!
The same could be said about college education. The increased availability in grants and loans has exploded education costs.
With regards to medical care, far too many types of care are required to be carried by insurance companies who then pass the costs to their customers. Hospitals do not get full reimbursement for all types of patients, specifically government covered patients, so they pass the costs along to groups who can and do pay. Those being individuals and insurance companies, the later nothing more than a collection of individuals.
With regards to medical care, far too many types of care are required to be carried by insurance companies who then pass the costs to their customers. Hospitals do not get full reimbursement for all types of patients, specifically government covered patients, so they pass the costs along to groups who can and do pay. Those being individuals and insurance companies, the later nothing more than a collection of individuals.
The same could be said about home mortgages. The increased availability in loans has exploded housing costs. ...and we've seen where that went.
The problem in all of these is the promise of a must-have little more if only repayment can be extended and others can be persuaded to contribute. What were luxuries become perceived as necessities. (And yes, I've said "no" to hospital tests, mortgage offers, and tuition financial aid.)
The problem in all of these is the promise of a must-have little more if only repayment can be extended and others can be persuaded to contribute. What were luxuries become perceived as necessities. (And yes, I've said "no" to hospital tests, mortgage offers, and tuition financial aid.)
You're definition of socialism is a little funny. There's a big difference between socialized medicine as a single-payer system where the government has an incentive to keep costs low and a somewhat-centralized and somewhat-regulated system "socialized" system where the government has no such incentive.
I am one of the lucky few who has insurance provided by their employer. Unfortunately, if I am in a car accident and rack up $100,000 in bills, I am bankrupt.
> Unfortunately, if I am in a car accident and rack up $100,000 in bills, I am bankrupt.
...or you just have to haggle with the hospital and refuse to pay their grossly inflated funny money prices.
I have a good friend who incurred 30K in bills for a 2 day stay related to a broken femur. He has no insurance. Since seeing his bill, which wasn't itemized at all, he's basically refusing to pay anything until he sees what he's being charged for. In response to this demand the hospital reduced his bill by about 12K, magically, and still providing no itemization.
He is still refusing to pay and only time will tell what the outcome will be. It's very clear, however, that he was grossly overcharged and that the hospital has no clue what they're really billing for. It's a game. Some people roll over, others fight.
If someone really ends up with 100K+ in medical bills after adjustments then it might actually make sense to take 7 years of 'bad credit' after a bankruptcy. No easy answers here, but it's pretty clear we're all being swindled.
...or you just have to haggle with the hospital and refuse to pay their grossly inflated funny money prices.
I have a good friend who incurred 30K in bills for a 2 day stay related to a broken femur. He has no insurance. Since seeing his bill, which wasn't itemized at all, he's basically refusing to pay anything until he sees what he's being charged for. In response to this demand the hospital reduced his bill by about 12K, magically, and still providing no itemization.
He is still refusing to pay and only time will tell what the outcome will be. It's very clear, however, that he was grossly overcharged and that the hospital has no clue what they're really billing for. It's a game. Some people roll over, others fight.
If someone really ends up with 100K+ in medical bills after adjustments then it might actually make sense to take 7 years of 'bad credit' after a bankruptcy. No easy answers here, but it's pretty clear we're all being swindled.
The rule of thumb that I've heard (from a health cost sharing ministry [0]) is that you should expect to be able to negotiate a discount of at least 40% if you're a self-pay patient.
My sister shattered an ankle a while back, and was billed around $40,000. Between reductions, writeoffs, and charities the hospital connected her to, she ended up only paying about $5000.
[0] http://www.chministries.org/whattodo.aspx under "general information"
My sister shattered an ankle a while back, and was billed around $40,000. Between reductions, writeoffs, and charities the hospital connected her to, she ended up only paying about $5000.
[0] http://www.chministries.org/whattodo.aspx under "general information"
Can you elaborate? Do you think your employer provided health insurance is related? If so, how?
Example 1: A procedure costs $6,000 to be done at a hospital. It prices out patients paying out of pocket. The doctor realized that he himself gets about $700 from it. So the doctor reached out to another facility who agreed to do it for $1,800 instead of $6,000 for the exact same procedure. You can imagine how happy the doctor's patients are, particularly ones paying out of pocket.
Example 2: A patient got upset a doctor's office wanted him to pay copay. The patient got the bill and felt the doctor already got paid $1,500. When the office informed the patient that out of the $1,500 the doctor only got about $300, the patient was shocked.
Really what we need is a doctor compensation to everything else index. When we get that, we will realize the sham most of the efforts to reduce healthcare cost is. Most healthcare cost efforts focus on paying the doctor a little less, say $300 instead of $400. Problem is, bulk of the cost is not the doctor's fees. It is the cost of the bed, breakfast, Tylenol etc. We need regulation on those fees.