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'Legitimate' US healthcare pricing could reduce costs by a third
- em3rgent0rdr 10y ago> "Congress need only mandate that all hospitals, physicians and labs publish legitimate prices—like all other businesses" Is that true for ALL other businesses? I know some businesses are under control of price fixing legislation, but is that true for all?
- toehead2000 10y agocollege tuition
- billsmithaustin 10y agoI guess that excludes enterprise software companies.
- deleted 10y ago[deleted]
- taeric 10y agoI would wager it is not true for any business.
- mcguire 10y agoAs others have pointed out, it's not true for some industries: auto repair, enterprise software and college tuition. Also, cell phone and Internet service "bundles". All of these industries have at least one thing in common: they're kind of scammy.
- rconti 10y agoSure it is. Auto shops have a labor rate. Say, $150/hr. That's the price. For parts, you'll pay the same markup as the next guy. You can negotiate, but you can negotiate ANYTHING.
- mcguire 10y agoThey also have a big book of how long each individual repair should take. If your insurance company has preferred repair shops, do you think the insurance company is paying the standard rate? They do have a better negotiating position than you do. Of course, this isn't as big of a problem as it used to be, back when they didn't post an hourly rate.
- chipperyman573 10y agoCollege tuition (at least, my state college) is straightforward. They even gave me an extremely detailed breakdown of every single fee that was a part of my tuition.
- djsumdog 10y agoI was about to say, college tuition is pretty clear cut. At least in the early 2000s, what they mention on the website and the estimated books/equipment costs pretty much lined up with what I saw on each bill. Some people paid less because of grants (although some people did have their grants disappear when FAFSA decided to change the income brackets), and I guess some people didn't look at the cost, but instead at their student loan returns. But I was an engineer. I'm sure there are other fields that might have crazy hidden lab costs.
- mcguire 10y agoSome people have grants or scholarships, some get free tuition, mostly at the discretion of someone in the administration. And some of us worked our way through grad school, paying MSRP.
- stuckagain 10y agoThis idea is based on healthcare not being a scam. You can ask for a price and then will tell you a price but even if you pay that price, up front, in cash, you will later get bills for more "services", received or perceived. In any other industry people would go to prison.
- maxxxxx 10y agoThere is way too much money in the current system for pricing to become legitimate. All the waste and overcharging is someone's profit. And the Republicans certainly won't do anything about this in the next years. Because "regulation" is bad.
- zanny 10y agoIt is the way that the licensed practice of medicine is so heavily regulated that creates the noncompetitive environment in the first place. Though I wouldn't expect Republicans to ever admit that, at least congressional ones. If the regulation existed under Reagan its the best thing ever (see: if establishment corporations abuse it) and if wasn't its communism (see: donor corporations don't want to be regulated).
- stuckagain 10y agoThe services are too expensive, yes, but that's not what I'm getting at. I'm saying that even the inflated sticker price won't prevent tons of random other bills from flying out of nowhere. Once I got an anesthesia bill -- for almost ten thousand dollars -- after an event that didn't involve anesthesia, at which the anesthesiologist was not even present. There was just some stored procedure in their database that fired off bills.
- maxxxxx 10y agoThe financial part of medicine seems pretty unregulated. They can charge phantasy prices and frequently charge for services never delivered without consequences. In other industries this would be plain fraud.
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- hardtke 10y agoError in the article: auto insurers also have negotiated rates with service providers, including body shops and auto glass repairers.
- tehlike 10y agobut there is less variance in prices, more flexibility in shopping, and less variance between estimated and final cost.
- cassieramen 10y agoI constantly feel like my doctors are hamstrung in providing me with the best medical care because of this. It's hard to recommend the best medical option for your patient when you have no idea at what point in time they will be able to afford it. It's fine to say a simple surgery will fix a problem for me but if you don't know how long I'll have to save to afford it it could snowball into a larger/more difficult surgery.
- mikepurvis 10y agoThis week my wife and I went to the hospital here in Waterloo and delivered our third child. Total cost was $16... to park our car overnight in the garage. Now, our delivery was as close to perfect as you can get. We were only there overnight, but there are a million unknowns with a baby, and I'm just so thankful knowing that no matter what might have happened, we would have received what we needed, when we needed it, and if it wasn't available at our local hospital, we would be transferred to where we needed to go— all at no charge. There isn't really a message here, just grateful to live in a country where my medical professionals can recommend me the care I need without having to have a conversation about costs. And most importantly, that that same care is available to everyone in my country, not just those who happen to work a salaried white collar job.
- rubidium 10y agoCost us $5,500 with "decent" insurance (fortune 200 company, $3k deductible, 20% after that) for my wife to have our first (normal delivery) here in the US of A. God bless America.... 'cause it needs it.
- ArtDev 10y agoWhat was the out of pocket? Thousands of dollars, correct? How many bills did they send you and for how long? How many billing errors were made? This is not normal in a developed country. My favorite part is when they bill the baby for the cost of its own birth against its own seperate deductible.
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- niftich 10y agoIt's hard to overstate how bizarrely opaque healthcare pricing is in the US. Despite the quality of the care ranking favorably worldwide, medical bills are an after-the-fact surprise. In the diplomatic, foreign exchange, and expat communities living in the US, a common advice is "don't get sick". Those who can afford to travel often get care "back home" or elsewhere in Europe or Asia, because the costs can be determined in advance -- not to mention almost always cheaper. Meanwhile, Americans are subject to surprise pricing, supposedly-helpful "Explanation of Benefits" forms that itemize procedures into miniscule sub-steps costing several hundreds of dollars each, a complete inability to reconcile a bill with the corresponding insurance claim -- to say nothing about trying to correct a paperwork mistake should it occur, or even being able to detect it in the first place.
- ChuckMcM 10y agoIt reminds me of the many ways that Congress could legislate better behavior from existing players in the health care field in order to achieve their objectives.
- WalterBright 10y agoFew people ask what the price will be in advance. I do know people that do, and they can and do shop around. You can get quite a bit better prices that way. Few procedures are an emergency.
- msrpotus 10y agoI've tried to do that for relatively routine care and it's a headache and a half. I spent half a workday (because, of course, I could only do it during business hours--good thing I have a job with a flexible schedule) calling up doctors' offices and waiting while they figured out how much they charged for a new patient appointment. If ZocDoc reliably had that information, it would make shopping around easier (my insurance had a directory but most of the price info was wrong). In the absence of that, it's just not so easy to shop around for medical care.
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- sethev 10y agoThe problem with this thinking is you don't know what services you'll require (apart from routine checkups and specific treatments for already diagnosed problems). It does me no good to have a list of all the thousands of possible things a hospital might do along with a price for each one.
- rgbrenner 10y agoThat's definitely part of the problem too.. but that exists because of the pricing structure hospitals use. If I go into a store and buy a part, they don't say, well let me call the factory, and they'll get a list of all the things that were done to create this particular part, and a price for each. The store comes back with a list: Raw materials: $ Packing materials: $ Surcharge for production delay caused by spill: $ Resurfacing of part because of material defect: $ If a manufacturer tried that, they would be out of business immediately. Yet that's exactly what hospitals do, even down to a charge for the 2 cents worth of aspirin. In normal businesses, they charge a price for the product that covers the details, the mistakes, the extras required to delivery the product. The mistakes, etc are averaged out over all of the items produced, along with the cost of the misc supplies, equipment, etc.
- sethev 10y agoThe current system sucks but I have trouble picturing your alternative. If a person has abdominal pain it could be caused any number of things - some of which could have no cure at all and some of which will just go away on their own. What price list could they possibly consult?
- tehlike 10y agothat's a very good analogy. thank you.
- niels_olson 10y agoThe methods of Medicare pricing were established by DeBakey's subordinates when Johnson pushed Medicare through. It's backroom deals all the way down.
- throwaway2016a 10y agoThe other day I went to the doctor and had a minor procedure done (I had two moles I wanted removed) and asked "How much will this cost if insurance doesn't cover it?" The answer: "I don't know" How can you not know what the cost of a routine procedure like that is? If a simple thing like that can't be give a cost what hope do we have? Edit: If anyone is curious, $580 but my insurance covered it.
- hkmurakami 10y agoHow big was the medical facility? Might be the case that the doctor genuinely doesn't know since the hospital operations folks determine the price?
- MBCook 10y agoThat's quite possible. And let's ignore insurance for a moment. How is the doctor supposed to responsibly recommend treatment if they don't have the faintest idea of what it costs? If you need some kind of drug in the doctor can think of to that would probably work just fine, would it be really useful if the doctor knew that one was $1/pill in the other was $45/pill? If the difference in the price for the patient ends up being significant maybe that should be something to take into account. However if you set up the system so that the doctors never actually know what it costs…
- throwaway2016a 10y agoSorry I was sleeping during the last message... but pretty big. Not a Hospital but it is 5 floor and if I were to guess at least 25 doctors.
- analog31 10y agoThis is not inconceivable. The doctor may know her own fee, but is also ordering services such as use of the clinic, assistants, supplies, and so forth. She has never had to pay for any of those things. She doesn't even know what business entities she's dealing with, possibly an impenetrable rats nest of LLC's. I've read that over half of all doctors are self employed, meaning that their salaries are not a good measure of their incomes. Were I inclined toward cynicism, I'd say that the purpose of the complexity is to make it impossible for anybody to figure out where the money is going, or who is actually gouging whom. Somebody is gouging us, but we'll never know who, and everybody can claim it's somebody else. In my view, the only way to get to the bottom of where the money is going, is to manage the whole thing. This may be why nationalized systems cost so much less. The people who are gouging would stick out like a sore thumb.
- johng 10y agoTruth in billing, which is required of telephone carriers would be huge by itself in the medical field. Also, being able to opt out of a $600 gown, etc...
- chimeracoder 10y ago> Truth in billing, which is required of telephone carriers would be huge by itself in the medical field. It would be, but Medicare would never let that happen, because opaque billing is how they ensure they can reimburse below cost and get private insurers to essentially subsidize Medicare patients.
- FireBeyond 10y agoThis is a claim often stated, but rarely actually demonstrated - ways in which Medicare doesn't cover costs, that is.
- costcopizza 10y agoI know this is reference pricing rather than legitimate, but it seems likes a start: https://www.mdsave.com https://www.mdsave.com
- kumarski 10y agoI think the pricing is an implicit way the cog in the engine works. I don't necessarily agree with it, but I see it and always think about it when anybody points out how expensive medical care is here in the USA. Biotech R&D advances in the USA are funded by monstrously price gouging insurance companies. Are you a biotech innovator? Your best bet is to start in the USA because you can charge a lot of money and nobody will lift a finger that influences your market potential like what happens in other countries. Hopefully a large pharma company will buy your small pharma or medical device company because they have 2 things you don't: 1. Distribution - 1 sales rep for every doctor 2. Synthetic Scaling Insight - They have deep insights and grandfathered advantages in this arena, lest you can double down on putting in 40M-100M to make it happen. ---Or so this was the way it was explained to me through hundreds of interactions trying to build a genetics company in the USA. --- The hunt for drug targets is the elusive hunt for the black swan. There's 8-10 new genetic tests that come out each day but very few if any of them can be tied to something specific, because it's tough. Data doesn't necessarily make it easier, despite the notion of big-data optimization. As such, prices will get higher, before they get lower. That or drug dev. stagnates. The elephant in the room anytime we talk about US healthcare is our flawed food environment - Sugar. It's creeping up on other countries fast.....
- y_u_no_rust 10y agoWe defiantly should be paying more for healthcare.
- fixxer 10y agoIf the ACA had sought to create a competitive market between the consumer and the provider instead of between the consumer and the insurer, it would have been a truly revolutionary leap forward. Instead, we got entitlement expansion.
- deleted 10y ago[deleted]
- MBCook 10y agoIt got A LOT more people covered. It made it so you don't have to worry about losing coverage when you switch jobs due to pre-existing conditions. No, it wasn't real reform. They could've allowed you to shop for plans offered in other states for example. But it was a truly useful step forward for TONS of people.
- deleted 10y ago[deleted]
- crispytx 10y agoMy wife's wheelchair that the insurance company is paying for costs $6,000. The "loaner" wheelchair she's using now costs $400. The $6,000 chair being built is essentially the same as the $400 chair. Fraud like this is the reason we have the most expensive per capita healthcare in the world.
- pcurve 10y agoExactly. Insurance companies don't care, because a lot of commercial clients are self-insured, and they just pass on the cost. If anything, they make more money off of administrative fee by selling higher ticket items. The only true way to fix this is to set costs centrally.
- orionblastar 10y agoMy mother needed a wheelchair, we went to Amazon and bought a $300 one instead of the $6000 one the insurance company wanted us to buy. No difference that we can tell.
- tehlike 10y agogood thing is those are the things you can shop around -easier-. when you are in a hospital getting care, you have very little idea about how much it's going to cost you.
- orionblastar 10y agoAlso don't throw stuff away. I had injured my knee and has surgery to correct it. I bought a walker until I got better. When my father got sick he borrowed my walker instead of buying a new one. If you look in thrift stores you can find canes and walkers as well sometimes. It is just like OTC aspirin, bring in your own bottle to save money as if a nurse gives it to you, you are charged $50 a pill. Buy one for $1 at a Dollar Store and use that.
- lobster_johnson 10y agoWouldn't the insurance company be interested in a solution that cost less? For example, if you told them you found a store that sold a new, cheaper wheelchair (another comment says they're on Amazon), wouldn't they rather pay for that one, given the option? Or are there liability concerns that would get in the way?
- Steeeve 10y ago> They can continue to set their own rates, but a different rate for each patient must be prohibited. This is a terrible idea. That means no discounts for people in need, and no doctors saying "don't charge her for that aspirin" as both would become illegal. I'm all for transparency in pricing, but the lack of flexibility in charging customers is already a big problem. When you go to the hospital, everything is charged at max-price, then insurance companies pay out their negotiated rates. People without insurance don't have the ability to negotiate and end up with ludicrous bills that even the most generous insurance company wouldn't pay.
- Veratyr 10y agoInstead of subsidising those in need through price changes, the government can simply subsidise those in need directly, paying part of the bill itself. This is how it works in many other countries.
- finiter 10y agoThe 46% of the country that gets to decide who runs the country hates doing that.
- rubidium 10y agoNo, it would just take some more creativity on the part of the doctor/clinic/hospital. Perhaps in the form of "pro bono" work where they waive the standard fees for their work.
- ma2rten 10y agoIsn't what you are describing (individuals being charged more than insurances who have negotiating power) exactly what this suggestion is trying to prevent?
- Steeeve 10y agoThat's the stated intent, but the plain reality is that it evens the playing field for insurance companies at the expense of leaving the uninsured and underinsured out in the cold.
- maxlybbert 10y agoIt's like he's never heard of "price discrimination" ( https://www.joelonsoftware.com/2004/12/15/camels-and-rubber-duckies/ https://www.joelonsoftware.com/2004/12/15/camels-and-rubber-... ). Yes, medical care in the US is priced to basically be as expensive as you (or your insurer) can afford. That isn't uncommon, as Spolsky points out. Airline tickets are priced the same way. But so is everything that has a premium model and a basic model, etc.
- rubidium 10y agoOk, that article linked was brilliant. It points out all the hypocrisy of being too analytical about pricing. The real question is how can your customers pay for it.
- mooneater 10y agoIt seems like a similar price inflation affects anything sold to the military. Every time I hear comparisons involving the size of the US military budget, I always think "yeah but everything they buy (including hammers + toilets) are 5x-10x the price, so their effective budget is only 10%-20% of that"
- deleted 10y ago[deleted]
- dd36 10y agoIf Thailand can do it, why can't we? https://www.bumrungrad.com/en/realcost-thailand-surgery https://www.bumrungrad.com/en/realcost-thailand-surgery
- seranwrap400 10y agoOne reason for the bizarro healthcare pricing situation is that hospitals can claim the writedown (difference between huge fake price and actual price) as a loss when filing taxes. A few changes to the Internal Revenue Code would help put a stop to this.
- MBCook 10y agoIRS code is the same way we got in to the nonsense of almost everyone getting their insurance through their employer, which led to the situation where there was almost no market for individual policies. That meant they were insanely expensive and the cost effective only way to get healthcare was to be employed by a big company. And that meant switching jobs could be insanely expensive. And that meant you could pay people less because you had a form of lock-in. Don't want to lose that pre-existing condition coverage. One little text change, design to either give companies more compensation options or promote health insurance (I'm not sure which) had a really huge unintended effect on the way the entire employment system runs.
- tehlike 10y agoa little context on the healthcare insurance by employer system: During WW2, the US banned increasing employee compensation, so employers looked for alternatives and they figured insurance would be one area. That's how the US got into the mess of "employer takes up the bill" :) ref: http://www.nber.org/papers/w14839.pdf?new_window=1 http://www.nber.org/papers/w14839.pdf?new_window=1 So wars have long lasting impacts on the society, taxes and insurance are some important examples.
- MBCook 10y agoI didn't realize it was a war thing. Thanks.
- branchless 10y agoHow's that "free" market workin' out for y'all?
- dang 10y agoPlease don't post ideological provocations to HN. It never does any good. We detached this comment from https://news.ycombinator.com/item?id=13324535 https://news.ycombinator.com/item?id=13324535 and marked it off-topic.
- adjkant 10y agoThis is the tip of a really trashy iceberg when it comes to general healthcare costs. Not only is consistent prices by patient a problem, but prices by procedure and by hospital has a huge range as well, as documented many times. An operation can cost $10K at one place and $100K at another. This isn't news though. http://www.huffingtonpost.com/2013/05/08/hospital-prices-cost-differences_n_3232678.html http://www.huffingtonpost.com/2013/05/08/hospital-prices-cos... What isn't talked about is this: when you want to get a procedure done, and your insurance will cover it the same at each place, how do you choose your hospital? Location is usually a big factor. You'd also probably want to go to the place with the best facilities. What ends up happening is that hospitals will build these expensive facilities in good locations to attract, for lack of a better term in this story, customers. Billion dollar construction projects. Do you think their prices went up or down during this build? That all is raw cost. Now throw in what you pay. If your insurance covers the 95K of the 100K, but won't cover any of the 10K, you're going to choose the 100K procedure. The health care insurer eats that 95K and then raises their prices across the board. Everyone nationally loses, except for that hospital, which is now closer to paying off its new facility. This situation in reality is much murkier, and I skated over plenty of details I'm sure, some I didn't even realize I skated over. Now, state of the art medical facilities are a good thing on their own, but there's a game being played here with the prices of the facilities themselves and how they are paid for. With the lack of transparency, we aren't really able to determine much. All of these dynamics come from the complexities of a system that badly needs to be simplified, regardless of if you think it should be done by the government or privately. You can probably already see here how a single payer system or some sort of direct proportionality costs could make a big difference. I can't say I have the solution, but I think this part of the narrative is often missing.
- samirillian 10y agoI've often heard/personally espoused the belief that health shouldn't be treated like a commodity. Interesting argument here that if health were only "truly" treated like a commodity, we'd have much fairer pricing. Capitalism has many faces, of which the free market is only one aspect. The healthcare industry in the US functions a lot more like other examples of what Naomi Klein might call "disaster capitalism": preying on the fact that health is by its very nature un-commodity-like to extort the sick. The problem with this whole line of reasoning may be that health just can't be fairly priced according to free market principles, and that acting like it can be will just continue to enable the status quo.
- djsumdog 10y agoI worked for a health care insurance company during the 2008 debates on the cost and quality web applications. Like people have mentioned, they only gave a range, and a useless one at that. This was during the big push to HSAs and how healthy people could save using them and roll that money over to an IRA later in life to aid in retirement, or kept in the HSA for medicare costs. We read Redefining Health care at work and there was a lot of talk, but always with the for-profit ends (even through we were a non-for-profit, not to be confused with a non-profit). I left the US for a while and I found it interesting that in other countries, doctors could always tell me a price. An office visit was never more than $70 and when I got better work visas, the doctors offices even worked with me to get a better rate (even though I didn't have a full residence visa needed for Medicare). Every lab I went to for imagination told me the price on the phone. The Affordable Care Act is terrible. I does help the very poor, but everyone in the middle still struggles between many terrible options. Contractors often get the worst plans that have little to no substantiation. I have not seen a doctor for a year and only have minimal effective coverage ($17). Full plans from my employer start at $400/month. I've open enrolled in an ACA plan for next year, but it's still $200 a month and I plan on quitting my job and travelling. Because it's based on last year's income, I can't switch to a low income plan until the following year. Employers should have been banned from offering plans at all, or at the very least, giving any discounts. But really, we should have a single payer system. The current state of health care under the ACA is still not good, and far from our European counterparts.
- cmurf 10y agoI'm convinced employer paid insurance is the single biggest problem. Very few people buy plans in the healthcare marketplace, most get it from their employer, and most of those have no idea what that plan costs compared to other plans. With employer paid care, the employer is the primary customer. A level playing field would be everyone having to go direct to insurer/broker or healthcare market. And people would be so irritated with that process, which also requires annually reevaluating to get the best price, as a society we'd either go back to bartering chickens or go single payer.
- lobster_johnson 10y agoPart of the original plan for the Affordable Care Act was, as I recall, to require members of Congress to use the government-run marketplaces. Congress refused. Not surprising -- they probably have the best health insurance in the US. If Congress were forced to "dogfood" the health system the way ordinary people experience it, I suspect Republicans would be falling over themselves to enact a single payer system.
- cmurf 10y agoYes but Republicans do everything they can to avoid government doing anything; or make it work badly on purpose whenever they can't prevent it, because government that works better than the free market is incompatible with their narrative that the government sucks and can't do anything right except blow people up on the other side of the world.
- jack9 10y agoRidiculous healthcare is one of the perks for govt officials. Any one of the Congress people or Executive administrators can get a full body scan on a whim (e.g. it was all the rage in washington during the first bush administration through the second bush terms). You get a clean bill of health for your campaign, or you get whatever you find, treated and maybe get well enough for the next campaign cycle.
- tkiley 10y ago> Healthcare providers must likewise be required to publish their rates in a uniform format such as industry standard CPT codes or a percentage of Medicare rates. This proposal does not address the primary reason that price transparency is really goddamn hard: Even if you know exactly what a provider will charge for each CPT code, you don't know which CPT codes are going to be billed for a particular patient care event. Inconsistent cost per line item is not the key problem with transparency. Tools like Castlight actually do a pretty decent job of guessing how much each item on a provider's CPT "menu" is going to cost a patient. In many (most?) situations, it is simply not possible to predict which CPT codes are going to be billed for a particular patient's care. This is the key reason price transparency tools tend to give a range rather than a specific price for a particular procedure. (Also: Big picture, the idea that this would decrease costs by 33% is absurd. If healthcare providers had to publish real legit price sheets that were used by real consumers, prices would converge within a market, but they would not converge that low. Published pricing is not going to cause these businesses to collectively roll over and give up 33% of their revenue.)
- tehlike 10y agoThere are many factors contributing to this actually. 1. Doctors overprescribe because they are afraid of mistakenly underprescribing (we are a litigious country after all). This end up costing patients more tests/procedures, and cost doctors malpractice insurance premiums. 2. Procedures are billed differently per insurance policy. There are millions of variations of anthem PPO, and what they cover and how much they pay differs. 3. You, as the policy beneficiary, only care about your out of pocket cost. You don't really care about the price unless 1) you pay some percent of the money (reference pricing), 2) you are below your deductible. So you are right, price transparency alone is not enough, but it is indeed a big step. If you knew in advance the price of thing, you probably wouldn't pay 400$ for a bag of saline solution [1] [1] http://www.nytimes.com/2013/08/27/health/exploring-salines-secret-costs.html http://www.nytimes.com/2013/08/27/health/exploring-salines-s...
- tkiley 10y ago> you probably wouldn't pay 400$ for a bag of saline solution Hey, this is a great example: I might very well pay $400 for a bag of saline solution even if I knew the price in advance, because I don't care about the price of the bag. I care about the all-in cost of my treatment. If that total cost happens to include a $400 bag, I don't really care. The "$30 Asprin" narrative sometimes misses the big picture of healthcare costs. The price of an apsrin or bag of saline solution is inflated to cover the enormous fixed costs of running a hospital with an ER. Could the ER charge $4 per bag or $0.25 per asprin? Of course, but if they lose their per-unit margin on the saline and asprin, they're going to jack up the price of some other CPT code because they have to cover their fixed costs somewhere.
- Animats 10y agoCalifornia's assembly passed a law requiring hospitals to charge Medicare's rates to self-pay patients. Schwarzenegger vetoed it.
- dzink 10y agoTo get a closer-to-real cost of healthcare, especially surgical procedures look at veterinary care in the US. Similar tools and equipment, similar medicines, similar training, except pricing is not defused by third party payers and padded by liability insurance costs.
- squozzer 10y agoHere's a similar take -- http://www.huffingtonpost.com/david-belk/hospital-bills_b_4257433.html http://www.huffingtonpost.com/david-belk/hospital-bills_b_42...