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I've always wondered about US health insurance -- why can't the physician give me quotes about my personal obligation for various treatment options? It's frust

• dannysu 9y ago
  I think what's happening is that your doctor will attempt to get as much money from the insurance company as he/she can. My wife has experience of the doctor's office asking insurance company for $X, and the insurance company comes back and say "no, max $Y". So then the final "cost" all of a sudden becomes $Y. Pay attention to the claims that your doctors send to insurance company and you might be able to see that. So instead of telling you, yes, whatever procedure is definitely just going to cost $Y. They can't tell you how much things are. It depends on maneuvers with other players in the industry. This is very different than say in Canada. If I want to get a teeth filling in Canada, my dentist straight up tells me how much before the procedure. If I want to price shop that, I can. In the US, nobody is willing to say how much, because "it depends". It's not because intrinsically there can't be price transparency. It's because of all the messed up incentives that the industry has that causes US health care to be as such.
  • youdontknowtho 9y ago
    That's actually a response to the insurance company performing a type of information arbitrage with multiple other parties. You could have health insurance with transparency, but there is too much profit potential in forcing information asymmetry between all of the parties involved in the system. Every time that you think...doctors...hospitals...nurses...are up to something, most of the time it can be tracked back to insurance companies and the sway that they hold over congress with their money. I'm not saying that there aren't doctors, nurses, hospitals trying to gouge people. I'm just saying that insurance companies are worse. (With some very rare and egregious exceptions.)
    • dannysu 9y ago
      Even with that I still don't give doctors an excuse. There are a bunch messed up incentives there too. Such as doctors recommending more expensive drugs, or giving me coupons to buy said drug. I'm assuming there's money exchanging hands there too. Not sure if it's with doctors directly. But the end result is that I simply cannot 100% trust any advice I'm given.
      • nmcfarl 9y ago
        These days there's not going to be money - but there might be steak dinners. But there are lots and lots of doctors who's ethics say that steak dinners with drug reps are off limits. But no steak dinners still doesn't mean you won't get this happening, because some docs look at your insurance and figure that for you, your out of pocket will be lower with a coupon than with a generic. Sure the insurance company might pay an arm and a leg - but by and large docs don't care about insurance company profits, and do care about the person in front of them. And thus waste. Other docs think all generics all the time -- even if the cost to the patient is massively higher. On the opposite side sometimes the expensive drugs just are better (even if just marginally) and most docs don't think about costs at all - as it's very very complex and their lives are busy enough. It's messed up for a thousand reasons, not for one reason.
        • xxSparkleSxx 9y ago
  • Domenic_S 9y ago
    Dental insurance in the US is a bad example, because they generally pay for (in a year) 2 routine cleanings, silver fillings, and a percent of anything else, up to some ridiculously small maximum of $2k or something. You very much can get price quotes for dentistry.
    • ams6110 9y ago
      And really, they should NOT be paying for 2 routine cleanings, because those costs are both modest and predictable and that's not the point of insurance. The reason they do pay for the cleanings is that it's probably cheaper than paying for the increased fillings and root canals that they would incur if people skipped the routine cleanings. So they want to incentivize that, even though it's not really the sort of unexpected ruinous expense risk that insurance is really meant to assume. They could achieve the same goal by providing a discounted premium with proof of routine cleanings, but that's probably more complicated for both them and their customers.
      • chimeracoder 9y ago
        > The reason they do pay for the cleanings is that it's probably cheaper than paying for the increased fillings and root canals that they would incur if people skipped the routine cleanings. Actually, no, they reason they do is because they're usually subsidized by employers providing the plans. In other words, it'd be equivalent to the employer reimbursing a portion of your regular dental care that you pay for out-of-pocket. The expected reduction in cost for the insurer due to routine cleanings is negligible from their perspective. If you purchase dental insurance individually, these treatments are very rarely covered, or if they are, the price under insurance is usually about the same as the price without insurance. Which makes sense from a risk model - when there is literally no risk at hand, the price under insurance should actually be higher than the uninsured price, by a tiny amount.
      • rlucas 9y ago
        This is a great example of why most "health insurance" (or dental or vision "insurance") isn't really insurance. It's a bundled prepayment model, similar to selling gift certificates/cards or the like. Basically making money on breakage / float. Real casualty insurance wants to reduce the number/magnitude of casualty losses. So the theft insurer wants you to get good locks and an alarm, the fire insurer wants you to get sprinklers, and they all want nice orderly public services with good response times and suitable building codes. Win-win-win. Nobody would ever be unhappy if they paid their whole life for fire insurance and their house never burned down. But health "insurance" can't really reduce the amount they pay out (the "medical losses") because the customer is expecting to consume healthcare. It's also more complicated because one of the best ways to reduce medium term healthcare costs is to spend more on short term healthcare costs. Can you imagine if the best way to prevent a house fire was to have a little house fire every year? (Well, that's not so crazy in terms of wildfires, perhaps.) Then, there's the fact that in the very long term, everyone will die and many will get really sick just before that. And the private health "insurance" companies do their damnedest to avoid that group entirely, having effectively shunted them all off onto the commonwealth (Medicare). Health insurance is not like other insurance and we need a new word for what it really is.
  • djrogers 9y ago
    Actually, dental care is like that in the US - your dentist can tell you the price, and you can price shop it. If you happen to have dental insurance, they may not know how much of that bill will be covered, but you can absolutely get costs from them. Other healthcare on the other hand is often a mess, although it is getting better. I've found recently (an MRI in this instance) that I was able to get costs beforehand, and even compare prices. I think the prevalence of HDHP (high deductible health plans) has steered people towards expecting to pay out-of-pocket for care, which has led to a positive change in this area.
    • dannysu 9y ago
      Got it. I only used dental as an example in Canada because majority of everything else is already covered by universal health care, so I don't have experience dealing with pricing for other things in Canada.
    • brianwawok 9y ago
      Vets are like this too. Vets and Dental are very simple. My root canal is $325? Cool. I can shop it around or go with it. Same with a pet procedure. Medical is the crazy town.
    • jessaustin 9y ago
      Is this because dentists can tell patients who forgot their wallets to take a hike, hospitals can't, and for the most part hospitals don't do emergency dentistry? [0] That is, if dentists were more "ethical", we might see the same problems with cost and payment in dentistry that we see in health care in general? [0] Sure, there are extreme exceptions, since most hospitals have a dentist they can call when an emergency patient is admitted because an abscessed tooth has destroyed their entire body... It takes commitment and/or great misfortune to get to that point.
  • vec 9y ago
    To be fair to doctors offices, this is in part because some insurance plans (Medicare's the biggest offender, but then again Medicare's the biggest everything) pay doctors below cost for certain procedures. Doctors cope with this by systematically overcharging other patients' insurance companies when they're reasonably sure the patient has already hit their copay for the procedure. Essentially, health insurance for the poor isn't formally subsidized well enough to make it actually workable, but doctors have professional ethics that disincentivize them from refusing care. So the system has evolved a clumsy, ad-hoc mechanism for wealthy patients to cross-subsidize poorer ones. American health insurance sucks.
    • sidlls 9y ago
      Below what cost?
      • chimeracoder 9y ago
        Below the marginal costs of care. In other words, if a practice can purchase a vaccine or supplies for a lab test at $100/unit wholesale, Medicare pays the doctor (in the aggregate) $93 for it. That doesn't take into account any overhead or costs of running a practice, of course, such as wages for nurses and administrative staff. Providers typically make a loss on Medicare patients and then make up the difference by charging private insurers (who are, by law, required to pay more than Medicare does). Medicare's rates are so notoriously low that for doctors who can't do this - doctors who treat a disproportionate number of Medicare patients - they actually have a separate stipend program to pay them enough to stay in business.
        • flubert 9y ago
          Does anyone know how to look up what Medicare/Medicaid pays for particular procedures, and how to look up codes in the first place? Somehow I came across that G8709 was for prescribing antibiotics. I figure I should be able to plug that into something like: https://www.cms.gov/apps/physician-fee-schedule/search/search-results.aspx?Y=0&T=0&HT=0&CT=0&H1=G8709&M=5 https://www.cms.gov/apps/physician-fee-schedule/search/searc... ...but I apparently don't know the proper incantation to get that to work. It would also be interesting is someone had concrete side-by-side examples of what Medicare/Medicaid pay vs. what everyone else pays for several different "common" items.
  • eli 9y ago
    The bill shows they asked for $X, but the doctor already has a negotiated agreement with the insurance company that says they will accept $Y for the service. Additionally, if you inform the office you are paying the bill yourself (without insurance) they usually give you a discounted price somewhere between $X and $Y. In other words, almost nobody is paying the list price of $X. It's not really a meaningful number. (And, as others have pointed out, the weak US dental insurance market means that actually dentists are pretty up-front about pricing in my experience.)
    • smw 9y ago
      And in a number of situations, they'll give you a price significantly below $Y.
• pkaye 9y ago
  I have Kaiser insurance which is an HMO with straightforward pricing for most things. One fixed copay for doctor visit, one for specialist visit, one for outpatient care, etc. The problem is you are stuck using only Kaiser facilities and doctors.
  • jonlucc 9y ago
    There are benefits to continuity of facilities, though. Anecdotally, my wife went to her regular doctor for a nominal fee at her yearly checkup. They drew blood, then asked her what hospital she wanted a follow-up diagnostic procedure to be scheduled at. She gave the one closest to us. She showed up, did the procedure, then almost a month later, we get 2 bills. One is for the blood ($1800) which, surprise, didn't go to an in-network lab despite all of our previous years' work being covered. The other bill was for the procedure ($800 if I remember correctly). If you go to the insurance website, enter her plan, enter the hospital and the procedure, it will tell you it costs something like $40. The whole system is broken, but at least these issues wouldn't have happened in a system like Kaiser. Also anecdotally, my sister is on Kaiser in Colorado, and she has a chronic disease along with her pregnancy. They are taking very good care of her, and nothing seems to be dropped despite her having 3 physicians whom she sees regularly. I have almost no faith that if my wife gets pregnant, we'd have the same continuity in our current setup.
    • mljoe 9y ago
      If an HMO got stupid amounts of marketshare it would probably fix the system naturally. It would also improve stuff like allowing HMOs to be able to better take advantage of medical data and provide better care through understanding the patient. The problem is there is too many HMOs, which makes HMOs in general less convenient.
• danvoell 9y ago
  I agree, to me the second biggest industry acceptance that is counter intuitive is that insurers need to make money off of the float. Why can't an insurer come along who charges a fee for the service of ACTUALLY BEING ACCESSIBLE TO THE CUSTOMER. Intead of fax me this paper and wait two months. I am paying the insurer on the basis that they want to draw out any claim I have. "All I've heard so far are physicians who don't accept insurance but instead have a straightforward "menu" for common items, which is interesting but not what I think most people want." - I think people want this but they are scared of going off of insurance in the event they need to see someone who doesn't offer this (chance occurance, expensive disease).
  • zerni 9y ago
    We are actually setting up an insurer in the UK which is doing exactly that by changing the business model to taking fees on settled insurance claims instead of betting on an underwriting/investment profit. Have a look. insureathing.com
  • deleted 9y ago
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• ubernostrum 9y ago
  For routine things, your responsibility is a flat amount, usually printed on your insurance card. So you know, for example, if you go to your general physician, you pay this much. Go to a specialist, pay this much. Go to emergency room, pay this much. For more complex things, it's usually: 1. Not possible to know in advance everything that will need to be done. Many medical procedures are not things that just go identically every single time, and complications can occur during the procedure. Having to call it off, re-quote, re-schedule, etc. is not optimal. 2. The doctor likely doesn't actually know how the procedure will be billed. Medical billing is done using standardized codes to describe procedures, and the doctor will have someone who knows how to do that, but that person may not even work in the same building as the doctor. And the sets of allowed codes and how to use them can change quarterly, and that's without getting into the arms race of doctors trying to "up-code" (rather than the most obvious code for a procedure, find a way to bill it as multiple procedures or as a plausible but higher-paying code, since doctors and insurance companies are locked in an eternal battle of doctors trying to make as much money as they'd like and insurance companies trying to pay as little money as they'd like).
  • jonlucc 9y ago
    On your first point, even if they know exactly what will be done, they can't answer. I can't look for it at the moment, but there was a Vox video maybe last year about a man who wanted to find out the cost to deliver his and his wife's baby. He called a bunch of hospitals in the area, gave them his insurance information, and he asked them the cost assuming everything goes to plan, just the cost of delivery. I don't remember exactly how long it took, but he got a number after hours on the phone. Then the bill came, and it was still a different number. The whole thing couldn't be more opaque.
    • ubernostrum 9y ago
      It's worth noting that this isn't always a "don't know". Often it may literally be a "can't say". The problem is that even if you call them up and say "sure, I know it could be more complex, I just want to know what it would be for a perfectly normal delivery", and then you go there and get a bigger bill due to complications, what happens? Do you have a case against them for misleading you into thinking it would be cheap? Do they have written evidence that you understood their quote was only for a no-complications scenario? The safest thing is to refuse to give an answer. To elaborate on this, I work for a company that offers health insurance. One of the nice features of our plans is that although it's PPO with a network of contracted providers, the co-pay for someone on the plan is the same whether a doctor is in- or out-of-network. But how do you advertise that? Saying "see any doctor you want" is a non-starter, because someone might take it to mean "doctors are required to see you even if they don't want to" and then claim we misled them with the "any doctor" line. It ended up taking quite a while to work out a way to advertise that benefit without tripping over anything that might be claimed to confuse or mislead.
• akharris 9y ago
  Health insurance is a very different business than P&C and one that I've spent a lot less time researching. Each customer interaction at least 3 participating actors (patient, provider, payer), each of which have different incentives, rules, and understanding of those rules. I think there are great companies being built in the space (take a look at what Clover Health is doing https://www.cloverhealth.com/en/ https://www.cloverhealth.com/en/), but it's not an area I'm focusing on.
• basseq 9y ago
  A lot of good answers here. A few straightforward ones: - Because healthcare providers negotiate different rates with providers, so the "list price" differs by your provider and plan. - Because your personal cost is unknown to the doctor, as it would depend on factors between you and your insurance company (like deductible met), coverage types, etc. Now, these are both solvable problems. And I agree with the sentiment of other posters here that it's predatory that medicine is one of the few fields where you simply don't know how much something will cost until you get the invoice.
  • snuxoll 9y ago
    > - Because your personal cost is unknown to the doctor, as it would depend on factors between you and your insurance company (like deductible met), coverage types, etc. This one CAN be known to the doctor, the full details of your coverage, current deductible met, copay amounts, etc are an X12 270 transaction away. Almost nobody does this though, unless you are planning on billing an expensive claim (outpatient surgery, post-acute care, etc) where non-payment can mean a significant monetary loss the time and money doing these checks isn't worth it for the provider. This is further exacerbated by most (all?) clearinghouse's charging to run these transactions, and a really slow adoption of CORE Phase II connectivity standards by payers (which would bypass the clearinghouses completely and allow providers to directly submit eligibility requests to payers over a standard interface).
    • basseq 9y ago
      Oh 100%. There's no technical excuse not to have that. As others have pointed out, there's a pessimistic line of reasoning as to why doctors and insurance companies don't want you to know what things are going to cost. The sad part is that we've allowed that to become an acceptable way of doing business. But imagine if your mechanic did that. "Hi, thanks for bringing your car in. We investigated that noise, ran a bunch of tests, and everything looks fine to us. That will be $5,000." (Fun story: many years ago, Jiffy Lube topped up my dad's transmission fluid without telling him there was an associated cost. When they tried to charge him the $25 or whatever it was, he told them to suck it back out.)
• rgoddard 9y ago
  Mostly due to all of the variables that go into pricing a claim. And that logic on lives in the insurer's claim processing system. Pieces that can impact the price. Your insurer and what product you have. These will affect who is considered in-network and the fee schedule to use. Different insures will have different arrangements. Depending on the product if you have a narrow network product they may or may not be in-network. It could also depend on the location. A provider can be in-network in one location but not in another. Also the procedure that is actually performed may be slightly different from what was planned due to unforeseen circumstances. This is assuming the provider is aware of what the actual costs are. In many cases they don't even know the ballpark price since that is not the portion that they deal with.
  • robotresearcher 9y ago
    Of course. We know it can be done since it happens with alacrity at bill time. Why not do it in advance? It could could save the insurers money as well as the patient if the patient chooses the less expensive option.
• snuxoll 9y ago
  The problem is there is a bunch of hidden complexity in medical coding and billing. There's 5 Evaluation & Maintenance (E&M) codes that may apply to an office visit, another 5 for ER visits, 4 for tele-medicine consults - which one is used depends on multiple factors that you can only know after the fact, and which one is applicable to the visit determines the expense. This doesn't factor in other procedures such as labs, and whether such charges are required to be bundled into the E&M fee by a specific payer or not - plus differing allowables from each payer. Add in the fact that nearly nobody bothers doing pre-authorizations except surgery centers and other outpatient services that payers require prior authorization for anyway and the whole situation turns into a giant clusterfuck. Is it POSSIBLE to do all of this and give you a proper quote before a visit? Sure, but it requires some fairly complex software to do so and manual input of tons of different data specific to your insurance contract that almost nobody wants to do it (ironically, the billing company I work for DOES this - but since we aren't involved in patient care it's only utilized to ensure we get paid properly by insurance companies).
  • tyingq 9y ago
    Even with a line item precoded estimate, it would require some negotiation between what the doctor/lab thinks it costs versus what the insurance thinks. Doctors/Labs are often surprised after the fact by what the insurance company allows, thinks is miscoded, will pay, etc.
  • amerkhalid 9y ago
    However, most hospitals don't enforce any requirements of "codes" or there are bunch of inter-changeable codes. If you get a bill from hospital, you can call billing department, ask them if they can try a different code to bill insurance company. And it is possible new code will lower your out of pocket cost. On few occasions I did this, I end up owing nothing out of pocket.
  • flubert 9y ago
    >Sure, but it requires some fairly complex software to do so and manual input of tons of different data specific to your insurance contract that almost nobody wants to do it Can someone quantify the value added by having this complexity baked into the system? Is there any advantage besides the "confusopoly" aspect? https://en.wikipedia.org/wiki/Confusopoly https://en.wikipedia.org/wiki/Confusopoly Who is the main benefactor (in $$$) behind the drive for complication of medical billing? Doctors? Medical Office Receptionists? Insurance companies? Other third parties that doctors hire to handle paperwork? What are the benefits supposed to be over whatever we were using in 1975? If you were founding a clinic on Mars for the first colony, would anyone duplicate our current system of medical billing?
• Mz 9y ago
  You might consider looking into Direct Primary Care. It is growing in popularity in the US. Here is a quick and dirty overview: http://micheleincalifornia.blogspot.com/2017/01/direct-primary-care.html http://micheleincalifornia.blogspot.com/2017/01/direct-prima...
• sbov 9y ago
  Even ignoring insurance, it can be impossible to get an accurate cash price depending upon the physician. And if they can't figure out the cash price, there is no way in hell they will figure out the insured price. We recently went to a physician who works in an area that regularly isn't covered by insurance. For all procedures, the cash pricing was upfront and understandable. In comparison, we tried to deal with another physician for a different procedure we knew our insurance didn't cover. Literally days worth of time was spent on the phone to try to figure it out and the day of the procedure we were told the prices were wrong and didn't account for some stuff.
• TommyBombadil 9y ago
  You might be interested in something like the Surgery Center of Oklahoma which has an upfront pricing page for their surgery procedures: https://surgerycenterok.com/pricing/ https://surgerycenterok.com/pricing/ Even though the ycombinator blog post is discussing innovation etc with regard to insurance, I like the idea of innovation on the side of service providers. And it is somewhat sad that a list of prices is innovative.
  • dsfyu404ed 9y ago
    Having it all in a list like that leads to some interesting comparisons.
• btilly 9y ago
  Nobody can tell you because nobody knows. And nobody can know. Here is a simple example that my sister (a nurse) gave me yesterday. Suppose that you go in for an operation at the hospital, spend a week recovering, and develop diarrhea on day 2 while you are there. That diarrhea is a "hospital acquired infection" and insurance won't pay a dime for your operation. Therefore until you've been through the hospital, nobody knows whether you'll get paid. Oh right, and the possibility of this happening is a reason for the hospital to kick you out of the hospital as quickly as possible. Average patient outcomes may be better if you stay a week, but their odds of getting paid are better if you're kicked out within 48 hours. This is just the tip of the iceberg. She went on about how broken health care is for an hour...
  • wyldfire 9y ago
    > Nobody can tell you because nobody knows. And nobody can know. That's definitely not the case, because they have to know in order to bill you. To get us back on the same page, let's rescope and consider only elective procedures and primary care. Your example is extraordinary and could be specifically excluded. Even if I got a treatment plan with equivocating language about "risk of procedures / changes / infections / etc" and all that noise at least I could make an informed decision about which treatment plan I think is appropriate. The guff I was sold when we were shoved to high deductible plans a ~decade or so ago was that we could make decisions about our healthcare. They come up with BS estimates or treatment calculators that are from the insurer and not the provider.
    • livingparadox 9y ago
      If you read the very next paragraph, you'll note that they meant that nobody can now know the total costs beforehand. I.e., the total costs often include events that they are unable to reliable predict in advance, so they are unable to give you a reliable or accurate estimate of costs until its all done (which is when billing occurs)
      • ghthor 9y ago
        They could provide mean, median and min/max.
• Spooky23 9y ago
  Because it's sort of like hotels. There's a "rack rate" which is a high price that nobody pays, and a price floor is whatever Medicare pays. (With Hotels, GSA is the "normal" price floor, and cheaper rates are usually wholesale) If you price cheaper than Medicare, you get sued for fraud unless you charge that low cost to Medicare. Everyone else has a bewildering discount scheme. The doctor literally has no idea what you pay. In other cases you have HMOs, where primary care doctors get a monthly nut to take care of you and don't get a fee for service in most cases.
  • wyldfire 9y ago
    > Because it's sort of like hotels. Great example. Ever checkout without an idea of what your hotel bill is going to be? > The doctor literally has no idea what you pay. But if it matters to me, then it should matter to my physician. Most of them will come up with a reasonable response if I tell them "doc, I checked at the pharmacist but I couldn't afford those drugs you prescribed, what else can we do?" Most of them empathize with their patients and come up with an alternate treatment plan if one exists. I don't think it's good enough to say "well gee discounts and providers and algorithms -- math is hard let's surprise you" because somehow they can figure it out at bill-generation time. At the very least, hospitals/physician's offices could produce a "given your insurance + the nature of your chief complaint, this visit will cost $x, these common diagnostics cost $y/z/w."
• fma 9y ago
  It's funny that I can take my car to a mechanic and get a free and pretty accurate diagnosis. But you go to a hospital, and you need pay for the diagnosis and it may not be accurate. Even for a checkup, after the procedures are done, the office can't tell me the bill. ...yet we we call mechanics "wrench monkey" in a demeaning manor. BTW, this is probably why services like Minute Clinic are getting popular...go in, get something done, pay a flat/low fee.
  • pinot 9y ago
    Well the diagnoses for your vehicle come from a 200 page Haynes manual, your body doesn't exactly have a Haynes manual for your make/model/year.
    • jheriko 9y ago
      i think the many books on human anatomy disagree with you by their very existence...
    • fma 9y ago
      How does the complexity of the human body come into play after they've done their procedure and still can't tell me how much I will be paying? Do you take your car to the mechanic, get some work done, only to get a bill 3 months later?