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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

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
      >But there are lots and lots of doctors who's ethics say that steak dinners with drug reps are off limits. There are a lot more that think it's not their job to care about those things. They think they are only responsible for curing the sick regardless of time or money constraints or conflicts of interest. They say they don't do this, especially in regards to money, but talk to all sorts of docs about how much of their patients' time they waste every day and they get real defensive. They think they are owed anything and everything and fuck running an efficient practice, fuck your time because they're a doctor and they are over in a different room performing miracles. The egos in medicine do WAY more harm than good.
      - youdontknowtho 9y ago
        I personally know a bunch of doctors and you are right, they are pretty arrogant. Each one of them is also brilliant. I'm actually pretty close to some of them so in one or two cases I'm biased. They actually have a hard time being "efficient" in the sense that you use the word, because if they don't run every possible test when they miss something and get sued they will have to answer for it. Why are there so many lawsuits? Because the first thing that insurance companies do is lawyer up. I'm not saying that doctors aren't also bastards sometimes, but Americans also think that doctors should deliver healthcare like a retail service and that's just stupid. Your whole "in a different room performing miracles" might actually be running late because they are double booked and behind schedule due to trying to be thorough with an old woman who has compounded issues related to multiple diseases. That woman is also a person, just like you and the doctor might be trying to spend some time trying to help them even though insurance and the shitty clinic they work in only want them to spend 10 minutes with any one patient. That may sound efficient until you need to spend 20 minutes to do something right. Then the schedule is effed the rest of the day and people will act like you are trying to do something to them by being late. Its hard for me to say this, because generally I hate people, but not everything is intended as a slight against you.
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.

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
    >But there are lots and lots of doctors who's ethics say that steak dinners with drug reps are off limits. There are a lot more that think it's not their job to care about those things. They think they are only responsible for curing the sick regardless of time or money constraints or conflicts of interest. They say they don't do this, especially in regards to money, but talk to all sorts of docs about how much of their patients' time they waste every day and they get real defensive. They think they are owed anything and everything and fuck running an efficient practice, fuck your time because they're a doctor and they are over in a different room performing miracles. The egos in medicine do WAY more harm than good.
    - youdontknowtho 9y ago
      I personally know a bunch of doctors and you are right, they are pretty arrogant. Each one of them is also brilliant. I'm actually pretty close to some of them so in one or two cases I'm biased. They actually have a hard time being "efficient" in the sense that you use the word, because if they don't run every possible test when they miss something and get sued they will have to answer for it. Why are there so many lawsuits? Because the first thing that insurance companies do is lawyer up. I'm not saying that doctors aren't also bastards sometimes, but Americans also think that doctors should deliver healthcare like a retail service and that's just stupid. Your whole "in a different room performing miracles" might actually be running late because they are double booked and behind schedule due to trying to be thorough with an old woman who has compounded issues related to multiple diseases. That woman is also a person, just like you and the doctor might be trying to spend some time trying to help them even though insurance and the shitty clinic they work in only want them to spend 10 minutes with any one patient. That may sound efficient until you need to spend 20 minutes to do something right. Then the schedule is effed the rest of the day and people will act like you are trying to do something to them by being late. Its hard for me to say this, because generally I hate people, but not everything is intended as a slight against you.

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.