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What Happens When Doctors Only Take Cash (2017)
- Feniks 9y agoThat would be a problem, I can't even withdraw more than €1000 from an ATM. Most of my transactions are plastic or digital, like 99%.
- jethro_tell 9y agoYou should maybe read the article then since it's about something else.
- cmurf 9y agoPretty sure they can take a debit card, which even in the U.S. is a chip + PIN transaction, with a minimal transaction fee rather than the substantial percentage applied to credit card transactions. Anyway, by cash they mean full payment now, rather than invoiced to an insurance company.
- jdpedrie 9y ago"Paying cash" in this context doesn't mean a briefcase full of $100 bills. It means direct payment from the consumer to the provider. That direct payment could be in the form of a check or credit card.
- sjsbsh 9y agoGo to a bank and they’ll give you significantly more money than 1000 euros. At a certain point you’ll be expected to explain what you need the money for (anti-laundry efforts). For safety reasons, you might not want to carry around cash. So banks provide cash-like instruments that are safer to walk around with. Also, often “cash only” includes debit cards. In which case you debit card limit is probably an order of magnitude higher than your daily withdrawal limit. Finally, do what I’d do as a poor grad student unwilling to pay bank fees: start withdrawing a week in advance ;)
- gwern 9y ago"Cash" here means 'not wacky insurance schemes'. Their FAQ says "To keep our prices as low as possible, cashier’s checks or cash are the methods preferred. Credit cards are accepted on a case by case basis. Human resource departments or divisions of self-insured companies can make other arrangements if necessary." (They also have a partnership with some sort of personal loan/financing company which presumably would take credit cards or bank transfers.)
- astura 9y agoIt would be silly for a doctors office to accept only suitcases full of $100 bills, not only would that be highly impractical for both parties, it would make them a prime target for robbery so they'd have to invest a ton in physical security. "Cash only" means "not insurance claims" in this context - usually when you go to the doctor you give them your insurance information and your expected copay the doctor (actually their admin staff) then submits a claim to your insurance company for payment. If the company doesn't pay, or pays less than expected, they will bill you. Large "cash" transactions aren't a problem. Multi thousands of dollars+ "cash" transactions are done all the time (such as a down payment on a house), you go to the bank and get a cashier's check. There's no reason you couldn't take out cash instead of getting a cashier's check, but it wouldn't be secure or practical. And your payee may have an issue with accepting physical cash from a risk perspective.
- SQL2219 9y agoNeed surgery? Here are the prices: https://surgerycenterok.com/pricing/ https://surgerycenterok.com/pricing/
- maxxxxx 9y agoA price list like this should be mandatory for all doctors.
- killjoywashere 9y agoShould software developers and lawyers also have upfront pricelists for all services? I will gladly develop a cure for cancer, for the low, low price of $20B.
- maxxxxx 9y agoWhen I hire a software developer or a lawyer I get an upfront price list. Would you hire a lawyer that either would not give you any price or told you "it costs between 2000 and 60000 depending on your insurance and some other factors we won't tell you"?
- killjoywashere 9y agoThe difference is law, software, car repair, home remodels, etc, are all man-made systems. Medicine is dealing with a system that I think we can all agree man did not make.
- maxxxxx 9y agoA hospital is a very man made system and most tools they use are man made too. Most procedures are pretty standard too. There is no reason that they can't publish numbers other than that it's beneficial to them to keep them secret. Insurances have these numbers too but they don't want to publish them either. Everybody knows the pricing, the only participant being kept in the dark is the customer, aka patient who eventually has to pay.
- grawprog 9y agoBahahahahahah oh my fucking god $19,000 for a surgery. Holy fuck. God and that's supposed to be the cheap reasonable choice. Holy shit. God I love living in a country where if I need a knee replacement I go to the hospital and they do it and then I walk out and the healthcare I pay less than $100 a month for covers it. Sure am glad I don't live in some third world shithole like the one described in the article.
- dukoid 9y agoI think it's an important reminder that markets need some level of transparency to function. And perhaps that relatively simple regulation (like a requirement to publish the prices -- or in other areas the first sale doctrine) might be the best regulation where feasible....
- conanbatt 9y agoThis is a very interesting case, but I'd be cautious about it. Its not that the surgery that costs 60k, will cost 16k if you don't have administrative staff. Its true administration is a huge expense, but I doubt it can make medical care cost 1/4. Also healthcare services can never be "all round service" because any complication could mean a million things from scans to medication. Even on primary care you cant really promise to give 100% service for a fixed fee without ending up working like an insurance.
- crpatino 9y agoIt is not as if the extra $44K goes all to the admin's payroll. Rather, if you have more personnel, it means you are running a bigger, more complex operation. That demands larger facilities, more equipment, a wider range of skills in your workforce, etc, and that all costs money. Furthermore, given that all those things require heavier capital investments, it makes less likely that the surgeon performing the surgery is a (partial) owner of the hospital itself, but rather a highly compensated employee. There is a double-bite effect there: 1. The doctor's interest is less alligned with that of the hospital, so he will demand higher compensation for the same amount of work, at least of there's enough scarcity of doctors to justify it. 2. The capitalist owner will naturally expect a return of investment. It is subtle, but in this case the expected profit is proportional to the total capital investment, not the number of hours/services provided.
- prostoalex 9y agoHospital chargemasters are required to be public in California https://www.oshpd.ca.gov/Chargemaster/ https://www.oshpd.ca.gov/Chargemaster/ Unfortunately, 1) The price agreements between hospitals and insurance companies are confidential, as both sides compete in their own industry and don't want to reveal their hands. 2) Consequently, chargemasters post some ridiculous price per procedure (with discounts available, naturally, to insurance carriers, who are the bulk buyers in the business). Which makes chargemasters similar to list prices you see at most retail establishments - only schmucks are expected to pay those.
- DoreenMichele 9y agoSince their surgery center does not employ the army of administrators that is often required to haggle with insurers and follow up on Medicare reimbursements, their overhead is smaller. This is part of why Obamacare is fundamentally broken. Using the existing commercial insurance system to try to provide universal coverage injects unavoidable extra expense and complications. Really happy to hear about the trend the article is describing.
- killjoywashere 9y agoThis may work for chronic conditions and non-lethal problems, but creates a problem when you're talking about urgent care: stroke has a 2-3 hour window for administration of TPA. The goal for intervention in a myocardial infarction is under an hour, same for trauma, where people may be in the ICU for days to months (a lot of months). Who covers those costs?
- Turing_Machine 9y agoEvery insurance company in the United States, along with Medicare and Medicaid, already has a fixed amount that they will pay the caregiver for administration of TPA. I guarantee it, even without bothering to look up what TPA is. If the procedure is covered by insurance at all, there's a pre-approved reimbursement amount for doing it. Outside of an expensive, time-consuming, and almost always useless appeals process, that flat rate is all the doctors are going to get. They can take it or leave it. There are medical codes for every imaginable procedure, and essentially every medical code has a fixed, preset amount that the insurance company will pay to have it performed.
- killjoywashere 9y agoI get that. Do you know the history of the CMS billing schedules? They called Dr. DeBakey and he sent a couple of his fellows to Washinton and they priced out every single thing. That has been revised, amended, and addended many times since, but yes, I'm well aware. The point is that there's no shopping around in the emergent cases. You can't say "Well, in my incapacitated, mid-stroke state, let me check the menu of the 3 nearest hospitals for the cost of a stroke admission." It ranges from "nothing to do here, looks like it was a TIA, patient demands to go home" to "We need to take your wife to the OR for an emergent craniotomy and clot removal to decompress the foramen of Monroe. Right now. Because minutes are brain cells."
- kolbe 9y agoI like that they take responsibility for complications. Instead of shoddy work being an opportunity for future revenue like with the rest of the system, it's an actual disincentive.
- asmithmd1 9y agoCash payments don't count toward a patient's (insurance) deductible This seems like a problem. How is this not an anti-trust violation? In order to benefit from the insurance contact you purchased, you must use a provider who will submit to an insurance company's capricious payment system.
- ksenzee 9y agoThis is probably a simplification. Normally if you use an out-of-network provider, the cost counts against your out-of-network deductible, which is significantly higher than your in-network deductible. So it may well be that his insurance would count this against his out-of-network deductible, which is so high that he would never reach it anyway.
- javadocmd 9y agoNo. In order to utilize your insurance plan's out-of-network services, the insurance company has to be in the loop. A cash-based system completely circumvents insurance.
- ksenzee 9y agoRight, you certainly have to loop in your insurance company, by filing a claim (which they won't pay, obviously).
- qubex 9y ago> Setting and casting a basic leg Oh good God, I’d never thought of this... I’ve broken more bones than I care to count (wrist, triple torsion fracture in my ankle, two ribs twice, shoulder) and I’ve never paid a penny (here in Italy). I’d never even remotely contemplated it might be a cost beyond the annoyance.
- t3rmi 9y agoHow does one break so many bones?
- Giacomot 9y agoFree healthcare is a great incentive to be careless with your body. /s* edit: I was being sarcastic
- qubex 9y agoYou're getting voted down but you might actually be right... if I had ever suspected this I wouldn’t even leave the house.
- qubex 9y agoI see you're being voted down but you might actually be right... if I feared that kind of monetary consequence I'd never walk out the door.
- berbec 9y agoI walk around fully aware I am one slip and fall away from inescapable, permanent financial ruin. I have insurance, but my $8,000 deductible means if I break my leg falling down a flight of stairs, I'll be in bankruptcy court once the cast comes off.
- Pokepokalypse 9y agoyes: only people who are wealthy enough to pay out of pocket for emergency medical treatment, should ever go skiing, or ride a bike, or even drive their car to work.
- linsomniac 9y agoMy local mechanic is required by law to tell me how much something is going to cost me before they start work. Why is my doctor not held to the same standard. Ever tried calling a provider to find out how much something is going to cost? Sounds like the medical industry had better lobbyists.
- sethammons 9y agoHeh. I have tried to call to see the cost. I see a retina specialist twice a year. I recently changed to a high deductible plan with an HSA. I called to see what the cost of my appointment would be. They could not or would not tell me. Incall three separate times, talking to different people and different departments. I went in and continued asking the front desk. "It depends on the services you end up getting." Ok, sure, but for a standard appointment, what then? "I can't say." Listen lady, I'm looking for a ball park. $50? $100? $1000? $5000? "Oh, I can't imagine it will be that much." Which one? "We will have to just bill you after." So absolutely frustrating. It ended up being like $150. Without price transparency like a public menu, we won't get better.
- maxxxxx 9y agoThe same happened to me when I had an HSA. Estimated price for a procedure was first $4000, then $2000, then $100. Eventually paid $500. they just seem to make up prices.
- inopinatus 9y agoAs the anecdotes offered in these threads illustrate, it is not possible to cost or value healthcare on an individual basis. Therefore, any market for individual purchase of healthcare (whether via insurance or directly) can only have faulty price signals. Systems based on markets with faulty price signals are wide open to manipulation. The perpetuation of such markets is contemptible, and particularly so in the case of healthcare since there is a straight line to be drawn from dysfunctional systems to human suffering.
- jjeaff 9y ago
- killjoywashere 9y agoThis whole thread is full of young, SV libertarians who haven't really thought out what healthcare involves. Lawyers don't have an upfront, all inclusive price for divorce, they charge by the hour. I'm pretty sure software developers charge by the hour, at least for the interesting work. Sure, I'll build you a Wordpress blog for $3k. Would you gaurantee you could build a clinic website that supports major insurance and Medicaid and Medicare billing for a fixed rate? Not knowing the physician's speciality or state of practice? C'mon. Orthopods might be able to replace knees on a fixed budget, but I'm thinking neurosurgeons and trauma surgeons would have a heckuva time. What about a dermatologist? Mole, sure? What if it's melanoma? What if you have mycosis fungoides? It'll take 5 years just to confidently diagnose.
- Jemmeh 9y agoThere's some things that definitely are going to be uncertain, but there are a -lot- of procedures that could be given a price tag. I can't even get info like, "How much will it cost to have an ultrasound? Not doing anything after that, but just for the ultrasound itself?" I've had somewhat similar issue with getting bloodwork done too. A lot of stuff can be broken down into smaller parts and put a price tag on that. Sure, it might take 5 years to diagnose, but that can be broken down into (5 hrs with doctor examination, 10 bloodwork tests with XYZ factors, 4 checkups, 10 months of X pill, etc). Unfortunately it's not that simple, the hospital doesn't want to charge everyone the same amount. They want to get the most they can out of everyone. Insurance companies want to pay less. Government laws get thrown in. There's a lot of issues with healthcare but knowing the general actual cost of standard procedures isn't one of the big problems. That's worked down to an art, after all insurance companies have to estimate that cost.
- rvail2 9y agoWhat about a dermatologist? An appointment has a set fee. If you need treatment for something out of the ordinary, they give you options and prices. Then, you get to decide on how you proceed. Seems pretty simple.
- killjoywashere 9y ago
- friedButter 9y ago> If unforeseen complications arose during or after the procedure, the Surgery Center would cover those costs Doesnt this expose the facility to additional risk? Overall healthy patients and those with sufficient insurance coverage do not have a reason to visit this place, while those without insurance coverage (who I assume are likely to be less healthy and hence have more complications) are more likely to visit the place. If instead they accepted insurance, and charged people based on complications, they would have a more average risk profile while being able to maintain higher profits, and keeping a USP of transparent charges (which would apply to non insurance patients w/o complications)
- harrisreynolds 9y agoI've been wondering for a while now why health insurance companies exist at all. They introduce a massive bureaucracy and massive costs and provide very little value. They evolved from a reasonable idea into a monster that just drains our system and do not provide enough value to justify their existence in my opinion.
- Buttons840 9y agoYeah. I've worked a few places in the healthcare industry, and I've always felt that I'm part of some ancillary service that would be better if regulated and automated. For healthcare to get cheaper the system must be made smaller, people will have to find new jobs.
- conanbatt 9y agoAnd yet, health insurance companies have very low profit margins, the lowest amongst the insurance companies. So who is getting all the money?
- wu-ikkyu 9y agoPharmaceuticals
- conanbatt 9y agoding ding ding. These ones take most of the share. It is quite incredible that the U.S., the symbol of freedom, can't freely import drugs from abroad. Considering the rampant use of pharma specially, dropping the costs 1/2 of meds would lower the cost of healthcare overnight by an enormous amount.
- tmnvix 9y agoYep. An interesting bit of data that highlights just how profitable this industry can be comes from the wikipedia page for McKesson Corporation[1]: > On June 24, 2013, The Wall Street Journal reported that McKesson Chairman and CEO John Hammergren's pension benefits of $159 million had set a record for "the largest pension on file for a current executive of a public company, and almost certainly the largest ever in corporate America." A study in 2012 by GMI Ratings, which tracks executive pay, found that 60% of CEOs at S&P 500 companies have pensions, and their value averages $11.5 million. [1] https://en.wikipedia.org/wiki/McKesson_Corporation https://en.wikipedia.org/wiki/McKesson_Corporation
- expertentipp 9y agoI've seen similar trends in post-Communist EU countries. We are importing the worst patterns from US. Public health insurance is most of the times miserable.
- tmnvix 9y ago> Public health insurance is most of the times miserable. I expect that your statement is about public health insurance in post-communist EU countries (I have no experience of this). Public health insurance in Australasia is very good (though has arguably been better in the past in some senses and could obviously be better in the future).
- achanda358 9y agoInterestingly, all-inclusive medical packages have been very common in India since last 10-15 years.
- otakucode 9y agoYou son has broken his arm. The doctors in your town will only take cash. One of the doctors charges $50 to set the broken arm. The other doctor charges $500. Which one are you going to take your child to? Most likely, the $500 one. Because going to the bargain basement doctor is not something you do when dealing with medical issues if there is absolutely any way to afford it. It creates what I call 'reverse capitalism.' You can only draw more customers by charging the highest price in the area. If your customers stop even being the ones footing the bill, it accelerates to a patently insane level. That makes footing peoples insurance bills a ludicrous and idiotic business to get into. Unless, of course, you've got protection from the government or special considerations where antitrust laws do not apply to you so you can engage in price-fixing, intimidation, and other tactics. Made to compete fairly, medical insurance companies would be out of business overnight because it's a downright stupid business to begin with.
- conanbatt 9y agoI don't think thats true. There is a price bias, but thats not the only quality signal for medical care. There's reviews, facility and installations, reputation, etc. People are price sensitive regarding their own life and their children's. You can find how much they value things with "revealed preferences", an economists principle. Its a bigger problem that as a consumer you don't have to or face the decision of choosing by price, eliminating marketing mechanics from healthcare.
- SpikeDad 9y ago"Little Billy - would you mind biting on a bullet for an hour while I check Yelp and online reviews to find the cheapest doctor to set your broken arm." ...said no one ever.
- conanbatt 9y ago"No time to look for the closest hospital, we need to drive straight to the one I know thats 1h away, lets go". Also, most care is not urgent care.
- 9y ago
- mrfusion 9y agoWhat about making a website people can enter the price of past procedures, their insurance plan and note where it was done. Then you could help people comparison shop before hand by showing typical prices.
- serichsen 9y agoFrom my german perspective, every assumption in this article looks quite gross and barbaric. Here, everyone is insured. If you break your arm, you get it fixed. If you get cancer, you get therapy. If you get the flu, you get a prescription. The overall cost is paid by the entire population, through the insurance system. For what is the alternative? Maybe the overall monetary cost would be lower if everyone had to watch the price, but you would pay for it in human lives and suffering, when people have to decide between dying of illness or dying of hunger, or between lifelong pain or clothes for their children.
- FLGMwt 9y agoAs an American working in healthcare tech: it is absolutely barbaric. We have the most expensive medicine in the world, but it's all treatment, not prevention and both only for those who can afford it.
- tomohawk 9y agoFrom my American perspective, the national health systems of other countries have their own barbarities. There is a reason why so many people from other countries come to the US for health care. When I was looking to have a very serious health problem taken care of, I heavily researched getting the procedure done anywhere in the world. It was pretty obvious that all the best places to have it done were in the US. The facility we went to had quite a few patients from other countries - and we're not talking 3rd world countries. Many of these patients had already had care in their own country, where the care was botched or insufficient. They were coming to the US to get it done right. On their own dime. Not sure how Germany is, but average wait time for an MRI in Canada is over 10 weeks. https://www.fraserinstitute.org/studies/waiting-your-turn-wait-times-for-health-care-in-canada-2015-report https://www.fraserinstitute.org/studies/waiting-your-turn-wa... In the US you can go right into an MRI on the same day. This is key to getting an appropriate standard of care. In Canada, average wait time for an ultrasound is 4 weeks. Our pets get better care in the US. I really don't see how people tolerate such things.
- qubex 9y agoIn northern Italy‘ve gone ”right into” an MRI with the public health system twice (once when I had a migraine aurea of incredible intensity with visual hallucinations and disorientation) and another time when I had smashed up my ankle so badly they needed to figure out the effect on the soft tissues after a bunch of X-rays in the broken bones. There’s a lot of myths about queues and waiting times (in my experience at least). When I was in the UK (of which I am also a citizen) while studying in very early 2000s I had slightly longer waiting times for specialist visits (allergy specialist, and then a dermatologist) but certainly not the kind of waiting times I hear tossed around now (on the order of a couple of weeks, tops).
- bawana 9y agoWe could adopt two simple precepts from this example of private enterprise. transparency and consistency. If this were applied to our healthcare system pricing would fix a lot.
- WillReplyfFood 9y agoMan you guys have to be busy beavers for this. Cheers frome europe.
- tomohawk 9y agoSuch a novel concept that when we seek to provide health care, we actually pay for care instead of insurance. Rand Paul made a similar case last summer that if the government is seeking to to provide care for people who can't afford it, it should put the money into care instead of into insurance companies. It would be much cheaper an much more effective. Note that if you go to the highlighted facility, you can still contact your insurance to pay for the procedure - its just that the doctors in this case are not doing that for you. I've never understood why doctors involved themselves in dealing with insurance companies. It's the patient's company, so the patient should deal with it. If more doctors did this, patients would realize that the real problem is the insurance companies. Market forces might even cause insurance companies to provide better service.
- erroneousfunk 9y ago"If unforeseen complications arose during or after the procedure, the Surgery Center would cover those costs. Villa wouldn't see another bill." So there is a sort of built-in insurance to this system. Those who don't have any complications are paying more to cover patients who do. They're simply passing the first line of medical costs (known, anticipated, where a price estimate can be created) on to consumers while letting insurance handle un-estimatable medical emergency type situations.