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What I learned from reading a thousand emergency room bills

424 points by jedwhite 8y ago

sparrish 8y ago
"The prices are high — even for things you can buy in a drugstore" Reminds me of the brief hospital visit I had in Paraguay where I needed to have a friend or relative always with me because the hospital didn't stock anything. If ibuprofen, bandages, syringes, antibiotics, etc were needed, the hospital staff would tell me and I would have my friend or relative run across the street to buy the necessary supplies from one of the pharmacies so the doctor or nurse could treat me. Cheap hospital bill, cheap pharmacy bill, pain in the butt for my friends and relatives.
lolsal 8y ago
I know $60 Ibuprofen can seem like a lot, but is anyone arguing that you're literally paying for only the pill(s) with that $60? Aren't you paying for the instant availability, the insurance that it's not expired (do they even expire? I really don't know), and confidence that your healthcare provider has signed off that XXX mg of Ibuprofen is a.) OK to have with your current medications and conditions and b.) sufficient to do the job? Isn't some of that cost the healthcare provider's expertise and service? Would it be better if they prescribed morphine and charged you a magnitude more when ibuprofen would have done the job? I charge clients similarly. I overbid projects that I don't really want to do. If you want me to setup Wordpress for you, I'll charge you out the nose. Granted, you get to accept my fees before I ever send you a bill. It's not a perfect analogy. > This is all due to the key fee I’ve been investigating this year: the ER facility fee. This is the fee that ERs charge for walking in the door and seeking care, something akin to a cover charge at a bar. This seems absolutely reasonable to me, I wish I could charge a 'fill my email with RFPs' type fees. Walking into a waiting room, signing in and waiting is not nothing. You and your symptoms get evaluated and triaged. That takes expertise and know-how. The prices vary wildly because different hospitals experience different levels of demand, I imagine.
- corybrown 8y ago
  > I charge clients similarly. I overbid projects that I don't really want to do. If you want me to setup Wordpress for you, I'll charge you out the nose. Granted, you get to accept my fees before I ever send you a bill. It's not a perfect analogy. One can always forgo setting up WordPress, which is not always the case with healthcare.
  - lolsal 8y ago
    Totally understood; that's one of the ways that it's not a perfect analogy. Conversely if someone told me to setup Wordpress and that I could only charge $50, I'd change industries in a heartbeat.
- scrollaway 8y ago
  > Isn't some of that cost the healthcare provider's expertise and service? In theory maybe. Usually I would say these things are not exactly top priority and you are not getting your money's worth in the premium there. At best, of your list, you're paying for the instant availability, but what about the times where it's not instantly available? You're not paying for a guarantee of it.
- mikeash 8y ago
  I'm guessing you tell your clients, "I'm not really the right person to set up WordPress for you. I can do it, but it'll be incredibly expensive. You can probably do it yourself with a good online tutorial." Hospitals aren't telling their patients, "We're not really the right institution to give you ibuprofen. We can do it if you really want us to, but it'll be incredibly expensive. You can just go buy some at the store for like ten cents." In fact, I bet that even if you have the presence of mind to decline their ibuprofen because you'd rather get your own, they'll strenuously argue against it, or even start treating you as not following medical orders. In any case, it would be a lot more palatable if they'd charge marginal costs for marginal items, and charge overhead separately. It may well cost them something on the order of $60 to give someone ibuprofen, on average, but it does not cost them $60 more to give one more person ibuprofen. It would be more honest to charge two cents for the pill, and separately charge your fair share of the cost of the staff that obtains, vets, distributes, and administers that pill along with everything else you're getting.
AngeloAnolin 8y ago
Reading this article and seeing all the startups sprouting in the field of health care and medicine tells me that there's still a lot more areas to innovate and disrupt in this industry. One big issue though are that lobbyists who wanted to keep prices high - to squeeze in as much profit as they can out of these. Drugs, Antibiotics, Procedures, Medical Professionals. I know it would be far-fetched to standardize and at least provide some level of transparency across all facets of operation in this field, but that would be a good start. Analyze the data, and find ways where things can be improved incrementally.
- davidw 8y ago
  One way to disrupt the industry might be to have everyone be in one giant insurance pool, perhaps paid for via taxes, and then give everyone access to health care via some kind of non-profit entity. Sounds crazy, right? It worked well for my family and I during the many years I spent in Italy, which has health care costs that are something like half of what they are in the US in terms of GDP.
  - AngeloAnolin 8y ago
    This is the same in Canada - universal health care administered in each province. Although I seemed to have noticed a lot of increase as well in terms of pricing and services. There's just really no cure for an appetite of greed.
  - normal_man 8y ago
    Yup, it's worked nearly all over the modern world, for years and years. The last thing I want in healthcare is more startup maniacs trying to "disrupt and innovate" when there is a clearly viable alternative.
- ryandrake 8y ago
  All this value being captured by middlemen “sprouting” up could also simply mean more money out of the pockets of healthcare customers, who already are going bankrupt paying for all of this inefficiency. The US healthcare industry is a raging river of money coming directly out of the wallets of consumers who have little choice. Not surprising that it attracts middlemen with spoons ready to dip into the river.
ams6110 8y ago
I'm not an advocate of government paid health care, but hospitals and medical providers should see that this train is coming and if they don't become more transparent it's going to be forced upon them. I don't have a problem with ER care being more expensive -- that isn't necessarily unreasonable when you are getting care in an expensive facility open 24x7, fitted out with equipment to handle any possible medical emergency, and staffed with highly educated people who make a lot of money. But it is unfair to have no idea what costs you are facing and whether any of those costs are out of network on your insurance.
- ttcbj 8y ago
  I was not an advocate for gov't health care, but I am now for the same reason you stated. I have a high deductible plan, and have tried to get quotes in advance, but never can. I have been ripped off multiple times, despite trying to do my research, etc. My wife is a doctor, and at this point, I think single-payer is the least bad option.
  - SlowRobotAhead 8y ago
    >have tried to get quotes in advance, but never can. >I have been ripped off multiple times, >I think single-payer is the least bad option. Can you help me understand why if everyone is paying for everyone's healthcare in a socialize system - how that reforms the transparency and stops the abuses?
    - ryanobjc 8y ago
      The presumption that competition between doctors and hospitals will create lower prices has not come to fruition. Individuals have no leverage or ability to make meaningful choices. There is no real healthcare market as a result. In a larger system, we get lower prices via several mechanisms: - Preventative care replacing ER care due to universal coverage - Larger risk pool lowers per-participant costs - Single payer has more leverage and depth of time/knowledge to regulate/negotiate with individual hospitals The reality of a competitive landscape, hand of market, etc, that just didn't happen.
codemusings 8y ago
Despite the fact that in my opinion this could be fixed by Universal Healthcare I'm left wondering: how is it legal to be billed these insane amounts of money without even getting a quote beforehand? Like just waiting in the ER is worth more than buying a first class airplane ticket and getting treated in another country.
- serg_chernata 8y ago
  > without even getting a quote beforehand Reminds me of this really good article. TLDR: Man tried to call a number of hospitals to find out how much childbirth is going to cost him and received no answers. https://www.vox.com/2016/5/5/11591592/birth-cost-hospital-bills https://www.vox.com/2016/5/5/11591592/birth-cost-hospital-bi...
  - davio 8y ago
    I like the disconnect between this reality and the "consumer driven health plans" being offered by employers
  - manfredo 8y ago
    Realistically, no hospital is going to give out a price. They don't know what unexpected complication may arise that requires additional services.
    - maxxxxx 8y ago
      They have nice pricing tables for insurances,. Just not for patients. Even unexpected complications will have a billing code but the prices are kept secret.
      - manfredo 8y ago
        Insurance companies are very different types of customers than uninsured patients. They're effectively averaging their price over a large number of patients. Most are probably slightly more expensive than necessary, but that difference helps subsidize those that experience complications. Furthermore, individual patients fail to pay at a much higher rate so that is reflected in the cost as well. A hospital can't just give the "insurance price" to uninsured patients as this may put them underwater.
edoo 8y ago
Health care is the only industry where the felony laws regarding up front pricing aren't enforced. It was allowed to become a twisted regulatory nightmare where the laws were written by the industry itself utilizing kneejerk methods to obtain profit at the cost of systemic corruption.
- merpnderp 8y ago
  And yet it is by far the most regulated industry in the US. Almost as if the more invasive the regulations the more invasive the corruption.
  - edoo 8y ago
    It takes a while to realize nearly every law is anti-competition protectionism. I didn't realize it until I was working for a multinational food company and the managers were bragging about how the company lobbied for a safety bill that exactly regulated their own industry in a way that cost their competitors billions in compliance fees. They were proud of it. I was disgusted.
    - asdff 8y ago
      Disgusting, but know that there are good regulations—like environmental protections—that are frequently combatted by industry groups and tend to get weakened by the Republicans before they pass into law. Regulation can be abused by industry and corrupt politicians for anticompetitive reasons, but most of the time, it's to force companies from doing highly profitable things that aren't good for people or the planet; its much cheaper to just dump all your hazardous waste into the river, after all.
  - AlexandrB 8y ago
    This is a non-sequitur. For something like emergency care, where the choice can literally be "pay up or die", a private provider has every incentive/opportunity to charge outrageous fees. Because what are you going to do? Tell the heart attack to wait while you find another provider? The price-opacity may be a product of regulation, but the prices themselves are free market capitalism working as intended. For another example of the same, consider the recent reporting on collusion between generic drug companies[1]. When you can't refuse to buy the product, the vendor has a ton of power to set prices as they wish. [1] https://www.wsj.com/articles/generic-drug-makers-shares-drop-on-report-of-possible-probe-1478209036 https://www.wsj.com/articles/generic-drug-makers-shares-drop...
vec 8y ago
Exhibit A for why "free market healthcare" is an oxymoron. I have yet to hear a coherent explanation for how anyone can reasonably expect for price discovery to even pretend to function in a market where the consumers can't even guess the prices until after they've already purchased and frequently couldn't reasonably be expected to refuse service even if they did believe it was overpriced.
- deleted 8y ago
  [deleted]
- UnpossibleJim 8y ago
  Exactly. It's the same reason we don't have free market police and fire services. You simply don't get to "shop around" for emergency services, which includes privatized ambulance services (which are outrageously expensive, on the order of $12,000 for the ride I took when I had to take one, and it was a relatively benign one... thank god I had insurance). EMS is covered, but that's the Fire Department. After that, it's all privatized. If it's cosmetic, then I could see the argument. But when it comes to emergency services, and for ambulances especially, the "free market" argument just doesn't hold water.
  - cabaalis 8y ago
    > You simply don't get to "shop around" for emergency services You do actually, by where you choose to live and also by the services as detailed in [1]. I think there's merit to investigating public health care. That line stops for me in eliminating private care. 1] https://www.theatlantic.com/technology/archive/2018/11/kim-kardashian-kanye-west-history-private-firefighting/575887/ https://www.theatlantic.com/technology/archive/2018/11/kim-k...
    - neurotrace 8y ago
      A lot of people don't get much choice in where they live.
      - 8y ago
deleted 8y ago
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lolsal 8y ago
I wonder what healthcare bills would look like if they were itemized so that things like Ibuprofen were literally billed at cost ($0.25 per?) and there were line items for services/labor that captured the real cost of being a medical professional: - Emergency room wait: $0.10 for lights - OTC eyedrops (4 drops): $0.20 - Triage by on-duty nurse: $100 (@ $300/hr) - Consult by on-duty physician: $220 (@ $600/hr) - Late-night convenience fee: $100 (between 7pm and 7am) etc. I made up all the numbers, I have no idea how healthcare professionals calculate their hourly rate.
- pessimizer 8y ago
  It would look like they should pay their nurses a lot more, according to this bill.
- newyankee 8y ago
  Isn't there something like generally accepted accounting principles in healthcare ? Genuine question if anyone knows the answer.
  - wyldfire 8y ago
    IIUC, much of healthcare billing in the US is governed by discrete codes for services performed. I suspect this allows big customers like Federal Gov't & insurers to audit bills easier. In order to either be more specific about the bills or allow less wiggle room, they made these codes remarkably more specific recently (ICD-10 [1]). IMO the descriptions of the items in these codes are humorously specific. Imagine if your auto mechanic got $650/hr for labor, I suppose you would get much more specific invoices for their work too. [1] https://en.wikipedia.org/wiki/ICD-10 https://en.wikipedia.org/wiki/ICD-10
    - newyankee 8y ago
      Interesting. Well the thing is if people really are motivated enough they will always find a way to skirt certain types of regulations.
- 8y ago
kevin_b_er 8y ago
> I started my project focused on one specific charge: the facility fee. I found this charge for walking through an emergency room’s doors could be as low as $533 or well over $3,000, depending on which hospital a patient visited and how severe her case was. I also learned that the price of this charge had skyrocketed in recent years, increasing much faster than other medical prices for no clear reason. Is this why my local hospitals are advertising their ER wait times? The arbitrary profit from arbitrary "in the door" fees?
y-c-o-m-b 8y ago
I was a victim of the surprise out of network bill in the Portland, OR area. I did all my research before hand: hospital in network, surgeon in network, etc. but ONE person in that operating room was not in network and SURPRISE i'm out thousands of dollars. The worst part about this is my state passed a bill to stop this prior to my surgery, but the bill's effective date was roughly 3 months later. Talk about bad timing.
- sjg007 8y ago
  You can try to appeal it.
  - y-c-o-m-b 8y ago
    Appealed twice and both times they denied it stating I didn't require the surgery despite the fact they pre-approved it and paid for all the in-network costs. I ended up paying it because I had the money and I couldn't handle the stress of a legal battle (which given what I've read is an uphill battle).
    - sjg007 8y ago
      Sorry to hear that.. you can usually appeal up the food chain sometimes.. e.g. to your states insurance department if the plan is regulated by your state. And at the Federal level you can also submit a ERISA appeal. None of it is fun and then there are deadlines... Also if you are on an employer provided insurance plan, you can talk to your HR who will have an insurance rep who can sometimes make these things go away e.g. get them paid. If you are at a large employer that self insures and uses a third party admin (like Cigna) then they can tell the admin to negotiate with the doctor/hospital and pay it.
- wycy 8y ago
  From what I understand (which is honestly not much), I think in cases like this you can contact the hospital and just insist on paying the same amount your insurance would have paid, and they'll often take it. That's just what I hear, though.
BenMorganIO 8y ago
This title should be updated to state it is only in regards to the United States and not relevant for Canadians, Australians, etc.
amriksohata 8y ago
Brit here, thank God for the NHS
- quickthrower2 8y ago
  +1. Moved from UK to Australia and it is very similar here too in that most medical care is free. One difference is that the ambulance service charges for residents, and usually it is reasonable priced (but not cheap) but if it turns out you need a helicopter the bill can be quite large! But insurance covers it. For most professionals insurance is very cheap because of the tax saving you get.
  - newyankee 8y ago
    any idea how is it in NZ ?
    - james_s_tayler 8y ago
      It's fantastic here too. I had a scare recently and called the ambulance, was at the hospital pretty quickly, got an x-ray, stayed overnight, turned out not to be a serious thing but finally figured out what was causing it. No drama and no crazy $100,000 bills. Just healthcare of an acceptable quality when you need it. There is just no way that any perceived marginal improvement in the quality of care on an individual basis warrants an off chance of maybe being bankrupted. I can't say I've ever found the quality of care of be poor or unacceptable. It's always been available and served me well. I kind of liken it to being forced to drive an $80,000 BMW as opposed to being provided with a reasonable Toyota that does the job. The economic experiment has been tried and the US is on the wrong side of it.
      - newyankee 8y ago
        Indeed. I am surprised though because the income taxes in NZ seem to be lower than the quality of healthcare then. Wondering what the catch is.
howard941 8y ago
Florida typically comes dead-last consumer protection-wise except that it requires ER physicians to be "in-network" when the hospital is also "in-network".
tgsovlerkhgsel 8y ago
Want to do something about it? Regulate it. Like literally, have some government body write a table: 1 pill of 400 mg paracetamol ............ $0.50 1 pill of 800 mg paracetamol ............ $0.60 prescribing medicine (once per day) ..... $4.32 base fee for an ER visit .............. $200.00 5 minutes of work by an ER physician ... $27.43 etc. and impose that as the maximum price that can be charged. It's not going to happen because "omg socialism", but this is literally how other countries handle it. Possibly with a multiplier that the hospital/doctor can apply within certain limits. If you really need to, maybe even allow deviating from it as long as the patient is conscious, in a position to make that choice (i.e. not emergency care), is explicitly informed that this is above the "official" rate, is informed about the rate, and signs off on it beforehand. And I'd like to point out that this sort of regulation isn't unprecedented in the US either. Taxi prices are regulated this way in many areas. Apparently, transportation is more important and less suitable to be left to a free market than healthcare...
- thatswrong0 8y ago
  Shouldn't the max price of services (not things like RX of course) be different depending on the cost of living in that area? You'd need different prices in different areas otherwise the prices might be too expensive in some areas and too cheap in others. If the prices set are too cheap, you might see more people using the ER for non-emergency purposes, which would be bad for the people that need to use the ER for actual emergencies.
  - chadcmulligan 8y ago
    a healthcare industry schil sowing confusion
  - AlexandrB 8y ago
    > If the prices set are too cheap, you might see more people using the ER for non-emergency purposes, which would be bad for the people that need to use the ER for actual emergencies. The "long wait times" that Canadians sometimes complain about actually address this problem within public healthcare. If you come into the ER for a non-emergency, fine, but prepare to wait 4-6 hours. Every emergency case coming in the door will get placement ahead of you. Some provinces (e.g. Ontario) address this with phone triage hotlines that help you make a decision about whether to go to the ER, a walk-in clinic, or wait for a doctor's appointment.
kawfey 8y ago
I'm patiently waiting to have injuries and sudden symptoms until ER bills become more reasonable and transparent. Until then, if something happens, I guess I'll just die. -youth of today
keithnz 8y ago
It would be interesting to compare prices with countries with free government sponsored medical care. In NZ I know they work out the cost, and if you aren't a resident/citizen you have to pay the bill.
- newyankee 8y ago
  Is NZ healthcare decent? Asking because i am trying to decide between NZ and Canada as my future destination for immigration after living in US for 10 years.
daniel_iversen 8y ago
It makes me sad that there are places in the world where people have to pay to go to an emergency doctor. I know it’s a political hot topic but all that aside doesn’t most people deep down inside think that every fellow human should have the right to free doctor?
- rhexs 8y ago
  Okay, sure, I agree in general, but how far do we go with this? Does every other human have the right to extraordinarily expensive, often unproven cancer treatments only available at research institutions in the United States? Are we willing to start making cost based decisions on who should die (i.e. should we really be spending hundreds of thousands of dollars keeping those above 90 alive for age related illnesses?) Everyone will want everything free, but for this to work you have to make uncomfortable decisions. If you put nothing into the system, how much should you get out? Should others with more resources then be able to then buy private insurance for access to better care even though that sounds "unfair"? Everyone always glosses over these fun questions when they talk about universal health-care systems.
  - im_cynical 8y ago
    We gloss over them because: 1. Your first point about "unproven cancer treatment" has an overly narrow focus on the edge of medical research. These cases are yes something that needs to be addressed, but they are far from the norm of normal medical care. 2. I've never heard anyone ask for anything free related to healthcare. There is very little truly free care in the US. The conversation here is about price transparency and what is considered reasonable.
  - jwr 8y ago
    Those are red herrings. Many (if not most) countries somehow figured it out without having to deal with absolutes and black/white decisions. You can (and should) draw a line somewhere, and this can be done reasonably. As a European living in the US I find it mind-boggling that the richest country in the world does not consider universal healthcare to be a fundamental right of its citizens.
- 8y ago
tschwimmer 8y ago
I'm surprised to see lots of people in the comments talking about line items. Line Items are irrelevant. They could include line items for oxygen and toilet paper if they wanted to. The hospital charges whatever the market (and where applicable, regulations) allow. The configuration of the line item is pretty much a customer service problem: 'how do we show what we've done in a way that will get the customer to pay it.'
- Wowfunhappy 8y ago
  > The hospital charges whatever the market [...] will allow. Except that in this case, the market is paying before being told the cost. So, what is enforcing the upper limit on price in this type of bizarro market?
- cogidub 8y ago
  There is an issue with what I'll call the "consumer-market" theory in emergency healthcare in that there is no transparency in pricing at time of purchase or prior to purchase. How can markets function without price-transparency?
theandrewbailey 8y ago
Duplicate of: https://news.ycombinator.com/item?id=18706522 https://news.ycombinator.com/item?id=18706522
phyller 8y ago
Great article. I think the narrative around health care is often around who has access to good insurance and who doesn't, and as the cost has skyrocketed we have doubled down on that debate. The real problem is that health care providers won't or even can't tell you how much something costs. This has set up this situation where, since money is not part of the decision making process, they just keep raising costs. Imagine a grocery store where prices are not labelled, and you get a complex bill a month afterwards. And every grocery store does this. What are the chances prices for groceries are going to be competitive? Zero. If we can find a way to bring market forces to bear, it will pressure healthcare organizations to reorganize themselves to provide services in a more affordable way. And before anyone gets sanctimonious about putting money over quality care, consider the actual harmful effects of these crazy bills on people's lives. I used to do title work, and I became familiar with a pattern of people quietly paying their mortgage on their house for a couple decades, no liens, and then all of a sudden a lien from a hospital bill shows up. And then everything starts to crumble, other liens accrue, and I'm doing the title search for the foreclosure. A family just got moved from middle class to living in poverty. Our healthcare system is becoming a vehicle to impoverish people.
- jwr 8y ago
  > If we can find a way to bring market forces to bear I think the problem (also outlined in other comments) is that there are no market forces in the US health services market. There is no pressure to provide less expensive services, no pressure to reorganize, and no reason not to do what is being done now: build a non-transparent system where people get charged arbitrary amounts and prices are not known beforehand.
jvln 8y ago
Last year my 1 year old baby had an accident in Germany. She fell off of a bed. I took her to an ER and after the examination I paid approx. 100€ = ~100usd. I assume in USA I would have paid 10kUSD or more..
- randyrand 8y ago
  But what is the per person cost of health care paid annually by the tax payer? That seems like an important number to know.
- Johnny555 8y ago
  $10K? That's ridiculous, I really wouldn't expect any kind of trauma visit to be that cheap, the ambulance ride alone could be over $2000 and the hospital could charge a "trauma activation" fee of $5,000 - $15,000 which doesn't include any treatment at all, that's just the price to have access to the ER facilities.
jayess 8y ago
I don't see the situation changing in the US anytime soon. In order for us to have single-payer healthcare, doctors would need to accept drastic pay cuts, pharma companies would get far less for drugs, and insurance companies would go out of business. None of that will happen. Instead we'll have more and more and more regulation until it just stops working.
krupan 8y ago
Let's be careful to not look at one type of health care, emergency care, and generalize to all types of health care. Right now we all (Americans at least) don't really have insurance. We are part of pre-paid health clubs and we try to use the health club membership to pay for everything. For true time-sensitive emergencies we should all have traditional insurance, and yes, the services should probably be supplied, like fire fighting, by non-profit organizations. Health care that is not time critical should not work like the fire department. In fact, emergency rooms, once they diagnose something as not being an emergency should be able to say, "sorry, this isn't the right place for this, go to a doctors office." With non-emergency care we should all be able to get price quotes up front, we should be completely aware of our choices and the be able to shop around. We could maybe outsource that to health care clubs like Aetna and UHC if we choose to (knowing that we are getting less choice and that we'll have to deal with those bureaucracies as a trade-off), but there shouldn't be any tax breaks or employee incentives for using those health clubs. I recently had surgery to have my vision corrected with no "insurance" (or health care club) involved and it was so nice. I shopped around, the doctors all competed for my business and treated me like royalty, there was absolutely no confusion over price, there were financing options available, the technology was cutting edge (or I could have chosen to go less cutting edge and paid less), it was incredibly refreshing. I'd love if most of my health care could be like that.
- vec 8y ago
  This works reasonably well for things like vision care because they're entirely opt-in. Patients who aren't satisfied with the prices they're being quoted can realistically choose to keep wearing glasses instead. No one in their right mind is going to decide that the going rate for chemotherapy is a little steep right now so they're going to sit with the cancer for a year or two and see if the prices come down.
  - krupan 8y ago
    So think of it in terms of food then. We don't have "food insurance," yet food is a short-term need and it works pretty darn well as a free market.
sly010 8y ago
This is outrageous because the regulation wouldn't even have to be complicated. In the EU there is a directive that you have the rights to know the retail prices of things before you make a purchase and in some countries, retailers have to honor the lowest posted price and we are talking about baguettes! I don't see why that same thing couldn't apply for healthcare. 1. ERs should publish prices in a public database. If a price is not published for an item/procedure, the customer can pay the lowest price she/he can find for the same procedure from an other provider. 2. The same price must be charged from everyone (regardless of insurance). Even if only a small fraction of people shop around it might push down the prices. Even if the above is too naive, I am sure someone smarter can come up with a less naive version of it.
- maxxxxx 8y ago
  "1. ERs should publish prices in a public database. If a price is not published for an item/procedure, the customer can pay the lowest price she/he can find for the same procedure from an other provider. 2. The same price must be charged from everyone (regardless of insurance)." this would bring a lot of sanity into the system.
diogenescynic 8y ago
>3) You can be charged just for sitting in a waiting room I once fainted during a comedy show because the comedian was talking about his wife almost dying in surgery in graphic detail and I got nauseous and fainted. I woke up outside the comedy club up against a wall with an ambulance there. They basically took my blood pressure and gave me a bottle of water then asked if I wanted to go to the hospital. I declined. I still received a $3000 emergency services bill later... Apparently they checked my ID/insurance when I passed out and somehow I ended up with a bill even though I declined service. In contrast, I once hit my head on a train in France and had a huge gash that needed stitches. I took a taxi to an ER, got seen within 20 minutes, left the ER within 90 minutes, then had a $50 Euro bill. The contrast between "socialized" healthcare in Europe vs privatized healthcare in the US is shocking. We receive far, far, far worse quality and fewer services despite paying a lot more. We're in the worst of all situations.
dmh2000 8y ago
I'm not saying the ER prices are reasonable, but an ER has to keep a lot of expensive staff and equipment sitting around until they are needed. OK, some ER's they are sitting around. But there is a price to have all that service ready for an emergency. As for high drug prices like the $60 ibuprofen, you are mainly paying for it to be delivered to you by a nurse. ER's have an average profitability of 7.8%. Higher than Walmart but lower than Apple. So if they became non-profit in some way, they could cut that percentage of costs. That's some, but still very expensive. https://www.beckershospitalreview.com/finance/7-things-to-know-about-emergency-department-profitability.html https://www.beckershospitalreview.com/finance/7-things-to-kn...
- ncallaway 8y ago
  The thing is the "paying for it to be delivered by a nurse" is covered by other things. There will be a line-item for the ibuprofen itself, there will then (generally) be a separate line item for staff time spent helping you, and there will almost always be another line item for the facility fee. The nurse's overhead is theoretically included in those latter two line items, so shouldn't _also_ be charged in the ibuprofen line item. Now, there are logistical concerns that will make the ibuprofen marginally more expensive at an ER than at a clinic, but definitely not $60. I accept the logic of high drug prices including staffing costs when those staffings costs aren't included in other line items. In most hospital bills, it seems, those staffing costs are already included.
janesvilleseo 8y ago
I wonder if price gouging laws can be applied in the case of healthcare, especially in the case of emergency care.
shdh 8y ago
Profit not service. The system has zero incentive to reduce inefficiencies. Its designed to increase overhead and deliver surprise bills. The American system is largely a joke where doctors rather collect their co-pays and write prescriptions.
gammateam 8y ago
Nice, now someone do this for legal fees Even a dot-plot chart from different peoples experience with different practices and needs would be a great improvement to the “it depends” of today
nonbel 8y ago
ctrl-F "chargemaster" gives no results.[1] This article is BS. I didn't read it, it would be a waste of time. [1] https://en.wikipedia.org/wiki/Chargemaster https://en.wikipedia.org/wiki/Chargemaster
dgzl 8y ago
Sooo.... It's the hospital's fault healthcare is expensive! (Mostly joking)
zinckiwi 8y ago
America: where hospitals advertise on the radio.
andrewfong 8y ago
I'm curious what percentage of costs were covered by insurance. I recently had some genetic testing done and they were pretty open that they charge one lower price if I paid out of pocket and another higher price if insurance covered it. My hunch is that some of the price variation is just from providers magically increasing prices to match whatever the insurer is willing to pay.
- nonbel 8y ago
  Yes, it is called the "chargemaster": https://news.ycombinator.com/item?id=18722182 https://news.ycombinator.com/item?id=18722182
cityzen 8y ago
There is a documentary on HBO now called Bleed Out. If you want to know how absolutely fucked the US medical system is, watch it. You will probably never want you or anyone you love to ever step foot in a hospital again. These insurance companies and hospital groups are pure evil. Absolutely disgusted with what a backwards ass country America is.
fallingfrog 8y ago
The reason we don’t have universal healthcare is mostly racism and male supremacy. Racist white people dont want anyone with dark skin getting a “free ride”. And, supporters of patriarchy don’t want their stay-at-home wives to be able to get healthcare without going through them because it undermines the husband’s power and control. They will use the language of “personal responsibility” or “free markets” to describe it, but the same people who don’t want universal healthcare also wave confederate flags and think that a woman’s place is in the home.
- fallingfrog 8y ago
  I was expecting to get downvoted for this, but it’s still true. In countries where women can get free childcare and free healthcare, they have more power. American men deeply fear this. In the end, like everything else, it’s all about power- who has it, who doesn’t. Big healthcare also makes a killing on the situation, but here in the states conservatives have always been willing to make the devils bargain of allying themselves with the ruling class in order to preserve white supremacy and male supremacy. It’s true no matter how many downvotes I get.
dredmorbius 8y ago
A question that frequently comes up in healthcare debates is "would you rather be alive now or alive with the medical technology of 1970". You'd be giving up genetic testing, numerous advances in wound care, a number of advanced antibiotics, leaps in transplant technology, and a whole slew of joint-replacement innovations. Plus cancer treatments, and of course, AIDS therapies. Massive impacts, right? And if today is better than 1970, 1970 was better than 1950, and 1950 better than 1920, and.... Right? Not so fast. New York City have been tracking mortality rates since 1800, and there's a chart I love to pass around in these discussions, with the charming cocktail-party friendly title of "The Conquest of Pestilence in New York City ... as shown by the death rate as recorded in the official records of the Department of Health and Mental Hygiene". The 20th century has seen a host of medical advances: antibiotics, vaccines, transplants, tailored drugs, implants. High-cost, yes, but huge impacts. No, not really. https://1.bp.blogspot.com/-uTWEATUzgxk/TXQoTibILtI/AAAAAAAAAAM/eyirotYDmXo/s1600/2004_01_healthstat.jpg https://1.bp.blogspot.com/-uTWEATUzgxk/TXQoTibILtI/AAAAAAAAA... The turning point in the chart -- where the increase in mortality as New York as it grew from a town of 60,515 (1800) to a city of 813,669 (1860), was the formation of the Department of Public Health itself, in 1866. Peak mortality hit 50/1,000 in the 1830s, 180s, and 1860s, with a sustained average above 35/1,000, and marked volatility as the city was rocked by epidemics. By the 1890s, it had fallen to 20, and 1920, about 12. The pre-WWII low was actually in 1939-40, at just over 10, and mortality rose through the early 1970s. There has been a further decline, to about 7.5, since 1990. Analysis elsewhere suggests that this is almost wholly attributable to increased longevity among minority populations -- nonwhites generally, black women, and especially black men. My suspicion (though I've not researched in depth) is that this is largely attributable to increased access to medical care, either through improved socioeconomic status and access to the commercial healthcare market, or through public health programmes. There is little if any evidence that the gains come from medical technology itself. This is a topic that's been much studied. Robert J. Gordon's epic assessment of US economic progress, The Rise and Fall of American Growth (2016) looks hard at medical advances, particularly since 1970, and finds them largely absent. Victor Fuchs, healthcare economist (heavily cited by Gordon) has found published similar results for the past few decades. A personal anecdote is a close friend who'd died of an obscure cancer in the early 1990s. The (brutal) treatments they'd undergone were essentially unchanged since the early 1970s, or even 1960s, as I read the literature, and have changed little in the ensuing nearly three decades. Given that one of the questions and agonies we faced at the time was "what if some miracle cure emerges, or we weren't doing enough", this failure-to-advance is in some ways a bit of validation: we really try to do everything we could, and applied the best available knowledge, and no, even now, the outcome is virtually unchanged: four out of five patients with that diagnosis die within five years, often less. (Other friends have survived their, mostly other, cancer diagnoses. And of the cancer-friends we'd made, some are still alive, others have died, in cases of complications from treatment, including blood- and tissue-donation related infections such as hepatitis. Life is not fair.) Real healthcare improvement, as with so many other quality-of-life improvements, comes not from heroic measures, but by assuring adequate access. And the market is a terrible mechanism for assuring such adequacy.
jackkinsella 8y ago
I often find in these discussions that Americans look with undue admiration over to Europe and imagine that the same stuff doesn't happen here. But it does. I recently got my wisdom teeth pulled out in Germany, and without my asking, the doctor sent me a pack of 12 Ibuprofen and billed me 24 euro, i.e. €2/pill. I didn't want them because I had 500 of the same at home, which I bought for 25 euro — i.e. €0.05/pill. That's a markup of 40x.
kwhitefoot 8y ago
I stopped reading when I saw the minimum charge for walking through the door was USD 500 and that a family was charged USD 18 k for a nap and some formula milk; it was just too depressing. No amount of analysis of the details is going to fix those things.
OliverJones 8y ago
This "ED is too expensive" situation has been going on for decades. Is it possible the fairly new walk-in clinics could help? Could there be a big red sign on the ED door saying, "Hey we are very expensive and if your condition isn't serious you will wait a long time! Consider using the walk-in clinic at 123 Main Street."
king_magic 8y ago
American healthcare is basically massive legalized fraud.
hamilyon2 8y ago
Meanwhile in Russia: free ER services, free nationwide health care and no-franchise cheap voluntary insurance for everyone who doesn't want state medicine. Cheap because you have to compete with rather-good and completely free for everyone.
Tepix 8y ago
The idea suggests itself that the problems of the US healthcare system are closely tied to unrestrained capitalism, includings its influence on/over US politics.
HillaryBriss 8y ago
the most amazing and unbelievable part of this story is "Congress wants to do something about the issue"

424 points by jedwhite 8y ago

"The prices are high — even for things you can buy in a drugstore" Reminds me of the brief hospital visit I had in Paraguay where I needed to have a friend or relative always with me because the hospital didn't stock anything. If ibuprofen, bandages, syringes, antibiotics, etc were needed, the hospital staff would tell me and I would have my friend or relative run across the street to buy the necessary supplies from one of the pharmacies so the doctor or nurse could treat me. Cheap hospital bill, cheap pharmacy bill, pain in the butt for my friends and relatives.

lolsal 8y ago

I know $60 Ibuprofen can seem like a lot, but is anyone arguing that you're literally paying for only the pill(s) with that $60? Aren't you paying for the instant availability, the insurance that it's not expired (do they even expire? I really don't know), and confidence that your healthcare provider has signed off that XXX mg of Ibuprofen is a.) OK to have with your current medications and conditions and b.) sufficient to do the job? Isn't some of that cost the healthcare provider's expertise and service? Would it be better if they prescribed morphine and charged you a magnitude more when ibuprofen would have done the job? I charge clients similarly. I overbid projects that I don't really want to do. If you want me to setup Wordpress for you, I'll charge you out the nose. Granted, you get to accept my fees before I ever send you a bill. It's not a perfect analogy. > This is all due to the key fee I’ve been investigating this year: the ER facility fee. This is the fee that ERs charge for walking in the door and seeking care, something akin to a cover charge at a bar. This seems absolutely reasonable to me, I wish I could charge a 'fill my email with RFPs' type fees. Walking into a waiting room, signing in and waiting is not nothing. You and your symptoms get evaluated and triaged. That takes expertise and know-how. The prices vary wildly because different hospitals experience different levels of demand, I imagine.

corybrown 8y ago
> I charge clients similarly. I overbid projects that I don't really want to do. If you want me to setup Wordpress for you, I'll charge you out the nose. Granted, you get to accept my fees before I ever send you a bill. It's not a perfect analogy. One can always forgo setting up WordPress, which is not always the case with healthcare.
- lolsal 8y ago
  Totally understood; that's one of the ways that it's not a perfect analogy. Conversely if someone told me to setup Wordpress and that I could only charge $50, I'd change industries in a heartbeat.
scrollaway 8y ago
> Isn't some of that cost the healthcare provider's expertise and service? In theory maybe. Usually I would say these things are not exactly top priority and you are not getting your money's worth in the premium there. At best, of your list, you're paying for the instant availability, but what about the times where it's not instantly available? You're not paying for a guarantee of it.
mikeash 8y ago
I'm guessing you tell your clients, "I'm not really the right person to set up WordPress for you. I can do it, but it'll be incredibly expensive. You can probably do it yourself with a good online tutorial." Hospitals aren't telling their patients, "We're not really the right institution to give you ibuprofen. We can do it if you really want us to, but it'll be incredibly expensive. You can just go buy some at the store for like ten cents." In fact, I bet that even if you have the presence of mind to decline their ibuprofen because you'd rather get your own, they'll strenuously argue against it, or even start treating you as not following medical orders. In any case, it would be a lot more palatable if they'd charge marginal costs for marginal items, and charge overhead separately. It may well cost them something on the order of $60 to give someone ibuprofen, on average, but it does not cost them $60 more to give one more person ibuprofen. It would be more honest to charge two cents for the pill, and separately charge your fair share of the cost of the staff that obtains, vets, distributes, and administers that pill along with everything else you're getting.

AngeloAnolin 8y ago

Reading this article and seeing all the startups sprouting in the field of health care and medicine tells me that there's still a lot more areas to innovate and disrupt in this industry. One big issue though are that lobbyists who wanted to keep prices high - to squeeze in as much profit as they can out of these. Drugs, Antibiotics, Procedures, Medical Professionals. I know it would be far-fetched to standardize and at least provide some level of transparency across all facets of operation in this field, but that would be a good start. Analyze the data, and find ways where things can be improved incrementally.

davidw 8y ago
One way to disrupt the industry might be to have everyone be in one giant insurance pool, perhaps paid for via taxes, and then give everyone access to health care via some kind of non-profit entity. Sounds crazy, right? It worked well for my family and I during the many years I spent in Italy, which has health care costs that are something like half of what they are in the US in terms of GDP.
- AngeloAnolin 8y ago
  This is the same in Canada - universal health care administered in each province. Although I seemed to have noticed a lot of increase as well in terms of pricing and services. There's just really no cure for an appetite of greed.
- normal_man 8y ago
  Yup, it's worked nearly all over the modern world, for years and years. The last thing I want in healthcare is more startup maniacs trying to "disrupt and innovate" when there is a clearly viable alternative.
ryandrake 8y ago
All this value being captured by middlemen “sprouting” up could also simply mean more money out of the pockets of healthcare customers, who already are going bankrupt paying for all of this inefficiency. The US healthcare industry is a raging river of money coming directly out of the wallets of consumers who have little choice. Not surprising that it attracts middlemen with spoons ready to dip into the river.

ams6110 8y ago

I'm not an advocate of government paid health care, but hospitals and medical providers should see that this train is coming and if they don't become more transparent it's going to be forced upon them. I don't have a problem with ER care being more expensive -- that isn't necessarily unreasonable when you are getting care in an expensive facility open 24x7, fitted out with equipment to handle any possible medical emergency, and staffed with highly educated people who make a lot of money. But it is unfair to have no idea what costs you are facing and whether any of those costs are out of network on your insurance.

ttcbj 8y ago
I was not an advocate for gov't health care, but I am now for the same reason you stated. I have a high deductible plan, and have tried to get quotes in advance, but never can. I have been ripped off multiple times, despite trying to do my research, etc. My wife is a doctor, and at this point, I think single-payer is the least bad option.
- SlowRobotAhead 8y ago
  >have tried to get quotes in advance, but never can. >I have been ripped off multiple times, >I think single-payer is the least bad option. Can you help me understand why if everyone is paying for everyone's healthcare in a socialize system - how that reforms the transparency and stops the abuses?
  - ryanobjc 8y ago
    The presumption that competition between doctors and hospitals will create lower prices has not come to fruition. Individuals have no leverage or ability to make meaningful choices. There is no real healthcare market as a result. In a larger system, we get lower prices via several mechanisms: - Preventative care replacing ER care due to universal coverage - Larger risk pool lowers per-participant costs - Single payer has more leverage and depth of time/knowledge to regulate/negotiate with individual hospitals The reality of a competitive landscape, hand of market, etc, that just didn't happen.

codemusings 8y ago

Despite the fact that in my opinion this could be fixed by Universal Healthcare I'm left wondering: how is it legal to be billed these insane amounts of money without even getting a quote beforehand? Like just waiting in the ER is worth more than buying a first class airplane ticket and getting treated in another country.

serg_chernata 8y ago
> without even getting a quote beforehand Reminds me of this really good article. TLDR: Man tried to call a number of hospitals to find out how much childbirth is going to cost him and received no answers. https://www.vox.com/2016/5/5/11591592/birth-cost-hospital-bills https://www.vox.com/2016/5/5/11591592/birth-cost-hospital-bi...
- davio 8y ago
  I like the disconnect between this reality and the "consumer driven health plans" being offered by employers
- manfredo 8y ago
  Realistically, no hospital is going to give out a price. They don't know what unexpected complication may arise that requires additional services.
  - maxxxxx 8y ago
    They have nice pricing tables for insurances,. Just not for patients. Even unexpected complications will have a billing code but the prices are kept secret.
    - manfredo 8y ago
      Insurance companies are very different types of customers than uninsured patients. They're effectively averaging their price over a large number of patients. Most are probably slightly more expensive than necessary, but that difference helps subsidize those that experience complications. Furthermore, individual patients fail to pay at a much higher rate so that is reflected in the cost as well. A hospital can't just give the "insurance price" to uninsured patients as this may put them underwater.

edoo 8y ago

Health care is the only industry where the felony laws regarding up front pricing aren't enforced. It was allowed to become a twisted regulatory nightmare where the laws were written by the industry itself utilizing kneejerk methods to obtain profit at the cost of systemic corruption.

merpnderp 8y ago
And yet it is by far the most regulated industry in the US. Almost as if the more invasive the regulations the more invasive the corruption.
- edoo 8y ago
  It takes a while to realize nearly every law is anti-competition protectionism. I didn't realize it until I was working for a multinational food company and the managers were bragging about how the company lobbied for a safety bill that exactly regulated their own industry in a way that cost their competitors billions in compliance fees. They were proud of it. I was disgusted.
  - asdff 8y ago
    Disgusting, but know that there are good regulations—like environmental protections—that are frequently combatted by industry groups and tend to get weakened by the Republicans before they pass into law. Regulation can be abused by industry and corrupt politicians for anticompetitive reasons, but most of the time, it's to force companies from doing highly profitable things that aren't good for people or the planet; its much cheaper to just dump all your hazardous waste into the river, after all.
- AlexandrB 8y ago
  This is a non-sequitur. For something like emergency care, where the choice can literally be "pay up or die", a private provider has every incentive/opportunity to charge outrageous fees. Because what are you going to do? Tell the heart attack to wait while you find another provider? The price-opacity may be a product of regulation, but the prices themselves are free market capitalism working as intended. For another example of the same, consider the recent reporting on collusion between generic drug companies[1]. When you can't refuse to buy the product, the vendor has a ton of power to set prices as they wish. [1] https://www.wsj.com/articles/generic-drug-makers-shares-drop-on-report-of-possible-probe-1478209036 https://www.wsj.com/articles/generic-drug-makers-shares-drop...

vec 8y ago

Exhibit A for why "free market healthcare" is an oxymoron. I have yet to hear a coherent explanation for how anyone can reasonably expect for price discovery to even pretend to function in a market where the consumers can't even guess the prices until after they've already purchased and frequently couldn't reasonably be expected to refuse service even if they did believe it was overpriced.

deleted 8y ago
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UnpossibleJim 8y ago
Exactly. It's the same reason we don't have free market police and fire services. You simply don't get to "shop around" for emergency services, which includes privatized ambulance services (which are outrageously expensive, on the order of $12,000 for the ride I took when I had to take one, and it was a relatively benign one... thank god I had insurance). EMS is covered, but that's the Fire Department. After that, it's all privatized. If it's cosmetic, then I could see the argument. But when it comes to emergency services, and for ambulances especially, the "free market" argument just doesn't hold water.
- cabaalis 8y ago
  > You simply don't get to "shop around" for emergency services You do actually, by where you choose to live and also by the services as detailed in [1]. I think there's merit to investigating public health care. That line stops for me in eliminating private care. 1] https://www.theatlantic.com/technology/archive/2018/11/kim-kardashian-kanye-west-history-private-firefighting/575887/ https://www.theatlantic.com/technology/archive/2018/11/kim-k...
  - neurotrace 8y ago
    A lot of people don't get much choice in where they live.
    - 8y ago

deleted 8y ago

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lolsal 8y ago

I wonder what healthcare bills would look like if they were itemized so that things like Ibuprofen were literally billed at cost ($0.25 per?) and there were line items for services/labor that captured the real cost of being a medical professional: - Emergency room wait: $0.10 for lights - OTC eyedrops (4 drops): $0.20 - Triage by on-duty nurse: $100 (@ $300/hr) - Consult by on-duty physician: $220 (@ $600/hr) - Late-night convenience fee: $100 (between 7pm and 7am) etc. I made up all the numbers, I have no idea how healthcare professionals calculate their hourly rate.

pessimizer 8y ago
It would look like they should pay their nurses a lot more, according to this bill.
newyankee 8y ago
Isn't there something like generally accepted accounting principles in healthcare ? Genuine question if anyone knows the answer.
- wyldfire 8y ago
  IIUC, much of healthcare billing in the US is governed by discrete codes for services performed. I suspect this allows big customers like Federal Gov't & insurers to audit bills easier. In order to either be more specific about the bills or allow less wiggle room, they made these codes remarkably more specific recently (ICD-10 [1]). IMO the descriptions of the items in these codes are humorously specific. Imagine if your auto mechanic got $650/hr for labor, I suppose you would get much more specific invoices for their work too. [1] https://en.wikipedia.org/wiki/ICD-10 https://en.wikipedia.org/wiki/ICD-10
  - newyankee 8y ago
    Interesting. Well the thing is if people really are motivated enough they will always find a way to skirt certain types of regulations.
8y ago

kevin_b_er 8y ago

> I started my project focused on one specific charge: the facility fee. I found this charge for walking through an emergency room’s doors could be as low as $533 or well over $3,000, depending on which hospital a patient visited and how severe her case was. I also learned that the price of this charge had skyrocketed in recent years, increasing much faster than other medical prices for no clear reason. Is this why my local hospitals are advertising their ER wait times? The arbitrary profit from arbitrary "in the door" fees?

y-c-o-m-b 8y ago

I was a victim of the surprise out of network bill in the Portland, OR area. I did all my research before hand: hospital in network, surgeon in network, etc. but ONE person in that operating room was not in network and SURPRISE i'm out thousands of dollars. The worst part about this is my state passed a bill to stop this prior to my surgery, but the bill's effective date was roughly 3 months later. Talk about bad timing.

sjg007 8y ago
You can try to appeal it.
- y-c-o-m-b 8y ago
  Appealed twice and both times they denied it stating I didn't require the surgery despite the fact they pre-approved it and paid for all the in-network costs. I ended up paying it because I had the money and I couldn't handle the stress of a legal battle (which given what I've read is an uphill battle).
  - sjg007 8y ago
    Sorry to hear that.. you can usually appeal up the food chain sometimes.. e.g. to your states insurance department if the plan is regulated by your state. And at the Federal level you can also submit a ERISA appeal. None of it is fun and then there are deadlines... Also if you are on an employer provided insurance plan, you can talk to your HR who will have an insurance rep who can sometimes make these things go away e.g. get them paid. If you are at a large employer that self insures and uses a third party admin (like Cigna) then they can tell the admin to negotiate with the doctor/hospital and pay it.
wycy 8y ago
From what I understand (which is honestly not much), I think in cases like this you can contact the hospital and just insist on paying the same amount your insurance would have paid, and they'll often take it. That's just what I hear, though.

BenMorganIO 8y ago

This title should be updated to state it is only in regards to the United States and not relevant for Canadians, Australians, etc.

amriksohata 8y ago

Brit here, thank God for the NHS

quickthrower2 8y ago
+1. Moved from UK to Australia and it is very similar here too in that most medical care is free. One difference is that the ambulance service charges for residents, and usually it is reasonable priced (but not cheap) but if it turns out you need a helicopter the bill can be quite large! But insurance covers it. For most professionals insurance is very cheap because of the tax saving you get.
- newyankee 8y ago
  any idea how is it in NZ ?
  - james_s_tayler 8y ago
    It's fantastic here too. I had a scare recently and called the ambulance, was at the hospital pretty quickly, got an x-ray, stayed overnight, turned out not to be a serious thing but finally figured out what was causing it. No drama and no crazy $100,000 bills. Just healthcare of an acceptable quality when you need it. There is just no way that any perceived marginal improvement in the quality of care on an individual basis warrants an off chance of maybe being bankrupted. I can't say I've ever found the quality of care of be poor or unacceptable. It's always been available and served me well. I kind of liken it to being forced to drive an $80,000 BMW as opposed to being provided with a reasonable Toyota that does the job. The economic experiment has been tried and the US is on the wrong side of it.
    - newyankee 8y ago
      Indeed. I am surprised though because the income taxes in NZ seem to be lower than the quality of healthcare then. Wondering what the catch is.

howard941 8y ago

Florida typically comes dead-last consumer protection-wise except that it requires ER physicians to be "in-network" when the hospital is also "in-network".

tgsovlerkhgsel 8y ago

Want to do something about it? Regulate it. Like literally, have some government body write a table: 1 pill of 400 mg paracetamol ............ $0.50 1 pill of 800 mg paracetamol ............ $0.60 prescribing medicine (once per day) ..... $4.32 base fee for an ER visit .............. $200.00 5 minutes of work by an ER physician ... $27.43 etc. and impose that as the maximum price that can be charged. It's not going to happen because "omg socialism", but this is literally how other countries handle it. Possibly with a multiplier that the hospital/doctor can apply within certain limits. If you really need to, maybe even allow deviating from it as long as the patient is conscious, in a position to make that choice (i.e. not emergency care), is explicitly informed that this is above the "official" rate, is informed about the rate, and signs off on it beforehand. And I'd like to point out that this sort of regulation isn't unprecedented in the US either. Taxi prices are regulated this way in many areas. Apparently, transportation is more important and less suitable to be left to a free market than healthcare...

thatswrong0 8y ago
Shouldn't the max price of services (not things like RX of course) be different depending on the cost of living in that area? You'd need different prices in different areas otherwise the prices might be too expensive in some areas and too cheap in others. If the prices set are too cheap, you might see more people using the ER for non-emergency purposes, which would be bad for the people that need to use the ER for actual emergencies.
- chadcmulligan 8y ago
  a healthcare industry schil sowing confusion
- AlexandrB 8y ago
  > If the prices set are too cheap, you might see more people using the ER for non-emergency purposes, which would be bad for the people that need to use the ER for actual emergencies. The "long wait times" that Canadians sometimes complain about actually address this problem within public healthcare. If you come into the ER for a non-emergency, fine, but prepare to wait 4-6 hours. Every emergency case coming in the door will get placement ahead of you. Some provinces (e.g. Ontario) address this with phone triage hotlines that help you make a decision about whether to go to the ER, a walk-in clinic, or wait for a doctor's appointment.

kawfey 8y ago

I'm patiently waiting to have injuries and sudden symptoms until ER bills become more reasonable and transparent. Until then, if something happens, I guess I'll just die. -youth of today

keithnz 8y ago

It would be interesting to compare prices with countries with free government sponsored medical care. In NZ I know they work out the cost, and if you aren't a resident/citizen you have to pay the bill.

newyankee 8y ago
Is NZ healthcare decent? Asking because i am trying to decide between NZ and Canada as my future destination for immigration after living in US for 10 years.

daniel_iversen 8y ago

It makes me sad that there are places in the world where people have to pay to go to an emergency doctor. I know it’s a political hot topic but all that aside doesn’t most people deep down inside think that every fellow human should have the right to free doctor?

rhexs 8y ago
Okay, sure, I agree in general, but how far do we go with this? Does every other human have the right to extraordinarily expensive, often unproven cancer treatments only available at research institutions in the United States? Are we willing to start making cost based decisions on who should die (i.e. should we really be spending hundreds of thousands of dollars keeping those above 90 alive for age related illnesses?) Everyone will want everything free, but for this to work you have to make uncomfortable decisions. If you put nothing into the system, how much should you get out? Should others with more resources then be able to then buy private insurance for access to better care even though that sounds "unfair"? Everyone always glosses over these fun questions when they talk about universal health-care systems.
- im_cynical 8y ago
  We gloss over them because: 1. Your first point about "unproven cancer treatment" has an overly narrow focus on the edge of medical research. These cases are yes something that needs to be addressed, but they are far from the norm of normal medical care. 2. I've never heard anyone ask for anything free related to healthcare. There is very little truly free care in the US. The conversation here is about price transparency and what is considered reasonable.
- jwr 8y ago
  Those are red herrings. Many (if not most) countries somehow figured it out without having to deal with absolutes and black/white decisions. You can (and should) draw a line somewhere, and this can be done reasonably. As a European living in the US I find it mind-boggling that the richest country in the world does not consider universal healthcare to be a fundamental right of its citizens.
8y ago

tschwimmer 8y ago

I'm surprised to see lots of people in the comments talking about line items. Line Items are irrelevant. They could include line items for oxygen and toilet paper if they wanted to. The hospital charges whatever the market (and where applicable, regulations) allow. The configuration of the line item is pretty much a customer service problem: 'how do we show what we've done in a way that will get the customer to pay it.'

Wowfunhappy 8y ago
> The hospital charges whatever the market [...] will allow. Except that in this case, the market is paying before being told the cost. So, what is enforcing the upper limit on price in this type of bizarro market?
cogidub 8y ago
There is an issue with what I'll call the "consumer-market" theory in emergency healthcare in that there is no transparency in pricing at time of purchase or prior to purchase. How can markets function without price-transparency?

theandrewbailey 8y ago

Duplicate of: https://news.ycombinator.com/item?id=18706522 https://news.ycombinator.com/item?id=18706522

phyller 8y ago

Great article. I think the narrative around health care is often around who has access to good insurance and who doesn't, and as the cost has skyrocketed we have doubled down on that debate. The real problem is that health care providers won't or even can't tell you how much something costs. This has set up this situation where, since money is not part of the decision making process, they just keep raising costs. Imagine a grocery store where prices are not labelled, and you get a complex bill a month afterwards. And every grocery store does this. What are the chances prices for groceries are going to be competitive? Zero. If we can find a way to bring market forces to bear, it will pressure healthcare organizations to reorganize themselves to provide services in a more affordable way. And before anyone gets sanctimonious about putting money over quality care, consider the actual harmful effects of these crazy bills on people's lives. I used to do title work, and I became familiar with a pattern of people quietly paying their mortgage on their house for a couple decades, no liens, and then all of a sudden a lien from a hospital bill shows up. And then everything starts to crumble, other liens accrue, and I'm doing the title search for the foreclosure. A family just got moved from middle class to living in poverty. Our healthcare system is becoming a vehicle to impoverish people.

jwr 8y ago
> If we can find a way to bring market forces to bear I think the problem (also outlined in other comments) is that there are no market forces in the US health services market. There is no pressure to provide less expensive services, no pressure to reorganize, and no reason not to do what is being done now: build a non-transparent system where people get charged arbitrary amounts and prices are not known beforehand.

jvln 8y ago

Last year my 1 year old baby had an accident in Germany. She fell off of a bed. I took her to an ER and after the examination I paid approx. 100€ = ~100usd. I assume in USA I would have paid 10kUSD or more..

randyrand 8y ago
But what is the per person cost of health care paid annually by the tax payer? That seems like an important number to know.
Johnny555 8y ago
$10K? That's ridiculous, I really wouldn't expect any kind of trauma visit to be that cheap, the ambulance ride alone could be over $2000 and the hospital could charge a "trauma activation" fee of $5,000 - $15,000 which doesn't include any treatment at all, that's just the price to have access to the ER facilities.

jayess 8y ago

I don't see the situation changing in the US anytime soon. In order for us to have single-payer healthcare, doctors would need to accept drastic pay cuts, pharma companies would get far less for drugs, and insurance companies would go out of business. None of that will happen. Instead we'll have more and more and more regulation until it just stops working.

krupan 8y ago

Let's be careful to not look at one type of health care, emergency care, and generalize to all types of health care. Right now we all (Americans at least) don't really have insurance. We are part of pre-paid health clubs and we try to use the health club membership to pay for everything. For true time-sensitive emergencies we should all have traditional insurance, and yes, the services should probably be supplied, like fire fighting, by non-profit organizations. Health care that is not time critical should not work like the fire department. In fact, emergency rooms, once they diagnose something as not being an emergency should be able to say, "sorry, this isn't the right place for this, go to a doctors office." With non-emergency care we should all be able to get price quotes up front, we should be completely aware of our choices and the be able to shop around. We could maybe outsource that to health care clubs like Aetna and UHC if we choose to (knowing that we are getting less choice and that we'll have to deal with those bureaucracies as a trade-off), but there shouldn't be any tax breaks or employee incentives for using those health clubs. I recently had surgery to have my vision corrected with no "insurance" (or health care club) involved and it was so nice. I shopped around, the doctors all competed for my business and treated me like royalty, there was absolutely no confusion over price, there were financing options available, the technology was cutting edge (or I could have chosen to go less cutting edge and paid less), it was incredibly refreshing. I'd love if most of my health care could be like that.

vec 8y ago
This works reasonably well for things like vision care because they're entirely opt-in. Patients who aren't satisfied with the prices they're being quoted can realistically choose to keep wearing glasses instead. No one in their right mind is going to decide that the going rate for chemotherapy is a little steep right now so they're going to sit with the cancer for a year or two and see if the prices come down.
- krupan 8y ago
  So think of it in terms of food then. We don't have "food insurance," yet food is a short-term need and it works pretty darn well as a free market.

sly010 8y ago

This is outrageous because the regulation wouldn't even have to be complicated. In the EU there is a directive that you have the rights to know the retail prices of things before you make a purchase and in some countries, retailers have to honor the lowest posted price and we are talking about baguettes! I don't see why that same thing couldn't apply for healthcare. 1. ERs should publish prices in a public database. If a price is not published for an item/procedure, the customer can pay the lowest price she/he can find for the same procedure from an other provider. 2. The same price must be charged from everyone (regardless of insurance). Even if only a small fraction of people shop around it might push down the prices. Even if the above is too naive, I am sure someone smarter can come up with a less naive version of it.

maxxxxx 8y ago
"1. ERs should publish prices in a public database. If a price is not published for an item/procedure, the customer can pay the lowest price she/he can find for the same procedure from an other provider. 2. The same price must be charged from everyone (regardless of insurance)." this would bring a lot of sanity into the system.

diogenescynic 8y ago

>3) You can be charged just for sitting in a waiting room I once fainted during a comedy show because the comedian was talking about his wife almost dying in surgery in graphic detail and I got nauseous and fainted. I woke up outside the comedy club up against a wall with an ambulance there. They basically took my blood pressure and gave me a bottle of water then asked if I wanted to go to the hospital. I declined. I still received a $3000 emergency services bill later... Apparently they checked my ID/insurance when I passed out and somehow I ended up with a bill even though I declined service. In contrast, I once hit my head on a train in France and had a huge gash that needed stitches. I took a taxi to an ER, got seen within 20 minutes, left the ER within 90 minutes, then had a $50 Euro bill. The contrast between "socialized" healthcare in Europe vs privatized healthcare in the US is shocking. We receive far, far, far worse quality and fewer services despite paying a lot more. We're in the worst of all situations.

dmh2000 8y ago

I'm not saying the ER prices are reasonable, but an ER has to keep a lot of expensive staff and equipment sitting around until they are needed. OK, some ER's they are sitting around. But there is a price to have all that service ready for an emergency. As for high drug prices like the $60 ibuprofen, you are mainly paying for it to be delivered to you by a nurse. ER's have an average profitability of 7.8%. Higher than Walmart but lower than Apple. So if they became non-profit in some way, they could cut that percentage of costs. That's some, but still very expensive. https://www.beckershospitalreview.com/finance/7-things-to-know-about-emergency-department-profitability.html https://www.beckershospitalreview.com/finance/7-things-to-kn...

ncallaway 8y ago
The thing is the "paying for it to be delivered by a nurse" is covered by other things. There will be a line-item for the ibuprofen itself, there will then (generally) be a separate line item for staff time spent helping you, and there will almost always be another line item for the facility fee. The nurse's overhead is theoretically included in those latter two line items, so shouldn't _also_ be charged in the ibuprofen line item. Now, there are logistical concerns that will make the ibuprofen marginally more expensive at an ER than at a clinic, but definitely not $60. I accept the logic of high drug prices including staffing costs when those staffings costs aren't included in other line items. In most hospital bills, it seems, those staffing costs are already included.

janesvilleseo 8y ago

I wonder if price gouging laws can be applied in the case of healthcare, especially in the case of emergency care.

shdh 8y ago

Profit not service. The system has zero incentive to reduce inefficiencies. Its designed to increase overhead and deliver surprise bills. The American system is largely a joke where doctors rather collect their co-pays and write prescriptions.

gammateam 8y ago

Nice, now someone do this for legal fees Even a dot-plot chart from different peoples experience with different practices and needs would be a great improvement to the “it depends” of today

nonbel 8y ago

ctrl-F "chargemaster" gives no results.[1] This article is BS. I didn't read it, it would be a waste of time. [1] https://en.wikipedia.org/wiki/Chargemaster https://en.wikipedia.org/wiki/Chargemaster

dgzl 8y ago

Sooo.... It's the hospital's fault healthcare is expensive! (Mostly joking)

zinckiwi 8y ago

America: where hospitals advertise on the radio.

andrewfong 8y ago

I'm curious what percentage of costs were covered by insurance. I recently had some genetic testing done and they were pretty open that they charge one lower price if I paid out of pocket and another higher price if insurance covered it. My hunch is that some of the price variation is just from providers magically increasing prices to match whatever the insurer is willing to pay.

nonbel 8y ago
Yes, it is called the "chargemaster": https://news.ycombinator.com/item?id=18722182 https://news.ycombinator.com/item?id=18722182

cityzen 8y ago

There is a documentary on HBO now called Bleed Out. If you want to know how absolutely fucked the US medical system is, watch it. You will probably never want you or anyone you love to ever step foot in a hospital again. These insurance companies and hospital groups are pure evil. Absolutely disgusted with what a backwards ass country America is.

fallingfrog 8y ago

The reason we don’t have universal healthcare is mostly racism and male supremacy. Racist white people dont want anyone with dark skin getting a “free ride”. And, supporters of patriarchy don’t want their stay-at-home wives to be able to get healthcare without going through them because it undermines the husband’s power and control. They will use the language of “personal responsibility” or “free markets” to describe it, but the same people who don’t want universal healthcare also wave confederate flags and think that a woman’s place is in the home.

fallingfrog 8y ago
I was expecting to get downvoted for this, but it’s still true. In countries where women can get free childcare and free healthcare, they have more power. American men deeply fear this. In the end, like everything else, it’s all about power- who has it, who doesn’t. Big healthcare also makes a killing on the situation, but here in the states conservatives have always been willing to make the devils bargain of allying themselves with the ruling class in order to preserve white supremacy and male supremacy. It’s true no matter how many downvotes I get.

dredmorbius 8y ago

A question that frequently comes up in healthcare debates is "would you rather be alive now or alive with the medical technology of 1970". You'd be giving up genetic testing, numerous advances in wound care, a number of advanced antibiotics, leaps in transplant technology, and a whole slew of joint-replacement innovations. Plus cancer treatments, and of course, AIDS therapies. Massive impacts, right? And if today is better than 1970, 1970 was better than 1950, and 1950 better than 1920, and.... Right? Not so fast. New York City have been tracking mortality rates since 1800, and there's a chart I love to pass around in these discussions, with the charming cocktail-party friendly title of "The Conquest of Pestilence in New York City ... as shown by the death rate as recorded in the official records of the Department of Health and Mental Hygiene". The 20th century has seen a host of medical advances: antibiotics, vaccines, transplants, tailored drugs, implants. High-cost, yes, but huge impacts. No, not really. https://1.bp.blogspot.com/-uTWEATUzgxk/TXQoTibILtI/AAAAAAAAAAM/eyirotYDmXo/s1600/2004_01_healthstat.jpg https://1.bp.blogspot.com/-uTWEATUzgxk/TXQoTibILtI/AAAAAAAAA... The turning point in the chart -- where the increase in mortality as New York as it grew from a town of 60,515 (1800) to a city of 813,669 (1860), was the formation of the Department of Public Health itself, in 1866. Peak mortality hit 50/1,000 in the 1830s, 180s, and 1860s, with a sustained average above 35/1,000, and marked volatility as the city was rocked by epidemics. By the 1890s, it had fallen to 20, and 1920, about 12. The pre-WWII low was actually in 1939-40, at just over 10, and mortality rose through the early 1970s. There has been a further decline, to about 7.5, since 1990. Analysis elsewhere suggests that this is almost wholly attributable to increased longevity among minority populations -- nonwhites generally, black women, and especially black men. My suspicion (though I've not researched in depth) is that this is largely attributable to increased access to medical care, either through improved socioeconomic status and access to the commercial healthcare market, or through public health programmes. There is little if any evidence that the gains come from medical technology itself. This is a topic that's been much studied. Robert J. Gordon's epic assessment of US economic progress, The Rise and Fall of American Growth (2016) looks hard at medical advances, particularly since 1970, and finds them largely absent. Victor Fuchs, healthcare economist (heavily cited by Gordon) has found published similar results for the past few decades. A personal anecdote is a close friend who'd died of an obscure cancer in the early 1990s. The (brutal) treatments they'd undergone were essentially unchanged since the early 1970s, or even 1960s, as I read the literature, and have changed little in the ensuing nearly three decades. Given that one of the questions and agonies we faced at the time was "what if some miracle cure emerges, or we weren't doing enough", this failure-to-advance is in some ways a bit of validation: we really try to do everything we could, and applied the best available knowledge, and no, even now, the outcome is virtually unchanged: four out of five patients with that diagnosis die within five years, often less. (Other friends have survived their, mostly other, cancer diagnoses. And of the cancer-friends we'd made, some are still alive, others have died, in cases of complications from treatment, including blood- and tissue-donation related infections such as hepatitis. Life is not fair.) Real healthcare improvement, as with so many other quality-of-life improvements, comes not from heroic measures, but by assuring adequate access. And the market is a terrible mechanism for assuring such adequacy.

jackkinsella 8y ago

I often find in these discussions that Americans look with undue admiration over to Europe and imagine that the same stuff doesn't happen here. But it does. I recently got my wisdom teeth pulled out in Germany, and without my asking, the doctor sent me a pack of 12 Ibuprofen and billed me 24 euro, i.e. €2/pill. I didn't want them because I had 500 of the same at home, which I bought for 25 euro — i.e. €0.05/pill. That's a markup of 40x.

kwhitefoot 8y ago

I stopped reading when I saw the minimum charge for walking through the door was USD 500 and that a family was charged USD 18 k for a nap and some formula milk; it was just too depressing. No amount of analysis of the details is going to fix those things.

OliverJones 8y ago

This "ED is too expensive" situation has been going on for decades. Is it possible the fairly new walk-in clinics could help? Could there be a big red sign on the ED door saying, "Hey we are very expensive and if your condition isn't serious you will wait a long time! Consider using the walk-in clinic at 123 Main Street."

king_magic 8y ago

American healthcare is basically massive legalized fraud.

hamilyon2 8y ago

Meanwhile in Russia: free ER services, free nationwide health care and no-franchise cheap voluntary insurance for everyone who doesn't want state medicine. Cheap because you have to compete with rather-good and completely free for everyone.

Tepix 8y ago

The idea suggests itself that the problems of the US healthcare system are closely tied to unrestrained capitalism, includings its influence on/over US politics.

HillaryBriss 8y ago

the most amazing and unbelievable part of this story is "Congress wants to do something about the issue"