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As an Australian living and working in the US with a wife who has a chronic medical condition that costs our insurance company on the order of $100k/yr for her

• golover721 7y ago
  What perhaps makes it crazier is that they never expect to get the whole $2900. They bill that and the insurance company will always reduce it by a huge amount. Individuals without insurance are expected to also "negotiate".
  • nicolethenerd 7y ago
    I keep hearing this "negotiate" thing, but I tried it when I was billed $254 for a strep test (after being quoted $25 at the walk-in clinic), and the provider refused to negotiate. I appealed with my insurance, the appeal sort of disappeared (I received a letter saying it had failed the first round of review, and they were sending it elsewhere, and then I never heard back again) - and after fighting it for four months, I gave up and paid. Should I not have?
    • deleted 7y ago
      [deleted]
    • cbluth 7y ago
      It sounds like their system is working as intended. closes ticket
      • Scoundreller 7y ago
        It’s like the PayPal and EBay dispute process. Lots of unnecessary manual lookups, waiting periods and then an arbitrary deadline, and my favourite: waiting for them to make an automated decision. Like, why not stall when they already have my money.
    • freedomben 7y ago
      Nope this was my experience too. I also heard that they'll knock 50% off or more if you offer to pay cash on the day of. This was also not true (at least in Alaska). In Utah I've gotten further, but usually if they knock off 20% I've had a good day. It's insanity. The market is completely messed up.
      • pauljurczak 7y ago
        50% cash discount is almost unheard of. 10% is a norm, 20% if you are lucky.
        • gardnerbickford 7y ago
          How often have you tried in non-emergency situations? I got 50% of at UCSF seeing a specialist there.
          • pauljurczak 7y ago
            My dentists always gave me 10% off for paying cash. Collection agencies often gave me 10 to 20% for paying the whole balance by credit card on the phone. Hospital sometimes gave me 25% for paying a year old balance within 1 month. These were all insurance repriced bills, except of the dental. Many bills were over 1 year old, because of billing errors and numerous back and forth between me, service provider and insurance company.
    • ArtDev 7y ago
      Same deal. Strep test, $250 plus a $50 "outside of business hours" clinic charge. I visited at 9am on a Monday morning. The billing dept claimed it was a standard charge they charged everyone. I fought them for months about it. Only after it reached collections did I pay it. The extra fee was missing, but $250 for a strep test is a rip off regardless!
    • maxxxxx 7y ago
      There is no real negotiation or defined process. . You have to be willing to play hardball and outright refuse to pay. Also be willing to call every day or get a lawyer that writes nasty letters. Also be willing to deal with collection agencies. It’s a stupid game about who is the biggest bully. Not many people have the nerves for this.
  • hahajk 7y ago
    Negotiate with whom? I don’t think there’s anyone at the hospital you’ll have access to that can guarantee you a lower price (or can probably even tell you what the price will be). After you’ve had the treatment and finally given the bill you don’t have any negotiating power; you can only beg at that point.
    • rfugger 7y ago
      You might have to just refuse to pay until someone calls you about it. Then you could offer to pay a portion. It may very well be a collections agency calling, and late payment could reflect poorly on your credit rating.
      • freedomben 7y ago
        This actually can work, but you have to remember to check up art the right time before they send to collections. Don't forget about it or a collector will be calling you.
        • rfugger 7y ago
          That's actually my point. Eventually someone will call you and want to negotiate to get partial payment.
          • freedomben 7y ago
            Yes, and you can negotiate with the collector, but at that point your credit report is damaged so probably not worth it.
      • ArtDev 7y ago
        The funny thing though, it is so common for medical bills to get to collections that it doesn't effect your credit rating like other bills would.
        • avgDev 7y ago
• ajmurmann 7y ago
  This econtalk episode[1] provides some interesting background on how this happens with medication. There are man-in-the-middle companies (Pharmacy Benefit Managers - PBM) that negotiate plans with pharma companies. These companies get paid a commission based on the delta between list price and the deal they got. The Pharma companies need these deals, so both benefit by the pharma company increasing list prices every year and then cutting better deals to those PBMs. If someone is offering a generic that's cheaper, there is less incentive for PBMs to add them to their plan, because the prices are too cheap to begin with and they have a smaller market share initially. It's all a giant Rube Goldberg machine of a mess. EDIT: One more interesting detail from the podcast and the book it's based on: Those deals between PBMs and pharma companies are secret. Not even the insurance companies know the details of what's in there. It's also fun to point out that typically this is everyone involved in a consumer getting their drug: * the consumer * the consumer's employer who selects the insurance * the insurance * a PBM who get a Pharma benefit plan for the insurance * the Pharma company that manufactures the drug * the pharmacy you actually buy the drugs. On top of that the actual payment apparently happens often months after you received the drug. Edit2: Clarifying "PBM" [1]http://www.econtalk.org/robin-feldman-on-drugs-money-and-secret-handshakes/ http://www.econtalk.org/robin-feldman-on-drugs-money-and-sec...
  • 3xblah 7y ago
    "Those deals between PBMs and pharma companies are secret." In some cases pharma co.'s created their own PBMs. There is a long and storied history of litigation on American drug pricing. If you want to understand the Rube Goldberg machine, I recommend searching the keywords "Average Wholesale Price" or "AWP". In terms of consumer protection, some states are better than others. Maine was a leader in this area. However it looks like the pharma industry has prevailed. https://www.policymed.com/2011/06/maine-set-to-repeal-unfair-prescription-drug-prices-act-and-end-pbm-discrimination.html https://www.policymed.com/2011/06/maine-set-to-repeal-unfair...
  • BurningFrog 7y ago
    And what's the root cause of this absurd arrangement that doesn't exist in unregulated markets?
• massivecali 7y ago
  >Imagine being sick, having no insurance, maybe no job... Sorry no. Long term unemployed people in the US qualify for free medical care, celphones and basic dental work. The process is arduous, yes, but it is comprehensive. I had entire recurring blood panels, multiple MRIs, neurological impairment tests , every hospital visit and all of my prescriptions provided for free. Lumping all levels of poor together is just lies that obfuscates larger issues.
  • dev_dull 7y ago
    It’s the working middle class that get soaked.
  • mnm1 7y ago
    What program are you referring to? AFAIK, This is only in states that expanded Medicaid so it's a real situation for millions in states that didn't. Or are you talking about some other program?
    • massivecali 7y ago
      California programs, so yes expanded Medicaid. But as the state that consumes the most in welfare, it seems highly relevant when discussing the needs of the 'poor'. Programs: California Medi-cal (which covered all of my medications, tests, etc), Denti-cal (all dental work thats not cosmetic), my obama phone, calfresh (for ebt food) and calworks (cash monthly stipend) are the only programs I can speak to. I'm grateful for what I had to fight to receive during a bad period of my life and hate seeing misrepresentations like this being spread without specific context. Had I not been able to finally get working again, I would have eventually qualified for free housing, utilities and all the other benefits available from programs that are funded from various sources. I made several friends through the course of going to these offices over a long period of time who were admittedly worse off than me (mentally) but somehow knew all the inside information on how to game the system. (Ex: if you are considered impaired you can get free bus/subway/van service card, which they all knew how to easily acquire). I had to ride my bicycle or walk everywhere to get back and forth from these appointments. https://www.marketwatch.com/story/no-other-state-comes-close-to-california-when-it-comes-to-welfare-spending-2017-11-28 https://www.marketwatch.com/story/no-other-state-comes-close...
• 3xblah 7y ago
  The costs of giving birth is another interesting example. BBC journalist recently said that even though it costs 4x as much under America's privatised system versus a socialised one (Finland), America has a worse record overall in terms of outcomes. https://open.live.bbc.co.uk/mediaselector/6/redir/version/2.0/mediaset/audio-nondrm-download/proto/https/vpid/p077rpgd.mp3 https://open.live.bbc.co.uk/mediaselector/6/redir/version/2....
  • barrkel 7y ago
    I think the US is good at the high end of the distribution, it's just that the average isn't very good. If you want and can afford the best care in the world, you'll find it in the US. But if you get basic care, not so much. This kind of discrepancy makes these debates somewhat pointless as different sides talk past one another.
    • curiousgal 7y ago
      There's probably a reason why most world leaders choose to get treated in Switzerland/France when they get sick.
      • barrkel 7y ago
        Citation needed for that. (And by world leaders do you mean politicians, or wealthy people? Many world politicians have other reasons for avoiding the US.)
        • retiredcoder 7y ago
          Even if there is citation here, would this data around super wealthy people be of use for public health?
        • saiya-jin 7y ago
          There isn't much motivation to release such data to public, those affected know this very well, rest shouldn't care (according to them). From living in Switzerland for 9 years and having fiancee as a doctor I can tell you it is at least somewhat true, nobody here bats an eye if some powerful person is treated in hospital across the street (or more likely private clinic in some nice place). There are many reasons - high quality of medical staff, top notch equipment, just a good place to be. Also, Suisse is long term perceived as creme de la creme in many aspects of life, so this fits the overall picture, be it real or some wishful thinking (mostly real though).
• notimetorelax 7y ago
  AFAIK there’s rule in Germany that a lawyer can chose to be paid 10% out of the difference they saved for the client. I wonder this rule would help with those shenanigans.
• zerr 7y ago
  Interesting, as an outsider, I've heard horror stories, including how US insurance companies treat patients with chronic medical conditions - trying to avoid compensations as much as possible, even invalidating insurance policies, stating as pre-condition, etc... May I ask, how you (and your family) were treated? Did you got lucky with some particular insurance company, or is it a norm in case one has a decent job? Also interesting, e.g. what happens if you lose your job, decide to go indie or until you find another job... In other words, how safe you feel? (compared to living in Australia with their universal healthcare)
  • lotsofpulp 7y ago
    Health insurance companies are not allowed to deny coverage based on pre existing conditions, and they all have out of pocket maximums (for in network providers - doctors/hospitals that they have deals with), and you can purchase health insurance at healthcare.gov if you don’t have a job. Unless your employer pays a portion for you, expect to spend $4,000 to $8,000 per year per person on health insurance premiums, depending on your age, plus up to $3,000 or so on out of pocket costs assuming you need medical care. It’s just your lifetime’s, up to 65 or whenever Medicare (taxpayer funded care) kicks in, health costs amortized over your whole life and then discounted for age since younger people don’t need as much healthcare. In America, the voters want doctors and hospitals and drug makers to provide everyone, no matter how destitute, with services and medicine. But the voters also don’t want any to pay any additional taxes, so this is all a work around to that. Poor people and old people get subsidized by Medicaid and Medicare (taxpayers) and they pay less or nothing at all, so the providers go after everyone else (middle class) for as much as they can. The bigger employers who have negotiating power can do well for themselves, but the smaller employers/individuals on healthcare.gov get screwed because they don’t have enough negotiating power to prevent getting taken for all they have.
    • erentz 7y ago
      > Poor people and old people get subsidized by Medicaid Everyone assumes if youre dirt poor you get Medicaid. But at least for some states as I’ve found out that’s far from true. In Florida for example (we have a poor friend there who is sick) non disabled adults do not ever qualify even if they earn zero dollars.
• dmayle 7y ago
  This was supposed to be the benefit of HMOs. There would be single-pricing, and all carriers are aware of this pricing beforehand. What I think we need, however, is a model that doesn't depend on single-pricing to work, because the real world isn't single-buyer. People tried to solve it by creating healthcare savings accounts, but the solution itself is very complex, and the end user is often in situations where they don't have the ability to negotiate (e.g. emergency health care). So in practice, the financial benefits seem to accrue with low-care patients, not low-cost-of-service patients, meaning it doesn't affect the system in the right way. Ultimately, I think the only way to fix it is to start adding negative pricing pressure in small ways to the system, not trying to tackle the whole problem at once. For example, waive deductibles for treatments which are billed below average (mean? median? in any case, this has to be independent of list price). That creates a financial incentive for insured patients to both seek out billing information, and to lower it. What's great about that (for insurers) is that you're specifically altering behavior of your most cost-conscious customers, who tend to be your lowest margin customers, without mucking about with the profit margins on your most valuable customers.
  • dsfyu404ed 7y ago
    >So in practice, the financial benefits seem to accrue with low-care patients, not low-cost-of-service patients, meaning it doesn't affect the system in the right way. Why is "use less, pay less" a bad thing?
    • dmayle 7y ago
      At first glance, it's not a bad thing, but it does nothing to solve the pricing problem that America's healthcare system has. Going a bit deeper, however, it will most likely increase health care costs over time. This is because it splits the population into two separate risk pools (low-risk low-use, and high-risk high-use). To save myself the time of explaining it in full, just compare it to the current state of the credit card market. When Discover pioneered the idea of splitting the risk pool (by offering cash back rewards to low risk clients), then it created upwards pressure on credit card fees (because the general risk pools slowly became high-risk pools, meaning that existing risk fees didn't cover the necessary spread). The traditional cards now started charging more to merchants, which left room for larger rewards for the low-risk pool in a vicious cycle.