3 ms·

> A "Wellness Exam" can certainly be offered with a different levels of service. But you cannot charge two different prices for the same exam. Same doctor, sam

> A "Wellness Exam" can certainly be offered with a different levels of service. But you cannot charge two different prices for the same exam. Same doctor, same location, same duration, same scope of care, same supplies, same patient-risk, same market demand, same season, same malpractice liability, etc etc ? A same price requirement pushes the economic adjustment to other variables. A simple example: do you take patients saturdays? All staff is more expensive to work a saturday, but revenue is the same. (adjust access). If anything, the market does not have enough price adjustments, which is why eeryone is so price insensitive, particularly the patient.

zaroth 8y ago
Luckily the law isn't an algorithm. Medicine is not perfectly packaged and shrink-wrapped, but a law can be written saying there must be a material basis for a difference in price. Let's keep in mind where we are today, which is that price is entirely arbitrary and capricious, and they are allowed to do that. I think people seeking medical care deserve much better than "arbitrary and capricious". Substantially similar services should not have two orders of magnitude differences in pricing. That should be illegal. EMR coding already provides the basis for establishing a non-discriminatory pricing regime. The problem is the billing system takes the EMR coding of the procedure performed, and then convolutes it with a pricing matrix which discriminates on what kind of insurance you have. I walk into CVS and try to fill a prescription. - That'll be $78 dollars they say; - OK, I have this benefit card, it is not insurance but it provides a discounted rate, and I paid nothing for the card. It's like a coupon code. That'll be $55. - OK, I have this prescription drug coverage insurance card, which carries a $200 deductible and a $20 copay. I've already exhausted the deductible. That'll be $20 and insurance pays $3.07. CVS is selling the same drug, from the same distributor, to different customers at wildly different prices (before an insurance contribution) based on some sort of shell game. To say nothing of the cases where insurance companies agree to pay more for one drug, like insulin, in exchange for charging less for other totally different and unrelated drugs, just because in their insurance pool it helps them optimize the number of patients which ultimately will pay the annual out-of-pocket maximum.
- conanbatt 8y ago
  > Luckily the law isn't an algorithm. Medicine is not perfectly packaged and shrink-wrapped, but a law can be written saying there must be a material basis for a difference in price. Let's keep in mind where we are today, which is that price is entirely arbitrary and capricious, and they are allowed to do that. Thats what insurance companies do. Basically their entire work is assigning different value to different care, based on quality metrics, on differential costs for different services, patient populations, etc. But insurance companies can't see how much are you willing to charge as a provider, thus the provider and the insurance are very much adversarial. > EMR coding already provides the basis for establishing a non-discriminatory pricing regime EMR is probably the main reason why upcoding has become a wide-industry practice. EMR allows you to think in how to maximize insurance values which is not the same as medical value, or patient experience. It is also not true that EMR's convolute with pricing matrix's, each insurance has a different negotiated price for different procedures. This happens for a multitude of reasons, and they are all crappy but real. > CVS is selling the same drug, from the same distributor, to different customers at wildly different prices (before an insurance contribution) based on some sort of shell game. Yes, but thats not a price problem, its a principal-agent problem. Insurance should not be covering regular medical services and procedures. It should be used for highly expensive-out of control actuarially sound events. But competition for clients has made it the way it is now since the 1950's. The way to solve that is High Deductible Plans. HDP people really price-shop and put pressure on providers to talk about cash pricing and caps.

zaroth 8y ago

Luckily the law isn't an algorithm. Medicine is not perfectly packaged and shrink-wrapped, but a law can be written saying there must be a material basis for a difference in price. Let's keep in mind where we are today, which is that price is entirely arbitrary and capricious, and they are allowed to do that. I think people seeking medical care deserve much better than "arbitrary and capricious". Substantially similar services should not have two orders of magnitude differences in pricing. That should be illegal. EMR coding already provides the basis for establishing a non-discriminatory pricing regime. The problem is the billing system takes the EMR coding of the procedure performed, and then convolutes it with a pricing matrix which discriminates on what kind of insurance you have. I walk into CVS and try to fill a prescription. - That'll be $78 dollars they say; - OK, I have this benefit card, it is not insurance but it provides a discounted rate, and I paid nothing for the card. It's like a coupon code. That'll be $55. - OK, I have this prescription drug coverage insurance card, which carries a $200 deductible and a $20 copay. I've already exhausted the deductible. That'll be $20 and insurance pays $3.07. CVS is selling the same drug, from the same distributor, to different customers at wildly different prices (before an insurance contribution) based on some sort of shell game. To say nothing of the cases where insurance companies agree to pay more for one drug, like insulin, in exchange for charging less for other totally different and unrelated drugs, just because in their insurance pool it helps them optimize the number of patients which ultimately will pay the annual out-of-pocket maximum.

conanbatt 8y ago
> Luckily the law isn't an algorithm. Medicine is not perfectly packaged and shrink-wrapped, but a law can be written saying there must be a material basis for a difference in price. Let's keep in mind where we are today, which is that price is entirely arbitrary and capricious, and they are allowed to do that. Thats what insurance companies do. Basically their entire work is assigning different value to different care, based on quality metrics, on differential costs for different services, patient populations, etc. But insurance companies can't see how much are you willing to charge as a provider, thus the provider and the insurance are very much adversarial. > EMR coding already provides the basis for establishing a non-discriminatory pricing regime EMR is probably the main reason why upcoding has become a wide-industry practice. EMR allows you to think in how to maximize insurance values which is not the same as medical value, or patient experience. It is also not true that EMR's convolute with pricing matrix's, each insurance has a different negotiated price for different procedures. This happens for a multitude of reasons, and they are all crappy but real. > CVS is selling the same drug, from the same distributor, to different customers at wildly different prices (before an insurance contribution) based on some sort of shell game. Yes, but thats not a price problem, its a principal-agent problem. Insurance should not be covering regular medical services and procedures. It should be used for highly expensive-out of control actuarially sound events. But competition for clients has made it the way it is now since the 1950's. The way to solve that is High Deductible Plans. HDP people really price-shop and put pressure on providers to talk about cash pricing and caps.